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ÒDaddy, can I stop being worried now?ÓText from my daughter “Should I worry about Ebola”

Text back from me “Are you considering moving to west Africa?”

My first class in medical school was in our freshman auditorium. The Dean (or someone who looked old, must have been about 50) came up to the podium and said: “This is a great time to be a doctor. When I was sitting in your seat, the person at the podium had us look to our left and to our right and then said “Of the three of you, one will not be here by the end of the 4 years because of tuberculosis.” You, fortunately, do not have to worry about that.”

Tuberculosis, I thought. What the heck is that and of course I’m going to worry about it (I remain uninfected to date).

When I was a third year medical student, AIDS hit New Orleans. I remember being on an infectious disease rotation and going into the emergency room where an emaciated man with blue tumors (Kaposi’s sarcoma, I now know) all over his body was in “isolation.” The isolation, in this case, was no one placed in the bed next to him (it was an open bay ward) and yellow CAUTION tape placed across the entrance to the bay where he had been placed. My attending, who remains a role model to me, tore the tape down and said “Whatever you THINK you are doing with this tape it is accomplishing nothing except dehumanizing this person who is ill.” The patient died. None of us on the health care team became ill.

Ebola virus is the latest illness to capture the public’s attention. Confined to west Africa unless those ill are transported, it has claimed the lives of 1427 people, about 10% of whom are health workers. Apparently my daughter’s text was prompted by the news reports associated with the transport of the American physician to Atlanta. Spurred on by movies like “Outbreak” and breathless news reports from Dakar by Ofeibea Quist-Arcton (pronunciation found here), folks here are concerned WAY out of proportion to what they should be (unless their neighbors are west African health care workers who just got back and appear mighty sick). Americans should worry about a lot of things: their diet, their lack of physical activity, their use of tobacco and guns. “Ebola” should be appear on the list below “death from bee sting” (100 Americans annually)

Turns out that Ebola is big news because people tend to make many decisions based on feeling and belief rather than based on a calculated risk assessment.  Psychologists have coined the term “Dread Factor” for the combination of

  • perceived lack of control,
  • catastrophic potential,
  • fatal consequences, and
  • the inequitable distribution of risks and benefits.

Ebola (0 deaths in America) hits the sweet spot. We humans worry more about what we can’t control, especially if the long term consequences are unknown, the potential risk is believed to be high, and there is nothing we can do to mitigate it. In “Perception of Risk Posed by Extreme Events” Peter Slovic points out that, probably as a result of eons of programming, we worry excessively about things such as a satellite falling out of the sky and hitting us (0 human deaths so far) and worry very little about backyard swimming pools (10 Americans die A DAY). Makes setting public health policy difficult. If you don’t believe me, look at the backlash regarding Michelle Obama’s healthy children initiative to reduce obesity (1375 American deaths A DAY).

Fine, you say, I know that smoking is unhealthy. What I don’t want to do is die from Ebola.What can I do? Turns out, a lot.

As a health care consumer, make your concerns known. If not dying from Ebola is the most important thing to you, let your doctor know. He or she might suggest something simple, like avoiding travel to the remote villages of west Africa. Meanwhile, take some time to understand why worrying about other elements of your physical well-being might be more useful in the long run.

As a health care professional, don’t just dismiss your patients’ concerns. Listen to them and provide information about why these fears might be unfounded. By the same token, don’t take advantage of your patients’ irrational fears. Providing excessive testing is expensive and often is less helpful than a frank discussion on risks.

We humans react instinctively (on feelings) and intellectually (based on rules and empirical evidence). We often make decisions based on feelings (I am unsafe and need a gun) that run counter to evidence (a person with a gun is 22 times more likely to kill a family member than a bad guy).

As physicians, much of what we do (and don’t do) affects health in a limited fashion. Perhaps we need to get better at helping people to overcome their own barriers to achieving health instead of offering tests for scary things we know aren’t going to happen because “the patients want them.”

Price Conscious 512My wife is reading (or listening to, I can never tell which) a book about “private life” (called At Home).  One of the vignettes is about the development of safe drinking water. The central character in this story was John Snow, a physician living in London in the time of cholera (temporally in the 1850s). The legend is that using a map (this was the first documented use of a map to determine the source of an outbreak, very cool stuff) he plotted the cholera deaths and placed them proximate to a fresh water concern on Broad Street. He attempted to get the local government to act on his theory that the water pump was contaminated and the cause of the outbreak. Convincing the authorities (the local Board of Guardians) to remove the handle, he is credited with stopping the outbreak (or at least preventing a resurgence in the neighborhood).

A couple of things about this story. First, Doctor Snow had lived through a previous outbreak of cholera several years earlier, and as a consequence he was unconvinced of the prevailing theory that miasma (bad air) caused the disease. His theory, that the disease was limited to the gastrointestinal tract and death was caused exclusively by dehydration, was consider not a little kooky. He was working on very little evidence as the existence of a cholera organism, though described in Florence roughly at the same time, was unknown to physicians in London. Robert Koch, the man who really put germs on the map as causative agents of disease, would not develop his postulates until 30 years later.  Doctor Snow, it turns out, was looking for an opportunity to test his theory, and the St James Parish outbreak happened to have everything he needed (water contaminated with sewage with little competition from clean water and so delicious that people knew of pump by name, people who were dying of cholera at a fast clip, and a Board that was willing to try new things out of a sense of responsibility to their parishioners). As luck would have it, the water was VERY contaminated (wash water from an infected baby’s diapers and fresh water kinda mingled right where the pump intake was) and so the intervention was successful. John Snow lives on as a medical hero.

Not everyone bought into the “drinking water causes disease” meme for a couple of reasons. First, miasma as a cause of disease had a lot going for it. If God made things smell bad, it must be for a reason, amirite? Second, because bad smells and disease tended to intersect where poor people lived, bad things must be happening to “bad people.” The slums were filled with people moving from the countryside during the Industrial Revolution, people who “were not nice people.” Therefore, in the Victorian age “the miasmas that seemed so prevalent among the poor slums were seen as God’s punishment for immoral lifestyle.” Over time, the sanitarian won and, by first building sanitary sewers and providing drinking water and later providing vaccinations, outbreaks of diseases like cholera and polio were conquered.

So, in this country we are heading into our own Broad Street Pump moment. 26 states have elected to take full advantage of the Affordable Care Act, including expanding Medicaid to those who make below 138% of poverty as a sole qualifying criteria. In these states, Medicaid rolls have grown by 8%. This means that more than 3 million adults will have the security afforded by knowing they are not one illness away from bankruptcy. They will have access to care for complaints such as “blood in my stool” which would have gotten them triaged out of an emergency room before but now, under the right circumstances, a colonoscopy to find and cure their colon cancer. They will get treatment for bladder infections, pneumonias, and cellulitises without needed to get so sick as to require hospitalization.

24 states, including Alabama, have not expanded.Their rolls have expanded by 1%. These folks are mostly working, some at several jobs. They are using their common sense to tell them when to seek expensive care. I f they guess right, bankruptcy and an opportunity continue to work and pay off medical bills. If they guess wrong, death from a preventable illness. Meanwhile many, including public officials, are convinced that they are uninsured because they are undeserving.

So, who will be our John Snow? Who will look at those dying from a lack of access in states like Alabama and say enough? How many deaths from preventable conditions will it take? Anyone know how to use Google Maps?