Posted on | October 8, 2015 | No Comments
This week, on October 6th, I hung on to “Morning Joe” a bit longer than I normally do to hear the interview of Patrick Kennedy by Joe Scarborough. My interest was personal, knowing some of the players, but also as a member of a large Catholic family (12 kids) with our own credo of family loyalty and our own share of trials and tribulations.
Two days earlier, Lesley Stahl had interviewed him on “60 Minutes”, his first public interview promoting his new memoir, “A Common Struggle”. That interview had veered off subject to Patrick’s father – Was he an alcoholic? Did he suffer from PTSD in the wake of his brothers’ assassinations? Valid questions I suppose, but coming close to suggesting this as just another book about America’s most famous (and tragic) family.
But in reality, Patrick’s book is much more than that. In it, he displays a modern understanding of the meaning of health as “human potential”. He clearly explains that unhealthy behaviors are often inherited, as both genetic and social constructs. And most importantly, he reveals that families, in their conspiracy of silence, often contribute to the problem rather than to the solution – and that communities and leaders are complicit.
In thirteen minutes, last Tuesday, Patrick Kennedy provided more health education on the subject of alcohol addiction, mental health, and their treatment, than I received in nearly a decade of training to be a physician.
As the interview opened, Joe Scarborough alluded to the fact that Patrick had broken some silent code, and at least some family members had reacted angrily. Why did he write the story?
Patrick’s answer, a simple three word sentence, declared his emancipation, and his right to both health and happiness, for he and his wife and children. He said simply: “It’s my story.” But what came through was, “It’s my life, and I’m taking control of it.”
He explained, “Often times you’re expected to keep your parents secrets. And yet it will bedevil you your whole life because we all grow up to be our parents. And everything that happens to you as children, we will live with that for the rest of our lives. And what makes that worse is keeping that secret or thinking that you’re keeping that secret…What I’m saying is that my story about keeping quiet in my family is like every other family in America who has these illnesses. Say nothing! Do nothing! See nothing!”
Patrick goes on to explain that the book explains in detail the policy issues involved with achieving expanded coverage and care for those suffering from mental illness and and addiction. He explains how he and his father wrote the Parity Law. Back then, law makers wanted nothing to do with it. As Patrick said, “No one wanted to be the author of Parity. No one wanted the words mental health and addiction next to their name.” When it did pass, he says, insurance companies wasted little time in figuring out how to renege on their obligations.
It is an individual disease marked by shame. In his words, “One of the biggest barriers is no one wants to be known as a patient who is getting mental health treatment or addiction treatment.” But that shame, for him, was uniquely reinforced by a secret code of silence. This extended not only to his parents, siblings and extended family, but also to the many important visitors and guests who wandered the hallways of his famous home in his formative years. Routinely, he was forced to witness his inebriated and incapacitated mother wandering in bathrobe midday past friends and family, heads down, all of whom refused to acknowledge, let alone confront, the disease. That was its’ cruel power over the family, and in part, over him, until recently.
At the core of his family was this secret, eating away at everyone’s health. As Patrick experienced it, “It’s an illness and we are running away from it. My family does not want to be identified with mental illness. That should tell you something about the shame and stigma that still surrounds this issue.”
So where did he find the courage to stand up to it? For whom, and why now? He said, “I have kids now. I don’t want my kids to feel ashamed because they have a genetic predisposition for mental illness and addiction. I want them to get treatment for them. I don’t want them to keep secret the fact that they have an emotional life, a spiritual life. We ought to be paying as much attention to their mental health as the rest of their physical health.”
The reaction from the family has been mixed. His older brother and his mother have issued statements disavowing and criticizing the book. Most family members have remained silent. And a few of the extended family have voiced support. Those who have focused on his right to speak out. In his words, “… a number of members of the family said I love your message that this is about breaking the silence and shame because all of us are saddled with the hangover of a shame that comes with growing up where you are not supposed to tell anything about what happened to you personally. That affects somebody if they are growing up in a family where everything is supposed to be kept quiet.”
As for the disapproval of his older brother, he said simply, “I love him, and I will always love him.” And added, “All I can do is do the next right thing and pray that my brother will understand that what I’m trying to do here is bigger than both of us. And that’s what my dad was all about – trying to make a difference for more people. I’m trying to move the ball forward as he did in his life.”
For Health Commentary, I’m Mike Magee
Posted on | October 1, 2015 | 2 Comments
To say the VA is a huge enterprise is a bit of an understatement. Over 9 million patients in a system with nearly 300,000 employees (including 20,000 doctors) and an annual budget just under $60 billion.
If the system is big, it is also controversial, and has been for a long, long time. There have been no less than 137 formal assessments of the system in the past. Falsification of waiting lists was what triggered the latest crisis. But issues of highly variable quality of care, delayed access, a phenomenal mental health disease burden, an historic and troubled step-sister relationship with academic medical centers, and decaying brick and mortar have been visible for decades.
In signing the Veterans Access, Choice and Accountability Act of 2014, President Obama provided a safety valve in allowing a non-VA treatment option for the unmet medical needs of veterans, but also funded an comprehensive assessment of VA performance in a dozen areas of delivery and management.
On September 18, 2015, the results became public, and sounded dire. To begin with, the capital needs of the system are pegged at $51 billion over the next decade. By the way, cost of construction inside the system is double that of the private sector. Timely access to a health professional requires more of everything, says the report – more staff, more exam rooms, more decision control close to the patient. The only thing that we require less of, apparently, is competing internal management silos.
There are a lot of “funny numbers” when it comes to the VA. For example, there are nearly 22 million living veterans in the U.S. But only 4 in 10 are actually enrolled in the VA health care system. Of those 9 million enrollees, only about 6 million are actual patients, and of these, on average, each receives less than 50% of his/her care from the VA. So effectively, and functionally, the system is actually servicing the full time equivalent of 3 million patients at a cost of $60 billion dollars. (And that doesn’t include the additional infusion of “research dollars” and special grants that find their way into the system). That is $20,000 + per year for each “full time equivalent” patient cared for in a system which, in the just released assessment “scored in the bottom quartile on every measure of organizational health”.
With all that, one would think that the solution to this problem could be delivered in just 5 words: “Time to close the doors”. But no, the solutions, as expressed by leaders of the assessment committee in this week’s New England Journal of Medicine, are far less definitive.
It reads, “The solution, we believe, is multidimensional but starts with immediate changes in practice that will ultimately change culture. It requires pushing decision rights, authority, and responsibilities down to the lowest appropriate administrative level and increasing the appeal of senior leadership positions by pursuing regulatory or legislative changes that create new classifications for VHA leaders. It’s important for VHA leadership to foster a ubiquitous patient-centric culture that encourages sharing of best practices (and failures), values feedback, and catalyzes innovation. To enhance continuity, we believe Congress should consider longer terms for key VHA leaders and medical center directors.”
A bit later, “We call for a shift in VHA focus from central bureaucracy to supporting clinicians in the field and clearly articulating what decision authority resides at each level of the organization. Most important, a systematic approach is needed for identifying and disseminating best practices.”
And finally, “Although VHA transformation will be a Herculean challenge, the country’s current shared sense of urgency and uniform commitment to veterans requires settling for nothing less than high-quality care at sustainable cost and within a culture comparable to that of the best health care organizations.”
A 2014 assessment of clinical preparedness in the AAMC journal, Academic Medicine, said this, “Since 2001, about 2.5 million U.S. troops have been deployed to Iraq or Afghanistan. More than 6,600 men and women have given their lives, and over 48,000 have been injured. However, these numbers do not reflect the long-term physical, psychological, social, and economic effects of deployment on service members and their families. With over one million service members separating from the military over the next several years, it seems prudent to ask whether our country’s health care professionals and systems of care are prepared to evaluate and treat the obvious and more subtle injuries ascribed to military deployment and combat.”
It also said this, “In fact, by itself, it cannot even ensure the health of the 40% of veterans enrolled in VA health care. Some three-quarters of those enrolled in VA health care also have alternate sources of health coverage, such as Medicare, Medicaid, or private insurance, and many of these veterans receive at least some portion of their health care outside the VA system. Ensuring veterans’ well-being is a duty for the entire health professions community.”
Since the passage of the Affordable Care Act, veterans have access to new insurance options that allow them to more easily opt-out of the broken VA system. And they are doing just that, in increasing numbers. So why does the most recent evaluation so clearly unlink reality (It is questionable whether the system is worth saving), with solution (Close it down, and merge these patients into our existing health delivery system)?
Part of the answer is likely geography and jobs. As with the “military-industrial complex” and military bases, these entities are spread throughout our nation, and closing them would have an immediate impact on jobs and local economies. These geographies have political representatives, and the institutions and their suppliers, who profit through weak controls, have their own networks and lobbyists who battle on, in their behalf.
But it is useful to also remember that these entities are an integral part of a larger “medical-industrial complex” which is not as readily visible, and includes the leaders of our academic health care institutions and corporate health care firms. These leaders were, in the post- WWII period, chosen to provide significant thought leadership and human resource supplies for the entire system. Today, 80% of U.S. medical schools have an active affiliation with a VA hospital. The academic medical centers and medical schools rotate over 100,000 residents and medical students through the VA, and receive a not insignificant portion of their training at these sites. Researchers from the academic centers also gain access to research subjects at the VA, and are funded by corporate and governmental grants for their studies.
The question worth asking then is who and what are the latest set of recommendations ultimately designed to serve – the veterans or the “military-industrial complex” whose interests continue to be served, even by an irreconcilably flawed system?
For Health Commentary, I’m Mike Magee.
Posted on | September 24, 2015 | No Comments
If health is about human potential, and if what we in the caring professions are challenged to do is “to heal, provide health, and keep families and communities whole”, then what we do is a holy pursuit.
In his remarks to Congress this morning, Pope Francis said as much. In addition to providing a seminar on the art and purpose of politics in society, the Pope hit on two themes central to Health Commentary over the past decade: 1) Health is Political, 2) It is imperative that we care for “The Planetary Patient”.
All health professionals would benefit from a careful reading of Pope Francis’s remarks which follow:
“I am most grateful for your invitation to address this Joint Session of Congress in “the land of the free and the home of the brave”. I would like to think that the reason for this is that I too am a son of this great continent, from which we have all received so much and toward which we share a common responsibility.
Each son or daughter of a given country has a mission, a personal and social responsibility. Your own responsibility as members of Congress is to enable this country, by your legislative activity, to grow as a nation. You are the face of its people, their representatives. You are called to defend and preserve the dignity of your fellow citizens in the tireless and demanding pursuit of the common good, for this is the chief aim of all politics. A political society endures when it seeks, as a vocation, to satisfy common needs by stimulating the growth of all its members, especially those in situations of greater vulnerability or risk. Legislative activity is always based on care for the people. To this you have been invited, called and convened by those who elected you.
Yours is a work which makes me reflect in two ways on the figure of Moses. On the one hand, the patriarch and lawgiver of the people of Israel symbolizes the need of peoples to keep alive their sense of unity by means of just legislation. On the other, the figure of Moses leads us directly to God and thus to the transcendent dignity of the human being. Moses provides us with a good synthesis of your work: you are asked to protect, by means of the law, the image and likeness fashioned by God on every human face.
Today I would like not only to address you, but through you the entire people of the United States. Here, together with their representatives, I would like to take this opportunity to dialogue with the many thousands of men and women who strive each day to do an honest day’s work, to bring home their daily bread, to save money and – one step at a time – to build a better life for their families. These are men and women who are not concerned simply with paying their taxes, but in their own quiet way sustain the life of society. They generate solidarity by their actions, and they create organizations which offer a helping hand to those most in need.
I would also like to enter into dialogue with the many elderly persons who are a storehouse of wisdom forged by experience, and who seek in many ways, especially through volunteer work, to share their stories and their insights. I know that many of them are retired, but still active; they keep working to build up this land. I also want to dialogue with all those young people who are working to realize their great and noble aspirations, who are not led astray by facile proposals, and who face difficult situations, often as a result of immaturity on the part of many adults. I wish to dialogue with all of you, and I would like to do so through the historical memory of your people.
My visit takes place at a time when men and women of good will are marking the anniversaries of several great Americans. The complexities of history and the reality of human weakness notwithstanding, these men and women, for all their many differences and limitations, were able by hard work and self- sacrifice – some at the cost of their lives – to build a better future. They shaped fundamental values which will endure forever in the spirit of the American people. A people with this spirit can live through many crises, tensions and conflicts, while always finding the resources to move forward, and to do so with dignity. These men and women offer us a way of seeing and interpreting reality. In honoring their memory, we are inspired, even amid conflicts, and in the here and now of each day, to draw upon our deepest cultural reserves.
I would like to mention four of these Americans: Abraham Lincoln, Martin Luther King, Dorothy Day and Thomas Merton.
This year marks the one hundred and fiftieth anniversary of the assassination of President Abraham Lincoln, the guardian of liberty, who labored tirelessly that “this nation, under God, [might] have a new birth of freedom”. Building a future of freedom requires love of the common good and cooperation in a spirit of subsidiarity and solidarity.
All of us are quite aware of, and deeply worried by, the disturbing social and political situation of the world today. Our world is increasingly a place of violent conflict, hatred and brutal atrocities, committed even in the name of God and of religion. We know that no religion is immune from forms of individual delusion or ideological extremism. This means that we must be especially attentive to every type of fundamentalism, whether religious or of any other kind. A delicate balance is required to combat violence perpetrated in the name of a religion, an ideology or an economic system, while also safeguarding religious freedom, intellectual freedom and individual freedoms. But there is another temptation which we must especially guard against: the simplistic reductionism which sees only good or evil; or, if you will, the righteous and sinners. The contemporary world, with its open wounds which affect so many of our brothers and sisters, demands that we confront every form of polarization which would divide it into these two camps. We know that in the attempt to be freed of the enemy without, we can be tempted to feed the enemy within. To imitate the hatred and violence of tyrants and murderers is the best way to take their place. That is something which you, as a people, reject.
Our response must instead be one of hope and healing, of peace and justice. We are asked to summon the courage and the intelligence to resolve today’s many geopolitical and economic crises. Even in the developed world, the effects of unjust structures and actions are all too apparent. Our efforts must aim at restoring hope, righting wrongs, maintaining commitments, and thus promoting the well-being of individuals and of peoples. We must move forward together, as one, in a renewed spirit of fraternity and solidarity, cooperating generously for the common good.
The challenges facing us today call for a renewal of that spirit of cooperation, which has accomplished so much good throughout the history of the United States. The complexity, the gravity and the urgency of these challenges demand that we pool our resources and talents, and resolve to support one another, with respect for our differences and our convictions of conscience.
In this land, the various religious denominations have greatly contributed to building and strengthening society. It is important that today, as in the past, the voice of faith continue to be heard, for it is a voice of fraternity and love, which tries to bring out the best in each person and in each society. Such cooperation is a powerful resource in the battle to eliminate new global forms of slavery, born of grave injustices which can be overcome only through new policies and new forms of social consensus.
Politics is, instead, an expression of our compelling need to live as one, in order to build as one the greatest common good: that of a community which sacrifices particular interests in order to share, in justice and peace, its goods, its interests, its social life. I do not underestimate the difficulty that this involves, but I encourage you in this effort.Here too I think of the march which Martin Luther King led from Selma to Montgomery fifty years ago as part of the campaign to fulfill his “dream” of full civil and political rights for African Americans. That dream continues to inspire us all. I am happy that America continues to be, for many, a land of “dreams”. Dreams which lead to action, to participation, to commitment. Dreams which awaken what is deepest and truest in the life of a people.
In recent centuries, millions of people came to this land to pursue their dream of building a future in freedom. We, the people of this continent, are not fearful of foreigners, because most of us were once foreigners. I say this to you as the son of immigrants, knowing that so many of you are also descended from immigrants. Tragically, the rights of those who were here long before us were not always respected. For those peoples and their nations, from the heart of American democracy, I wish to reaffirm my highest esteem and appreciation. Those first contacts were often turbulent and violent, but it is difficult to judge the past by the criteria of the present. Nonetheless, when the stranger in our midst appeals to us, we must not repeat the sins and the errors of the past. We must resolve now to live as nobly and as justly as possible, as we educate new generations not to turn their back on our “neighbors” and everything around us. Building a nation calls us to recognize that we must constantly relate to others, rejecting a mindset of hostility in order to adopt one of reciprocal subsidiarity, in a constant effort to do our best. I am confident that we can do this.
Our world is facing a refugee crisis of a magnitude not seen since the Second World War. This presents us with great challenges and many hard decisions. On this continent, too, thousands of persons are led to travel north in search of a better life for themselves and for their loved ones, in search of greater opportunities. Is this not what we want for our own children? We must not be taken aback by their numbers, but rather view them as persons, seeing their faces and listening to their stories, trying to respond as best we can to their situation. To respond in a way which is always humane, just and fraternal. We need to avoid a common temptation nowadays: to discard whatever proves troublesome. Let us remember the Golden Rule: “Do unto others as you would have them do unto you” (Mt 7:12).
This Rule points us in a clear direction. Let us treat others with the same passion and compassion with which we want to be treated. Let us seek for others the same possibilities which we seek for ourselves. Let us help others to grow, as we would like to be helped ourselves. In a word, if we want security, let us give security; if we want life, let us give life; if we want opportunities, let us provide opportunities. The yardstick we use for others will be the yardstick which time will use for us. The Golden Rule also reminds us of our responsibility to protect and defend human life at every stage of its development.
This conviction has led me, from the beginning of my ministry, to advocate at different levels for the global abolition of the death penalty. I am convinced that this way is the best, since every life is sacred, every human person is endowed with an inalienable dignity, and society can only benefit from the rehabilitation of those convicted of crimes. Recently my brother bishops here in the United States renewed their call for the abolition of the death penalty. Not only do I support them, but I also offer encouragement to all those who are convinced that a just and necessary punishment must never exclude the dimension of hope and the goal of rehabilitation.
In these times when social concerns are so important, I cannot fail to mention the Servant of God Dorothy Day, who founded the Catholic Worker Movement. Her social activism, her passion for justice and for the cause of the oppressed, were inspired by the Gospel, her faith, and the example of the saints.
How much progress has been made in this area in so many parts of the world! How much has been done in these first years of the third millennium to raise people out of extreme poverty! I know that you share my conviction that much more still needs to be done, and that in times of crisis and economic hardship a spirit of global solidarity must not be lost. At the same time I would encourage you to keep in mind all those people around us who are trapped in a cycle of poverty. They too need to be given hope. The fight against poverty and hunger must be fought constantly and on many fronts, especially in its causes. I know that many Americans today, as in the past, are working to deal with this problem.
It goes without saying that part of this great effort is the creation and distribution of wealth. The right use of natural resources, the proper application of technology and the harnessing of the spirit of enterprise are essential elements of an economy which seeks to be modern, inclusive and sustainable. “Business is a noble vocation, directed to producing wealth and improving the world. It can be a fruitful source of prosperity for the area in which it operates, especially if it sees the creation of jobs as an essential part of its service to the common good” (Laudato Si’, 129). This common good also includes the earth, a central theme of the encyclical which I recently wrote in order to “enter into dialogue with all people about our common home” . “We need a conversation which includes everyone, since the environmental challenge we are undergoing, and its human roots, concern and affect us all” .
In Laudato Si’, I call for a courageous and responsible effort to “redirect our steps” , and to avert the most serious effects of the environmental deterioration caused by human activity. I am convinced that we can make a difference and I have no doubt that the United States – and this Congress – have an important role to play. Now is the time for courageous actions and strategies, aimed at implementing a “culture of care” and “an integrated approach to combating poverty, restoring dignity to the excluded, and at the same time protecting nature” . “We have the freedom needed to limit and direct technology” ; “to devise intelligent ways of… developing and limiting our power” ; and to put technology “at the service of another type of progress, one which is healthier, more human, more social, more integral” . In this regard, I am confident that America’s outstanding academic and research institutions can make a vital contribution in the years ahead.
A century ago, at the beginning of the Great War, which Pope Benedict XV termed a “pointless slaughter”, another notable American was born: the Cistercian monk Thomas Merton. He remains a source of spiritual inspiration and a guide for many people. In his autobiography he wrote: “I came into the world. Free by nature, in the image of God, I was nevertheless the prisoner of my own violence and my own selfishness, in the image of the world into which I was born. That world was the picture of Hell, full of men like myself, loving God, and yet hating him; born to love him, living instead in fear of hopeless self-contradictory hungers”. Merton was above all a man of prayer, a thinker who challenged the certitudes of his time and opened new horizons for souls and for the Church. He was also a man of dialogue, a promoter of peace between peoples and religions.
From this perspective of dialogue, I would like to recognize the efforts made in recent months to help overcome historic differences linked to painful episodes of the past. It is my duty to build bridges and to help all men and women, in any way possible, to do the same. When countries which have been at odds resume the path of dialogue – a dialogue which may have been interrupted for the most legitimate of reasons – new opportunities open up for all. This has required, and requires, courage and daring, which is not the same as irresponsibility. A good political leader is one who, with the interests of all in mind, seizes the moment in a spirit of openness and pragmatism. A good political leader always opts to initiate processes rather than possessing spaces .
Being at the service of dialogue and peace also means being truly determined to minimize and, in the long term, to end the many armed conflicts throughout our world. Here we have to ask ourselves: Why are deadly weapons being sold to those who plan to inflict untold suffering on individuals and society? Sadly, the answer, as we all know, is simply for money: money that is drenched in blood, often innocent blood. In the face of this shameful and culpable silence, it is our duty to confront the problem and to stop the arms trade.
Three sons and a daughter of this land, four individuals and four dreams: Lincoln, liberty; Martin Luther King, liberty in plurality and non-exclusion; Dorothy Day, social justice and the rights of persons; and Thomas Merton, the capacity for dialogue and openness to God.
Four representatives of the American people.
I will end my visit to your country in Philadelphia, where I will take part in the World Meeting of Families. It is my wish that throughout my visit the family should be a recurrent theme. How essential the family has been to the building of this country! And how worthy it remains of our support and encouragement! Yet I cannot hide my concern for the family, which is threatened, perhaps as never before, from within and without. Fundamental relationships are being called into question, as is the very basis of marriage and the family. I can only reiterate the importance and, above all, the richness and the beauty of family life.
In particular, I would like to call attention to those family members who are the most vulnerable, the young. For many of them, a future filled with countless possibilities beckons, yet so many others seem disoriented and aimless, trapped in a hopeless maze of violence, abuse and despair. Their problems are our problems. We cannot avoid them. We need to face them together, to talk about them and to seek effective solutions rather than getting bogged down in discussions. At the risk of oversimplifying, we might say that we live in a culture which pressures young people not to start a family, because they lack possibilities for the future. Yet this same culture presents others with so many options that they too are dissuaded from starting a family.
A nation can be considered great when it defends liberty as Lincoln did, when it fosters a culture which enables people to “dream” of full rights for all their brothers and sisters, as Martin Luther King sought to do; when it strives for justice and the cause of the oppressed, as Dorothy Day did by her tireless work, the fruit of a faith which becomes dialogue and sows peace in the contemplative style of Thomas Merton.
In these remarks I have sought to present some of the richness of your cultural heritage, of the spirit of the American people. It is my desire that this spirit continue to develop and grow, so that as many young people as possible can inherit and dwell in a land which has inspired so many people to dream.
God bless America!”
Posted on | September 20, 2015 | No Comments
Since 2003, we’ve been delivering weekly packets of virtual health education. Now, twelve years after we began, the movement has become increasingly institutionalized and professional. Some of the offerings are small and some are huge. Consider the giant MOOC offerings (Massive Open Online Course) like Stanford’s 2013 course which rapidly reached an open enrollment of 160,000. By then, more than 6 million U.S. students had taken at least one course online, and 2/3 of all institutions of higher education cited online learning as critical to their future survival.
Virtual students in the best programs rate their virtual experiences highly for content, interaction, convenience, depth of learning, and exposure to the most advanced educational technologies. Students coming out of these programs, or working for the organizations that sponsor them, tend to be lifelong virtual learners and active sharers. Exploring, producing, and sharing content seems to be in their DNA.
At Health Commentary, we’re happy in a small way to be part of the movement. In celebrating its’ growth and success, we are pleased to introduce you to this week’s two guest authors who are intimately involved in the virtual healthcare education field:
Sophia Bernazzani is the community manager for MHA@GW, the online master of health administration offered by the Milken Institute School of Public Health at the George Washington University. She’s passionate about global health, sustainability, and nutrition. Her piece is titled, “A Closer Look at Preventable Harm”. Follow her on Twitter.
Julie Sweet is an editor of healthcare information for 2U.com. She earned her bachelor’s degree at Fordham University in New York City. She has recently moved from New York to Durham, North Carolina, where she supports 2U’s Healthcare Degree programs. Her post is titled, “How Climate Change is Hurting Our Health.”
When faced with a serious medical issue, most of us think about direct outcomes. Will there be a scar? How long will it be until I can go back to work or pick up my daughter? We spend much less time considering that things could go wrong: a surgery on the wrong site, a fall in the hospital, or an infection from improperly sterilized materials. Sadly, these types of medical errors, referred to as preventable harm, affect up to 1 in 4 discharges and cause an estimated 1,000 patient deaths per day. Only heart disease and cancer kill more Americans. It would seem the solution to the preventable harm question would be easy… find a way to “prevent” the harm. Unfortunately, it is not nearly that simple.(…continue)
Amid continued warnings about melting arctic ice and dangerous greenhouse gas emissions, a new conversation is emerging—how climate change is hurting our health. The human impact is already evident to 7 out of 10 physicians, according to a study published in the February Annals of the American Thoracic Society. The majority polled said they see the effects of climate change reflected in patients in several ways: more severe chronic disease as a result of air pollution, more allergies from exposure to plants and mold, and more injuries caused by severe weather.
“Around the world, variations in climate are affecting, in profoundly diverse ways, the air we breathe, the food we eat, and the water we drink,” wrote Dr. Maria Neira, director of the World Health Organization’s public health and environment department, in a recent commentary. “We are losing our capacity to sustain human life in good health.”
Although the world’s poor and sick are most vulnerable, every person on the planet is subject to the health effects of climate change. Here’s a look at how our hurting environment is gearing up to impact human health in the United States. (…continue)
Posted on | September 16, 2015 | No Comments
If you search under “The Future of Medicine”, you’ll see that the “Microbiome” is getting a great deal of air space these days. In fact, the NIH has committed $173 million to a collaborative dive titled the Human Microbiome Project. And yet, for most of us, it’s a new enough term that we need to continue to remind ourselves just what it means. But medical researchers have already moved beyond universal theories of its’ significance in normal homeostasis and the pathogenesis of inflammation and a wide range of diseases, and are now honing in on the questions that might be answered in formal studies.
But first, the definitions with the help of David Relman in this week’s JAMA:
Microbiota – “The human microbiota is a fundamental component of what it means to be human.” The term refers to the unique and personalized collection of microorganisms that live and thrive in each of us. As Relman explains: “All animals coexist in intimate, dependent relationships with microbes. Humans are no exception. Host-associated microbes, like nearly all others on this planet, form communities in which the overall composition, structure, and function are explained by ecological processes and environmental factors. Evidence of coadaptation and mutual benefit are key features of these symbioses between hosts and their microbial communities, or microbiotas.”
Microbiome – This term refers to the the collection of genes or genetic material that are contained in each of our microbiotas. Our growing ability to rapidly and cost-effectively analyze genetic structure has now allowed investigators to begin to peer into our microbiota and deconstruct the microbiome.
What they are finding raises some pretty serious questions including “Who’s hosting whom?” As Relman explains, “A recent examination of metagenomic sequence data obtained directly from human microbiota samples at 5 body sites identified more than 3000 biosynthetic gene clusters, each predicted to produce a small molecule with biological activity. Oral and gut communities contained more of these gene clusters (roughly 1100 and 600 per site, respectively) than communities at other, less diverse sites (such as skin and urogenital tract). Some of the most common types of predicted small molecules in the human microbiome are ribosomally synthesized and posttranslationally modified peptides—including lantibiotics, bacteriocins, and thiopeptides.”
Translation – our microbiomes are anything but passive. They are remarkably active and integrated with normal metabolism, physiology and pathophysiology. As importantly, their actions and products can be manipulated. This means that they are potential drug targets, which means that profit seeking individuals and corporations are and will continue to invest time and money in figuring out how they do what they do, and how to adjust their actions to favor wellness.
Relman says we already know a fair amount. Benefits include “differentiation of host mucosa, food digestion and nutrition, regulation of metabolism, processing and detoxification of environmental chemicals, development and ongoing regulation of the immune system, and prevention of invasion and growth of pathogens.” Debits? “…disturbance and alterations of the human microbiota… are associated with a wide variety of human diseases, such as chronic periodontitis, inflammatory bowel disease, and antibiotic-associated diarrhea.”
The field itself is beginning to feel a bit like environmental science turned inward. Consider these remarks, “The current surge of interest in this topic reflects in part recent advances in DNA sequencing technology and its use in characterizing the microbial world directly from environmental samples, as well as a renewed appreciation for ecological principles, including the importance of interactions among organisms; the formation, activities, and stability of communities of microbes; and the relationships between communities and their environment.”
This seems to bring a more nuanced appreciation of the old adage, “We are what we eat”. And it also suggests a note of caution (or optimism), as we see here, “Familiarity with an individual’s microbial ecosystem stability landscape might provide an understanding of their vulnerability to destabilizing factors such as antibiotics, as well as the likelihood of restoring their ecosystem to a health-associated state, for example, using a defined personalized synthetic community and complementary set of nutrients.”
So where are we. The experts seem focused on asking the right questions. Here’s Relman’s list:
1. “What are the most effective approaches for measuring human microbial ecosystem beneficial services?”
2. “What are the most important processes and factors that determine human microbiota assembly after birth?”
3. “Do different community assembly trajectories determine health and disease later in life, and if so, how?”
4. “What are the most important determinants of microbiome stability and resilience?”
5. “How can the stability and resilience of health-associated ecosystem states be strengthened?”
6. “How can health-associated ecosystem states be restored?”
5. “How (does) the microbiome…contribute to disease?”
For HealthCommentary, I’m Mike Magee.
Posted on | September 9, 2015 | No Comments
In the New York Times today, Thomas Friedman made the case that we are beginning to segregate nations worldwide into “worlds of order” versus “worlds of disorder”. In support of this comment, he presents the multi-border exodus from the Middle East to various nation’s of the European Union.
This I know, is not especially revelatory. But it does, of course, have health implications, especially for the young. And believe it or not, we have been making progress in worldwide childhood mortality. In fact, deaths in vulnerable kids have dropped 53% since 1990 according to a recent UNICEF report. Under-5 deaths have declined from a high of 12.7 million in 1990 to 5.9 million in 2015. Nearly half of those deaths (45%) occur in the first month of life. Putting vulnerable families in full flight, and exposed to the elements, without clean water, adequate food, and decent shelter, certainly won’t help.
Friedman has been watching mega-trends, and he is not optimistic that the world will rediscover its sanity any time soon. He cites three trends in particular as the source for future major destabilization. They are:
1. “Mother Nature -climate change, biodiversity loss and population growth in developing countries”,
2. Moore’s law: microchip power doubling every few years assuring expansion of inexpensive information technology, making it difficult for despots to control their populations,
3. Market globalization with every increasing competition for profits – witness the shifting tides of the energy sector these days,
Of course, Tom is right. Poor climate policy, a highjacked or poorly advantaged Internet, and unfettered capitalism with a few mega-winners and many, many losers, is not healthy.
But I think his insights extend beyond the developing world, and are already affecting our own shores. My contention is that bad policy decisions at this moment could significantly undermine our nation’s future health and stability.
For example a wrong-headed approach to immigration that weakens the economic stability of neighbors like Canada and Mexico simply assures an additional future illegal influx of desperate and vulnerable migrants trying to survive. We should be contributing to those nation’s successes, not trying to “wall them off”, because that will help to continue to ensure an additional buffer of sanity and stability on our northern and southern borders.
Similarly, our ignorant denial of global warming is already adversely effecting population and personal health and safety in enumerable ways. Our actions are accelerating these changes, with solutions increasingly out of reach. The great challenge here is to continue to support national energy independence without destroying our environment in the process.
Finally, there’s the special problem of unfettered capitalism. In a nation that relies on “balance of power” to check greed and ignorance – three branches of government, separation of church and state, for-profit versus not-for-profit, corporations versus government – dismantling these boundaries in the name of theoretical gains in efficiency and productivity, is beyond ill-advised.
One need only to critically examine our health delivery system – whose power players are able to manipulate regulation by passing seamlessly from government to academic to industry posts – to appreciate how easy it is to corrupt a system and its policies when unopposed by a significant countervailing force.
For HealthCommentary, I’m Mike Magee.
Posted on | September 2, 2015 | 8 Comments
I live in West Hartford, CT, an affluent town with more than its’ share of Type A personalities. In a town such as this, people would rather not give in to aging, have access to a wide range of community services, and remain active.
If you go to our skating ring, at any time, you are very unlikely to encounter skaters above the age of 55 – except rarely perhaps, a grandfather like me, whose love of his grandchildren is so extreme, that, with the encouragement of his wife, he ventures out on the ice with a four year dangling from either arm. But let me emphasize, this is highly unusual.
When it comes to aquatics, depending on day and time, use is far more inter-generational, from very young to very old, and heavily involves both men and women. I swim at least once a week, always the same number of laps. My goal is as much mental and spiritual, as it is physical. Mine is an emersion, similar I suppose to meditation or yoga. A video of me would show a half hour of slow-medium “crawl” – consistent, acceptable, but no one is signing me up for swim team. It is exercise, and I’m convinced does keep my upper body from completely drooping, but really, I do it because it helps put me in the right frame of mind, and makes me feel like I’ve at least accomplished something that day.
There are older, mostly male (3:1) swimmers who take it considerably more seriously than me. They wear Speedos and are racing the clock. They seem to arrive between 7:45 and 8:25 AM each day, and have a gear bag that includes hand cups, foot fins, and a wide range of toiletries. They are focused, serious, and committed.
Finally there’s the reservoir loops – some 30 miles of integrated paved trails that connect five different reservoirs, which provide a semi-natural setting for wildlife, but no access to boating, fishing, swiming, or other human activity. This is where my wife and I, each day, usually at 5 PM, weather permitting, walk for about 1 hour. The trails receive a moderate amount of use, more on weekends than on weekdays. At times you will see a three generational family walking along, laughing and talking, leisurely enjoying each others company. Rarely we’ll pass a couple our age. Infrequently we’ll see couples our children’s ages, and if so, they are working to teach a child to bike ride, or attempting to sooth a toddler trying to climb out of her stroller or catapult from the Bjorn pack.
The pathways are segregate by a vertical painted white line that separates the trail into thirds – 1/3 to the right and 2/3 to the left. Biking goes on the right, walking and jogging on the left. In theory, the system should quite simple protect the lives and limbs of most participants, except for two problems – the paths intersect with each other and also loop around the various reservoirs which creates some left/right confusion. And second, their is an oversupply of crazy type A, mostly male, mostly older (55 to 75) bike riders whose many objective appears to be to break speed records and escape the Grim Reaper. They universally overestimate their skill levels, judgement and reaction times, and underestimate the risks to themselves and all they pass along the way.
Think John Kerry, and his recent femur fracture – then multiple by 100, and insert a dizzying whirrrrring sound track, approaching blindly from behind, and you come close to our daily experience. Were this not bad enough, these aging male cyclists arrive at these protected trails by traveling the congested suburban roads shared by young and old alike. When I say they have absolute no concept of risk/benefit, I am sure you will agree.
So you will not be surprised that I was not surprised to read in the recent JAMA report that bicycle accidents are way up in the U.S. and that it’s mostly the result of older, male riders.
That report documented that over the past 15 years, injuries have risen almost 30% and resultant hospitalizations are up 120%. Those numbers were primarily driven by older males. Injuries in those over 45 during the study period, outpaced all others – up over 80%. Casual male cyclists outpace female cyclists (60%/40%). But in the sports cyclists category (think skin tight suits, pegged cycle shoes, and prostate injuring saddles) males own an 87% share.
I don’t agree with Trump on much – in fact, nothing – except perhaps this. To be speed cycling when you’re John Kerry’s age, is just plain stupid. He should take up swimming instead – with or without a Speedo- where there’s little risk of injuring himself or others.
For HealthCommentary, I’m Mike Mageekeep looking »