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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.

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.

 

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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.

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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Public health has an odd place in medical education and the physician’s practice. Although clearly required as a part of the curriculum, it has historically been underemphasized.  By historically, I mean since 1848. Medical schools were created to train doctors in the science of the person (singular) but not in the science of people. Someone had the bright idea of offering further training to doctors (further detailed here) to allow them to have a broader perspective:

To earn this postgraduate certificate, students took courses on“preventive medicine and sanitary science, personal hygiene, public health administration, sanitary biology, sanitary chemistry, special pathology, communicable diseases, sanitary engineering, and demography” as well as“special courses and lectures in infant mortality, social service work, mental hygiene, oral prophylaxis, the prevention of ear, nose and throat disease, hygiene of the eyes, industrial hygiene and medicine, eugenics, genetics, and sanitary law.

Because it was a post-graduate degree, rather than create a cadre of “super docs” it moved public health out of the medical school entirely.

In 1998, the Association of  American Medical Colleges urged medical schools to incorporate public health by “first, teaching students the practical fundamentals of the core disciplines that underpin the effective application of population health; second, giving students experiences in studying real populations; and, third, integrating the teaching and learning into all parts of  medical curriculum rather than relying solely on a stand-alone population health course.”

In the last 20 years, medical schools didn’t answer the call.  From the requirements for medical school curriculum they are required to provide instruction in the following:

  • The recognition and development of solutions for health care disparities
  • The importance of meeting the health care needs of medically underserved populations
  • The development of core professional attributes (e.g., altruism, accountability) needed to provide effective care in a multidimensional and diverse society

As someone with an interest in the health of the population, I sought more than just “recognition.” My medical school offered a joint degree (MD/MPH) which allowed me to obtain instruction in the health of people (plural) in addition to health of a person.

One class in particular sticks with me. It was a health policy class taught by a professor who was a self-described Maoist. Communism in the mid-1980s was scary and having a person who admired a communist leader was more than a little controversial. I would leave my basic science lectures at the medical school and go to a class where we discussed how China had markedly improved the health of their citizens with “barefoot doctors” who indeed were barefoot, and had minimal training. They transformed the Chinese countryside by providing primary health care services, and focused on prevention rather than treatment. They provided immunizations, delivery for pregnant women, and improvement of sanitation. To my medical school classmates they were in no way doctors. To my public health classmates they were a model for the future.

Fast forward 30 years, and we are coming around to learning that China was onto something. People from the community are much more likely to work to improve their community and care for their friends and neighbors. Known as community health workers in this country, they are frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served. This trusting relationship enables the workers to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. It looks like we are going to start employing these folks to help improve the health of the citizens of Alabama.

Unfortunately, I’m afraid my physician colleagues won’t recognize a good thing when they see it. After all, it’s only been 150 years.

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Patient: I can’t afford the insulin you prescribed for me.

Me: It’s a pretty standard long acting insulin

Patient: My insurance says it’ll cost $350 a month to use it, is there something less expensive?

Insulin is a magic drug. Discovered in 1921, it was first administered to humans in 1922. Although there were a long line of discoveries that made the discovery possible, Drs. Banting and Best at the University of Toronto were the first to identify the source (the pancreas) and to extract insulin for use. Even more amazing, the University made the discovery “open source,” allowing the manufacture and distribution without royalty.

The discovery was not without its problems. Although human insulin was synthesized in the lab, it was difficult to make for many years. Insulin taken from cows and pigs was commonly used clinically. Unfortunately, in one of the Creator’s little jokes, these insulins vary from human insulin by a couple of amino acids. Not enough to make them unusable as extracted but enough so that over time the diabetic patient developed antibodies and was unable to use the insulin, leading to his or her premature death.

In 1982 Richard diMarche and Eli Lilly obtained a patent for human insulin made from recombinant DNA. Originally sold as Humalog, this was the first medication manufactured in this manner and it was a game changer. No longer were we putting a foreign body into people to lower their blood sugar temporarily. We were putting human insulin into people and keeping people alive longer and keeping people healthier.

Which brings us to today. Drug companies developed pens, different types of insulins, and different delivery methods. They have also jealously guarded their patents, preventing cheaper generics from being developed. To quote the New England Journal:

“But whether each incremental innovation is worth the price we pay, in a world where insulin remains unaffordable to many patients with diabetes, is less certain.”

Reasons used for the high cost might include the need to ship the medication in liquid form as well as the different delivery mechanisms. The bulk of the cost of the drug, however, is in R&D. These drugs have been developed for years and there are no more R&D costs. Their investment has been recouped. It is becoming clear that a major reason is good old-fashioned “profit taking”:

Between 2005 and 2015 the cost of a lispro vial went up 264 percent, while a vial of insulin glargine went up 348 percent, and a vial of NPH went up 364 percent. That’s a lot, but other insulins went up even more.

The cost of an aspart pen rose in this 10-year period by 389 percent. And the cost of a vial of U-500 regular insulin jumped a staggering 508 percent.,

 

So, in America in 2016 we have people choosing between insulin and food. People that weren’t having to do that in 2006. The speculation is that this profit taking is in advance of the loss of the patent as well as the lack of “blockbuster” drugs on the horizon. Perhaps generics will be developed soon.

What did I do for my patient? There is one type of intermediate acting insulin that is $27 a vial at Wal-mart. No special pen, has to take it twice a day. For now, it turns out that diabetes in now a two-tiered disease, easy for the rich to handle but increasingly difficult to manage if you are poor.

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“Of the many painters I have known, almost all I found unhealthy … If we search for the cause of the cachectic and colorless appearance of the painters, as well as the melancholy feelings that they are so often victims of, we should look no further than the harmful nature of the pigments…”

Italian physician Bernardinus Ramazzini in De Morbis Artificum Diatriba

Humans have had  love-hate relationship with lead. Easy to find and convert from an ore to a malleable metal, lead was in cosmetics, eating utensils, and used to create the pipes that move water from the Alps to Rome. The Romans were not universally impressed. Per Vitruvius:

“Water conducted through earthen pipes is more wholesome than that through lead; indeed that conveyed in lead must be injurious, because from it white lead [ceruse or lead carbonate, PbCO3] is obtained, and this is said to be injurious to the human system. Hence, if what is generated from it is pernicious, there can be no doubt that itself cannot be a wholesome body. “

We now know that lead poisoning, or plumbism, is a very real problem (image from Wikipedia).

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For those of us who live in older houses, lead is a constant concern. Our pipes are made of lead, there is lead in our paint, there is lead on the dirt from leaded gasoline. My children were at continuous risk from lead growing up. From the CDC:

Lead-based paint and lead contaminated dust are the most hazardous sources of lead for U.S. children. Lead-based paints were banned for use in housing in 1978. All houses built before 1978 are likely to contain some lead-based paint. However, it is the deterioration of this paint that causes a problem. Approximately 24 million housing units have deteriorated leaded paint and elevated levels of lead-contaminated house dust. More than 4 million of these dwellings are homes to one or more young children.

What those of us who live in old houses and old cities know is that lead much less of a problem if you leave it alone. As long as  the paint is not peeling, the kids won’t eat it. As long as the dirt is not disturbed, the kids (who always eat dirt) will only eat lead free dirt. As long as the pipes are not disturbed, the water will be lead free. Those of us that live in older cities rely on the water board to do the right thing and not create a problem where none exists. And it turns out there is a lot they need to take into consideration.

Flint Michigan is an old city full of old houses. The older houses were mostly lived in by poor people, who unfortunately were living in a town with an infrastructure built for many, many more people than are currently living there, making the infrastructure very expensive. The people, unable to pay for existing services, were taken over by the state. The state, in a story worth reading, elected to go with cheaper drinking water from the Flint River. The cheaper drinking water, in a predictable chemical reaction, leached the lead out of the pipes and put it into people’s drinking water.

What are the lessons to learn? First, our public infrastructure is aging and that will affect people’s health. Clean water and sanitary sewer systems were a game changer in the 1880s but that was 100 years ago. We need to pay attention. Second, poor people are disproportionately affected by our failing infrastructure. They are more likely to live in poor cities and more likely to live in older neighborhoods. Third, listen to the patient/constituent. The state of Michigan looks especially bad because they tried to substitute toxic waste  for water and when people caught on they tried to cover it up.

Hopefully, Flint will overcome this though it may not be financially feasible to rebuild the water delivery system. I only hope leaders in other towns with aging infrastructures (such as Mobile) heed the warning.

 

 

 

 

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Snake oil” was brought over by the Chinese in the 1800s as a traditional cure. As it turns out, the oil was found to be very effective for the aches and pains associated with doing labor such as, well, building a railroad across America. As this is what the Chinese were doing, they found it very valuable. They also shared it with their non-Chinese counterparts, who found it to be a useful salve as well. Unfortunately for snake oil users, extracting oil from Chinese snakes (or pretty much any snake) in America was tough. Selling snake oil was not. Witness the story of Clark Stanley, aka The Rattlesnake King:

“[Stanley] reached into a sack, plucked out a snake, slit it open and plunged it into boiling water. When the fat rose to the top, he skimmed it off and used it on the spot to create ‘Stanley’s Snake Oil,’ a liniment that was immediately snapped up by the throng that had gathered to watch the spectacle.”

Rattlesnakes, as it turns out, are missing the anti-inflammatory properties of Chinese water snakes. Since Stanley didn’t put any snake in his snake oil, the oil was remarkable ineffective but very lucrative for Stanley.

The evidence based medicine movement, now 20 years old,  helped us to focus our efforts on “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Our attention is now focused on things like “is the patient’s diabetes under control” as opposed to “should I use the latest new drug that the nice rep lady came and told me about.” A blow against snakeless snake oil.

The extension of this movement is focusing us on quality. We are now looking at the quality implications of analyzing large numbers to determine small differences in outcomes. For example, a certain surgeon might have an infection rate of 10% and another of 5%. If this difference is not due to dirtier patients (the surgeon only operates on people who fall in sewers), a patient will likely choose to go to the one with the better outcomes. This data is now becoming available from the federal government from Medicare. For example, hospital outcomes for Medicare patients can be found here.  The score care for orthopedic surgeons replacing hips and knees can be found here. These, data, though useful, only paint a partial picture. The hospitals and the surgeons take care of folks other than Medicare so the truth, although likely present in the data, may be difficult to pull out.

For certain types of procedures a more complete picture can be obtained. If only a few places do a procedure, for example, and they keep track of their outcomes, then folks can see how the program performs over time. Such was the case with pediatric heart operation in Florida. Children’s Medical Services, a state agency that pays for the bulk of the services provided to children with congenital defects, had been quietly tracking information and collecting data of years on heart surgeries done to small children as part of a quality initiative. In information obtained by CNN, about 2300 such procedures were done in eight Florida hospitals from 2011 to 2014, with 4 of the hospitals accounting for over 90% of the cases. These procedures can be very lucrative, bringing in over $500,000 for each operation. The reason CNN began looking into this is because St Mary’s hospital in Palm Beach, one of the low volume programs that was trying to build business, had an extraordinarily high death rate. The rate was even higher than it appeared because several dying patients were transferred to other hospitals immediately prior to death, unusual in a center that performs such complex procedures. Also unusual was when a quality panel was called in and made recommendations on how to fix the problem including not operating on some of the more complex cases, the recommendations appeared not to be followed.  Lastly, unusual because the hospital’s parent company gave money to the governor and, coincidentally, the quality panel which tried to keep the hospital from doing operations they were bad at (and which the governor had created) was disbanded because it had no statutory authority. The hospital eventually did closed their pediatric cardiac surgery program, the CEO resigned, and the physician is giving depositions while being protected by armed security guards in case you were concerned. Florida’s side of the mess can be found here.

The CNN story begins with a mother whose child has just been paralyzed and, in the elevator, she has the following exchange:

“Do you know a child with a heart problem here?” asked the stranger.

“Yes. My daughter,” McCarthy answered, and explained what had happened to Layla.

“You need to get her out of here,” the stranger warned.

The hospital had not revealed their their pediatric cardiothoracic surgery team’s low volume,  complication rate, or inexperience to prospective patients. If patients had looked, they would have found outcomes for the 4 high volume Florida programs posted on the internet (here is the one from Nicklaus Children’s). St Mary’s, rather than posting quality data, posted releases heralding the arrival of “nationally renowned pediatric heart surgeon Dr. Michael Black” with glowing claims such as “smaller incisions — improved self-esteem.”

In this era of complex care, the great doctor has been supplanted by the great team. Great teams keep score. Hiding poor quality as an institution is  akin to selling snakeless snake oil. Consumers for elective procedures should demand to know outcomes. Those who insist on keeping their data to themselves should not have the privilege of your business. Et qui vendit pellucidum. Insist on knowing how much snake is in your snake oil.

 

 

 

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When last we left the village (about 2 weeks ago) whose entire existence was to support pulling babies form the stream, a search party had gone upstream to find out where the babies were coming from. Meanwhile there were still babies coming down the stream. As you may remember, a very sophisticated infrastructure had arisen to pull the babies from the stream. The folks who took the lead, the “baby savers,” took their job very seriously and were valued. They often had to jump in and save babies who were coming down or might have to manipulate the equipment to pluck one from the waterfall. As befits their importance, they were paid very well and had an honored place in the village.

The baby savers executive committee, already threatened by the fear that the search party might find where the babies are coming from and put a stop to it, began looking somewhat critically at the entire operation:

Baby saver president: As you know, we have been looking into the “babies in the stream” issue. We have a lot of folks who care a whole lot about babies and have been giving  there time to make sure the babies are pulled safely from the water. However, it seems there is room for improvement.

Village baby saver: What do you mean improvement, we work our butts off.

Village baby saver 2: Yeah, we are up all night. Often I have to jump in. The water is cold.

Baby saver president: Well, we have started to keep track of your work and, to be honest, we are not doing some of the things we should. As you know, we pay you by the baby.

Village baby saver 3: Your point?

Baby saver president: Not to name names, but I think we should have thought through this more carefully. I’m not going to name names, but one of you pulls out a lot of babies. Many of these babies are blue when they come out and the baby resuscitators are complaining. They say you (not to name names) are too rough and push others out of the way so that you can get the most babies.

Village baby saver 2: They are just jealous.

Baby saver president: And one of you, again I’m not naming names, is just too old to do this. Your eyesight is poor and you don’t swim well. The resuscitators have to jump in and grab your babies but then you take credit.

Village baby saver 3: They need to step back and let me do my job.

Baby saver president: I suspect the search party will be successful and there will be many fewer babies going forward. So we are going to start posting how well you do on the wall over there and it may well be that some of you won’t be able to be baby savers any more. From now on, everyone will know how many babies you catch, what percent are blue, and how many went over the waterfall that you should have saved.

Village baby savers (talking at once): wait, that isn’t fair. How is it my problem if they come down too fast? What if more than 2 people are on a shift? I have a wife and kids to feed. Those resuscitators can kiss my…

If you want to see how hospitals do in regards to preventable mortality and certain procedures and use that to pick your hospital, the government’s hospital compare website is for you (go to this site). If you want to see if your hospital or surgeon has an unusual number of complications or just doesn’t do a lot of the procedures that you need, Propublica has a tool that compares individual surgeons (go to this site). If you want to float along and let a random person pull you out of the water and hope they do a good job, enjoy the ride and I hope you avoid the waterfall.

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