Even the greatest among us can stumble.
As the world mourns the passing of Nelson Mandela, it is important to look at the one area where the iconic former president of South Africa slipped — AIDS. The most outstanding moral figure of our age did not do what was needed as HIV began to destroy the country he loved. But his actions after he realized his failures are an important part of his legacy.
South Africa is beset with the worst epidemic of HIV in the world. According to the United Nations, out of a South African population of just over 51 million, 6.1 million of its citizens were infected with HIV in 2012, including 410,000 children under the age of 14. An estimated 240,000 South Africans died in 2012 from AIDS. There are 2.5 million children orphaned because of the disease. The grim social, economic and medical toll AIDS has exacted on Mandela’s country is almost beyond description.
In 1990, when Mandela was released from a 27-year prison sentence, the rate of HIV infection among adult South Africans was less than 1 percent. When the anti-apartheid activist was elected president four years later, AIDS was on it way to being an out-of-control plague, with infection rates doubling every year. In 1998, the rate of HIV infection among adults in South Africa was almost 13 percent, with 2.9 million people HIV positive.
Mandela and his party were more or less indifferent to AIDS throughout his five-year tenure. There were other huge challenges in rebuilding the new post-apartheid nation — but the indifference was not just a matter of priorities. Mandela and his party did not want to admit they had a problem.
Why they did not take prompt action to slow the epidemic’s spread is not clear. Perhaps Mandela and his people — like United States President Ronald Reagan and his administration in the 1980s — found the disease and its modes of transmission too repellent to acknowledge. Maybe they did not want to tarnish the new state with a problem that at the time carried so much stigma and shame.
Continue reading “Mandela’s AIDS Legacy of Silence and Courage”
Filed Under: THCB
Tagged: Arthur Caplan, HIV/AIDS, Nelson Mandela, public health, South Africa
Dec 9, 2013
Between October 1 and 17, the federal government ceased all nonessential operations because of a partisan stalemate over Obamacare. Although it is premature to declare this the greatest example of misgovernance in modern U.S. Congressional history, this impasse ranks highly.
One casualty of the showdown was any consideration of changes to lessen the impact of the across-the-board sequestration cuts that began on March 1. The cuts have caused economic and other distress across the nation, including serious impacts within the health care sector. Nearly eight months into sequestration, we can move beyond predictions and begin to quantify these effects.
Consider the following impacts of sequestration on Federal health agencies and activities:
NATIONAL INSTITUTES OF HEALTH
Cuts to the FY13 budget: $1.71 billion or 5.5%
A 5.8% cut to the National Cancer Institute, including 6% to ongoing grants, 6.5% to cancer centers, and 8.5% to existing contracts
A 5.0% cut to National Institute of General Medical Sciences, and a 21.6% drop in new grant awards
Among the effects:
- 703 fewer new and competing research projects
- 1,357 fewer research grants in total
- 750 or 7% fewer patients admitted to NIH Clinical Center
- $3 billion in lost economic activity and 20,500 lost jobs
- Estimated lost medical and scientific funding in California, Massachusetts, and New York alone of $180, $128, and $104 million respectively.
Dr. Randy Schekman, whose first major grant was from the National Institutes of Health in 1978, said winning this year’s Nobel Prize for Medicine made him reflect on how his original proposal might have fared in today’s depressed funding climate. “It would have been much, much more difficult to get support,” he said. Congresswoman Zoe Lofgren (D-Calif.) noted the irony that because of sequester cuts, NIH funding was reduced for the research that resulted in Yale’s James Rothman sharing in the 2013 Nobel Prize for Medicine.
Continue reading “The Sequestration Cuts That Are Harming Health Care”
Filed Under: OP-ED
Tagged: CDC, FDA, federal budget deficit, government shutdown, John E. McDonough, Medicare, NIH, public health, sequestration
Oct 24, 2013
At least two-thirds of the perpetrators and victims of gun violence are males under the age of 30. What else do they have in common? They live in neighborhoods with high crime rates and low family incomes, they knew each other before the violence broke out, they usually aren’t employed.
But there’s another commonality these young people share which isn’t often mentioned in discussions about gun violence and crime.
It turns out that the part of the brain that controls processing of information about impulse, desire, goals, self-interest, rules and risk develops latest and probably isn’t fully formed until the mid-20s or later. And while adolescents and young men understand the concepts of ‘good’ versus ‘bad’ as well as older adults, they tend to let peer pressures rather than expected outcomes guide their behavior when choosing between risks and rewards.
Take this neurological-behavioral profile of males between ages 15 to 30 and stick a gun in their hands. The brain research clearly demonstrates that kids and young adults walking around with guns understand the risks involved. Whether it’s the NSSF’s new Project ChildSafe, the NRA’s Eddie Eagle or the grassroots gun safety programs that have expanded since Sandy Hook, nobody’s telling the kids something they don’t already know.
So what can we do to mitigate what President Obama calls this ‘epidemic’ of gun violence when the population most at risk consciously chooses to ignore the risk? I suggest that we look at what communities have done to protect themselves from other kinds of epidemics that threatened public health in the past.
And the most effective method has been to quarantine, or isolate, the area or population where the threat is most extreme. It worked in 14th-century Italy, according to Boccaccio in The Decameron. Why wouldn’t it work now?
Last month the city of Springfield, Mass., recorded its 12th gun homicide. If the killing rate continues, the city might hit 15 shooting fatalities this year, a number it actually surpassed in 2010. This gives the city a homicide rate of 10.2 per 100,000 residents, nearly three times the national rate. Virtually all the violence takes place in two specific neighborhoods bounded by Interstate 291 and State Route 83, and all the victims are between 15 and 30 years old.
Continue reading “If Gun Violence is a Health Epidemic, Can We Quarantine It Like a Virus?”
Filed Under: Uncategorized
Tagged: at-risk youth, crime, gun violence, Mike Weisser, Population Health, public health
Oct 20, 2013
As Washington remains deadlocked on the implementation of the Affordable Care Act, the US government’s shutdown has resulted in the furlough of nearly 70% of the Centers for Disease Control‘s (CDC’s) workforce. CDC Director Tom Frieden recently shared his thoughts in a tweet. We agree whole-heartedly. Although it’s all too easy to take the CDC staff for granted, they are the frontline sentinels (and the gold standard) for monitoring disease outbreaks. Their ramp-down could have serious public health consequences.
We are particularly concerned about the apparent temporary discontinuation of the CDC’s flu surveillance program, which normally provides weekly reports on flu activity. Although flu season typically begins in late fall, outbreaks have occurred earlier in previous years. In 2009, flu cases started accumulating in late summer/early fall. And given the potential for unique variants, such as the swine or avian flu, every season is unpredictable, making the need for regular CDC flu reports essential. We therefore hope to see the CDC restored to full capacity as soon as possible.
In the meantime, we would like to help by sharing data we have on communicable diseases, starting with the flu.
Because the athenahealth database is built on a single-instance, cloud-based architecture, we have the ability to report data in real time. As we have described in earlier posts, the physicians we serve are dispersed around the country with good statistical representation across practice types and sizes.
To get a read on influenza vaccination rates so far this season, we looked at more than two million patients who visited a primary care provider between August 1 and September 28, 2013 (Figure 1). We did not include data on vaccinations provided at retail clinics, schools or workplaces.
This year’s rates are trending in parallel to rates over the last four years, and slightly below those of the 2012-2013 season. However, immunizations accelerate when the CDC, and consequently the media, announce disease outbreaks and mount public awareness campaigns.
Continue reading “With CDC Seasonal Flu Data Unavailable, An Electronic Medical Record Offers a Glimpse of Early Activity Levels”
Filed Under: Tech, THCB
Tagged: athenahealth, CDC, Data, flu, Iyue Sung, public health
Oct 4, 2013
The Navy Yard shooting in Washington, D.C. has once again confronted us with the issues of guns and mental illness, but what we really should address is the inadequacy of mental health care in the United States. Since 2009 there have been 21 mass shootings and the perpetrators in over half of these were suffering from or suspected to have a serious mental illness like schizophrenia, bipolar disorder and depression. (The other killers with no signs of mental illness were ideological zealots, disgruntled employees and disaffected loners.)
After each incident there is a great hue and cry, and calls for action but no substantive action is taken. Our reflexive approach has repeatedly failed to provide care in a timely fashion to individuals in need. As a country, we continue to ignore the growing public health need for greater access and a more proactive approach to mental health care. It is time that we say enough is enough and do something to prevent future tragedies.
When you strip away the hype and politics, the causal factors in these horrific incidents are clear and solvable. Yet we’ve lacked the social and political will to fashion and apply the solution.
The plain truth of the matter is that we do not provide adequate services to the 26% of the U.S. population with mental illness. The scope of and access to mental health services available to most people are limited and fragmented. Moreover, insurance coverage is all too often lacking and discriminatory. Consequently, we do not provide the level and quality of care of which physicians and health care providers are capable. It is the equivalent of knowing that a woman has breast cancer but not offering the indicated treatment options of surgery, radiation and chemotherapy. The result is that many people go untreated or inadequately treated.
Continue reading “After the Navy Yard Shooting: A Call to Action On Mental Illness”
Filed Under: OP-ED, THCB
Tagged: American Psychiatric Association, Jeffrey Lieberman, Mental Health, mental health care access, Navy Yard Shooting, Psychiatry, public health
Sep 27, 2013
How do you tell the family members of a critically ill patient that their loved one is going to die because there are no antibiotics left to treat the patient’s infection? In the 21st century, doctors are not supposed to have to say things like this to patients or their families.
Ever since the discovery of penicillin in 1940, patients have expected a pill or an intravenous injection to cure their infections. But our hubris as a society with respect to antibiotics has been exposed by the rise of antibiotic-resistant “superbugs.”
The Centers for Disease Control and Prevention (CDC) recently issued a new study, entitled “Antibiotic resistance threats in the United States, 2013,” reporting that at least 2 million people become infected with bacteria that are highly resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. These estimates are highly conservative. Many more people die from other conditions that were complicated by an antibiotic-resistant infection.
Meantime, we have ever-decreasing new weapons to wage the war against such infections because the availability of new antibiotics is down by more than 90% since 1983.
Interventions are needed to encourage investment in new antibiotics, to prevent the infections in the first place, to slow the spread of resistance and to discover new ways to attack microbes without driving resistance.
A major reason for the “market failure” of antibiotics is that they are taken for short periods of time, so they have a lower return on investment than drugs that are taken for years (such as cholesterol-lowering drugs). The Food and Drug Administration can help reverse the market failure by adopting new regulatory approaches to encourage development of critically needed new antibiotics.
Continue reading “New Interventions Needed to Halt the Growth of “Superbugs””
Filed Under: OP-ED
Tagged: Antibiotic resistance, Brad Spellberg, CDC, Harbor-UCLA Medical Center, infectious diseases, LA Biomedical Research, public health
Sep 24, 2013
Porn stars all across San Fernando were told to put their clothes back on and go home a couple of weeks ago on the news that a 29 year-old adult actress named Cameron Bay tested positive for HIV.
Shortly thereafter, the Internet lit up. News, judgments, and jokes shot left and right in newsrooms as freely as bodily fluids fly on set. Countless reporters and pundits surely worked overtime to do the deep background: who were Ms. Bay’s co-actors, who did what to whom, and inquiring minds want to know: were condoms used? Imagine the frenzied speculation, all those sticky keystrokes.
Don’t get me wrong: the details of the whodunit have medical import. Public health workers need to find who is at risk. Those who are at risk need testing and education including reminders that early tests can be falsely negative and must be repeated. Since this isn’t the first case of HIV among the scantily clad actors of San Fernando, CA, Ms. Bay’s diagnosis demands we try again to get porn stars to practice safer sex. My guess is legal maneuvers will never do much to affect the sex lives of the nude and infamous, but if porn viewers could learn to have fun even with a condom on set there might be a hope.
Twitter captured all this and more. It showed the diversity of our reactions to Ms. Bay and people like her. Some tweets expressed a sense of inevitability:
Some were judgmental:
Continue reading “Death of a Porn Star”
Filed Under: The Insider's Guide To Health Care
Tagged: HIV/AIDS, Medical Ethics, Patients, public health, public health messaging, stigma, Tim Lahey
Sep 12, 2013
The American Psychiatric Association recently published a new version of the Diagnostic and Statistical Manual (DSM). The DSM-5 is what medical, mental health, and chemical dependency professionals use to diagnose developmental, mental health, substance abuse and dependence, learning, and personality “disorders.” Now in its 5th edition, the DSM was first published in 1952. At that time, the DSM was 129 pages containing 106 diagnoses.
Now, 61 years later, the DSM-5 consists of approximately 950 pages and roughly 375 diagnoses. The DSM-5, while researched far more than previous editions, is based on the medical model or the model of disease. Simply put, the medical model finds the causes of disease and illness and then prescribes a treatment to cure the disease or illness. This means a person has a pathology or pathogen that needs to be treated and cured.
The questions that eat at me during my day as a psychologist and at night as a person searching for answers are:
- Is it possible to accurately identify mental health “issues,” “illness,” or “disorders?” versus extreme ranges within the sphere of the human condition?
- Even if it is possible to identify these conditions, does it determine the course of “treatment” or “intervention?”
- If so, is there a “treatment” for every identified “condition?”
- Does it mean there is a treatment that works?
- Do you need a diagnosis to get help?
Over the years, many have been critical of this approach to mental “health” issues. Referring to mental “health” is actually a newer name as people have historically been thought to have mental “illness.” This makes more sense for people who are unfortunately compromised by severe conditions termed schizophrenia, bi-polar (manic-depressive), and severe depression and anxiety. But does this make sense for children, adolescents, and adults who are challenged with some other, and possibly less severe, aspect of their functioning and development? Do all human problems warrant a medical or mental health diagnosis? When did a weakness become a “disorder” that requires “intervention” and/or “treatment?”
To be fair, the DSM provided structure and guidelines for approaching the complicated business of determining who had a “problem” that required help. However, it seems things have gone too far. Critics of the DSM believe that this latest edition has taken the business of diagnosing to a new level, one where approximately 50% of the population can be diagnosed with something. Critics also believe that this pathology finding approach supports the continued trend of medication prescribing as the number one mode of treatment, and continued trend of increased health care costs and premiums with increased utilization of individuals who need a “diagnosis” to meet “medical necessity” to receive services. What does that mean? It means if you don’t have a diagnosis, you don’t get help. It means you have to have a problem (pathology) to get help (treatment and intervention).
Without going into detail about some of the changes in the newest edition of the DSM, some diagnostic categories have been added and some diagnosis “thresholds” have been lowered. This means that you need fewer symptoms to “meet diagnostic criteria.” Here are some examples of concerns with the new DSM-5:
- Temper tantrums will now be diagnosed as Disruptive Mood Dysregulation Disorder
- Normal forgetting will now be diagnosed as Minor Neurocognitive Disorder
- Gluttony will be diagnosed as Binge Eating Disorder
- Grief will be diagnosed as Major Depression
- First time substance users and college partiers will get a diagnosis of Substance Use Disorder
- Everyday Worry will be diagnosed as Generalized Anxiety Disorder Continue reading “Pathologizing the Human Condition”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: American Psychiatric Association, Dan Peters, Diagnosis, DSM-5, Mental Health, practice of medicine, public health
Sep 1, 2013
The dangers of texting while driving recently received renewed attention thanks to a public service video produced by German film director Werner Herzog. The National Highway Traffic Safety Administration estimates that driver distraction results in approximately 3,000 deaths per year, as well as an additional 400,000 injuries. Experts have estimated that the risk of a crash may increase by more than 20 times when texting, exceeding the risk associated with intoxication.
Texting while driving is just one example of a larger phenomenon of our age, often referred to as multitasking. The term was coined by IBM engineers in the 1960s to refer to the ability of a microprocessor to perform multiple tasks at once. Today the term is more often applied to human beings attempting to do more than one thing, such as simultaneously watching television and folding laundry, or answering emails while talking on the phone. Many health professionals pride themselves on their multitasking.
In fact, however, the term multitasking is a bit of a misnomer, even in the domain of computing. At least where one microprocessor is concerned, a computer does not so much multitask as it switches back and forth between tasks at such a high rate of speed that it appears to be doing multiple things at once. Only more recently, with the advent of multicore processing, has it become possible for computers genuinely to multitask.
The same thing applies to human beings. Health professionals and others who think they are multitasking are typically switching back and forth between different tasks over short periods of time. And in most cases, multitaskers are not able to perform any of the activities in which they are engaged as well as they could if they concentrated on them one at a time. It takes time and effort to re-focus on each task at hand, and this tends to degrade the effectiveness and efficiency of each.
To be sure, multitasking is not impossible. In one sense, simply remaining alive requires us to multitask all the time. Our hearts are continuously pumping, lungs exchanging gases, kidneys filtering the blood, immune system fighting infections, and all the while we are also digesting our last meal. Add to this the ceaseless multitasking of the brain, which is monitoring the environment and maintaining our posture while simultaneously walking and chewing gum, and the complexity multiples.
Continue reading “The Perils of Multitasking”
Filed Under: THCB, The Insider's Guide To Health Care
Tagged: culture of health, multitasking, Patient Safety, public health, Richard Gunderman, texting
Aug 24, 2013
The hype over mobile health is deafening on most days and downright annoying on some. So it is with some reluctance that I admit that mobile has the potential to be a game-changer in health. I’ve professed enthusiasm before, but that was largely around the use of wireless sensors to measure physiologic signals and SMS text as a way to deliver messages to patients and consumers. For several years, the industry has been awash with smartphone apps (by a recent count more than 40,000). At the Center for Connected Health, we started looking at mobile health as far back as 2008 and could not justify the excitement around smart phones and apps at that time, mostly because our patient population did not demonstrate significant enough adoption of smartphones to justify development in this area.
I felt very unpopular at all of the major conferences. I talked about our success with text messaging as a tool for engaging pregnant teens in their prenatal care and helping patients battling addiction to stick with their care plan, while others were touting the virtues of their various apps.
It’s worth noting that our primary focus at the Center for Connected Health has been patients with chronic illness. As such, we are every bit as concerned about the 85 year old with congestive heart failure as we are about the young professional with hypertension. However, across the population of people with chronic disease, smartphone adoption has lagged. I felt like our strategy was vindicated when my friend Susannah Fox published research showing that folks with two or more chronic illnesses (independent of other variables such as age and socioeconomic status) use technology in the context of their health less than others.
The world of patient care appears to be catching up to the rest of mobile. Not that I would ever endorse the irrational exuberance shown for mobile health apps in general, but some recent data points that changed my thinking are worth noting.
Continue reading “Could Mobile Health Become Addictive?”
Filed Under: Tech, THCB
Tagged: Apps, Joseph Kvedar, mHealth, Mobile health, public health, Smartphones
Aug 22, 2013