Rebuilding our healthcare infrastructure

https://www.kff.org/coronavirus-covid-19/issue-brief/one-year-into-the-pandemic-implications-of-covid-19-for-social-determinants-of-health/

When I was studying public health, my professors would invariably get around to pointing out to the physicians in the class that running water and window screens had saved more lives than physicians ever would. In the ensuing 35 years the balance of payments has moved rather dramatically in the favor of curative medicine when compared to the payments needed to maintain the health of the population. As we come out of a (hopefully) once in a lifetime pandemic, the nation’s health infrastructure is about to get a huge boost from the $1.9 trillion Coronavirus relief package with the money to be spent over one to two years. By comparison, the Affordable Care Act was slated to cost a little under $1 trillion over 10 years. Although much of the funding is framed as Covid -19 specific, as we have found out activities spent to prevent Covid-19 also work to prevent other things such as influenza. The spending that can be identified as health related is categorized as either public health, improved access via health insurance affordability, or funding targeted to improve the “social determinants” such as food, housing, and income security.

Funding for public health focused activities totals almost $93 billion. The main public health provisions are as follows:

• The Centers for Disease Control gets $10.75 billion.  This money goes for COVID–19 vaccine distribution and administration and supported activities include the establishment and expansion of community vaccination centers and mobile vaccination units, particularly in underserved areas. It also supports transportation of individuals to vaccination, particularly underserved populations. These is also money to promote vaccine confidence, information, and education activities. On the science side there is money for SARS-CoV-2 genomic sequencing and surveillance as well as data modernization and forecasting.
• The Food and Drug Administration gets $500 million  for activities around COVID-19 vaccine safety.
• For public health manpower needs there is $55.56 billion. This money is for testing, contact tracing, surveillance, and mitigation activities including increasing contact tracing capabilities. In addition, there is money for State, local, and territorial public health departments to hire and train case investigators, contact tracers, social support specialists, community health workers, public health nurses, disease intervention specialists, epidemiologists, program managers, laboratory personnel, informaticians, communication and policy experts, and any other positions as may be required to prevent, prepare for, and respond to COVID–19. There is some additional money for the medical reserve corps.
• The community health centers get $7.6 billion for activities including COVID-19 vaccine distribution and administration, testing, contact tracing, mitigation, workforce enhancement, and community outreach and education.
• There is $16.05 billion to support the supply chain for COVID-19 vaccines from development to distribution and to enhance use of the Defense Production Act for the purchase, production, or distribution of medical supplies and equipment for COVID-19.
• The Indian Health Service gets $2.34 billionfor COVID-19 vaccine distribution and administration ($600 million); testing, contact tracing and mitigation ($1.5 billion); and public health workforce for COVID-19 ($240 million).

Funding for individual health coverage included in the bill focuses on making health insurance more affordable but not on systemic change

• Many people who found “Obamacare policies” unaffordable will now be able to purchase insurance through the ACA premium tax credit expansion. This provision lowers the monthly premium for those who purchase coverage through the exchange and in particular for those who are just above the previous coverage “cliff.” During 2021 and 2022, individuals and families above the income cutoff can access premium tax credits. They will also pay no more than 8.5 percent of their household income for a plan purchased through the state or federal marketplaces. Nearly 15 million uninsured Americans could now qualify for subsidies if they enroll through the federal or state marketplace, the Department of Health & Human Services estimates.
• Those who lose their jobs will be able to continue on their current insurance because of COBRA subsidies included in the bill. 100% of the cost of insurance premium will be subsidized for those who lose their jobs for up to 36 months
• Those who need help and support the most will (hopefully) be able to get it through expanded Medicaid benefits and coverage. The improved benefits include increasing funding to states for home- and community-based services, allowing states to offer 12 months of postpartum coverage for new mothers, requiring the coverage of COVID-19 vaccines and treatment for Medicaid enrollees, and expanding COVID-19 testing for people who are uninsured. In addition, reducing disparities will be a priority. There are also new incentives for the 12 “hold-out” states (of which Alabama is one) that have not yet expanded their Medicaid program under the ACA. This expansion would extend Medicaid benefits in those states to households with incomes up to 138 percent of the federal poverty level, an evidence based approach to improving the health and wellbeing of a state’s low-income population.

The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020

Lastly, there is funding to support those Americans who are on the lower end of the economic spectrum. Many believe this to be the most significant piece of anti-poverty legislation passed since the Social Security was initiated during the New Deal.

• Support for all Americans will come through extensive poverty abatement funding. There are direct payments of $1,400 to most Americans in addition to the $600 in aid provided in the December stimulus bill. The legislation also extends emergency unemployment benefits beyond their March expiration date to September 6 and increases the child tax credit. Under current law, most taxpayers could claim up to $2,000 per child. In a significant change, the bill would increase the tax break to $3,000 for every child age 6 to 17 and $3,600 for every child under the age of 6. It also provides $20 billion in rental assistance plus $510 million for the FEMA Emergency Food and Shelter Program to support organizations that provide services to homeless people.
• Support for housing security with about $27 billion going towards emergency rental assistance. This is targeted towards low-income individuals. Household income cannot exceed 80 percent of the area median income, at least one household member must be at risk of homelessness or housing instability, and individuals have to qualify for unemployment benefits or have experienced financial hardship (directly or indirectly) because of the pandemic.
• Support for food security. About 10% of Americans, or 22.5 million people, reported they sometimes or often do not have enough to eat on a weekly basis. There is $1.15 billion in targeted funding to continue an increase in the maximum Supplemental Nutrition Assistance Program through September 2021. In addition, money is included to provide food security for low-income mothers and their children, the elderly, and residents of Puerto Rico, Samoa, and the Northern Mariana Islands.
• Support for younger Americans who are entering an uncertain workforce will come through Americorps. The legislation includes nearly $1 billion in funding over three years for AmeriCorps to expand national-service programs to respond to the pandemic. This is a 100% increase.  AmeriCorps budgets in recent years have hovered around $1 billion a year. The funding will be primarily directed to existing programs to increase the living allowances paid to AmeriCorps members and expand their ranks, though AmeriCorps officials are still sorting out the details.

In summary, this bill supports enhanced care access, strengthens the public health infrastructure, and directly attacks poverty, one of the root causes of poor health. It will take the efforts of all of us to make sure that these resources are put to good use.

Obamacare vs Trumpcare

It has been a while since I have written in this space. Partly this was a result of a personal medical problem (I am OK now and perhaps one day I will regale you with stories of my treatment) and partly because I do not have much new to say. I practice and teach family medicine in the deep south. My state, Alabama, has declined to expand Medicaid. 90% of White Alabamians have the luxury of having health insurance and feeling, well, entitled. 84% of Black Alabamians have health insurance. Only 70% of Hispanic Alabamians report the same. My practice has been colored by these facts ever since the passage of Obamacare. Much of what I have written has been about the passage, implementation, trials and tribulations of Obamacare in Alabama.

My lack of writing in this space recently has been, in part, because health policy wise there has been not much to write about. The last three and a half years have been about the states that have chosen to expand working to correct other gaps in care while those of us in non-expansion states have been watching. In what is likely not a coincidence, many of the people live in the states that have chosen not to expand Medicaid which are also those states which chose to enslave humans (92%). From a policy standpoint, I have to admit that when I am asking for money to study a healthcare problem (hospital closure, unnecessary hospitalization, vaccination gaps) and the reviewers ask “Why not expand Medicaid instead of my giving you money” I don’t have a good answer.

What are we missing out on? Improved health outcomes, for one. This includes patient based outcomes (an improvement in healthy days in the month, reduced overall and disease specific mortality), provider based outcomes (improvement in the physicians’ bottom line), state based outcomes (less money spent on healthcare). In addition, because people are more steps away from bankruptcy, they report in general being better off (reductions in rates of food insecurity, poverty, and home evictions). In short, we in Alabama are much worse off for not having expanded.

In just over a month we will select a president. The incumbent, Donald Trump, ran for office 4 years ago with the promise to “repeal and replace Obamacare.” As part of that he vowed to “block grant” Medicaid. He promised to replace the ACA with something “terrific,” “phenomenal” and “fantastic.” In 2020 alone he has promised an Obamacare replacement plan five times, each time promising to unveil it “within 2 weeks.” The plan has never materialized. Instead, his administration has joined a lawsuit with 18 non-expansion states to gut the law (an unusual stance for the federal government to work towards the nullification of one of the federal laws, but as the kids used to say, WHATEVER). If they prevail they will take health care access away from 25 million people. In addition, for the last six months the lack of federal leadership regarding Covid-19 has also put us in a bind because we are a low tax state, meaning that we rely on the federal government to work on matters such as this. The result of the last three and a half years has been that, in Alabama, we have been in health policy limbo, waiting for President Trump to drop the other shoe.

Joe Biden, on the other hand, had an active role in the passage of the Affordable Care Act. He understands healthcare and healthcare policy. He has a viable plan to effectively get universal coverage in the United States. Although, one can never underestimate the ability of the powers that be to do something dumb, maybe even Alabama can’t screw this up.

Which brings us to last night. I was asked to watch and comment on the health policy aspects of the debate. Here is what we learned: Short answer, nothing new. Long answer, the candidates argued, obfuscated and hurled accusations over a range of health issues, including but not limited to: coronavirus, Obamacare, abortion, drug prices, vaccines, trust in science, stay-at-home orders, private health insurance, the public option, and the Trump administration’s ongoing lack of a health care plan. Specifics were as follows –

The President repeated assertions that he’d done a “great job” managing the public health threat and urged states to reopen, contradicting the head of the CDC whom he appointed.

Joe Biden believes that 200,000 deaths were way too many from Covid-19. The President disagrees.

Joe Biden understands that the future of care access in America is intertwined with the Supreme Court nomination, the President disagrees.

The President believes he has reduced the price of insulin, which, he has not for most people.

The President accused Joe Biden of wanting to take over all of medicine. Joe Biden pointed to the work he had already done and said he would not.

For me, as someone who has watched the poor of Alabama suffer from a failing of the healthcare infrastructure brought on by failed federal policies, needless deaths from preventable illnesses and now from Covid-19, and unnecessary bankruptcies for the past three and a health years, I am ready for a change. Last night did not convince me otherwise.

What a difference 6 miles makes

Sign in Comic Cowboys parade. Prichard is an African American community north of Mobile

I grew up in Baton Rouge, Louisiana. I graduated from Robert E. Lee High School. I ran track in high school and had many Black teammates. I did not go to their house and they did not come to mine. I was in college prep courses as well. I had Black friends who were relatively well off and whose parents were professionals. I rarely went to their house and they rarely came to mine. I do not pretend to understand what it is like to grow up poor and Black, or just Black, in the South.

I went to medical school in New Orleans, caring for the underserved of that city. One of my most vivid memories was when the wealthiest woman in New Orleans drove up to Charity Hospital in her Limousine to visit her servant of 50 years, whom she had paid in cash so was not eligible for Medicare. As I recall, she was dying of breast cancer. In an open bay ward. With no one to help her change out her bed pan. The society lady visited for an hour then went back home. I did not know what it was like to be poor and Black in New Orleans.

I moved to Mobile in the 1990s. I did my residency and stayed on at the University of South Alabama, caring for the underserved. I spoke with people who were thought to have “anxiety” because they “couldn’t sleep” as part of a study. Ever try sleeping in a bathtub so the bullets won’t hit you accidentally? I had a colleague who would hide his pager when he came to events in “white” neighborhoods because, if pulled over for being Black, he feared going to jail for dealing drugs. I have had patients stop seeing me because “you take care of n_____.” I have no clue what it is like to be poor and Black, or just Black, in Mobile Alabama.

I now work, in part, trying to undo systemic problems in our care delivery system in Mobile. My offices are in the “medical complex” area of Mobile. Six miles to the east is Springhill, the neighborhood where the well-heeled (white) Mobilians live. When they are born, evidence suggests that they will have, on average, 83 years until they die. They enroll in private school at the age of 5. They have a car from the time they are 16. They go to expensive colleges and return in time to be the magnate of industry that they were born to be and then another lifetime to enjoy the fruits of their labor. They get to ride in parades with signs that belittle the Black folks in the community for, well, being poor.

Six miles to the south of us is the working class community of Maysville. When they are born they are, on average, predicted to live for 65 years. They are not destined to be captains of industry. They have to drive for miles just to get fresh produce. Because they work multiple, low wage jobs, most do not have health insurance. Because Mobile has systematically underfunded public transportation, they have to beg for rides to the doctor. They are descendants of the enslaved humans that once made Alabama one of the richest states in the union. They are accused of being lazy, crack heads, and drug dealers. They are convicted of the crime of living while Black. They are sentenced to 55 years of hard labor, 10 years of a broken body and no way to pay the doctor’s bills, and a death at 65. They get to come to parades and see signs telling them that they should be ashamed for being Black.

I don’t know what it is like to be poor and Black in Mobile, but what I do know is that there are a lot of folks that do. They find out because they were born in the wrong place. They find out because, despite working hard, they can’t get a job that offers a living wage, much less basic benefits such as health insurance. Mobile has one of the highest rates of disparities between the wealthy and the poor in the country. Last night, the mayor offered “thoughts and prayers” to those Black citizens who live in Maysville and hurting and those white citizens who live in Springhill and are scared. He suggested that:

“By creating One Mobile to become a safer, more business and family friendly city, and By uniting America into One Nation under God, indivisible, with liberty and justice for all.”

I hope that his prayer is answered. I hope that the Lord commands him to speak out against white privilege and work to eliminate it in all aspects of city life. I hope that the Lord commands him to lead the charge to remove vestiges of the confederacy from the city, which have traditionally been an instrument of oppression. I hope that the Lord commands him to make it a priority that workers have a living wage if they are willing to work a 40 hour week. I hope that the Lord commands him to make combating food deserts, public transportation deserts, and health care deserts a priority of his administration. Mostly, I pray he will do what it takes to erase the legacy of 300 years of enslavement on half the citizens of Mobile. While I don’t know what it is like to be Black, I sure know what equity looks like.

You have not had the ‘rona (of this I am 95% certain) but you want to get out

The young people (those younger than me) call Covid-19 “the ‘rona.” As in, I think he has the ‘rona. Or, to be more specific, If you were in “Lake of the Ozarks” Missouri at the pool party where 400 strangers gathered (pictured above), you had a 1 in 3 chance of catching the ‘rona if your were coughed on by a ‘rona infected person.  Pool parties are known for spreading Covid. This should deter people. However, apparently this Memorial Day weekend the water is just too enticing

Jodi Akins, from Blue Springs, told CNN in a message that she visited the bar with four friends for a pool party on Saturday.

“When we walked up my first words were ‘oh my gosh’ it was intense for sure!! Social distancing was nonexistent. However everyone was enjoying themselves. It was a very carefree environment but security was heavy!!” she wrote to CNN.

We are all tired of the ‘rona. What’s  more, many of us are convinced we have already had the ‘roma. The conversation goes something “Remember when I had that little cough? That was it, let’s go to the beach.” Unfortunately, the science is not behind you. Here is Mobile, we mostly test for symptoms. People call up and say, to paraphrase, “I think I got the ‘rona.” They are then brought to an outdoor testing site where they are tested for ‘rona. Guess what…8 in 10 who believe they have it do not. They have some onther pesky viral infection. We also test people who are going in for routine medical procedures Guess how many of those folks have it….1 in 200. We also test antibodies  (markers in the blood for a current or past infection) for various reasons. Guess how many people have evidence that they had a known infection? Less than 1 in 20. And most of those who were infected worked or lived in nursing home or other group facility.

Why so few? Because social distancing worked. All the restaurants you didn’t go to. All the weddings you missed. All the church hymn sings that didn’t happen. This is how the spread stopped.  It turns out that mostly, the ‘rona spreads like this: Person A, for whatever reason, has a lot of ‘rona and doesn’t know it. This might be because they work at a nursing home and were taking care of a dying patient who was never tested but had a lot of ‘rona. It might be because they are gonna get really sick but it is still early.  It might be because, well,  they are just one of those people….Anyway, they show up at the pool party. Grab an adult beverage and get waist deep in the shallow end.. Cough on 15 people. 11 people don’t get it. Why not? Didn’t get inside of them. 4 people get the ‘rona. But, see, they don’t know it for 2 days. They go home to their family and cough on them. Of the 4 people in the house, 2 people get it. One just sucks it up and powers through. The other, an older man with hypertension and lung problems, ends up in the hospital and possibly dead.

Second problem. One of the other people hanging out at the pool who gets a ‘rona lugie to the face really doesn’t get sick and works in a grocery store, stocking the shelves. He works side by side with someone who is older and has some lung problems. A little cough (no mask ’cause they are for sissies) and 3 days later this guy’s sick. 100 grocery “heros” have died this way.

So, here are the facts: 1) You are still capable of getting the ‘rona and spread it to others with 95% certainty. 2) You might have the ‘rona now and don’t even know it ‘CAUSE YOU DIDN”T HAVE IT BEFORE. 3) You might be a super spreader and, in a crowd, could be responsible for multiple people dying which I am certain you do not want to do. 3) You could get it from a superspreader  at a crowded event and be responsible for the death of a family member or coworker, which I am certain you do not want to do. 4) You are lonely, bored and want to GET OUT.

Assuming you are young, not as selfish as some of your friends, and don’t want to actually kill someone, here are some suggestions for how to SAFELY hang out with folks on Memorial Day and beyond until we get a vaccine:

Pick your guests wisely – Don’t have people leave the Lake of the Ozarks pool party only to come to yours. Mostly stick to careful family and friends. Ask them if they have been careful. Limit to under 10 if possible and under 25 for certain.

Pick your space wisely – STAY OUTSIDE. Their have, to date, been no superspreader events outside. Eat with your quarantine unit. Do not spend a lot of close contact with folks you have not already been with. Remember that hand washing is very important as are disposable plates and utensils.

Avoid sharing covered dishes – The grilled meats, almost certainly ok, especially if you take them off the grill yourself. Aunt Rita’s carrot and raisin salad made with mayonnaise and lots of love? Possibly Covid-central. Each unit needs to bring their own sides. Also, no chips and dip. You ever watch folk eat that…

Practice social distancing – If you know that Uncle Harry sprays when he talks, stay 6-10 feet away and wear a mask. Better yet, tell him to wear a mask. When he goes all Fox News on you and says “where’s the evidence” you can either pull out your phone and show him studies OR you can ask him “where’s the evidence that hydroxychloriquine actually doesn’t kill people with the ‘rona OR you can do as I recommend and stay 30 feet away.  Especially avoid the crowd in the corner doing tequila shots as, aside from being inside, the other constant in superspreader events is booze.

Let folks burn off steam – Kids need to go outside and play. They are not proving to be the little bags on “rona we thought they were. Having said that, any child with a fever or a cough should be kept at home. Try to avoid games where spit is shared such as tackle football. In the pool, remember the 6 to 10 foot rule regarding strangers.

Afterwards, let the sun do the work – While everyone should pick up their own trash, leave the chairs and the tables. A couple of hours in the sun and the ‘rona is gone.

So, go outside, have fun, avoid strangers, and don’t kill any co-workers. Hopefully we can find a happy place between desolate isolation and 2,000,000 deaths soon.

 

Testing, testing, testing…

Patient: I know I already had the Covid. Remember when I was so sick in January? Couldn’t breathe without coughing, so weak? THAT was the Covid, I’m sure. 

Me: No, it wasn’t. Covid didn’t move from the bats to people until late 2019 and it really wasn’t here in Mobile. I think that was probably the flu

Patient: But the test said it wasn’t. Did you test me for the Covid? I’m sure I had it.

Me: No, we didn’t have tests yet in this country. But the flu test could have been wrong

Patient: Wait, you ordered the wrong test on me???

Testing in healthcare is rather more complex than one might think. Folks come to me as a physician and want a diagnosis. I order a test and then say “Have you had it before?” When they say yes I say “Well ya got it again.” Not really. Actually, before I order the test I need to know a lot of stuff, otherwise the results will not be useful.

The first thing I need to know is how the test “performs.” Take a pregnancy test, for example. What the over-the-counter pregnancy tests measure is a chemical produced by the body in early pregnancy. In order to be more accurate, it only detects a level that is consistent with a 3 1/2 week pregnancy. So if a woman gets up, has sex, and uses a pregnancy test to see if she is pregnant, the answer will be “Not Pregnant” even though she is “maybe” pregnant. Also, late in the pregnancy, the chemical goes away in some woman, So if a woman has gained 30 pounds and feels something inside her kicking and moving, and has an ultrasound showing a baby she is “pregnant” despite the negative test. The number of times the test accurately detects the condition (in this case pregnancy between 3 1/2 and 15 weeks) is known as the positive predictive value (98%) and the number of times it accurately tells woman “not pregnant” is known as the negative predictive value (95%).

The other thing is that if there is a lot of disease, a positive test is more likely to be a “true positive.” If there is little disease, a negative test is more likely to be a “true negative.” So, if you do a pregnancy test on a woman who has had a hysterectomy, a positive is almost certainly not a pregnancy and is a “false positive.” Conversely, if the young woman pours water on the strip because she doesn’t want her mom to know she is having sex, the negative is almost certainly a “false negative.” Here is a really good video explanation.

What, you say, does this have to do with Covid-19? Currently, there is  controversy over testing. Initially, in this country, there were no tests. In the absence of tests, all the doctors and patients had was their clinical intuition. This works really well in flu season EVERYONE in the house has the flu and then MOM gets sick (OH MY GOD, WHAT DO WE DO). Mom has the flu ,and no one needs a doctor to tell her or the other people in the family, who have to resort to eating Kleenex. This works just OK in strep throat season when, even under the best of circumstances, the child with the sore throat might have a 50:50 shot at having strep even if his best friend had strep. The possibility that the person has the disease prior to the test being run is known as “pre-test probability.” If that number is very low, then the a positive test will almost certainly be a “false positive.” So, before the plane loads of Italians and Wuhanians debarked, we needed 0 tests. All of the coughing and shortness of breath was not Covid.

Once the first plane loads of feverish (and pre-feverish) folks from Wuhan and Milan were in America, lots of tests would have really been nice for multiple reasons. First, one of the ways to stop an infection for which there is no treatment is to catch the potentially infected people and quarantine them until the risk of spread is diminished. Had we kept these folks separated from the rest of America until we had a “true-negative” test, the virus would have never come here. Secondly, there is no way to distinguish this virus from the influenza virus, the parainfluenza virus, or any of the other viruses that cause fever, chills, shaking chills, and the rest of the symptoms associated with Covid-19. The difference is that Covid-19 kills people over 65 and is spread by people who don’t know they have it. A positive test (whether true or false) in combination with paid sick leave could have kept meat plant workers away from their colleagues, infected visitors away from their family member in the nursing home, and allowed patients with infection to be treated by an appropriately dressed care team.

The timeline for the test for the virus is as follows: The gene sequence was known on January 12. Once this is known a test can be created. The first known infected person got off an airplane on January 15. We only had 200 test kits made by February 4th but they had a really high (almost 100%) false positive rate. It was another month before the CDC would let commercial labs create their own test. By March 14th we were collecting specimens in Mobile and sending them to a commercial lab in Birmingham that had just gotten permission to run the swabs. Problem was that the results took 5 days to come back. It was several weeks before we could get a result back in the same day.

If everything works right (the person has the right swab stuck up his or her nose and put into the right liquid and sent to the right lab) the virus test allows us to tell people if they are currently shedding virus with excellent certainty (it is a “true positive”). If they have fever, it tells us that they have the Covid. If they have no fever it tells us they have a 50:50 shot at developing the Covid fever. Either way, it also tells us that they can give it to folks they live with, work with, or cough on in a nightclub. It allows us to tell them to wear a mask and stay away from folks for 14 days or until they test negative. Even if it turns out they had a “false-negative,” their being quarantined would save lives and allow live to go on for others.

What we lost by not having good virus testing is control of the disease. We had people coming to the hospital who were potentially (but not certainly) sick with the Covid. We had their family members and the hospital staff who helped them exposed to the Covid, who they then went home to their families. We had people who were dying anyway catch the Covid and give it to their caregivers and we had no clue that they had the Covid. We had people come to the Mardi Gras because they had a scheduled hotel room and cough on people at the parade who then, with a little headache and muscle aches, went to their job at the nursing home. It came to funerals in rural Georgia, Easter service in rural Alabama, and Veterans Nursing Home where it killed 22 of our greatest generation. It is now in every county in Alabama.

Where are we now with testing? We, as a country, have tested over 10 million people since March 8th and found 1.4 million folks with the Covid. Although it sounds like a lot, since Covid is in every nook and cranny of the country experts say we need to test up to 35 million folks A DAY to find everyone infected. We also need to test more than people with fever or headaches. We need to test people who have contact with those who are sick to find virus shedders who are not going to run a fever. We need to identify those people who are infected and have them sit out the next 14 days so the chain of infection can be broken.

But wait, you say, if I already had it, can’t I be free to move about the country without fear? The answer is yes, but I’m 99% sure that you haven’t. That, my friend, is the story for next time.

If we really care, what can WE do

As states in the deep South and elsewhere are starting to open up from shelter-in-place orders I think we need to get some things straight.

Things that the virus is not:

1. A deep state conspiracy. It was not created in a lab in Wuhan. It almost certainly is a naturally occuring coronavirus that moved from a bat to humans via an intermediate mammal.
2. Going to magically go away. Very few people have immunity right now. Summer does not make this virus go away. We are stuck with it until 60% to 80% of Americans get it (culminating in about 1,500,000 dead Americans), we get a vaccine (unlikely in the next year) or we take stopping the spread of the virus seriously as other countries have done.
3. That thing you had in January. It is almost certain that only 1% to 5% of the population in any place in America except New York City has been exposed to the virus based in antibody testing
4. Just a bad “flu.” In a really bad flu year in the United States we have 61,000 deaths over the entire season. We have had at least 75,000 deaths from this virus in 2 months.
5. Not going to hurt me. Randomly people die in car accidents. Randomly people die of this virus. Less randomly older and chronically ill people die of this virus when exposed.
6. A plot by big pharma to harvest your healthcare dollars. This is a virus that is killing people. It is not activated by masks. It is spread through coughing droplets on others.

What the virus is…The virus is real.  It  came over from China (west coast) and Europe (east coast). It has almost certainly killed almost 100,000 people in this country so far although the death toll will be artificially low due to the way we categorize deaths (I know, I fill out death certificates all the time). It is almost certain that a medication will not help with mortality. If you get the virus, your risk of death depends on your age (very few under 65 die as compared to a lot over 80), your underlying health (those with chronic illness and/or obesity fair much worse than those who are basically healthy), and your exposure history (if you do not come in contact with droplets of spit contaminated with Covid-19, you will not catch it).

The way it came into the United States is a follows. Initially people got off an airplane from either China or Europe with the virus growing in their upper respiratory tract. They may have had a fever, cough and body aches. They may have developed a fever and body aches once off the plane. They may never have done so and cleared the virus. The travelers then went to an activity where there were a lot of other people. A scientific meeting in Boston, A jet setter party in Connecticut. Mardi Gras in New Orleans. They coughed on people at these places and a lot of them got infected. Problem was we were not testing those folks who were coming from infected areas. No tests.

First 100 deaths in the US didn’t happen until the last half of March. How did it happen? The people at  Mardi Gras, at meetings, in New York, the ones who were young and healthy then went and infected a couple of other people and mostly, the virus stopped there. Sometimes, before these people got sick (or even after), they went and did another group activity. They went to a community sing along. They went to a funeral and cried on their sister’s shoulder. They went to church and coughed on someone. At these events, though, there were older and sicker folks. When these folks got sick, they got really sick. Sometimes they went to the hospital, who couldn’t test them. When they got to the hospital there may have been lack of concern because it wasn’t in the community (again, no tests), and/or a lack of protective clothing. Health care workers would get exposed. They would get sick but, because they are troopers, would continue to work through the “flu.” If their job happened to be in a nursing home, many older people who were at risk would get exposed and some would die (either in the nursing home or in the hospital), many other health care workers would get exposed, and then many more people died. The workers in the nursing homes then go back to THEIR families and the cycle continues. Although, as the saying goes, we all have to die sometime, it doesn’t have to all be in the next month. Even now, we do not have enough tests, the ability to administer tests, or protective gear for folks caring for nursing home patients. About 1.5 million people live in nursing homes in this country. That will be a lot of deaths that don’t have to happen

So, the country is opening up and, in the words of the President, “some people will be affected badly.” Assuming you do not want to be the proximate cause (or the 2 degrees of separation cause) of someone’s Papa’s death, there are some things you can do:

1. Wear a mask. If we get infected we may not know it for 3 or more days. A mask keeps us from infecting someone else who may have an underlying condition or just be older and more susceptible.
2. Wash your hands or use hand sanitizer. This will keep you and others from getting it.
3. Stay physically active. Outside is usually safe with social distancing.
4. Stay away from and don’t hold gatherings of more than 10 people now and 50 people until there is a vaccine. There is clear evidence that social distancing works and when it goes away people die. Stay 6 feet away from folks you are not quarantining with.
5. Stay home when possible. Remember, you don’t know if you will become sick 2 days from now
6. Most importantly, stay home if you are sick. If you have a new loss of smell, cough, fever, shills, shaking chills, or shortness of breath but are otherwise healthy, don’t go out for 14 days.

Unlike many countries, we missed the opportunity to control this virus before is became endemic. If we follow the above measures, become much better at testing and protection of healthcare workers and first responders, and learn how to give up some freedom so that those infected can be isolated, then we can get control of our lives back with minimal loss of Meemees and Papas. The alternative is to lose 2,000,000 folks. Guess we each have some choices to make.

 

Natural Experiments

My first wife died almost 4 years ago, in April. She was 55 years old when she died. Her life story was remarkable in and of itself, one in which I was fortunate to play a part. Her story began, it turns out, with a natural experiment.

First, she was taken from her biological mother and placed in foster care for several months. Second, her adoptive parents were carefully selected. They were screened for resemblance (white but not too white), religion (not Catholic), and temperament.  Third, little Delphine had the full 1960’s data wipe. Her birth certificate was changed to reflect her adoptive parents and new name (Danielle). The date and size (I suppose) remained the same but the hospital, mother’s city of birth, father’s name, and any other detail was transferred over then attested to be the truth by the Orleans Parish registrar. She was a tabula rosa, existing to be filled out with the essence of Bev and Hank. She was one of 100,000 “closed adoptions” in 1961.

How did this experiment turn out? By the 1970’s, adoptees (mostly post WWII babies) were clamoring for personal information. Many were unhappy with their wiped identity. By the 1980s registries popped up and birth parents were allowed to register as were adoptees. By the 1990s most adoptions had some degree of openness. With the advent of 23 and Me, there were no secrets. Most adoptions now include some degree of openness.

Well, we really don’t know how the “taking away of babies and wiping them clean” experiment worked out because it wasn’t treated as an experiment. The societal belief  was that being taken out of a house where one is unwanted and being placed in a loving, nurturing environment would always be a good thing. Perhaps we should have looked more closely.

But a research brief published in October by the Institute for Family Studies threw a bit of cold water on this fantasy. The report, written by psychologist Nicholas Zill, was sobering: At the start of kindergarten, about one in four adopted children has a diagnosed disability, twice the rate of children being raised by both biological parents. Adopted children were significantly likelier than birth children to have behavior and learning problems; teachers reported they were worse at paying attention in class, and less able to persevere on difficult tasks.

In Danielle’s case, she found her birth mother (Pat) when we were in our 30s and had just moved back to Mobile. Or, rather, her birth family found her. At the reunion (on Royal Street during Mardi Gras), I knew that the slate was never wiped clean, despite the efforts of the state of Louisiana. Where Bev was shrewd, Pat was open (like Danielle). Where Bev was practical, Pat was creative (like Danielle). Where Bev was closed, Pat was open. Where Bev used soaps whose smells I found irritating, Pat used THE SAME SOAP AS DANIELLE. Oddly enough, Pat was 55 years old when she died.

The tabula rosa thing was not studied as an experiment. Why study something we knew “felt right?”  The closest science came to looking at this was the Minnesota Study of Twins Reared Apart. These investigators look at closed adoptions where twins were taken from families and raised as singletons. They have found that genetic factors appear to influence personality, mental, and activity-level changes as adults become older, to the tune of half. Yup, turns out you can only wipe the slate 50% clean.

One example of the amazing similarity of twins reared apart is the so-called “Jim twins”. These twins were adopted at the age of four weeks. Both of the adopting couples, unknown to each other, named their son James. Upon reunion of the twins when they were 39 years old, Jim and Jim have learned that:

• Both twins are married to women named Betty and divorced from women named Linda.
• One has named his first son James Alan while the other named his first son James Allan.
• Both twins have an adopted brother whose name is Larry.
• Both named their pet dog “Toy.”
• Both had some law-enforcement training and had been a part-time deputy sheriff in Ohio.
• Each did poorly in spelling and well in math.
• Each did carpentry, mechanical drawing, and block lettering.
• Each vacation in Florida in the same three-block-long beach area.
• Both twins began suffering from tension headaches at eighteen, gained ten pounds at the same time, and are six feet tall and 180 pounds.

Closed adoption have not stopped. This is because when people look at a newborn they don’t see a thing half full of mom and dad but believe they are viewing a tabula rosa, despite evidence to the contrary.

Why think about natural studies? Because we are about to embark on one in this country around Covid-19 spread. What we know is that, left unchecked, every person with Covid-19 infects about 3 other folks and they infect 3 other folks, and so on until the whole world is infected and about 2% of the world is dead. That is, unless, the person who is infected stays home AND the person who is not infected doesn’t come into contact with an infected person. This breakage in the chain of infection has occurred because of shelter in place severe social distancing. Currently, this is a nationwide effort. As we reach the end of this phase, we are about to see 50 states going in different directions. The East Coast and West Coast states, for the most part, seem poised to maintain distancing for a bit longer, test a lot of folks, and chase down those that are infected to keep them from restarting the chain of infection. We on the Gulf Coast seem poised to demand an end to social distancing, eschew testing, hit the beaches and the baseball stadiums, and blame Barack Obama for the destruction of the economy.

Many are looking at this Covid-19 crisis through a different lens than I. What I see is a broken the chain of infection. What I see is a virus that is deadly and lurking, waiting for the chain of infection to be re-activated. We are about to embark on a natural experiment. Those of us whose neighbors look around and see conspiracy may bring Covid-19 deaths back into our nursing homes. I only hope we are measuring what happens.

 

Covid to do, 2 weeks later

My, how time flies when you are having fun. As president of our national organization of Family Medicine Department chairs, I had the opportunity to lead our group in a discussion regarding the response to Covid-19. As a work product (a great meeting BINGO word) we created a to do list for America (found here). We are now 3 weeks, 500,000 cases, and 20,000 additional deaths from the publication of this work product. How did we do?

1. 4 week shelter in place order for all jurisdictions – as of April 7th, at least 316 million people in at least 42 states, three counties, nine cities, the District of Columbia and Puerto Rico are being urged to stay home. This is up from 9 states on March 23. While correlation does not prove causality, at least we were on the leading edge of recommendations. It is believed that this action saved (or will save) over a million lives in this country.
2. Training and deploying a cadre of individuals capable of contact tracing and dramatically increasing access to testing – This will be vital to the SUCCESSFUL reopening of the country. As of today we have tested 3,000,000 Americans over the course of the outbreak. While a big number, in a country of 325 million people, not so many. We need to test close to 2,000,000 folks PER WEEK. We need to test people who have fevers. We need to test people who have been with someone with a fever. We need to test people who work in nursing homes. We also need to, once we find a positive, go and make sure that they are quarantined AND THEN TEST THEIR CONTACTS. This is a skill set that many in public health have allowed to atrophy since infectious disease became unsexy. If we were good at this, syphilis would not be a problem. For Covid control if we were to open the country, everybody would need to be tested approximately every 2 weeks with adequate investigators for the positives.
3. Adequate personal protective equipment. – As someone who trains medical learners, this is near and dear to my heart. It is unclear how many health care workers, first responders, even grocery workers have been infected in their line of work. This is due to a broken supply chain, inadequate planning, and an inability to plan for the “unthinkable.” The CDC, on April 3rd, issued guidance on reusing “single use” equipment, One can only hope that we are working to adequately protect our health care workers. While there are many feel good stories about folks repurposing their plants to make eye protectors, there are many more about the lack of PPE and the fear that care delivery workers carry home with them.

So, now what? Hopefully we will continue to shelter in place, obtain testing and case finding to allow us to open the country, and obtain adequate PPE to protect vital workers. Fact is, Covid-19 is a disease that has no effective treatment and when fully manifested does not respond well to supportive care. It kills very few people in their 30s, more in their 40s, and so on until the population gets to be around 80, where 20% of those who develop an infection will die. For most of these older folks, besides protecting them from the virus we cannot alter the course of the disease

What can we do? To quote one of America’s great physicians, Sir William quote Osler, “Ask not what disease the person has, but rather what person the disease has”. The reality is we as caregivers are back in the era of “The Doctor.” I took some time today to read the bio’s of the Covid victims and I recommend you all do the same. Honor the victims. Let’s take some time to remember the people we care for, despite the isolation.

This is not about an invisible enemy except in that if you remain isolated you will not encounter it. This is about an insidious disease that is brought to our patients because of the efficient way we care for them (nursing homes, group homes), the way we ask them to work (low wages, no health insurance, limited childcare, no sick leave), and the limited information we give them (let’s reopen the economy). We need to fight THOSE enemies.

 

To do list

The group of academic family physicians that I have the honor of leading this year have found themselves in the midst of a Covid 19 outbreak. Representing all 50 states, these academic leaders are working in some of the largest, most modern academic health centers in the world. Academic health centers that, unfortunately, are not prepared for the challenge that is just now hitting the coasts but will soon spread across the country.

The preamble to this crisis goes back 30 years. As hospitals have tried to maximize their profits, they began using “just-in-time” inventory. Toyota, it turns out, does not have a warehouse for parts. Instead it gets the carburetor (or whatever parts cars have in them now) delivered at the exact moment the car rolls to that point on the assembly line. Hospitals began using the same, getting only the masks or other equipment they need for the next week from the plant (in China) rather that maintain a warehouse. Well, also only having enough hospital beds for people who need them. Toyota never needed to plan on all of America needing a car within the same 2 month period. Hospitals, turns out, also never planned for Americans to get sick all at once. Guess now we know.

We might have overcome the lack of protective gear except for one problem. If you are treating all of America for a virus that acts like 5 other viruses except it kills you, the only way to “not going to die” people from “just might die” people is by testing for the bad virus. If you know the patient has the bad virus, you can isolate him or her and protect the health care workers more accurately. America, with the best funded health systems in the world, botched the test.

If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

We have less protective equipment, fewer hospital beds, and more chronically ill people than Italy (7503 deaths to date, 743 last night) and Spain (3434 deaths to date, 514 last night). We did not spend the last year preparing for this surge and, by screwing up the testing, we probably have 200,000 infected people going around infecting others. If you look at the cities where things are bad, they are also cities where either lots of people live (New York, Los Angeles) or cities that had a lot of recent visitors from all over (Mardi Gras in New Orleans). It takes about 4 days to know if you are infected (with something….is it the flu? I just feel a little achy) and if you are going to get really sick it happens on about day 8. So now what?

1. Sheltering in place. What we know is that if people who are infected limit themselves to limited contact with a small group people, the virus “dies out.” It takes enough time for the virus to finish with patient 0 (the first sick person) and the 2 other people who will likely get sick from that person as well. This virus is spread through coughing, sneezing, and otherwise having fluid spewed. 15 days is not nearly enough time to reduce the number of infected people. Even of only 5% of Americans get this virus (17,000,000) and 10% need intensive care we would need almost 1,000,000 ventilators. This is about 700,000 less than we have now. Without these ventilators people die, with them they live.
2. Testing and contact tracing. Once we stop sheltering in place, the virus will still be with us. The countries that have successfully reopened have continued to test their populations and, once a positive is found, identified all of the folks they have come in contact with and placed them in “shelter in place” for 2 weeks as well. We not only have not invested in protective gear, we have not invested in this very basic public health workforce.
3. Adequate personal protective equipment. 40% of those who became ill in China were associated with health care delivery, either as care providers or the families of care providers. Protecting health care workers is vital. Sending health care workers out to potentially die is unconscionable.

So, here we are. One choice is to shelter in place for the next month or three, put up with occasional outbreak which gets tamped down, and delay until a vaccine is developed. Another choice is to throw our hands in the air, declare this too hard, and sit back while 4,000,000 die a potentially preventable death. My colleagues and I believe the first choice is the only choice. Please discuss with the policymakers in your states.

Just what IS the cost of living under a bridge?

“Nobody knew that health care could be so complicated”  @realDonaldJTrump

We are 341 days and some change away from the presidential election which will determine the fate of healthcare in this country. The current president, Donald J Trump, campaigned in 2016 on the “repeal and replace Obamacare” platform. Although there was a flurry of activity which threatened to bring back the fear of preexisting conditions and the creation of an Obamacarelite product (perfect for those not planning on being sick) for the most part Obamacare remains intact. In fact one of the key components, Medicaid expansion, actually seems stronger than it did under president Obama.

As we gear up for the next election it seems that healthcare is once again getting the politician’s attention. The Republicans are still of the mind that “Obamacare doesn’t work” although they are unable to come up with anything better. The Democrats have pushed out seemingly hundreds of ideas. Though somewhat of a moving target, it seems that the ideas can be coalesced into “Medicare for All” (Sanders and Warren), “Medicare for some more” (most folks), and “Better Obamacare for some” (Harris and Buttigeig). What piqued my interest today was what I thought was an arcane mental health discussion. Senator Harris called to:

Repeal the Institutions of Mental Disease (IMD) exclusion. The IMD exclusion precludes Medicaid funding for adults receiving care in psychiatric facilities with more than 16 beds, and has also exacerbated a severe shortage of acute psychiatric care beds nationwide. Repealing the IMD exclusion will reduce the number of Medicaid patients who end up in already strained general hospital emergency rooms when they need acute psychiatric care.

I thought “This makes sense” until I saw this Vox article:

But on Monday, when Harris’s campaign rolled out its mental health policy plan, it had not been nearly so thoughtful. Harris seems to have gone all-in on attacking the freedom, dignity, and privacy of people with mental health conditions. People like me.

I have to admit, although I know little about the Senator, she does not strike me as THAT evil.

As it turns out, back in 1965 when Medicare and Medicaid were being designed, there were a lot of people in mental institutions that were being imprisoned for their mental illness. Congress, fearful of states using the new Medicaid money to build bigger insane asylums, created a mental illness exception for inpatient treatment. Any facility with more than 16 beds that exclusively treated mental illness was ineligible for Medicaid funding. Although there have been some attempts to repeal it, this exception has stuck over the years. In part because of fears of mental health advocates such as those expressed in Vox. In part because of fears of increased cost. From a demonstration project which included Alabama where the exception was waived:

“Overall, we found little to no evidence of MEPD effects on inpatient admissions to IMDs or general hospital scatter beds; IMD or scatter bed lengths of stays; ER visits and ED boarding; discharge planning by participating IMDs; or the Medicaid share of IMD admissions of adults with psychiatric EMCs.

Available data suggest, however, that increased access of adult Medicaid beneficiaries to IMD inpatient care would likely come at a cost to the federal government.

In short, we are likely to find ourselves where we have always been. Folks suffering from serious mental illness (including substance abuse) only able to use their Medicaid for treatment if they are not too sick. This is in part due to a fear that those who are functional have that they will be locked away rather than treated in the least restrictive environment. This is also reflects the reality that the feds fund “healthcare,” not the prisons and underpass encampments where folks with intractable mental illness are now found.

Nobody knew mental health care was THIS complicated…