Are you going to provide free clinics for sick underprivileged children? Will you do in Alabama what you do on mission trips to other states and countries?

Senator Jim McClendon, explaining why he is sponsoring not one but TWO lottery bills

The legislature in Alabama is meeting in special session starting today to see if they can find more money for the General Fund budget. The budget passed in the regular session was about $100 million short for what was needed to maintain the Medicaid program at its current bare bones level. Medicaid and corrections are the major programs funded by this complicated and convoluted budget process and, as you can imagine, the constituency tends to be silent. The legislature comes back into special session today to determine whether Alabama will become the first state to reduce Medicaid funding below the threshold required for the match.The funding possibilities are as follows:

  1. Governor Bentley’s proposal- a $225 million lottery, with proceeds going to the General Fund. Would require constitutional amendment. Money not available for about a year.
  2. Jim McClendon’s bill, which would include electronic lottery machines in four counties – Greene, Jefferson, Macon and Mobile – with a bond issue to pay for Medicaid in the coming year. Would require constitutional amendment.
  3. House Minority Leader Craig Ford, D-Gadsden, said he’ll bring a lottery-only bill that would set aside lottery proceeds for education. Another Ford bill would include casino gambling as well.  Would require constitutional amendment. Money not available for about a year.
  4. The legislature may create a compact with the Poarch Creeks, allowing them to offer more types of gambling in exchange for an annual fee or a cut of the proceeds. Critics worry that under federal gaming regulations, a lottery could open the door to Creek expansion without a compact. Unclear how this would work. Likely would draw a lot of attention form the feds.
  5. They may opt to use the BP money to fill the gap this year, leaving the hard work for next year.
  6. They may, and possibly will, do nothing and allow Medicaid to become a non-compliant program

If they fail to act. the feds will do one of two things. Because the program’s recipients are disproportionately poor and of color, the feds may sue under the Fourteenth Amendment and require us to find $100 million to maintain a $6 billion program, maintain access to healthcare for ALL Alabamians, and not force the layoffs of tens of thousands of individuals who work in healthcare. Conversely, the Supreme Court has ruled that Medicaid is an optional program. The feds may just allow us to opt out and allow our natural experiment to continue. Let’s see how many folks will come to Alabama instead of Ecuador for mission work.

 

I will be appearing at a press conference on Friday, August 5th as a representative of the Alabama Academy of Family Physicians. Beside me will be representatives from the Alabama Academy of Pediatrics, the Alabama Hospital Association, and the community. We will share the following message. This message is being shared in across the state in a series of press conferences beginning Monday:

On August 1st (tomorrow), Alabama begins applying cuts to the state’s Medicaid system that will impact the quality of care all Alabamians receive. In Alabama, Medicaid:

  • Provides health coverage for eligible children, pregnant women, and severely disabled and impoverished adults
    • About 1 million Alabamians
    • More than half the births in Alabama
    • About 47 percent of Alabama’s children
    • About 60 percent of Alabama’s nursing home residents

These cuts are devastating and dangerous. Because Alabama already operates a bare bones program, the following will occur:

  • Reduction of payments per visit to primary care physicians by 50% beginning tomorrow
  • Reduction of reimbursement rates for ambulatory surgical centers, all other specialty physicians, dentists, optometry, hearing and other programs
  • Elimination of the prescription drug coverage for adults for the first time
  • Elimination of adult eyeglasses
  • Elimination of outpatient dialysis
  • Elimination of prosthetics and orthotics
  • Elimination of Health Home and Physician case management fees
  • Consideration of a pharmacy preferred provider program

As a result of the Medicaid cuts put in place August 1, my colleagues in primary care are being put between a rock and hard place. Medicaid rates will not cover the cost of keeping the practice open. My primary care colleagues will either accept fewer Medicaid patients, limit the number of office locations, lay off staff – including nurses and other clinical staff. In some cases they will make the very tough decision of closing their practice and moving to a state that has a more hospitable practice environment.

So what? Turns out primary care doctors are the economic engines of small communities and provide economic vitality to all communities.  Combined, we support 83,095 jobs and generating $11.2 billion in economic activity, according to a report by the Medical Association and the American Medical Association. Specifically:

  • Jobs: Each physician supported an average of 9.5 jobs, including his/her own, and contributed to a total of 83,095 jobs statewide.
  • Output: Each physician supported an average of $1.3 million in economic output and contributed to a total of $11.2 billion in economic output statewide.
  • Wages and Benefits: Each physician supported an average of $758,744 in total wages and benefits and contributed to a total of $6.7 billion in wages and benefits statewide.
  • Tax Revenues: Each physician supported $46,148 in local and state tax revenues and contributed to a total of $404.9 million in local and state tax revenues statewide.

When these cuts take effect, doctors will leave. Consequently it much more difficult for any patient in the state – including those on private insurance like Blue Cross/Blue Shield – to make an appointment with a doctor of their choice at a time convenient for their schedule. Jobs will leave these towns, towns will die.

Isn’t Medicaid full of fraud? Turns out, not. In fact state lawmakers recently conducted an extensive review of Medicaid’s funding and operations. Our program is one of the most frugal health plans available.

What needs to happen? In order to protect the state’s fragile healthcare system from collapse and ensure that all Alabamians have access to the doctor of their choice, legislators must find a long-term, sustainable solution to fund Medicaid, and shore up funding for the coming year.

How can you help?  Visit IamMedicaid.com  for more information and go HERE to contact state leaders to let them know how you feel.  Encourage them to protect Alabama’s healthcare system by fully funding Alabama Medicaid. Let them know that you are concerned and you vote!

“Trade, we are going to fix it; health care, we are going to fix it; women’s health issues, we are going to fix it,” Trump said.

Mobile, Alabama August 21, 2015

I was in of of the 30,000 (well, more like 15,000) people in stands at Ladd-Peebles stadium when Donald Trump announced his health care position. My late wife Danielle Juzan live-tweeted the rally as well.Whatever was wrong, he said, he would fix it.

My friend Josh Freeman just posted a blog where he cites the JAMA article written by President Obama to detail the successes and failures of the Affordable Care Act (now in year 6 of being enacted and year 4 of implementation). Bottom line, in those states that have expanded Medicaid, poor much better off. In all states, health insurance for those working still too expensive. In all states, quality of care is beginning to improve. It is widely assumed that a Clinton/Kaine administration will work to strengthen the gains made through Obamacare.

Trump declined to explain how he would lower insurance costs (other than saying “more competition”), but he did specify how he would deal with those who lack insurance. He said that the government would negotiate with hospitals to cover the uninsured.

60 minutes, September 27, 2015

In the evolution of Donald Trump’s health care policy, he has transitioned from universal coverage. As a business man with interests in many countries, he has seen the impact of more healthcare delivery in countries such as Scotland and has admired the ease and efficiency of care. In one of the debates, in fact, he expressed his admiration for other country’s care delivery.  “As far as single payer, it works in Canada. It works incredibly well in Scotland.”

“We will repeal and replace disastrous Obamacare,” Trump said. “You will be able to choose your own doctor again.”

Donald J Trump’s acceptance speech, Republican National Convention

Upon wrapping up the nomination, the Trump campaign fleshed out his healthcare position (found here). Aside from “repeal and replace with something terrific” the plan is a little light on specifics. However, as this is a presidential candidate and we have to assume he has a shot at being elected, I feel compelled to analyze his stated position on how almost 20% of the GDP will be managed and 25% of our tax dollars will be spent. The key points are as follows:

  • Want universal coverage? The Trump position is to eliminate the mandate BUT keep the pre-existing condition coverage. Policy analysts are a little confused about how this would impact the care delivery system.
  • Like a bare bones policy? Trump proposes eliminated limits on intrastate policy sales. So your company might buy your insurance but there may be no local care delivery options, so you might have to drive to Delaware for care.Now THAT would be bare bones.
  • Allow deductions of premiums from income taxes and use of a healthcare savings account. A nice position to take if you want the vote of young, healthy people. As most chronically ill people make very little money and spend a lot on healthcare, this does not benefit those who are sick.
  • Require price transparency. Now this one, I can get behind. Check out health care blue book, kinda coming anyway.
  • Block grant Medicaid. Theory is “States know how to use the money best.” Bill Clinton did this with “welfare” (actually cash payments known as TANF) in the 1990s. The outcome? Total money available was reduced and less money was spent on child care (increasing the penalty to working parents who needed assistance). In fact, half of the money the federal government sent for TANF-like programs went for things like middle class tuition reimbursement.
  • Allow people to negotiate with foreign drug companies. This started out as “Medicare ought to negotiate for lower drug prices” but has ended up “feel free to mail order drugs from Canada.” Kinda odd how our negotiator-in-chief let that happen.

Should make for an interesting debate.

 

 

I grew up in Baton Rouge, Louisiana. My parents moved there in 1959 so my father could go to graduate school at LSU. After a couple of non-academic jobs my father took a job at LSU in academia and we moved to an area near campus. So near, in fact, that on Saturday night I could see the glow from the lights at Tiger Stadium. The Baton Rouge I knew was mostly college professors and their kids and mostly “white” although my neighborhood had it’s share of brown and black college professors kids. The schools I attended were good schools. The Baton Rouge I knew was a good place to grow up.

I looked at Google Maps to try to get my bearings and determine if I knew the area where Alton Sterling was shot. I realized that though I didn’t know the area, I KNEW the area. Some auto repair stores, several convenience food stores, a dialysis center, and a couple of cell phone shops. The area is over 80% minority and has lost 10% of its population in the past 10 years. The median household income is less than 50% that of the Louisiana average and Louisiana is a poor state. I suspect you have driven through this area as well. Often by accident. Checking the door locks to make sure the doors are secured.

Race is a funny thing. The construct of race dates from the 1700s and, though there is some controversy, seems to be more tied to a desire to boost folks of certain color or ethnic make-up than to be a clarifying concept with any basis in science. Though life expectancy clearly does track with self identified race, many “whites” have African ancestors and many “african-americans” have more native American than African ancestry. Some point to sickle cell disease as evidence of a racial component of disease but the disorder clearly  tracks with factors other than black skin color.

A better construct is this study,  reported by Vox last year. Instead of being a dichotomous variable (black-white) or even a categorical variable (race is now often sorted into as many as eight categories, including “two or more”) the investigators suggested that how you self-identify your  “race” is actually a compilation of attributes that include skin color and genetics but also include such attributes as religion, social-status, power relationships, and dialect. Instead of being assigned at conception, race becomes a more dynamic construct. Other research identifies the act of ANTICIPATING being a victim of racism is clearly harmful to the health of the victim, regardless of any objective, “scientific” status of the victims “race.”

None of this brings back Alton Sterling. If, however, we could stop seeing things in the South as “black-white” maybe we could make some progress. Once we do that, here are some other things to work on:

  • Improve public transportation
  • Acknowledge that access to healthcare is a right
  • Hire public servants who are of the community and train them appropriately.
  • Demilitarize the police force.
  • Disarm the citizenry.
  • Stop being scared of “the other” because they live in poverty
  • Most importantly, stop making the poor and disenfranchised the victims of our fear.

 

  1. Ebola
  2. 9/11
  3. Stealing grease
  4. Batman and Robin “Ice to meet you”
  5. The lemon tree theft
  6. Farmville
  7. Miley Cyrus’ “Wrecking ball”
  8. GMO tomato-nicotine hybrid
  9. Horse meat in commercial food
  10. Donald Trump’s presidential run

10 things predicted by the Simpson’s before they became “a thing”

There is a running gag over several years in “The Simpsons” television show about series of movies which included an action hero named “McBain.” Loosely based on a combination of Bruce Willis and Arnold Schwarzenegger, in the movies McBain’s nemesis is Senator Mendoza from some unnamed Central or South American 1980s drug cartel country. In one of the most “haunting” scenes, McBain’s long-term partner is shot as he is outlining his plans for retirement. In fact,he actually takes a bullet intended for McBain while showing a picture of his recently purchased retirement boat, aptly named ” Live-4-ever.”  McBain is shown holding the body of his fallen comrade, crying out “MEEEENNNDDOOZZAAA!!!!”

Federally Qualified Health Centers (FQHCs) have been around since the 1960s. They were modeled on a South African system for effective care delivery to the disenfranchised. One of the first was started not too far from me in Mound Bayou, Mississippi.

The health center model that emerged targeted the roots of poverty by combining the resources of local communities with federal funds to establish neighborhood clinics in both rural and urban areas around America. It was a formula that not only empowered communities to establish and direct health services at the local level via consumer-majority governing boards, but also generated compelling proof that affordable and accessible healthcare produced compounding benefits.

Over the years the federal funding has been generous, though much of the funding comes from patient generated revenue (money for seeing patients).  The Centers are also eligible for grant money for facility development, staffing increases, and offsets for seeing the uninsured among other things. The funding streams vary quite a bit from state to state, with those in Alabama being more heavily reliant on federal grants and less so on patient care. Legislators loved them because they put money in local, impoverished areas. Republicans in particular loved them because of the “block grant” nature of the funding. The local folks were best able, so the saying went, to determine where the money could best be spent.

One of the goals of the  Affordable Care Act was to move the money from direct funding programs into programs where the money followed the patient. It was hoped that this would give patients incentives to seek more effective care. It clearly would cut down on shenanigans such as this criminal case in Birmingham where the CEO bought a building, leased it back to the FQHC, videotaped his assistant in compromising positions, and made off with $14 million of federal money. As outlined in an article today, this money was money NOT used to deliver care to homeless individuals, poor folks, and others in need for whom it was intended. In fact, though they were receiving money to care for the homeless, they created barriers of transportation and distance to keep the poor, sick folks away. This money then made its way to the CEO’s pocket.

The ACA, as designed, would allow all the poor, including the homeless, to use Medicaid for their healthcare needs. This would allow a patient to identify the best care for his or her situation. We, in Alabama, have chosen not to accept the law as designed. Instead we have allowed it to be implemented  in a manner inconsistent with the design. We allow those in charge of implementing the law at the state level as well as those in charge of local care delivery to siphon money off. Then, when the system fails, we shake our fists at the clouds and blame Obama.

 

Q: How many magicians does it take to change a light bulb?
A: Depends on what you want to change it into.

Turns out, weekends are especially hard. On weekdays, I would get up, do chores (mostly dog and chicken related), go to work, then come home. Either Danielle would have supper ready or, increasingly, we would go out because it was too much hassle cooking for two. Then I would settle down to do a little work and Danielle would do her thing until it was time for bed. Our days would overlap mostly at supper. The weekends, though, would be when we did OUR thing.

Danielle: Remember, tonight is Art Walk Friday

Me: Ok, but I’ll be about 6 because I have patients

Danielle: Well don’t be late because we’re meeting folks at the Bike Shop for dinner at 7:30 and I have to see the show at the Skinny Gallery. And then tomorrow we have to go to the symphony, and then…

Even on days like this when I was on call, we would carefully plan our trips and errands around my rounding schedule.

Now I have had to change my weekend routine.  Change, as they say, is inevitable.

Q: How many Marxists does it take to change a light bulb?
A: None. The light bulb contains the seeds of its own revolution.

Ranking things seems to be the new “news.” Almost everyone has put together a list of best and worst based on some criteria or another. My kids tell me these are called listicles. having the list without information in the title, so I understand, encourages folks to “click” ensuring more ad revenue. USA Today’s offering today was “The least healthy cities in America.” As everyone in America clicked to find out how their city fared, we in Mobile were (dis)honored to be #4:

4. Mobile, Ala.
>Premature death rate:
 490.3 per 100,000
> Adult obesity rate: 36.1%
> Pct. adults without health insurance: 12.9%
> Poverty rate: 19.9%

The average Mobile adult feels in poor mental shape for five days a month on average, far longer than the 3.5 days the average American feels in such a state. Poor mental health outcomes in Mobile may be tied to multiple unhealthy behavioral and socioeconomic factors in the area.

Mobile’s 36.1% obesity rate and 29.6% inactivity rate are both far higher than the corresponding national figures. Additionally, nearly one-fifth of area residents live in poverty, and 7.0% of the workforce is unemployed, each some of the highest such figures in the country.

Wow. For those with a memory for these things, in 2013 Business Insider tagged us the 3rd most miserable city in 2013. At the time I pointed out

The results of that survey, Perkins said, made it clear that Mobilians suffer from poor mental and physical health in large part because the city’s built environment is not conducive to being active. Access to healthy foods in poor neighborhoods is also poor, he said.

If Mobile wants to work its way off these lists, it’ll take change (see figure). We’ll need to invest in infrastructure  such as parks and bike lanes so people make healthier choices. Increase the minimum wage so folks have time to use these amenities to get and stay healthy. Expand Medicaid so folks are not one illness away from bankruptcy. Focus our care delivery system on health instead of on making money off of illness. In other words, while change may not be inevitable for Mobilians, it is the only way to get off of these lists.

Or, we could just double down on our football success:

HOW MANY SEC STUDENTS DOES IT TAKE TO CHANGE A LIGHT BULB?

At ALABAMA: It takes five, one to change it, three to reminisce about how The Bear would have done it, and one to throw the old bulb at an NCAA investigator.

8802-figure-1

[In response to increased dependence on oil from unstable countries] EEN began to create the “What Would Jesus Drive?” (WWJDrive) educational campaign in February 2002 to help Christians and others understand the relationship between our transportation choices and these three major problems – human health impacts, the threat of global warming, and our increasing oil dependence.

Evangelical Environmental Network

Remember those WWJD bracelets. Folks wore them as a reminder to act “right” when no one was looking. The letters stood for “What Would Jesus Do?” and the presumption was that in every given situation there was a “Godly” answer. Of course, placing yourself into the mindset of a person who lived 2000 years ago to establish a course of actions in a given modern-day situation led to some strange speculation. What Would Jesus Do when confronted with pork? Is veganism the established Jesus-like diet? This person can site scripture to say it is. It also leads to some creative marketing. On ETSY are several pages of handmade items embossed with the official WWJD query. One “ladies T” substitutes the letter “D” for the “J” allowing one to substitute The Donald’s thought process for those of the Other Big Guy.

In 2002 a group of creative and and liberal soles asked themselves “What would Jesus drive?” This was a time immediately after the trade towers went down. The national narrative was being shaped and it was understood that our purchasing of oil from the Middle East was a proximate source of terrorist funding, bad for the environment, and bad for our health. Their solution?  Drive smaller and more efficient cars. Not SUVs. Unfortunately, the opportunity to invade an oil rich country seemed much more the Jesus-like answer to some:

God told me to strike at al-Qaeda and I struck them, and then he instructed me to strike at Saddam, which I did, and now I am determined to solve the problem in the Middle East. If you help me I will act, and if not, the elections will come and I will have to focus on them

George W. Bush. 2005

Why the walk through memory lane? I was sent a copy of the Alabama Department of Public Health’s transportation survey (found here). Groups from every county in Alabama who care for the poor and underserved were interviewed and to a group they coalesced around a single theme -Transportation for poor people is terrible in Alabama. Agency after agency identified between 25% and 50% of their clients have to rely on friends, strangers, or don’t keep health care appointments at all because of a lack of affordable transportation. Most counties in Alabama have no public transportation; for example in Marion County:

The hospital is not aware of any other transportation entities available to patients in this area, with the exception of one called “Tommy’s Taxi Service,” consisting of one elderly man and his personal vehicle, which they have known patients to use to get back and forth from their dialysis appointments. These dialysis appointments represent one of the largest challenges to patients without reliable transportation access, due to the necessity of attending multiple times per week.

Multiple agencies including this “for profit” entity suggested that churches are the answer:

Finding a way to involve the churches and other faith-based organizations in this area with the issue of non-emergency medical transport would help a lot of people in this area, and could be done by scheduling specific pick-up points and times at regular intervals. However, issues with reimbursement and assumption of liability are most likely the largest roadblocks to developing this type of solution.

So, Jesus might drive a passenger van and make scheduled stops to keep Alabamians from having to budget tax dollars for transportation. Perhaps He would work on His followers in the legislature to create and fund an effective bus service. I’m betting He would just heal the poor, sick people in Alabama. Alabamians who drive SUVs could take their turn being sick for a while.

“It is one of the happy incidents of the federal system, that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.”

Justice Louis D. Brandeis

The state of Alabama continues to deny its citizens access to expanded Medicaid. One of the arguments made by Alabama state Senator Tripp Pittman, a harsh critic of government in general and Medicaid in particular, is that the states are not given enough flexibility. He blamed the poor for the “excessive” cost of care, in fact, and suggested that if more control were given to the state the undeserving could be weeded out. Then, as one does with weeds, left in a pile on the side of the road to wilt I suppose.

An inside look of how the state of Alabama would REALLY handle this serious responsibility can be seen in the trial of our Speaker of the House, going on now. For those who don’t watch Rachel Maddow or read the New York Times, the state has its Governor under grand jury investigation and its Supreme Court Chief Justice under judicial review. These, however, are not the worst. Mike Hubbard, the Speaker, has been under indictment for 23 felony counts involving violations of the ethics laws he authored. It has taken two years for this to come to trial. In the interim he has been reelected to his seat and reelected as Speaker by his “peers.” Several of his peers have already pled guilty and are scheduled to testify. Others will likely plead the fifth.

It is an interesting set of charges. He is charged with taking money as a lobbyist (unregistered) from a gas company and then  passing laws to push business in their direction. He is also charged with using his position as head of the Republican party to push business towards his formerly failing company. These are all your typical corrupt politician charges and his defense is one of confusion about the illegality of the actions (“I don’t know what he was talking about,” says defense attorney Baxley, it’s all “mumbo jumbo and gobbledygook.”) combined with the good-old-boy defense (“What he didn’t show was the parts of the ethics law that offers exceptions for friendships in business dealings,” Baxley said). Makes for fun theater.

The most serious charges and the ones that likely have gotten the feds interested are the ones regarding Medicaid. As a program that costs the state under a billion dollars and brings six billion dollars into the state, a bunch of money is available for folks to use for “bidness.” Speaker Hubbard, as documented in the New Republic, saw a huge opportunity. As the revenue stream for the general fund (which funds Medicaid) is diminishing and folks like Senator Pittman have no compunction to raise taxes, controlling medication costs seemed to be the natural course of action. Speaker Hubbard called a meeting and:

So three legislators, two lobbyists, and a handful of staff privately decided, after the briefest of deliberations, to enact a policy that would give a $20 million monopoly over the state’s Medicaid drug business to a corporation that had no experience running such a program, a move that would impact the lives of the 600,000 poorest and least powerful people in Alabama—children, senior citizens, people with disabilities.

Afterwards the group discovered to their surprise that one of the Speaker’s clients was involved in this Medicaid medication management scheme and would have benefited significantly.

The former chief of staff also urged Hubbard not to vote on the budget bill because it “looked bad,” but Hubbard said it would send up “too many red flags.” The language was later stripped in committee.

His current defense? “No harm, no foul” and/or “we stuck it to them city slickers.”

So in this one laboratory of democracy, even with significant federal oversight, Medicaid money seeps out around the edges to enrich a small number of folks. Imagine what’ll happen when the oversight is less. My prediction: It’ll be HUGE for some people, very few of those being the poor and the sick.

 

Through pestilence, hurricanes, and conflagrations the people continued to sing. They sang through the long oppressive years of conquering the swampland and fortifying the town against the ever threatening Mississippi. They are singing today. An irrepressible joie de vivre maintains the unbroken thread of music through the air. Yet, on occasion, if you ask an overburdened citizen why he is singing so gaily, he will give the time-honored reason, “Why to keep from crying, of course!

Lura Robinson, It’s An Old New Orleans Custom, 1948

It is a month today since Danielle’s death. I had already planned to go to New Orleans for my 30th medical school reunion by myself prior to her death, as she was to be playing Amanda this weekend in a local production of Glass Menagerie. The play is set in St Louis. Tennessee Williams, the writer of the play, once said “America has only three cities: New York, San Francisco, and New Orleans. Everywhere else is Cleveland.” Clearly, he set it in St Louis for a reason. Danielle was a New Orleans native, and she understood those reasons.

I lived in the Faubourg Marigny (a neighborhood just outside of the French Quarter) while I was in medical school. After we married, Danielle and I moved to the Irish Channel, a neighborhood that is quite gentrified now but was much less so 34 years ago. For those of you who know New Orleans, we were one block off Magazine and spent many afternoons there walking and window shopping.

After moving to Mobile we found ourselves in New Orleans many times a year. We would go to Danielle’s mother’s house and, after a suitable time, we would make an excuse and go to Magazine Street. The children had valuable grandparent bonding time, and we had New Orleans time. This became less frequent as the children grew older. After Katrina, both of our immediate families left south Louisiana and so our visits were limited to special occasions. We still made it about three or four times a year, however, enjoying many delicious meals with our friends and extended family, and spending time window shopping on Magazine.

This weekend, I played hooky for much of my 30th reunion. Staying with friends of ours in their uptown home, we drank wine and remembered the old times. New Orleans being New Orleans, we went to the Boogaloo Festival and heard the Lost Bayou Ramblers. We spent time among the thirty-somethings, watching them  frolic in the old (not very clean looking) Bayou St. John canal. It was hot. All in all, a very New Orleans experience.

At the reunion events I did attend, word quickly spread about my wife’s death. Many came up to me and offered condolences. Most of them only knew Danielle peripherally, so I didn’t have many in-depth conversations. “So sorry for your loss,” they would say. “Thank you for your kind words,” I would mumble back. Since many of these old acquaintances are no longer married to the spouse they boasted in medical school, discussions of marriage and relationships are typically avoided at these reunions altogether. One of the more awkward moments, in fact, was when we toasted to those who helped us get where we are and the person next to me said: “Wait, am I toasting my EX-wives?”

I guess my loss really hit me when I was driving down Magazine Street on my way out of town. I saw all the familiar buildings that were built before we were born and will likely be there after our deaths, and I realized that my loss is not just the Danielle of today. My loss is the life we built together and the life we expected to continue to share. That loss includes our shared experiences and memories. Our stories. Our jokes. I realized that I had lost not only Danielle but our shared New Orleans.

“So sorry for your loss.” For those who knew us, it is a shared loss and I am sorry for your loss as well. For others, I really do appreciate the sentiment, even though I may respond less than enthusiastically at times.

 

I have a saying I use with my patients who are prone to fret as they grow, and feel, older.  “Every day on the green side,” I say to them, “is a good day.” Now that my wife, Danielle, is no longer here to share these days with me, I appreciate very much the effort she put in to making our “green side” as pleasant and inviting as possible.

We recently spent a long weekend mucking out the backyard pond and removing several dozen crawfish so the tadpoles and dragon flies would come back. They are back in force. The blueberry bushes, including the new ones we brought at the Botanical Gardens plant sale, are producing berries and the birds are, with the help of a netting reminder, leaving them on the bush long enough to stay ripe. The chickens continue to lay even after the flock has been reduced to a more manageable three birds. The citrus trees are loaded with fruit. Even the leak in the fountain has slowed, allowing me to keep the water feature flowing and providing the birds with a place to bathe. Here, in Danielle’s urban patch of green, the promise of renewal that spring brings to the gulf coast continues. Danielle is still with us, in her way, here on the green side.

Sudden cardiac death. That, in stark “doctor words,” is how she left those of us still on the green side. Although because of prompt paramedic response she still had a heart rhythm on and off after arriving at the hospital, it soon became clear that, clinically, she had left us on that Sunday, three weeks ago, while still in the house. I like to think that, once called, she decided to stick around. At the very least, she intends to make sure that the crawfish population stays down so she can continue to watch the dragon flies from the kitchen window. I choose to believe that is the case in part because draining that pond was very hard work.

Very few people study sudden cardiac death (SCD) in the general population, mostly because there is little clinical information to be had after the fact. If people make it to the hospital while having their heart attacks, we can mobilize millions of dollars of equipment and personnel to preserve their heart function. When we know that a person is at significant risk for sudden cardiac death, we implant defibrillators which stand at the ready to shock the heart back into compliance should it get out of kilter.

Most SCD happens to relatively healthy people, as it did with Danielle. As documented on the American Heart Association web site, every year about 300,000 people will succumb to SCD. This is about 15% of the deaths that occur in America annually. Of those, about half of the men and two-thirds of the women will have no reason at all to suspect a problem. The modifiable risk factors (hypertension, hypercholesterolemia, diabetes mellitus, kidney dysfunction, obesity, and smoking) have all been brought to the attention of the public. Improvements in management of hypertension and diabetes and reduction of smoking has lead to a reduction in all deaths from heart disease, including SCD.  A surprising number of these events occur during exercise (which tends to make the news and provides an excuse  for those who embrace the couch potato lifestyle). Jim Fixx perhaps is the most famous victim of sudden cardiac death while exercising. For the most part, habitual exercise is protective. That is, once it becomes a habit.

In Danielle’s case, genetics clearly played a role. However, saying “genetics plays a role” is not the same as saying “it runs in families” like red hair. There is a complex interaction between genes that makes us all unique. Family history doubles the risk of SCD. A rare event becomes half as rare. So far, researchers have identified 23 different gene areas that might play a part. Mathematics suggests that finding a pattern useful for screening or targeted treatment is still many years away.

So, what does this mean for SCD? In the words of the investigators, “Our ability to accurately identify individuals most at risk for SCD within the population remains poor.” Preventing SCD, as of now, is the same as preventing all heart disease. Eat right, exercise regularly, monitor blood pressure and get checked for diabetes if you are one of those at risk. Make exercise a habit and report unusual symptoms such as passing out, chest pain while exercising that improves with rest,  or unusual amounts of fatigue. Fund emergency services adequately but realize they are not the answer. Support policy efforts to make exercise more accessible.  Bike lanes are one such example. Support policies to reduce exposure to cigarette smoke and access to healthy food. Support research but realize the research will be difficult and expensive to perform.

How about for those of us still on the green side? Support dragon fly habitats. Eschew backyard crawfish breeding. Plant fruit trees. And remember, every day on the green side is a good day.

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