I was driving home the other day, noticed all the above-ground telephone/power lines, and thought to myself: this is not the 21st century I thought I’d be living in.
When I was growing up, the 21st century was the distant future, the stuff of science fiction. We’d have flying cars, personal robots, interstellar travel, artificial food, and, of course, tricorders. There’d be computers, although not PCs. Still, we’d have been baffled by smartphones, GPS, or the Internet. We’d have been even more flummoxed by women in the workforce or #BlackLivesMatter.
We’re living in the future, but we’re also hanging on to the past, and that applies especially to healthcare. We all poke fun at the persistence of the fax, but I’d also point out that currently our best advice for dealing with the COVID-19 pandemic is pretty much what it was for the 1918 Spanish Flu pandemic: masks and distancing (and we’re facing similar resistance). One would have hoped the 21st century would have found us better equipped.
So I was heartened to read an op-ed in The Washington Postby ReginaDugan, PhD. Dr. Dugan calls for a “Health Age,” akin to how Sputnik set off the Space Age. The pandemic, she says, “is the kind of event that alters the course of history so much that we measure time by it: before the pandemic — and after.”
Analysis on peer accountability focused community building efforts in making lifestyle changes through digital therapeutic programs
Before we jump ahead to the medicine piece, what the heck does a community even mean? In the past, communities were more likely associated with a group of people living in the same physical location such as a neighborhood, school, or a town. I remember my neighborhood soccer community very well, for instance. Instead of being born into or trying to fit in, community is something we choose for ourselves and express our identities through. With the advancement of accessing the high-speed internet globally, today’s community has no physical or geographical boundaries.
Community builder Fabian Pfortmüller brilliantly explains the difference between communities and other groups. He asserts that unlike project teams or companies who are optimizing for external purposes (collective goals); communities optimize for internal purposes (the relationship and the shared identity). His definition of a community deeply resonated with me and the communities that I had the opportunity to build.
By DALLAS M. DUCAR, MSN, PMHNP-BC, RN, CNL and KATIE WOLF, MBA
We’re not in Kansas anymore. Kansas has rescinded an executive order that dramatically empowered and expanded its healthcare workforce as COVID-19 cases soared. In the best interest of patients now and in the future, other states must not follow Kansas’ example.
The story of coronavirus is far from over in the United States and the impacts to our healthcare systems continue. America’s clinical workforce began this battle at a deficit and, in certain states, continues under those conditions. For years, studies outlined shortages of medical doctors and predicted gaps to worsen over time. Prior to the presence of COVID-19, a contentious debate emerged as to how to address the deficit of physicians. Nurse practitioners (NPs) lobbied for broader clinical autonomy to help bridge this gap. At present, rapid influxes of critically ill patients have strained our healthcare systems to a breaking point laying bare the resource constraints in our healthcare system.
Alex Azar, the Secretary of Health and Human Services responded to this need by sending a letter to governors to expand the 290,000NPs in the United States, bolstering our provider workforce during this time of crisis. Empowering NPs to independently treat patients has needlessly been a long-standing point of contention in healthcare. Increasing the breadth of NP autonomy makes sense in the face of COVID-19. Wisely, since the start of the pandemic, the number of states allowing NP autonomy jumped from 22 states to 48. This structural change to healthcare is long overdue and should remain in perpetuity. However, at the end of May, Kansas became the first state to expire this expansion of NP authority.
NPs are independently licensed and trained to diagnose and prescribe medications and treatments. This role grew organically out of the field of nursing, to provide holistic and patient-centered care to their communities. Nurses become nurse practitioners by choice, honing their skills through years of training at patients’ bedsides, and are part of the most trusted profession in the United States.
As COVID-19 cases soar across the country, the federal government has lost control of the situation. Amid the Trump Administration’s happy talk and outright dismissal of the crisis, the U.S. is experiencing a forest fire of contagion and hospitalizations, and an upsurge in COVID-related deaths has already begun.
Other countries like Taiwan, South Korea, Germany, Australia and New Zealand have controlled their outbreaks, which is why their COVID-19 infections and deaths have been minimal or trending downward in recent months. To replicate those nations’ strategies of testing, contact tracing and quarantining, the U.S. Congress would have to appropriate about $43.5 billion, according to one estimate. But as we know, Senate Republicans won’t pass such a bill without Donald Trump’s prior approval—and that’s unlikely as long as his main focus is on reopening the economy.
We can hope that electoral victory by the Democrats in November will change this equation, but Joe Biden won’t take office until January if he wins. Meanwhile, the coronavirus is chewing up America. We can’t afford to wait six months to blunt the impact of this horrible disease. However, there is a solution that doesn’t depend on federal leadership: states can form compacts that would form the basis for collective action to get us out of the trap we’re in.
Interstate compacts are very common in the U.S. Various pacts cover everything from clean water and clean air to medical licensure, mental health and interstate transportation. For example, under the Middle-Atlantic Forest Fire Protection Compact, which includes Ohio, West Virginia, Virginia, Pennsylvania, New Jersey, Delaware, and Maryland, member states assist one another in fire prevention and suppression and firefighter training.
As hopefully most of you know, Rep. John Lewis, civil right icon and longtime member of Congress, died this past Friday. Rep. Lewis was often described the “conscience of Congress” – perhaps a low bar in today’s Congress but important nonetheless — for his unwavering commitment to social justice. I have always been struck in particular by one of his quotes:
Rep. Lewis must have been heartened by the fact that, in 2020, plenty of people are, indeed, making noise and getting into good trouble, necessary trouble over issues that he cared deeply about, like Black Lives Matter and voting rights. There are others who are better able to write about those people and that trouble. So I’d like to talk about his call to action with respect to healthcare.
If you are working today in healthcare — especially in the United States — or, for that matter, someone getting healthcare or having a loved one get it, then you should be making some noise and getting into good trouble, because our healthcare system most definitely makes it necessary.
It should come as no surprise that we’re not very happy with our healthcare system, rating it lower than do citizens in most other developed countries. And for good reason: it’s the world’s most expensive while delivering sub-par health results and leaving tens of millions without financial protection. Even our physicians don’t like it. Even our latest, best effort for improving the sorry state of our healthcare system — the Affordable Care Act – is under risk of repeal due to a lawsuit brought by 18 states and backed by the Trump Administration.
Every day, too many of us suffer in the healthcare system, ranging from waits to indignities to critical mistakes, and some face financial ruin due to the care — whether good or bad. Most of us suffer in silence, or only complain to our friends and family. We don’t see a lot of mass protests about the pitiful state of our healthcare system, and I have to wonder why.
COVID-19 exposed our country’s lack of centralized coordination when it comes to managing and preventing disease spread. Today, our public health system relies on flawed data and obsolete technology that fails to accurately track current and suspected cases, risk stratify patients, monitor disease progression or predict future spread. Not only do these blind spots create opportunities for the disease to spread, they also undermine the ability to safely plan for economic recovery.
What may surprise some, though, is the fact that we don’t have to start from scratch in order to build an effective system that stems the spread of COVID-19. In large part, the infrastructure we need is already here.
In 2009, Congress passed the HITECH Act, which allocated roughly $30 billion for providers to purchase electronic health records (EHRs). As a result of this stimulus, EHRs went from relative obscurity to ubiquity, and today about 96 percent of all providers are users of EHRs. Five years later, Congress passed the Protecting Access to Medicare Act (PAMA), which requires healthcare providers to consult with an approved Clinical Decision Support Mechanism (CDSM) in order to receive reimbursement for advanced imaging procedures for Medicare beneficiaries.
The net result of these two laws is that there is now visibility into nearly every patient-provider interaction in the United States at the moment that care is delivered, through more than a dozen CDSMs that have been certified by CMS. Although PAMA was intended for use with imaging, it’s not difficult to add on and repurpose decision support apps to conduct symptom surveillance for COVID, enabling healthcare workers to spot cases more reliably and earlier in the disease progression for prompt action.
The average American elementary school class includes two students living with one or multiple food allergies. That’s nearly six million children in the United States alone. And these numbers are climbing. There was a staggering 377 percent increase in medical claims with diagnoses of anaphylactic food reactions between 2007 and 2016, two-thirds of these were children.
As parents, we want the absolute best for our children. For many years, guidance around food introduction was unclear. Parents were told that babies, and especially those considered at risk for food allergies, should avoid some allergy-causing foods such as peanuts until they were three years old.
But thanks to ongoing research from our nation’s top allergists and immunologists, we are beginning to learn more and more about food allergies, including what new and expecting parents can do to reduce the risk of their children developing food allergies. In fact, studies now show that introducing a variety of foods early is the best course of action and has been shown to reduce the occurrence of certain food allergies like peanuts for many children.
For instance, the partially FARE-funded Learning Early About Peanut Allergy (LEAP) study showed a remarkable 80 percent reduction in peanut food allergies in high-risk infants who were exposed to peanut foods at a young age. Shortly after LEAP, there was the Enquiring About Tolerance, or EAT, study. This project, led by top medical researchers at Kings College London, found significant reductions in allergies to both peanut and egg after introducing small amounts of the foods into infants’ diets. The LEAP-on study soon followed, and had the same children from the original LEAP study remove peanut from their diets for 12-months. The results showed that they maintained their tolerance to peanut, indicating early introduction to babies can result in long-lasting protection from peanut allergy.
What a strange irony. Trump decides, full-bravado, to challenge China to a trade war just months before China unwittingly hatches a virulent pandemic that collapses our deeply segmented health care system and our economy simultaneously. And rather than cry “Uncle”, our President then fires the WHO just as their experts are heading to China to attempt to unravel the mystery of COVID-19.
With the ongoing, cascading catastrophe of Trump’s mishandling of COVID-19, it is easy to lose sight that the next pandemic (fueled by global warming, global trade, and human and animal migration) is just around the corner. And we haven’t even begun to nail down the origin story of this one.
Unraveling the transmission trail requires international cooperation. As one expert recently noted, “Origin riddles for other new infectious diseases often took years to solve, and the route to answers has involved wrong turns, surprising twists, technological advances, lawsuits, allegations of cover-ups, and high-level politics.”
What we do know is that there are originators, intermediate hosts, and human super-spreaders….and COVID-19 appears to have begun in China. These are not new insights. We’ve seen this playbook before.
The 2020 US election will be vicious, with a nasty pandemonium following a nasty pandemic.
By SAURABH JHA, MD
When the COVID-19 pandemic is dissected in the 2020 presidential election debates, Donald Trump will be at a disadvantage. The coronavirus has killed over 100,000 Americans and maimed thousands more. The caveat is that deaths per capita, rather than total deaths, better measure national failure, and by that metric the US fares better than Belgium, Italy and the United Kingdom. New York City owns a disproportionate share of the deaths, but this hyperconnected megapolis is an outlier whose misfortunes can’t be used to draw conclusions about administrative competence for the country as a whole.
Nevertheless, even after introducing nuance, the numbers aren’t flattering. President Donald Trump may claim that the US dodged the calamity predicted by the epidemiological models, which foretold millions of deaths. To be fair, we don’t know the counterfactual — Jeremiads aren’t verifiable. The paradox of successful mitigation is that we can’t see the future we dodged, precisely because we avoided it.
Reducing the death count logarithmically, rather than merely arithmetically, won’t be celebrated because as bad as the worst case scenario could have been, the situation still looks awfully bad. Many still disbelieve the high death toll predicted by epidemiologists early on, particularly Trump supporters who believe the response to the virus, specifically the economic shutdown, has been criminally disproportionate. One can’t simultaneously believe that COVID-19 is no more dangerous than the seasonal flu and that Trump saved millions from the coronavirus. The constituency that acknowledges the lethality of COVID-19 and credits Trump for decisive action against it is small.
Triangle of Incompetence
Trump’s challenger, former Vice President Joe Biden, will charge that fewer Americans would have died had the Trump administration acted earlier. Trump may be accused of having blood on his hands, but such rhetoric is unnecessary. Biden’s team can simply show a montage of Trump’s bombast where he downplayed COVID-19’s lethality, dismissed doctors’ concerns about the shortage of personal protective equipment or exaggerated how well the US was containing the pandemic. Incidentally, the most iconic picture of the administration’s scornful indifference is the current vice president, Michael Pence, visiting a hospital without a mask, surrounded by health-care workers wearing masks.
Suppose tomorrow you were informed that patients could no longer have medications delivered to their homes. Thus, in the midst of the worst pandemic in recent history, your patients would have to go to pharmacies to get essential medications. Undoubtedly, you’d be puzzled, wondering why your patients must needlessly put themselves and others in harms’ way to care for their own health. In light of the change, you might even debate if it’s worth the risk of getting your own medications.
Thankfully, the common-sense practice of delivering medication to people’s homes seems here to stay. Yet many people will face a similar issue on election day this November: Fifteen states severely restrict who can vote by mail. In these states, millions of citizens will be forced to choose between exercising their right to vote and safeguarding their own health.
So long as SARS-CoV-2 remains a threat, in-person voting is a public health crisis. Unless we want to risk a spike in new COVID-19 cases, with the concomitant deaths and strain on the healthcare system, it is critical to ensure that anyone who wants to vote in the upcoming general election can use mail-in voting. Indeed, a peer-reviewed study published in May found a statistically significant increase in COVID-19 cases in the weeks after the Wisconsin primary, specifically in counties with higher in-person votes per voting location. The study also found a decrease in COVID-19 cases in counties with the highest rates of absentee ballots. Unsurprisingly, the study’s authors exhort policy makers to “expand the number of polling locations or encourage absentee voting for future elections.”