Archive for the ‘Medicine’ category

Your Daily Apocalypse, Outsourced Antibiotic Edition

November 21, 2013

Go read this piece by Maryn McKenna — who is, in my never humble opinion, one of the handful of very best reporters on matters of infectious disease, global health, and really scary stuff.

I was born in 1958, fifteen years into the era of clinically-available antibiotics.  I was my mother’s third child.  Had we shifted that timeline back a few years, that would have meant that there would have been a measure of luck in mom simply making it to and not through her third lying in.  As Maryn writes, before antiobiotics, five out of 1,000 births ended with the death of the mother.  No worries by the time I popped my head out into the maternity floor at Alta Bates.

But this a must read not because of any remembrance of the pre-antibiotic era, but because Maryn plausibly analyzes a post-antibiotic future.

Plaguet03

Here’s a sample:

Doctors routinely perform procedures that carry an extraordinary infection risk unless antibiotics are used. Chief among them: any treatment that requires the construction of portals into the bloodstream and gives bacteria a direct route to the heart or brain. That rules out intensive-care medicine, with its ventilators, catheters, and ports—but also something as prosaic as kidney dialysis, which mechanically filters the blood.

Next to go: surgery, especially on sites that harbor large populations of bacteria such as the intestines and the urinary tract. Those bacteria are benign in their regular homes in the body, but introduce them into the blood, as surgery can, and infections are practically guaranteed. And then implantable devices, because bacteria can form sticky films of infection on the devices’ surfaces that can be broken down only by antibiotics

Dr. Donald Fry, a member of the American College of Surgeons who finished medical school in 1972, says: “In my professional life, it has been breathtaking to watch what can be done with synthetic prosthetic materials: joints, vessels, heart valves. But in these operations, infection is a catastrophe.” British health economists with similar concerns recently calculated the costs of antibiotic resistance. To examine how it would affect surgery, they picked hip replacements, a common procedure in once-athletic Baby Boomers. They estimated that without antibiotics, one out of every six recipients of new hip joints would die.

As Maryn reports, the problem is tangled and complex — but there are clear actions that could be taken and aren’t, most obviously ending the reckless use of antibiotics in agriculture, which consumes something like 80% of the total produced.  But don’t waste time here: go read the whole thing. Get scared; get mad; call your congressfolk.

Image: Josse Lieferinxe, St. Sebastian prays for plague victims, 1497-99.

The Difference Between Democrats and Republicans

October 1, 2013

In California, a Democratic Party-run state:

Dozens of workers at a call center in the Sacramento suburb of Rancho Cordova began fielding calls after a countdown to 8 a.m. Tuesday, the time the state’s health exchange opened for business. The agency that runs the exchange, Covered California, reported on Twitter that more than 30,000 telephone calls were received during the first 90 minutes of operations. Another 1,200 were on hold and about 4 percent had hung up.

Peter Lee, executive director of Covered California…said Tuesday was just the starting point, and it was evident that exchange officials had work to do after the website and phone system were hit with a crush of inquiries.

Gov. Jerry Brown, meanwhile, announced he had signed a package of bills to help implement the new law and expand the state’s Medi-Cal program for those who are too poor to pay for the subsidized insurance.

“While extreme radicals in Washington shut down our government, here in California we’re taking action to extend decent health care to millions of families,” Brown said in a statement, referring to the impasse in Congress that has led to a partial shutdown of federal government operations.

Meanwhile, as a result of the government shut down triggered by those GOP extremists, there’s this news:

Cecil_Beaton_Photographs-_General;_China_1944,_Canadian_Mission_Hospital_in_Chengtu_IB2569C

At the National Institutes of Health, nearly three-quarters of the staff was furloughed. One result: director Francis Collins said about 200 patients who otherwise would be admitted to the NIH Clinical Center into clinical trials each week will be turned away. This includes about 30 children, most of them cancer patients, he said. (From behind the WSJ paywall via the Atlantic) (h/t a tweet from science writer extraordinaire Steve Silberman aka @stevesilberman.)

So there you have it:  Democrats strive to get sick people care (and the well, protected), and labor to fix  the bits that don’t work.

Republicans leave kids with cancer on the street.

Update:  H/t commenter Baud, it turns out   that Americans in those (GOP-led) states that have chosen to abandon their responsibility to their citizens actually do twant healthcare from the Feds (via TPM):

Nearly three million people have visited the federal health insurance marketplace created by Obamacare on its first day, according to the U.S. Department of Health and Human Services.

Since midnight, 2.8 million people have visited the website, which will serve consumers in more than 30 states, and 81,000 have called the marketplace’s call center. Those numbers were current as of late Tuesday afternoon.

Image:  Cecil Beaton, A mother resting her head on her sick child’s pillow in the Canadian Mission Hospital in Chengtu, 1944.

American Exceptionalism, Healthcare Division

September 18, 2013

With a h/t to my spouse, this piece from a couple of days ago offers a beautiful (not really the mot juste) window onto the multiple levels of fail of US medical business and (or rather, hence) practice.  The action gets going as a young physicians assistant named Andrew T. Gray describes waking up an upset stomach, which over the course of the day blossoms into really nasty pain.  Then comes the twist:

Crawling into bed, however, I realized that my pain had coalesced in the right lower quadrant of my abdomen. Could it be appendicitis?

Panic flooded me. After six weeks at my new job, I now qualified for health insurance, but I’d neglected to fill out the necessary paperwork.

Only an hour after leaving the clinic, I returned. Almost hysterically, I completed and faxed in the insurance forms.

“Go to the emergency room right now,” urged one of my supervising physicians.

Instead, Gray waited overnight so as to reduce the odds of insurance company shenanigans.  The next morning, though he can’t wait anymore:

Waiting for the ER doctor, I recalled that, at some point in my schooling, I’d read a Swedish study about treating appendicitis with antibiotics. Googling the study on my smartphone, I found it.

By the time the ER resident approached, I was ready.

“I don’t have health insurance,” I said calmly. “Can I be treated with antibiotics instead of surgery?”

“I doubt they’re going to let you do that here,” he said. “But keep expressing interest.”

When the ER attending physician came in, I repeated the question.

“Absolutely not,” he replied flatly. “This is America, not Sweden. If you have appendicitis, we operate.”

The story gets better — which is to say from a policy and medical care point of view, worse.  Go read the whole thing.

As to it’s relevance beyond itself. Well, Gray’s telling an anecdote, of course, a single encounter in a system that touches millions every day.  Even so, there are at least two key points I draw from it:  (a)  there are structural problems with the culture of medical practice in the US that both drive up costs and affect (not for the better) patient outcomes.  “This is America…we operate.”

Hans_Holbein_d._J._-_Henry_VIII_and_the_Barber_Surgeons_-_WGA11566

And (b):  there are lots of reasons medical costs in the US seem both arbitrary and excessive. But (a) they are and (b) it actually matters to know what happens elsewhere, because from such knowledge it finally becomes much easier to see that US health care is exceptional alright — but not how the foaming hordes raving against tyranny in the form of Obamacare would have it.  We sure do lead the world in what we pay. Just not in getting what (we think) we’re paying for.*

*This is not to say that for particular conditions in particular cities there is no better place in the world to receive care than, say, my current dwelling place, Boston.  But brilliant tertiary care available  to those clued in and covered in just the right ways doth not a system make.

Image:  Hans Holbein, Henry VIII and the Barber Surgeons, 1543.

The FSM Moves In Mysterious Ways

August 26, 2013

Presented without (much) comment:

The latest measles outbreak is in Texas, where the virus has sickened 25 people, most of whom are members or visitors of a church led by the daughter of televangelist Kenneth Copeland.

Fifteen of the measles cases are centered around Eagle Mountain International Church in Newark, Texas, whose senior pastor, Terri Pearsons, has previously been critical of measles vaccinations. [via TPM]

 

Titian_-_The_Sick_Man_-_WGA22934

The church in question understands how to deal with such awkwardness:

 We know the truth; we are healed according to Isaiah 53:4-­5 and I Peter 2:24 and are standing against any plague that would try to attack us as a body. So agree with us that this will stop now according to Matthew 18:19.

But nonetheless hedges its bets:

Kenneth Copeland Ministries’ position regarding dealing with any medical condition involving yourself or someone in your family is to first seek the wisdom of God, His Word, and appropriate medical attention from a professional that you know and trust. Apply wisdom and discernment in carrying out their recommendations for treatment. This would include:  vaccinations, immunizations, surgeries, prescriptions, or any other medical procedures.

For my part, I’d skip the other stuff and head straight for one of the greatest inventions ever in the service of human well-being, the prophylactic vaccine.

I’ll close here, without diving into any “it’s not whether you believe in evolution, it’s whether evolution believes in you” species of snark.

Image:  Titian, The Sick Man, c. 151

A Stray Thought, Plus, For A Good Time On The ‘Tubes, Really Scary Microbe Edition

April 24, 2013

Sad to say, but true, some folks have complained to me that I don’t give enough notice of all the good stuff.  So, as usual around here, the beatings continue until morale improves…

…which is something of an apology for the fact that I’m only now mentioning that at 5 p.m. Eastern time I’ll be talking to Maryn McKenna on my monthly science-radio-web/podcast, Virtually Speaking Science (where I’m one of several hosts as we inch our way to regular weekly episodes).  (You’ll be able to pick up the podcast later at that link, or on iTunes, having searched for Virtually Speaking Science.)

Maryn, for those of you who have for some odd reason not glued yourself to her blog Superbug, or immersed yourself in her book by the same name, is the leading journalist working in the US on problems of antibiotic resistance, infectious disease and similar sources of gnawing (and occasionally acute) anxiety.  She and I have talked before, but, sadly, there’s always more scary bug stuff to talk about.

Flea_Micrographia_Hooke

This time, our focus will be on an under-reported outbreak of (likely) Totally Drug Resistant Tuberculosis (TDR – TB) and on the H7N9 flu story out of China.  But we’ll no doubt talk about antibiotics in agriculture and the way agribusiness and the tocsin of cheap food is posing such a thread.  Should be, dare I say it, fun.  Or at least interesting.  Or perhaps just terrifying.

Oh — and as for that stray thought.  Am I the only one wondering whether The Pet Goat will have a place of honor in Wee Bush’s presidential library?

Thought not.

ETA: Here’s a nice  bit of reporting on potentially untreatable gonorrhea appearing in the US.  I’ll be asking Maryn about this too.

Image:  Robert Hooke, Flea, in Micrographia, 1665

Scary Diseases; Agribiz Denialism; and Why We Need Health Care Reform (It’s more than just coverage)

March 28, 2012

Just a quick heads up.  I’ll be talking at 5 Eastern Time today with Maryn McKenna, aka Scary Disease Girl on Virtually Speaking Science. You can listen, but if you’re a virtual kind of person you can also head over to the open air theater in Second Life see Maryn’s magnificent avatar with its gloriously purple hair.  (One commenter compared the shade to Beaujolais Nouveau, but I’m not so sure.)

McKenna is a science and medicine writer who has focused the last several years of her career on the truly vexing and terrifying issue of antiobiotic resistance, focusing on the scourge of MRSA:  methicillin-resistant Staphylococcus aureus, or drug-resistant staph.  She blogs at Wired.com, under a title shared with the book — Superbug — that will be the leaping off point for our conversation.

So check it out, if not synchronously, then via the podcast, available either at Blog Talk Radio (from about midnight tonight, I think, though it may be tomorrow), via the RSS feed, or as found within the greater Virtually Speaking iTunes podcast.

Just to give a tease of the conversation — we’ll start by talking about the great squander:  how, some 75 years into the antibiotic era, we’re on the verge of destroying what had once seemed to be a truly transformative gift, a way to salve so much human suffering…and we will start to look at the reasons why.  High among them will be the area Maryn’s focused on a lot since publishing Superbug, the use of antibiotics in agriculture in a non-therapeutic situations — that is, not as a response to an infection, but either as a prophylactic, or simply to fatten up livestock before slaughter.

There’s been some news over the last week that makes this issue genuinely hot, but the most interesting aspect of it, to me, is the way agribusiness and their congressional allies (on both sides of the aisle, alas) have simply changed a few of the nouns and then copied the denialist playbook written for the tobacco wars, and updated for use in turning the threat of climate change into a world-wide conspiracy of fanatical socialist-facist greens.

Which is to say, as readers of this blog know, the transformation of science from a source of public knowledge into a post-modern body of jargon to be manipulated by those with the biggest and most sophisticated megaphones, is literally killing us — as we will discuss in a bit.

Oh — and one more thing.  One of the key threads to emerge from Maryn’s work is just how badly we are served by the fragmentary system of health care delivery that we now have, that the GOP wishes to preserve, and that Obamacare goes some way to repair.  The lack of uniform systems of electronic charts, the failure to disseminate key medical knowledge outside of its silos — sometimes single hospitals, or even single services within hospitals — the inability to construct a truly national system of health care knowledge and the dissemination of best practices (Death Panels!) all have contributed directly to the deaths of kids, grown ups, grandma and grandpa from preventable or much earlier-treatable MRSA infections, as Maryn has documented — and much else besides.  Remember:  when our friends who decry the fascism inherent in public regulation of a public good seek to repeal without replacing, they are advocating a policy choice that will kill people.  This is a known, predictable consequence of any swerve to the status quo ante.  In other circumstances, taking actions that a reasonable person understands will lead directly to the deaths of others has a name, and the people who do so have names to.  Now we call them GOP Presidential candidates.  Just sayin.

Just the cheery kind of conversation that will set you up for a truly heroic cocktail hour.  May I recommend either one of these…or,  maybe, doses by mouth of this concoction, repeated as necessary.

Image:  Barent Fabritius, The Slaughtered Pig, 1656

None Dare Call It Murder

February 1, 2012

I’ve got just one quick note to add to the discussion of the Komen Foundation’s surrender to Greater Wingnuttia and the Global War on Women.

That would be that this decision is not just about the dollars.  It’s genuinely a matter of life and death  — of murder, really, with only the anonymity of the victims to obscure the the connection between act and consequence.*

Y’all may recall that I wrote along these lines about eight months ago in connection with Mitch Daniels’ decision to defund Planned Parenthood in Indiana.  (Yup, that Daniels — the hack our friends in literate Wingnutistan see as the great hope of the GOP).  Now we’re back again to run the numbers on what the removal of the services Planned Parenthood provides to women seeking preventative care for breast cancer will do.**

Here are the basic figures:  over the last five years, the Komen Foundation provided Planned Parenthood with sufficient support to pay for 170,000 breast exams and 6,700 referrals for mammography. The question of how frequent and how early a mammography program should be has been, shall we say, vigorously debated, but the issue gained some clarity last year with the publication of a large scale longitudinal study by Swedish researcher in which over 133,000 women were followed for a total of 29 years.

The results of this study provide low-end estimates for the lives saved by screening:  for every 414 or 519 women screened*** for seven years running, one breast cancer death would be prevented.  What’s more, the researchers emphasized that this is a conservative conclusion:

Evaluation of the full impact of screening, in particular estimates of absolute benefit and number needed to screen, requires follow-up times exceeding 20 years because the observed number of breast cancer deaths prevented increases with increasing time of follow-up.

I’m being deliberately dry in this telling, and I’m sure you can guess why:  I do not wish the conclusion to lose any of its force to misplaced snark.  The bald facts are grim enough.

How grim?  Take the most modest number from this study —519 women screened for each life saved.  That’s on the order of 13 women from the 6,700 screened with Komen Foundation money who get to live.****

Or:  that’s 13 women who will die for lack of those funds.

As I wrote about cervical cancer screening in Indiana:  we won’t know who those women are.  We will never know their names; who loved them; how many kids they will leave behind.  But if the total funds for screening in the system drop with the withdrawal of Komen Foundation support, they’ll be dead all the same.

Caveats, before I drop this “just the facts, Ma’am” tone:  this is a blunt, back of the envelope bit of arithmetic.  There are all kinds of factors that a real epidemiologist would consider before making any such bold claim.  Some of the obvious ones push the conclusion to a higher likely total of preventable deaths:  these women are being referred for screening, which suggests that someone had an inkling that they might be at risk.  Planned Parenthood sees a clientele that is likely to lack more health care services than the general population.  And there are the general points the original researchers made to suggest that the total of lives saved through screening would be greater than their baseline number.  There are probably factors that weigh in the other direction as well — one could imagine, for example, that the preliminary examinations turned up more aggressive cancers, which may have outcomes that mammographic detection does not much alter.  You get the point.  The reality of public health, medicine, and the basic biology of cancer is such that precise predictions are always wrong.

That said, the broader claim still stands:  there is a significant and growing body of evidence that regular mammographic breast cancer screening saves lives.  The converse follows:  withholding that screening means real people will suffer.

And here I’ll drop the pretense of dispassion.  The Komen Foundation’s decision links directly to illness, to death and loss and dreadful sorrow left behind.

Those losses can’t be called manslaughter either, not as I see it.  Preventable deaths that flow from lack of access to the standard of care are wholly predictable, even if the individual victims are not identifiable.  Those blocking access through want of funds know — or should — what will happen.  There’s nothing accidental about these outcomes.w

Which means that this isn’t just another salvo in the culture war.  This is nothing to be clever about in 850 word columns on the back pages of the Grey Lady.  This is not a bit of clever gamesmanship to rev up a base for whom just the name Planned Parenthood conjures up all their horrors of female agency.

This is real life, and real lives lost…and, once again, this is why this election matters so much.

*Yup.  Still working the refs for that Moore Award.

**Just to be clear:  for what follows, I’m assuming that these services are withdrawn, that the withholding of resources from the Komen Foundation doesn’t get made up somewhere else.

*** The spread is down to the details of data collection and analysis in the Swedish study.

****The weasel is about the difference in the five year span of screening Komen funds are said to cover, and the seven year screening sequence identified in the Swedish study.  I lack both the data and the skill to do more than waffle a bit here.

Image:  Artemisia Gentileschi, Jael and Sisera, 1620


Follow

Get every new post delivered to your Inbox.

Join 9,517 other followers