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Reflections From the Ukraine

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By MIKE MAGEE

The English translator of Tolstoy’s epic Russian novel, “War and Peace”, Richard Pevear, writes in his introduction, “The book is set in the period of the Napoleonic wars (1805-1812) and tells the interweaving historical events of two very different families of the Russian nobility – the severe Bolonskys and the easygoing Rostovs – and of a singular man reminiscent of the author himself – Count Pierre Bezukhov. It embodies the national myth of ‘Russia’s glorious period’ as Tolstoy himself called it…”

On page 348, in a moment of intense introspection, the very same Pierre broodingly reflects, “What is bad? What is good? What should one love, what hate? Why live, and what am I? What is life and what is death? What power rules over everything?”

Pierre’s mind provides this very dark response, “You will die – and everything will end. You will die and learn everything – or stop asking.”

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Will Microbes Finally Force Modernization of the American Health Care System?

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BY MIKE MAGEE

Science has a way of punishing humans for their arrogance.

In 1996, Dr. Michael Osterholm found himself rather lonely and isolated in medical research circles. This was the adrenaline-infused decade of blockbuster pharmaceuticals focused squarely on chronic debilitating diseases of aging.

And yet, there was Osterholm, in Congressional testimony delivering this message: “I am here to bring you the sobering and unfortunate news that our ability to detect and monitor infectious disease threats to health in this country is in serious jeopardy…For 12 of the States or territories, there is no one who is responsible for food or water-borne surveillance. You could sink the Titanic in their back yard and they would not know they had water.”

Osterholm’s choice of metaphor perhaps reflected his own frustration and inability to alter the course of the medical-industrial complex despite microbial icebergs directly ahead.

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Does Digital Health Technology Have a “Famous Trio” in the Making?

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By MIKE MAGEE

Yale historian, Frank M. Snowden wisely notes in his 2020 book, “Epidemics and Society”, that “We must avoid the pitfall of believing the driver of scientific knowledge is ever a single genius working alone.”

His insight came to mind this week as I was reviewing the January 11, 2020 Forbes article by Seth Joseph, health tech policy correspondent, titled “What Bubble? Digital Health Funding Year in Review 2021.”

By one measure of success – dollars invested – it’s been a banner year. According to Joseph, there was over $29 billion funded, and 729 digital health US-based startups in 2021. But according to Scott Barclay, Managing Director at Insight Partners, who is quoted generously in the Forbes piece, “digital health is still in its relative infancy.”

This level of churn, passion, and (some might say) financial frenzy is reminiscent of another moment in scientific history – the latter half of the 19th century. Over a few decades, “The Germ Theory” was fleshed out with unprecedented and remarkable human progress following in its wake.

The breakthroughs were not the result of 729 often-repetitive and unoriginal ideas, but rather the work of three successive innovators whose work built on each other, combining innovation, technology and health.

Snowden termed the three “The Famous Trio.”

The first was Louis Pasteur (1822-1895) a chemist with a sharp eye and mind. He had been hired to find a solution for wine and milk that was spoiling too fast. The tools he wielded were mostly observational, including a still primitive microscope. With it, Pasteur was able to identify putrefying microbes as causal but went two steps further. He noted that a heating process killed the microbes and halted the product putrefaction, and tied the microscopic organisms to specific human diseases. With this knowledge, he unveiled a commercial process of serial attenuation of disease-causing microbes that allowed safe inoculation of humans and acquired immunity.

The second of the trio was Robert Koch (1834-1910), a physician 20 years younger than Pasteur. While studying Anthrax at the University of Gottingen, he visualized the large causative bacteria, introduced it into a lab animal, and reproduced the disease. Going one step further, he described resistant spores of the bacteria, identified them in grazing fields, and proved that eating grass laden with spores could spread Anthrax between animals. His careful investigative approach led to the uncovering of the etiology of tuberculosis and to “Koch’s Postulates”, four steps still in place today, which when followed, constitute laboratory-based scientific proof of a theory. Beyond this, Koch was a technology innovator, teaming up with the Carl Zeiss optical company, whose lenses, in combination with specialized tissue stains and fixed culture mediums, allowed Koch to visualize and describe M. tuberculosis.

The third innovator was Joseph Lister (1827-1912), a professor of surgery at Edinburgh.  Thanks to the development of ether and nitrous oxide in the 1840s, pain management intra-operatively was under partial control. Improving techniques and tools helped control blood loss. But post-operative infection remained a persistent and deadly threat. Viewing the work of Pasteur and Koch, Lister recognized the possibility that contamination with microbes might be the cause. In carefully designed studies, employing hand scrubbing, sterilization of tools, and spraying the patient with carbolic acid, rates of post-operative sepsis declined. Other colleagues added sterile gowns, gloves, and masks, merging these added measures with Lister’s support.

 Arguably, the life-saving “Germ Theory” was the work product of complementary insights and serial incremental progress. It might then be reasonable to ask, of the $29 billion funded 729 digital health tech US-based startups in 2021, how many represent additive and progressive insights that might eventually lead to game-changing advances in the health of America?

Scott Barclay appears to be mining this same territory. In Forbes, he says, “The green shoots of the past 10 years are turning into new vibrant ecosystems that are growing, but young. We are early in what may turn out to be a two-decade epoch of super innovative ideas, strong founders with execution experience bringing change to a $4T sector of the economy that has been sclerotic and in many parts oligopolistic. The majority of the largest digital health companies in 2040 public markets have not yet been started.”

Does Digital Health Technology have a “Famous Trio” in the making to link infrastructure, AI diagnostics, and evidence-based health? Who are they, and how do they complement each other?

Mike Magee, MD is a Medical Historian and Health Economist, and author of  “CodeBlue: Inside the Medical Industrial Complex.“

Ecology and Technical Advance

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By MIKE MAGEE

It is fair to say that the vast majority of Americans know more about viruses today than they did 24 months ago. The death and destruction in the wake of COVID-19 and its progeny have been a powerful motivator. Fear and worry tend to focus one’s attention.

Our collective learnings are evolving. We have already seen historic comparisons to other epidemics. Just search “The 10 worst epidemics” for confirmation. But one critical area which has been skimmed over, and only delicately probed (if at all) is the ecology or “the ecological point of view.”

For those interested, let me recommend “Natural History of Infectious Disease” published in 1972 by Nobel laureate and Australian biologist Sir Macfarlane Burnet and his colleague David O. White.

Chapter 1 begins: “In the final third of the twentieth century, we of the affluent West are confronted with no lack of environmental, social, and political problems, but one of the immemorial hazards of human existence is gone. Young people today have had almost no experience of serious infectious disease…For the first time in history deaths in infancy and childhood are not predominantly from infection.” But a few sentences on, they add this addendum, “Infectious diseases may be almost invisible, but it is still potentially as important as ever it was.”

Americans are all too familiar with the living biologic organism named COVID-19. By now, they know what it looks like, the role of its outer spikes, its nuclear makeup, and genetic alterations that allow the creation of derivative variants and vaccines. But in addition to its biological science, it also has an ecological life as well.

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The Social Science of Covid

By MIKE MAGEE

As we enter the third year of the Covid pandemic, with perhaps a partial end in sight, the weight of the debate shows signs of shifting away from genetically engineered therapies, and toward a social science search for historic context.

Renowned historian, Charles E. Rosenberg, envisioned a similar transition for the AIDS epidemic in 1989. He described its likely future course then as a “social phenomenon” with these words, “Epidemics start at a moment in time, proceed on a stage limited in space and duration, follow a plot line of increasing and revelatory tension, move to a crisis of individual and collective character, then drift toward closure.”

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THCB Gang Episode 78, Jan 13

On #THCBGang I hosted the double trouble of vaunted futurists Ian Morrison (@seccurve) & Jeff Goldsmith, and medical historian Mike Magee (@drmikemagee) for an hour of conversation and banter about the health care system, the world in politics, and whether “Don’t Look Up” is a spoof or a documentary. Really good stuff, especially from Jeff on whether Medicare pays enough to keep hospitals alive. (Spoiler alter–he doesn’t think so!)

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

“Playing Doctor” – A Cautionary Tale From Health IT Pioneers.

By MIKE MAGEE

Warner Vincent Slack, MD, a pioneer of medical informatics, was a Professor of Medicine at Harvard Medical School in the Division of Clinical Informatics. When he died in 2018 at age 85, his memoriam read:

“For over 50 years, Dr. Slack conducted pioneering research on the use of computers in the medical world and was one of the founders of medical informatics. His goal was to empower both doctors and patients by improving the communication between them.”

Followers of Dr. Slack have labored hard over the past half-century to design solutions that will strengthen rather than weaken the bonds of the patient-physician relationship. But as he suggested at multiple points throughout his career, this goal becomes exponentially more difficult if politicians are allowed to “play doctor” with citizens’ lives.

His awareness of the fallout of the Terri Schiavo “right to die” case, beginning a dozen years after his seminal publication of  “Patient Power: A Patient Oriented Value System”, likely cast a long shadow on his optimistic vision. The case spanned 15 years, as it rode the poor health and disability of one unfortunate woman literally into her grave with devastating consequences for all concerned. 

As the Supreme Court readies itself to serve up opinions in the Texas vigilante and Mississippi abortion cases, the Schiavo case remains a cautionary tale that deserves a careful review. Here’s a quick summary:

  • Theresa Marie Schindler was born in a Philadelphia suburb on December 3, 1963.
  • Terri married her husband, Michael in 1984 and moved to Florida to be close to her parents. 
  • On February 25, 1990, suffering from an eating disorder, she collapsed in the lobby of their apartment, was resuscitated, and hospitalized.
  • Her husband, Michael, was made legal guardian on June 18, 1990. Two physicians independently declared her in a “permanent vegetative state.” A gastric feeding tube was inserted.
  • In mid-1993, Michael signed a Do Not Resuscitate (DNR) order.
  • In May 1998, he filed a petition to remove the feeding tube.
  • The parents challenged the removal in court and lost. The tube was finally removed on April 24, 2001.
  • The parents charged Michael Schiavo with perjury, and a judge ordered the tube reinserted 2 days later.
  • On September 17, 2003,  the appellate judge ordered the feeding tube removed for a second time.
  • Operation Rescue/Right to Life extremist Randall Terry began daily public demonstrations at the care facility.
  • The Florida legislature passed “Terri’s Law”, allowing Gov. Jeb Bush to order the feeding tube surgically reinserted for the third time.
  • On May 5, 2004, “Terri’s Law” was declared unconstitutional.
  • Senator Mel Martinez’s (R-FL) political career was damaged irreparably when memo’s revealed he played politics with the issue.
  • Senator Bill Frist’s hopes for the presidency went up in smoke on March 17, 2005, when he declared on the Senate floor, “I question it (vegetative state) based on a review of the video footage which I spent an hour or so looking at last night in my office.”
  • President Bush transferred the case to Federal Courts. The Federal Court agreed with prior State Court Appeals.
  • Terri Schiavo’s feeding tube was removed a final time on March 24, 2005. She died at a Pinellas Park hospice on March 31, 2005.
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THCB Gang Episode 75, Dec 16

Joining Matthew Holt (@boltyboy) for an hour of topical and sometime combative conversation on what’s happening in health care and beyond were — medical historian Mike Magee (@drmikemagee); futurist Jeff Goldsmith; fierce patient activist Casey Quinlan (@MightyCasey); and policy consultant/author Rosemarie Day (@Rosemarie_Day1).

Plenty of talk about voting rights, the future of American “democracy” and much more, and we did get back to health care eventually. A great & fun, while important, conversation!

You can see the video below where it’s kept for posterity. If you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels

THCB Gang Episode 73, Dec 2 1pm PT – 4pm ET

#THCBGang is back from its Turkey day snooze! Joining Matthew Holt (@boltyboy) at 1pm PT 4pm ET Thursday for an hour of topical and sometime combative conversation on what’s happening in health care and beyond will be patient activist, author & entrepreneur Robin Farmanfarmaian (@Robinff3);  Queen of all employer benefits related issues Jennifer Benz (@Jenbenz); medical historian Mike Magee (@drmikemagee); and patient safety expert and all around wit Michael Millenson (@MLMillenson)

You can see the video below live at 1pm/4pm or it’s kept here for posterity. If you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels

Can Democracy Survive In The Absence of Health Care Security?

By MIKE MAGEE

In my course this fall at the President’s College at the University of Hartford, we began by exploring the word “right” at the intersection of health care services and the U.S. Constitution.  But where we have ended up is at the crossroads of American history, considering conflicting federal and state law, and exploring Social Epidemiology, a branch of epidemiology that concentrates on the impact of the various social determinants of health on American citizens.

What makes the course timely and relevant is that we are uncovering a linkage between health and the construction or destruction of a functional democracy at a moment in America’s history when our democracy is under direct attack.

This was familiar territory for Eleanor Roosevelt. She spent the greater part of World War II creating what she labeled in 1948 “Humanity’s Magna Carta” – aka the “Universal Declaration of Human Rights (UDHR.)”

Embedded in the declaration was a much broader definition of health. It reads “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The Marshall Plan, for reconstruction of war torn Germany and Japan, embodied these principles, and successfully established stable democracies by funding national health plans in these nations as their first priority.

Although our nation signed the UDHR, it carried no legal obligations or consequences. In fact, the U.S. medical establishment’s bias was to embrace a far narrower definition of health – one that targeted disease as enemy #1. They believed that in defeating disease, health would be left in its wake.

In contrast, neighboring Canada took the UDHR to heart, and as a starting point asked themselves, “How do we make Canada and all Canadians healthy?” Where our nation embraced profiteering and entrepreneurship, leaving no room for solidarity, Canada embraced the tools of social justice and population health.

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