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'I hate it when people vote with their feet'

‘I hate it when people vote with their feet’

About 10 years ago, Mobile County landed one of the last large pre-recession “smokestack” projects. Competing against multiple states, the state and the county ultimately gave a lot of money in anticipation of “29,000 jobs during construction, and 2,700 jobs paying an average of $50,000 to $65,000 annually once the plant is operational in 2010.” One of the more controversial aspects of the corporate welfare was the amount paid by Alabama and Mobile County ($1 BILLION) as compared to the benefit accrued. Many of the skilled construction jobs were filled not by locals but by a nomadic group of people who traveled from places like North Carolina and Virginia, lived in campers for several months, and left to go to the next big construction job. Our corporate welfare went not to Alabamians but to people from all over the south who sought employment by “voting with their feet.”

Our legislature is electing not to spend $85 MILLION on adequately funding Medicaid. They are going to begin holding hearings on the budget they just passed next week, focusing on finding out why healthcare is so expensive, where the waste and fraud is, and finding out how to “fix the program.”

State Rep. Paul Lee, R-Dothan, said he believed a part of the Medicaid issue might be that the system does more “handing out” than “handing up.”

“We have children in need and elderly in need. …We need to start encouraging those that are able and willing to go to work rather than sitting and waiting for a check to come in,” he said.

“We can fix Medicaid in 24 hours if we could make our own rules (versus federal regulations) and do it the way it should be done.”

The first person to suggest that states should be given much greater leeway to “fix programs” was Ronald Reagan. Pointing to the migration of blacks to the north during World War II and to the migration to the energy belt in the 1970s, he suggested that America was not composed of static folks tied to a community, but was instead a moveable army of workers and others who would move from their current state to another if services were inadequate. Like the construction workers were drawn to Alabama. Or perhaps like poor, sick folks might leave Alabama

Do poor, sick people move from a low-service local to a high-service one? Do wealthy folks move to areas with low taxes? Are we finally entering a Reaganesque utopia to which the Ayn Rand capitalists will move after we eliminate Medicaid funding, creating a little Somalia  right here?

As it turns out, the great migration of poor sick people to blue states after Obamacare never happened. Folks it seems are content to stay put and use the Emergency Department near their family rather than move to an expansion state. The exception are the chronically homeless, as it turns out that up to 40% are rather nomadic  and identify service availability as a reason to relocate. This is about 40,000 people nationwide.

What about the converse? Are wealthy entrepreneurs leaving for the promise of lower state taxes? Despite what the moving company “data” reveals, the truth is nope. In a very well done study by the Center of Budget and Policy Priorities using IRS data which combined income and address change information, it turns out:

  • 70% of folks never leave the state in  which they were born
  • The income tax status of the state does not correlate with the movement of people in or out in general
  • If anything, poor people are MORE likely to move to a low tax state, which probably correlates with lower housing costs
  • Old people are more likely to move away from snow

People move for two reasons, jobs and family. Well, warm weather as well for old folks.

Reagan’s belief was based on a theory by Charles Tiebout, a rather obscure economist, as well as personal observations about blacks moving north and and Houston’s energy-sector driven growth. Tiebout’s theory was based on faulty assumptions, and Reagan’s observations were not really contextual (the reason for the black diaspora was a little more complex).

Folks that vote with their feet, it seems, are nomadic. They come to either work on large construction projects or to seek out services to substitute for their lack of a permanent residence. It is probably more realistic to fully fund services such as Medicaid rather than fight the federal government and hope for an influx of wealthy Ayn Rand followers. I do not think this will come out in the hearings.

 

 

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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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“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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Childhood vaccines are one of the great triumphs of modern medicine. Indeed, parents  whose children are vaccinated no longer have to worry about their child’s death or disability from whooping cough, polio, diphtheria, hepatitis, or a host of other infections.
Ezekiel Emmanuel

If you give us a safe vaccine, we’ll use it. It shouldn’t be polio versus autism. Jenny McCarthy

One of the earliest choices parents have a chance to make is one of whether or not to have their child “get shots.” On day one of life, the medical system is mobilized to prevent Vitamin K deficiency bleeding and liver cancer in the child. For 90% of parents, the response is “Thank you.” For 10% (but a very vocal and increasingly evangelistic 10%) the answer is “could we wait a little while?

Why do they want the delay? Most blame it on a general distrust of the “medical-industrial” complex and a lot of conflicting (and overwhelmingly incorrect) data on the internet regarding vaccine safety. I suspect a large part of the problem is our inherent inability to work with probabilities to understand health risks.

First is our conviction that because we can see a relationship we can extrapolate a cause. Take polio and ice cream. Setting aside the crazies who deny that polio ever existed, there was a time (1952, to be specific) when 50,000 American children came down with paralytic polio. Several folks quickly identifies a striking relationship between ice cream sales and the peak of the polio epidemic. Ice cream was banned in several states before it was determined that summer was the common factor. It is flawed observations like this (leukemia and Vitamin K, autism and MMR vaccine) that have led to some of our problem. Oprah, in a nod to allowing personal observations to be treated as fact, brought on Jenny McCarthy and treated her as an expert on autism because she had “mommy instinct…. She knows what she’s talking about.”

Second, and perhaps more problematic, is our inability as physicians (and a society) to communicate the consequences of a delay. Vitamin K deficiency bleeding, for example, is only a problem very early in the infant’s life. Delaying the shot (only the shot is effective) beyond 2 months of age renders it worthless. You have already placed a bet on your child’s life (or at least risked his or her future ability to function), reducing his or her ability to pass kindergarten by 1:10,000. So what, you say? By making children get out of the pool when there is lightning over a lifetime, the risk of dying of a lightning strike is reduced by approximately the same amount (1:12,000). Why is this? I suspect the difference is folks see the damage lightning causes to trees and fuse boxes so the risk to them is much more real. Who knows, though, maybe there are anti-lightningers as well.

According to the article on vaccine delay, approximately 50% (9 minutes of the 18 minute visit) of the face-to-face time is spent discussing vaccination instead of other, more pressing issues of development and parenting. Brochures alone are not helpful in speeding up the discussion. What we as health professionals need to do is change the discussion. First, we need to be frank and truthful with the parent provide factual data and address the parent’s fears. Parents need to catalog their fears going in but need to be open minded to evidence that these fears are unfounded. Secondly, we need to address risk. Third, the use of motivational interview techniques might help clinicians to get patients to better verbalize their concern.

So, parents, you need to learn to be just as skeptical of the “interwebs” as you are of “big medicine.” Doctors, you need to understand that parents will do the right thing (witness the lack of anti-lightningers) but they gotta believe.

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Parent: My child had a fever last night to 102 degrees and isn’t taking in anything. He’s one year old tomorrow

Me (looking at what appears to be a very ill child): Does your child have any other medical problems? Are his vaccinations up to date?

Parent: We were waiting until after his first birthday. We were afraid of the vaccines.

germ theory n. The doctrine holding that infectious diseases are caused by the activity of microorganisms within the body.

The local web log decided to weigh in on the vaccination controversy last week. In an article that presented both sides equally weighted, several physicians were quoted as imploring their patients to follow the vaccination guidelines. Speaking against vaccination, Michael Bucknell, DC, BS was interviewed:

Bucknell said that many parents who choose not to vaccinate their children don’t just stop at reading one blog. “I’ve never met a parent who heard one study and said I’m not going to do it,” Bucknell explained. On his business website, Bucknell has listed numerous articles he cites in his decision not to vaccinate his sons. He also said his oldest who is 10 years old was sick for the first time in his life recently.

I really don’t want to litigate the germ theory of disease in this space though it turns out there is a long history in chiropractic thought, beginning with Palmer, of disbelief of germs as a causative agent and thus vaccination as a mechanism of prevention. Let’s concede that although not all human disease is caused by germs and not all exposure to a germ leads to disease, there is a lot of overlap between germ exposure and diseases linked to the germ. For those of you who are unwilling to concede this, you can stop reading here and move onto this article. If you have doubts but are “germ questioning,” here is a very nice article about why your personal observations (I smoke and don’t have cancer) often conflict with empiric evidence.

Now that they’re gone, let’s address the broad issue of vaccine safety and the more narrow issue of what the kids won’t catch. First, to the broad issue of vaccine safety. Turns out over half of parents have such concern with a quarter of them specifically thinking the vaccine will increase their child’s chances of being autistic. As the media clearly is unwilling to pick sides on this, let me help (thanks to the American Academy of Pediatrics):

Almost every vaccine contains an immune stimulator (antigen) in a liquid (adjuvant). If you are worried about the adjuvant having mercury – the type of mercury found in thimerosal is  ethylmercury which is broken down and leaves the body very quickly and has NEVER been shown to be harmful. Because of parental concern, however, anything that contains the word mercury has been removed from almost all vaccines given to children (some influenza preparations are the exception).

If you are worried about the adjuvant containing aluminum (used to boost the effect), there is less aluminum in the shot as there is in a weeks worth of formula or breast milk. We need it to live.

The vaccines work by exposing the body to a part of the germ, allowing the body to develop an immune response the first time it is exposed. Many people are concerned that this “revved up” immunity leads to certain disease, specifically autism. The initial autism correlation was based on a bad study where scientists lied, a study that has since been retracted from the medical literature and described as an “elaborate fraud.” There have subsequently been A LOT of studies that fail to show any correlation.

Lastly, many parents worry about “why so many shots?” Through vaccines, we protect against 14 diseases. To do that it takes a lot of shots, given that it takes about 3 shots 6 months apart to confer immunity to a specific disease. Why so young? Many of the diseases that kill children occur prior to the child turning 2. In perspective, however, we expose the child to 150 antigens over the entire schedule through the age of 2. That same child, eating doodle bugs outside, is exposed to up to 2000 antigens a day.

As a medical student, I cared for children who became seriously ill from Haemophilus Influenza B. It affected approximately one child in every 1000 and in New Orleans we would almost always have 2 or 3 children in the pediatric intensive care unit on a ventilator because of it. Of those, one in 10 would die and about 1/3rd of the survivors would be deaf or neurologically devastated. The HIb vaccine was introduced into the vaccine schedule in 1989. With vaccination, the occurrence of the disease is for all intents and purposes, 0. I haven’t seen a case in 25 years. This is why I believe in vaccines. What can I do to further convince you?

63514_cartoon_mainNews item: An airplane in Birmingham is detained because a passenger threw up (into a vomit bag, I hope) and, not being clearly Caucasian, concern was raised among the crew about EEEEE BBBBB OOOO LLLL AAAA. Two hours later, the fellow passengers were allowed to deplane and the poor, sick Jordanian (home to no Ebola) who had a layover in Turkey (also straddling two continents without Ebola) was allowed to go to his destination. I hope to take his Zofran and suffer in peace.

News item: A woman in Mobile, Alabama who has lived in this country for seven years BUT who had visitors from the Congo ( in east Africa, where no Ebola is but sure sounds like Ebola should be there) was transported via ambulance (with roads blocked off in case the Ebola jumped out, I suppose) to a local hospital where, upon taking an effective history, the patient’s lack of Ebola was confirmed. Who paid for the ambulance ride was not discussed.

It has been a long time since we have had a good pandemic scare in this country. A pandemic, typically caused by an infectious agent, is notable for  its ability to cross over country boundaries and in general wreak havoc.America tends to be protected because of our size, limited number of international boundaries, and  public health infrastructure. The last really good pandemic we had was the “Spanish” flu which was blamed for almost 700,000 deaths in the US. The stories from that era consistently identify the randomness of being stricken as a dominant feature (person gets on the streetcar healthy and at the end of the line is found dead). It is the randomness of being afflicted that seems to create havoc as much as anything else. When a pandemic comes, there are often voices prematurely calling for closing the borders and the schools. Way back in 2009-2010, the public health officials were able to resist such calls when swine flu came. They were able to vaccinate the population and keep public concern to a minimum through creative use of media. They were also fortunate in that the case mortality rate was 1:2000 (as compared to 1:40 for the Spanish Flu and an apparent 1:2 for Ebola).

American reaction to pandemic risk can be constructive. For example, it was a measles epidemic in 1989 to 1991 that led Congress to change the way vaccines were distributed, creating the Vaccines for Children program. Maybe some day we’ll look back and see improved infection control in our hospitals in response. For now, my current hope is that the media, medical establishment, and all branches of government will act responsibly.

Some facts about Ebola:

  • As of today, there are 0 deaths of American citizens from this virus.
  • It is only transmitted through blood and body fluids of a person with a significant infection. People who are contagious are REALLY SICK. Don’t be afraid of the not so sick ones. Casual contact with a person will not infect you if there is no blood or body fluid transmission. If someone looks sick and you happen to touch their skin, hand sanitizer is likely sufficient protection
  • It is found in the semen of people who have recovered for 3 months. It is wise to avoid sexual contact with men who have a questionable illness history (likely always wise).
  • Avoid eating bats and monkeys (especially ones found already dead)
  • Avoid hospitals in West Africa. They don’t have enough gloves. In fact, get a flu shot so you can potentially avoid health care workers completely

Interestingly, Shep Smith on Fox News makes the same points…go figure.

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