Trump and the Big, Bad Bugs

Trump & The Big Bad Bugs

Dispatches From The Edge

July 12, 2018

 

 

When people contemplate potential disasters ignited by the Trump administration’s foreign policy, places like the South China Sea, Central Asia, or the Korean Peninsula come first to mind. Certainly a dustup with Beijing, Teheran or Pyongyang is a scary thing to contemplate. But the thing that should also keep people up at night is Washington’s approach to international health organizations and the President’s stubborn refusal to address climate change.

 

Bad bugs are coming, and they are stronger and nastier than they have ever been. A few—like malaria and yellow fever—are ancient nemeses, but they’re increasingly immune to standard drugs and widening their reach behind a warming climate. Others—like Ebola, SARS, MERS and Zika—are new, exotic and fearsome. And antibiotic resistant bacteria threaten to turn the clock back to pre-penicillin days, when a cut could be a death sentence.

 

Trump’s disdain for international agencies and treaties, plus cuts in public health programs, and a relaxation of regulations on the use of antibiotics in animal husbandry could create a worldwide medical catastrophe.

 

The President recently asked Congress to cut over $15 billion from health care, especially in the area of overseas response. On the very day that the World Health Organization (WHO) declared an emergency over the latest Ebola outbreak, National Security Advisor John Bolton eliminated the National Security Agency’s program for epidemic prevention.

 

As Laurie Garrett—winner of the Pulitzer Prize for her writings on health care—notes, Bolton’s move “leaves the United States with no clear line of authority for responding to any outbreak of disease, whether naturally arising or as an act of bioterrorism,” adding “the U.S. government is increasingly withdrawing from global health efforts.”

 

The cost of that retreat may be dear.

 

The 2014-16 Ebola epidemic killed 11,300 people in Liberia, Sierra Leone and Guinea, and infected health workers brought it back to Europe and the U.S.. While the disease was eventually corralled, it continues to flare up.

 

WHO found that the key to stopping Ebola’s spread is an immediate response that combines vaccination with isolation and hospitalization, a strategy that stopped a 2018 outbreak in the Democratic Republic of the Congo in its tracks. But the Trump budget cuts all Ebola spending and reduces emergency funds for the State Department. A post-epidemic analysis found that an extra 300 hospital beds would have stopped the disease’s spread in 2014.

 

Diseases like Ebola get media attention, in part because Ebola kills more than 80 percent of its victims in a particularly grotesque manner: death by massive hemorrhaging.

 

But the more familiar diseases like malaria do the most damage. The malaria plasmodium infects 216 million people a year and kills 450,000, many of them children. And after decades of retreat, the disease is roaring back with varieties that are increasingly hard to treat. One by one, the barriers that once kept the disease at bay have fallen. Having overcome chloroquine, and then fansidar, now malaria has begun to breach the latest cure, artenisinin.

 

Public health experts predict that if the drug-resistant malaria strain ever reaches Africa, its impact will be catastrophic.

 

Yellow fever, once a major killer but largely tamed by mosquito control and vaccinations, is also making a comeback. Dengue, or “break-bone fever, which infects 400 million worldwide and kills over 25,000 people a year, has spread from nine countries in 1970 to over 100 today.

 

The fact that diseases overcome defenses is nothing new. Natural selection will generally find a way to outflank whatever chemicals humans come up with to defend themselves. Penicillin was discovered in 1939, and by 1941 doctor discovered Staphylococcus bacteria that were immune to the drug.

 

But bad policies and bad pathogens go hand in hand. The Trump administration’s withdrawal from the Paris Climate Accords will certainly accelerate climate change in a way that encourages the spread of disease. Earlier Springs and later Falls mean longer life spans for disease vectors like ticks and mosquitoes, which translates into greater infection rates. Researchers in Scandinavia and Massachusetts suspect that an increase in Lyme’s disease is due to climate change, and malaria is moving up the Andes as the higher altitudes warm.

 

Other diseases, like chagis—which kills 50,000 people a year—is already moving north as its vector, the assassin bug, migrates out of its base in Latin America. Diseases like West Nile is now part of the standard disease loads of Europe and the U.S.

 

Again, pathogen mobility is hardly new. Malaria, yellow fever, measles and small pox were all introduced to the New World by travelers, conquerors and African slaves. But disease is even less a local phenomenon today than it was in the 15^th century. As Dr. Don Francis, who played a key role in identifying the HIV virus and was on the first medical team to confront Ebola, points out how disease spreads: “Just sit in an airport and watch all the costumes walk by.”

 

Trump is famously resistant to science. He doesn’t yet have a White House science advisor and is relying, instead, on Michael Kratsios, a 31-year old political science major who studied Hellenic Greece. Kratsios was the former chief of staff of California billionaire Peter Thiel, founder of PayPal, who advocates rolling back Food and Drug Administration regulations.

 

Those regulations cover the use of antibiotics in animal husbandry. Chickens, cattle and pigs account for 70 percent of the antibiotics used in the U.S. The animals are not ill, just packed into pens and cages that would sicken them if they were not juiced with Bambermycin, Salinomycin or Bacitracin. Antibiotics also increase the animals’ weight.

 

But animals jammed into rarely cleaned cages and pens are the perfect Petri dish for generating drug resistant germs. According to the Environmental Working Group, nearly 80 percent of U.S. supermarket meat is infected with antibiotic resistant germs. Studies of meats in the U.S. show that up to 70 percent are laced with germs immune to antibiotics.

When the European Union banned non-therapeutic antibiotics on animals, drug resistant germ levels declined dramatically.

 

Eventually those pathogens move from animal pens to hospitals and gyms and airports. What you do in an Iowa pig farm does not stay in Iowa.

 

The U.S. Center for Disease Control and Prevention (CDC) says that 23,000 Americans die each year from drug resistant germs, and a British study predicted that, unless something is done about the crisis, antibiotic resistant bacteria could kill 10 million people a year by 2050. The WHO says “superbugs” pose one of the most serous threats that humanity faces, and the medical magazine Lancet called drug resistant pathogens “The biggest global health threat in the 21^st Century.”.

 

The White House’s hostility to the Obama administration’s Affordable Care Act could also have major consequences, not only for Americans, but the world. In 1918, a mild Spanish flu mutated—probably in Kansas—into a fearsome virus that killed between 50 and 100 million people worldwide.

 

The 1918-19 pandemic almost certainly started in the digestive tracts of Chinese pigs, then passed to birds, and from birds to people. Those Chinese pigs are still out there, and lethal varieties of bird flu are currently circulating in China and Southeast Asia. So far, most can only be passed by direct contact with infected animals, but sooner or later there will be a mutation that will make a virus far more communicable. A deadly worldwide pandemic is a “when,” not an “if.”

 

And when that pandemic hits, Americans will find that there are not enough hospital beds—so-called “surge capacity” is non-existent—or robust public health programs to cope with it. China has also cut back on public health care programs and, as a result, was initially unable to deal with the 2003 SARS crisis that sickened 8,000 people and killed 800.

 

Europeans, with their national health services, are better prepared, but even their public health systems have been hollowed out by years of austerity-driven economic policies. But there is a worldwide shortage of medical workers, particularly nurses.

 

In his “Second Coming,” the Irish writer William Butler Yeats seems to have foreseen the future: “Some rough beast, its time come round at last, Slouches toward Bethlehem, waiting to be born.”

 

The beasts are out there, and they will be born. The Trump administration’s denial of climate change, hostility to international institutions, and laissez faire approach to governance at home will make those beasts far more dangerous than they have to be.

 

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Traumatic Brain Injuries: The War Comes Home

The Wars Come Home: The Traumatic Brain

Injury Epidemic

Dispatches From The Edge

June 18, 20011

 

 

“We are facing a massive mental health problem as a result of our wars in Iraq and Afghanistan. As a country we have not responded adequately to the problem. Unless we act urgently and wisely, we will be dealing with an epidemic of service related psychological wounds for years to come.”

Bobby Muller, President Veterans for America

 

“The multiple nature of it [multiple tours and longer deployments] is unprecedented. People just get blasted and blasted and blasted.”

Maj. Connie Johnmeyer, 332^nd Medical Group

 

According to official Defense Department (DOD) figures, 332,000 soldiers have suffered brain injuries since 2000, although most independent experts estimate that the number is over 400,000. Many of these are mild traumatic brain injuries (mTBI), a term that is profoundly misleading.

 

As David Hovda, director of the Brain Injury Research Center at the University of California at Los Angeles, points out, “I don’t know what makes it ‘mild,’ because it can evolve into anxiety disorders, personality changes, and depression.” It can also set off a constellation of physical disabilities from chronic pain to sexual dysfunction and insomnia.

 

MTBI is defined as any incident that produces unconsciousness lasting for up to a half hour or creates an altered state consciousness. It is the signature wound for the wars in Iraq and Afghanistan, where roadside bombs are the principal weapon for insurgents.

 

Most soldiers recover from mTBI, but between five and 15 percent do not. According to Dr. Elaine Peskind of the University of Washington Medical School, “The estimate of the number who returned with symptomatic mild traumatic brain injury due to blast exposure has varied from the official VA [Veterans Administration] number of 9 percent officially diagnosed with mTBI to over 20 percent, and, I think, ultimately it will be higher than that.”

 

Serious consequences from mTBI are increased when troops are subjected to multiple explosions and “just get blasted and blasted and blasted,” in the words of Maj. Connie Johnmeyer. Out of two million troops who have served in Iraq and Afghanistan, over 800,000 have had multiple deployments, many up to five times or more.

 

But mTBI is difficult to diagnose because it does not show up on standard CAT scans and MRIs. “Our scans show nothing,” says Dr. Michael Weiner, professor of radiology, psychiatry and neurology at the University of California at San Francisco and director of the Center for Imaging Neurodegenerative Disease at the Veteran’s Administration Medical Center.

 

They do now.

 

An MRI set to track the flow of water through the brain’s neurons, has turned up anomalies that indicate the presence of mTBI. However, the military has blocked informing patients of results of the research, and if history is any guide, the Pentagon will do its best to shelve or ignore the results.

 

The DOD has long resisted the diagnosis of mTBI, as it has avoided paying for a successful—but expensive—way to treat it. The price of that resistance is escalating suicide rates and domestic violence incidents among returning soldiers. In 2010, almost as many soldiers committed suicide as fell in battle.

 

MTBI is hardly new. Some 5.3 million people in the U.S. are currently hospitalized or in residential facilities because of it, and its social consequences are severe.

 

A Mt. Sinai Hospital study of 100 homeless men in New York found that 80 percent of them had suffered brain trauma, much of it from child abuse. A study of 5,000 homeless people in New Haven discovered that those who had suffered a blow that knocked them unconscious or into an altered state were twice as likely to have alcohol and drug problems and to be depressed. It also found mTBI injuries were correlated with suicide attempts, panic attacks, and obsessive-compulsive disorders. And a recent study by Dr. Elaine Peskind of the University of Washington School of Medicine found that mTBI is a risk factor for developing Alzheimer’s disease.

 

In spite of the documented consequences of mTBI, the military has been extremely tardy in dealing with it. Part of the problem is military culture itself. The Pentagon found that 60 percent of the soldiers who suffered from the symptoms of mTBI refused help because they feared their unit leaders would treat them differently. Many were also afraid that if they reported their condition it would prevent them from getting jobs as police and fire fighters after they got out of the service.

 

Even if soldiers wanted treatment, there are few resources available to them. “There are two things going on regarding vets,” says Col. (ret) Will Wilson, chair of the American Psychological Association’s Division 19 (Military Psychology). “One, there are not enough care providers available, and, two, there are not enough people focusing on the problem outside the military.”

 

Indeed, there are not enough military psychologists to treat the problem, and since the military pays below-market rates for civilian psychologists, up to 30 percent of private psychologists are unwilling to take on soldiers as patients. The cheapest and easiest solution is to shoot up the vets with drugs. A study by Veterans for America found that some soldiers were taking up to 20 different medications, many of which canceled out the effect of others.

 

The situation appears to be even worse for National Guard and Reserve units, who make up almost 50 percent of the troops deployed in Iraq and Afghanistan. The Veterans for America found that such troops “are experiencing rates of mental health problems 44 percent higher than their active duty counterparts” and that their health care is generally inferior.

 

A Harvard study found that 1.8 million vets under 65 have no health care or access to the Veterans Administration. “Most uninsured veterans are low-to-middle income workers who are too poor to afford private coverage but are not poor enough to qualify for Medicaid or free VA care,” the study found.

 

Treating mTBI injuries is difficult, but by no means impossible. Dr. Alisa Gean, chief of Neuroradiology at San Francisco General Hospital, who has worked with wounded soldiers at U.S. Army’s Regional Medical Center at Landstuhl, Germany says the old conventional wisdom that brain damage was untreatable is wrong. “We now know that the brain can heal. It has an intrinsic plasticity that allows it to recover, and this is particularly true for the young brain.”

 

A recent study by the Massachusetts Institute of Technology found that “neurons in the adult brain can remodel their connections,” thus “overturning a century of prevailing thought.”

 

One method that has worked effectively is cognitive rehabilitation therapy (CRT) that retrains patients for tasks like counting, cooking, and memory. But CRT takes time and it can be expensive, ranging from $15,000 to $50,000 per patient. However, the DOD’s health program—Tricare—refuses to endorse CRT, because it says there is no scientific evidence that justifies the expense involved.

 

However, an investigation by T. Christian Miller of ProPublica and Daniel Zwerdling of National Public Radio found that the vast majority of researchers, even those associated with the DOD, sharply disagreed with Tricare’s evaluation of CRT. According to the two reporters, “A panel of 50 civilian and military brain specialists convened by the Pentagon unanimously concluded that cognitive therapy was an effective treatment and would help many brain damaged troops.”

 

The therapy is also endorsed by the National Institutes of Health, the National Academy of Neurophysiology and the British Society of Rehabilitative Medicine.

 

Instead of accepting the advice of its own researchers, however, Tricare hired ECRI—a company which had already done a study concluding that CRT was ineffective—to examine the therapy. But critics charge that the study was so narrow, and the assumptions behind it so loaded, that it was almost a given that the study would conclude the benefits of cognitive therapy were “inconclusive.” Outside researchers blasted the ECRI study, one of them describing it as “hooey” and “baloney.”

 

In spite of the criticism, then Deputy Secretary of Defense Gordon England concluded, “The rigor of the research…has not met the required standard.”

 

However, Miller and Zwerdling concluded that Tricare’s resistance to CRT was not about science, but the bottom dollar. According to the reporters, a Tricare-sponsored study found “that comprehensive rehabilitative therapy could cost as much as $51,480 per patient. By contrast, sending patients home from the hospital to get a weekly phone call from a therapist amounted to only $504 a patient.”

 

Defense Secretary Robert Gates has already made it clear that he intends to cut the military’s $50 billion annual health budget. No matter how effective CRT is, it’s not likely to get past the brass, who would rather spend the money on weapon systems than on healing the men and women who they so casually put in harm’s way.

 

So far, the military has put the clamps on the new MRI technique. Dr. David L. Brody, an author of the study, told the New York Times that researchers were blocked from giving the MRI results to patients. “We were specifically directed by the Department of Defense not to so,” adding, “It was anguishing for us, because as a doctor I would like to be able to help them in any way. But that was not the protocol we agreed to.”

 

Given that mTBI is so difficult to diagnose, and sufferers are many times told there is nothing wrong with them, that seems an especially cruel protocol. “Many of them [the doctors] were hoping we could give results to their care providers to document or validate their concerns.”

 

In the end it will come down to treatment, and whether the wounded vets will get the care they need, or sit by a phone and wait for their once a week call from a therapist.

 

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“War Is Not Good For You” review

War Is Not Good For You Review

Dispatches From The Edge

Nov. 23, 2010

“War and Public Health” edited by Barry S. Levy and Victor W. Sidel. Second edition, Oxford University Press, 2008, $51.22

Back in the 60s peace activists sported a bumper sticker that read: “War is not good for children and other living creatures.” In a way, that sums up Barry S. Levy and Victor W. Sidel’s “War and Public Health,” where 46 experts on everything from epidemiology to international law weigh in on the authors’ central premise: “War and militarism have catastrophic effects on human health and well being.”

Levy and Sidel, both former presidents of the American Public Health Association, as well as distinguished researchers and practitioners in their fields, make the point that, in the end, wars always come home. The most obvious casualties are the young men and women shattered in body and mind by the cauldron of battle itself, but the devastation includes the terrible things that organized violence inflicts on the population and infrastructure where those wars are fought.

But the authors see the shock and awe of battle as only the beginning of the damage war inflicts. War means that nations divert their resources from things like education and health to smart bombs and high tech drones. It means choosing mayhem over economic development, exposing the most vulnerable in our society to disease and privation, and the systematic destruction of the environment. “War threatens much of the fabric of our civilization,” write Levy and Sidel.

Thinking of war as a public health issue allows the authors to break the subject into digestible pieces: consequences, types of weapons, vulnerable populations, specific wars, and prevention. Each major section is divided into chapters, spanning everything from “The Epidemiology of War” to “The Role of Health Professionals in Postconflict Situations.”

According to a recent estimate by sociologist Chalmers Johnson, if all U.S. military-related spending were added together it would come to about $1 trillion a year. Nobel Laureate economist Joseph Stiglitz concludes that the lifetime costs of treating veterans of Afghanistan and Iraq will top $3 trillion. At the same time, according to the U.S. Census, 50.7 million people in the U.S. are currently without health care.

These are the kinds of tradeoffs the authors and contributors to “War and Public Health” find unacceptable.

The book is more than an expose, however. Levy and Sidel argue that public health officials should be involved in preventing war, just as they would throw themselves into stopping an epidemic.

And in case the reader is not sure how to go about doing this, the book includes an appendix with the names, addresses, phone numbers and emails of virtually every international organization concerned with war and peace.

“War is hell,” said Union General William Tecumseh Sherman, and so it is. But the authors of this well-written and accessible book argue that wars are not inevitable, and that time and again human beings have demonstrated a capacity to avoid them. On one hand, “War and Public Health” is an important and valuable effort to expose the consequences of war. On the other, a practical guide to creating a world where health is a human right and war is an anachronism.

Conn Hallinan’s writings can be found atdispatchesfromtheedgeblog.wordpress.com

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Vaccine Policy

Revolution

11-19-2005

Conn Hallinan & Carl Bloice

“For too long, the development and manufacture of vaccines and antiviral drugs has been of limited interest to drug companies”

–editorial, The Lancet

Oct. 1, 2005

Dr. Don Francis’ office at Global Solutions for Infectious Disease (GSID) is a museum of his family’s long war with disease.

His grandfather and parents’ medical degrees are next to a California State Legislative Resolution thanking him for his “outstanding” service in the battle against AIDS. A small trophy from the Hemophilia/HIV Peer Association celebrates him as a “Warrior for Justice,” and a plaque on the wall thanks him for helping to eradicate smallpox in India. He has just returned from trying to beat back polio in the Indian state of Bihar, and he is preparing to leave for Africa.

But if his office is crowded with laurels, the rest of GSID in Brisbane, Ca. is a study in minimalism. The wall-to-wall carpet is rarely broken by furniture, and the place feels blank and cavernous. Asked why it looks so bare, Development Manager Ian Francis—a nephew—looks up from his laptop: “No money,” he shrugs.

Indeed, until recently, Francis and his partner paid the rent out of their own pockets, forgoing any salary. And while GSID has an AIDS vaccine ready to go into its final testing phase, it doesn’t have the money to move it into the field.

It is a bind Francis finds deeply aggravating. “Vaccines have had the biggest impact on health of any product ever made,” says Francis. “With biotechnology we now have a revolution in our ability to make vaccines, but we are only beginning to take advantage of it because we don’t value what they do.”

GSID’s mix of poverty, combined with veterans in the battle against humanities great killers—malaria, AIDS, dysentery—sums up the problem and the potential of medicine’s new kid on the block, Public-Private Partnerships (PPPs).

PPPs are non-profit organizations that meld pharmaceutical companies, non-governmental organizations, charitable foundations, universities, and national and international institutions like the Center for Disease Control (CDC) and the World Health Organization (WHO) into coalitions. Their goal is to stimulate research and figure out how to deliver vaccines and medicines to people too poor to afford them.

Started in the mid-1990s, such PPPs as Roll Back Malaria (RBM) and the Global Alliance for Vaccines and Immunization (GAVI) are leading campaigns against the so-called “neglected diseases” that inflict millions of deaths each year, particularly among the poor, and especially in sub-Saharan Africa.

According to Doctors Without Borders, between 1973 and 1997, out of 1450 new drugs, only 13 were for the “ignored diseases, and the number of vaccine developers declined from 26 in 1967 to five today.

That may be changing. A Wellcome Trust study by the London School of Economics suggests that PPPs are successful in generating new drugs. Since 2000, some 63 new drugs aimed at these diseases are in the pipeline, 18 of them in clinical trials.

Some even see vaccines as a growth industry. According to a study by the investment bank, Morgan Stanley, “Vaccines are one of the most overlooked new opportunities in phrarma/biotech.”

Which some people see as a problem.

“We have gone from people seeing vaccines as something that is for the public good and that should reside in the public sector, to something that makes profits,” says Dr. Anthony Robbins of Tufts University, adding “We haven’t changed the behavior of the private sector, we are just financing it.”

Robbins is a former president of the American Public Health Assn. (APHA), directed several state public health programs, and is the former director of the U.S. National Institute for Occupational Health and Safety.

Figures on PPPs tend to bear Robbins out. According to a study by the South Asian health and environmental magazine, Down To Earth, the public sector, including WHO and the U.S. National Institute for Health (NIH), underwrites about 88 percent of PPP budgets. The private sector contributes about 10 percent, and philanthropy picks up the rest.

Philanthropic contributions, led by the Bill and Melinda Gates Foundation with its $29 billion endowment, more than doubled from 2002 to 2004. Gates accounts for 75 percent of philanthropic donations and recently announced an infusion of $258.3 million to malaria research.

In contrast, private sector contributions appear to have fallen. Drug and biotech companies donated $68 million last year, $31 million less than in 2004.

The annual WHO budget is $1.65 billion.

While pharmaceutical companies contribute only a small part of PPPs research and development money, they reap the patents The AIDS drug AZT was developed by Yale University on a grant from NIH, but GlaxoSmithKline ended up with it.

Drug companies also fiercely defend intellectual property laws. “Our ability to invest such huge sums in R&D (research and development) depends on strong patent protection,” says Richard Sykes, former CEO at Glaxo Wellcome. A patent lasts 20 years.

The companies claim it costs between $500 and $800 million and 12 to 15 years to develop a drug.

But those are industry-generated figures. No outside agency has ever examined drug company books, nor has Congress ever subpoenaed such records. Critics claim the costs are overblown, and that non-research and development costs, like marketing, administration and lobbying, are folded into that $500 to $800 million figure.

According to health researcher Hannah Plumb in “Putting a Price on Life,” advertising costs are more than double R&D. In 2000, Merck spent $6.2 billion on marketing and advertising (M&A), and $2.3 billion on R&D. Pfizer spent $11.4 billion on M&A and $4.4 billion on R&D. And BristolMyersSquibb spent $5.6 billion on M&A and $1.9 billion on R&D.

In comparison, of R&D money spent for an AIDS vaccine in 2004, 67 percent was spent on pre-clinical research, 32 percent on clinical trials and development, and 1 percent on advocacy.

The companies also write off 46 cents for every $1 spent on R&D, a deduction they conveniently ignore when they add up bottom line figures for drug development.

Profits have never been a problem for drug companies, which posted gains four times greater than the average Fortune 500 company in 2000, out performing even mega-empires like Microsoft.

This private-public alliance is not always a comfortable one, and public health advocates like Dr. Victor Sidel are “very suspicious” of the private side’s motivations, since their “bottom line is to make money.”

Sidel, a former president of the APHA and Distinguished University Professor at Montifiore Hospital in New York, has recently co-authored a book with Dr. Barry Levy,” Social Justice and Public Health.”

For instance, because the private sector is only willing to underwrite vaccines that can be patented, the use of older vaccines is declining at a time when a combination of growing poverty and an explosion of urbanization is increasing the disease burden in the Third World.

A UNICEF study found that in 1990, 80 percent of the world’s children were immunized against the main childhood diseases: diphtheria, tetanus, whooping cough, measles, polio and tuberculosis. By 2000 that had fallen to 75 percent. In 19 African countries only 50 percent were vaccinated for the “big six.” The price those children pay for going unvaccinated is a heavy one: about 1.5 million under the age of five die each year.

While vaccines past their 20-year patent date go a-begging, Sanofi-Pasteur is pouring tens of millions into developing a dengue fever vaccine. According to a 2002 GAVI report, 63 percent of its resources are slotted for new vaccines, vaccines, that is, which can be patented.

A major focus of vaccine R&D is malaria. It is an ancient disease that plagued the Greeks, and was a major problem in Southern Europe and the American South until well into the 1940s. It consumes nearly 40 percent of the public health spending in Africa and cuts a grim swath through children under the age of five. There are at least 500 million cases of malaria a year.

“It is a moral outrage,” Richard Feachem, professor of Public Health at the University of California, Berkeley and director of the Global Fund, told the New Yorker magazine. “This is an utterly preventable holocaust, and numbers are far higher than the WHO says. They have put the dead at one million (a year) for years, and now it is really three million in terms of deaths to which malaria might have contributed.”

And the situation is getting worse, as conditions that favor malaria—from increasing urbanization to global warming—widen the disease’s reach. Currently, 50 percent of the world’s population is exposed to malaria, an increase of 10% over the past decade. “More people have suffered from malaria in the past 50 years,” says Feachem, “than in the history of mankind. It is a remarkable march backward.”

At the same time, fewer and fewer drugs are effective against it. The plasmodium that causes the disease is complex and, in terms of developing a resistance to drugs and insecticides and fooling the body’s immune system, devilishly clever.

Part of the problem is that the developed world eliminated malaria by the mid-1950s, easing the pressure to develop a vaccine. With the exception of the military’s interest in a vaccine, research funds dried up. Abandoned by wealthy nations, and unable to pay for the R&D themselves, Third World countries have increasingly relied on philanthropy to help them control the disease.

But how that money is spent is fraught with controversy. For example, the Gates Foundation, the largest of these philanthropies, is strongly biased toward the development of new technology. Almost half of the Foundation’s recent grant will go toward a malaria vaccine being developed by two drug companies, Rixensart of Belgium and the British giant, GlaxcoSmithKline.

A malaria vaccine is certainly a worthy goal, particularly since the disease has long resisted one, and with new biotechnology techniques, it may be possible to finally develop one. A GlaxoSmithKline vaccine, largely bankrolled by Gates, is presently being tested in Mozambique and reportedly reduces severe malaria in children by 58 percent.

But a number of public health advocates argue that what is needed is not so much new technology, as the ability to deliver things like mosquito nets and medicine. “I think we need not put our hopes in magic bullets when we have an arsenal to make such an impact now,” argues David Schellenberg from the London School of Hygiene & Tropical Medicine. “What we need are magic guns, not magic bullets. We need to be able to deliver what we already have.”

The influential British medical magazine, The Lancet, recently editorialized that “The eradication of disease and the alleviation of suffering depends more on developing the skills of talented people than on technology,” and suggested that PPPs consider underwriting medical training.

Canadian health economist Anne-Emanuelle Birn is also critical of the “technology” solution. “In calling on the world’s researchers to develop innovative solution targets to ‘the most critical scientific challenges in the global health’ the Gates Foundation has turned a narrowly conceived understanding of health as a product of technological interventions divorced from economic, social and political contexts.”

A number of PPP advocates argue that reducing the disease burden on the Third World will be an important ingredient toward lifting populations out of poverty. But the link between poverty and disease is a complex and tangled one.

Shortly after World War II, on a grant from the Rockefeller Foundation, anthropologist Peter Brown examined what effect eliminating malaria in Sardinia would have on poverty. It turned out, very little. Brown found that while malaria consumed 4.6 percent of its victim’s caloric intake, landlords swallowed up 62 percent of the island’s calories.

Regardless of the critiques, however, PPPs appear to be one of the few games in town. “PPPs are the result of people realizing that returns on investment isn’t going to be the the model that drives forward the development of needed vaccines,” says Dr. David Olson, medical advisor of Doctors Without Borders (DWB). “PPPs are seeking a way to bring together scientists, donors and industry to focus on particular problems. They also keep someone responsible for keeping their eye on the ball.”

Even those who are leery of PPPs admit that creating alternatives is, as Sidel puts it, a “long-term” project.

For warriors like Francis, battling AIDS, polio, and diseases that are little heard of in the First World but extract a deadly tithe in the Third, “long-term” is a luxury. “Time is money in the private sector, but in vaccines, time is death and suffering. For every day we don’t have vaccine ‘Y,’ so many people die,” he says.

His view of Bill and Melinda Gates? “Bless them,” he says.

Sidel agrees that “in the short run” Francis is probably correct about PPPs, but that the long-term project of building a public sector vaccine industry, where profit is not the bottom line, needs to be done. “And in so far as they (PPPs) delay the buildup of a public sector,” they can be problematical, he says

Tuft’s Robbins says there is a long history of successful government intervention to solve problems, “like landing people on the Moon. No one thought the private sector would do that, the government did it.”

There is certainly precedent for government intervention in health. Popular campaigns in India, Thailand and China forced governments to manufacture cheap generics to treat HIV.

A similar movement in Brazil pushed the government to withdraw from the World Trade Organization because of its objections to patenting generic anti-virals. Not only were the Brazilian generics five to six times cheaper, but under market pressure, Merck dropped the price of the antivirals Indiarvir by 65 percent and Rfavirencz by 59 percent. From 1996 to 2001, AIDS treatment costs in Brazil fell 73 percent.

Olson argues that governments need to see that just because disease is somewhere else, doesn’t mean is shouldn’t be their concern. “Take, for instance, Botswana where there is a possibility that the existence of the country is at stake, that the AIDS crisis could get so large as to make the country non-functional.” He says that possibility should be seen as a “security concern,” and that governments need to realize “that their countries will be affected in the long run—if not the short run.”

While drug companies argue that profit has been the driving force behind vaccine creation, profit has not always been the motive, even in the most successful vaccine campaigns. Jonas Salk and Albert Sabin refused to patent their polio vaccines, and Alexander Fleming rejected patenting penicillin. The discoverer of insulin handed his patent over to the University of Toronto for $1.

Relying on drug companies to find cures for “neglected diseases” in the Third World has not worked very well, although PPPs have helped make progress in this area. Ultimately, however the bottom line for drug companies is profit. “The private sector is not much concerned with countries or people without disposable income,” Robbins points out.

Indeed, when it comes to vaccines, profit may be part of the problem. “Vaccines are almost treated like orphan drugs,” says Francie Wise, RN, MPH, the Contra Costa County director of public nursing and an expert on communicable diseases. “There is not enough profit in them.”

Francis agrees that vaccines are not profitable because of the very nature of the drugs themselves. “From the drug manufacturers point of view, the ideal drug is one that doesn’t cure, is defective, in a sense, but good enough to keep taking for years.” Vaccines, he says, are generally given only once or twice.

The global shortfall is also about haves and have-nots, illustrated by the Global Forum for Health Research’s “10/90 gap”: 10 percent of the world’s resources are directed at diseases that are responsible for 90 percent of the world’s disease burden.

Put another way, North America, Europe and Japan constitute 23 percent of the world’s population, but account for 80 percent of the world’s drug market. Only 0.3 percent of the money spent on medical research goes to malaria, unarguably the biggest killer on the planet. Sixteen times that amount goes into researching and treating diabetes, a dangerous disease, but hardly comparable to malaria.

Poor countries fear that in the advent of a flu pandemic, wealthy countries will hoard any vaccines that are developed. Markos Kyprianou, health and consumer protection minister for the European Union, recently called for “Rich and powerful countries” to share vaccines and antivirals drugs with “poor and affected ones.”

Poverty and unequal access to health care, however, is not just a Third World problem. The U.S., is the wealthiest country in the world, but it is 29^th in life expectancy and 38^th in infant mortality. A child born in the upper East Side of New York City has a one in 600 chance of dying before the age of one. A child born 20 blocks further uptown in Harlem has a one in 50 chance. As hurricane Katrina demonstrated, the Third World can exist in the heart of the First World.

And lastly there are politics.

“We live in a world where people have decided that government doesn’t have a role,” says Robbins, something he thinks needs changing. One suggestion he has is for the United Nations to establish a vaccine cartel. He understands the impulse behind PPPs, but doesn’t believe they are the solution in the long run. “We have to rescue these dedicated scientists from a trap not of their own making.”

Traumatic Brain Injury

Traumatic Brain Injury

Registered Nurse

3-30-2008

Conn Hallinan

Carl Bloice

“We are facing a massive mental health problem as a result of our wars in Iraq and Afghanistan. As a country, we have not responded adequately to this problem. Unless we act urgently and wisely, we’ll be dealing with an epidemic of service-related psychological wounds for years to come.”

–Bobby Muller, President Veterans For America

David Hovda, director of the Brain Injury Research Center at the University of California at Los Angeles (UCLA), calls traumatic brain injury (TBI) the “silent epidemic.” It is the most common cause of death for U.S. adults under the age of 45, deadlier than AIDS, Multiple Sclerosis, spinal cord injury and breast cancer combined. It strikes down 1.6 million Americans a year. And while TBI may be a quiet wound, its consequences for victims, family, friends and co-workers can be catastrophic.

Adding to that 1.6 million figure are two wars whose signature injury are blast-induced head wounds. A recent study by the General Accounting Office found that, “Traumatic brain injury has emerged as the leading injury among U.S. forces serving in Afghanistan and Iraq.”

According to a Walter Reed Hospital study, “closed brain” injuries—injuries with no visible marks—outnumber “penetrating brain injuries” seven to one. Other researchers put the ratio much higher.

“We are looking at a very frightening situation,” says Dr. Judith Landau,psychiatrist and president of Linking Human Systems in Boulder, Colorado, who works with vets and their families.

And yet, according to Dr. Michael Weiner, professor of medicine, radiology, psychiatry and neurology at the University of California at San Francisco (UCSF) and director of the Center for Imaging of Neurodegenerative Disease at the Veteran’s Administration Medical Center,

“There is a lot more that we don’t know about it [TBI], than we do.”

For starters it’s hard to spot. “Our scans show nothing,” says Weiner.

TBI is a slippery beast, or “murky” as Weiner puts it. It can cause symptoms ranging from depression and uncontrollable rages to irritable bowels and emotional disengagement. It can suddenly appear long after the incident that caused it, and it is difficult and complex to treat.

While medicine is beginning to understand more about the kind of TBI generated by car accidents, falls, or sports injuries, no one is quite sure exactly what causes the TBI generated by roadside bombs in Iraq and Afghanistan. “It is a complicated injury to the most complicated part of the body,” says Dr. Alisa Gean, chief of Neuroradiology at San Francisco General Hospital, who has worked with wounded soldiers at the U.S. Army’s Regional Medical Center at Landstuhl, Germany.

Whatever the causes, the constellation of symptoms that TBI induces include short term memory loss, stomach, chest, back and head pain, dizziness, racing pulse, constipation, diarrhea, sexual dysfunction, insomnia, inability to concentrate, damage to hearing and vision, personality changes, and Post Traumatic Stress Disorder (PTSD).

Indeed, part of the problem in identifying TBI is that its symptoms are so similar to PTSD.

A recent study of veterans returning from Iraq and Afghanistan found that the severity of those symptoms was greatly affected by how serious the incident that caused the TBI was: whether the victim was knocked unconsciousness, or was simply dazed and confused, inwhat is called an “altered state.” A U.S. military study notes, “Injuries associated with the loss of consciousness carried a much greater risk of health problems than did injuries associated with altered mental states.”

The Pentagon says about 20,000 GIs have returned with TBI, but most experts say the figure is much higher. U.S. Rep. Bill Pascrell (D-NJ), founder of the Congressional Brain Injury Task Force, says the figure could be as high as 150,000.

TBI is hardy new. Some 5.3 million people in the country are currently hospitalized or in residential facilities because of it. And its consequences surround us.

For instance, researchers have found a relationship between TBI and problems like addiction and homelessness. “Unidentified traumatic brain injury is an unrecognized major source of social and vocational failure,” says Wayne A. Gordon, director of the Brain Injury Research Center at Mt. Sinai School of Medicine.

One Mt. Sinai study of 100 homeless men in New York found that 80 of them had suffered brain trauma, much of it from child abuse. A similar study of 5,000 homeless people in New Haven, Conn.., discovered that those who had suffered a blow that knocked them unconscious or into an altered statewere twice as likely to have alcohol and drug problems and to be depressed. It also found higher rates of suicide attempts, panic attacks, and obsessive-compulsive disorder.

A Canadian study indicates that a blow powerful enough to cause unconsciousness causes a loss of brain tissue. “There is more damage and it is more widespread that we had expected,” Brian Levine of the University of Toronto’s Rotman Research Institute told the Toronto Star.

Levine says the cell loss appears to be in the brain’s white matter that is essential to communication. Even a small loss in this region of the brain, “Will have a quite large effect on behavior,” he says.

If its effects are dramatic, its profile has been modest until recently. Gean says she has been “carrying a torch” on civilian TBI for over 20 years—she is the author of what is considered the standard textbook on imaging TBI—but the subject has “escaped the radar of funding.” People worry about whether they are going to get breast cancer or AIDS, but “people don’t think they are going to get TBI,” she says.

Afghanistan and Iraq have changed all that. “The wars have caused people to come around to acknowledge the psychological aspects of TBI,” says Gean, and she credits ABC’s Bob Woodruff for helping to bring the subject before the public.

Woodruff was seriously wounded in the head by a roadside bomb in Iraq and his struggle to return to work was covered extensively by the news organization. Woodruff has since done a number of reports on soldiers suffering from TBI

Gean says there are many similarities between civilian TBIs and those inflicted in combat; “Penetrating injuries are penetrating injuries. They are seen everyday in gang warfare,” she says, although in Iran and Afghanistan the projectiles may be “nuts, bolts and pieces of car fenders” rather than bullets.

But there are also major differences. “Combat trauma is trauma on steroids,” she says, “It is truly polytraumatic.” When she talks about seeing soldiers with burns, open wounds, multiple amputations and TBI at Landstuhl. At one point she stops, remembering looking at one mutilated 20-year old. “I will never forget those injuries,” she says quietly.

While there is general agreement in the field about what causes TBI in impact injuries like an auto accident or a sports concussion, there is no such agreement when it comes to how massive explosions affect the brain.

Most researchers assume the damage comes from a violent shaking of the head. “These brains are rattled like a yolk in an egg,” says Jessica Martinez, an occupational therapist at Scripps Memorial Hospital in Encinitas, Ca.

However, P. Stephen Macedo, a doctor formerly with the VA, told the Toronto Starthat when the force of an explosion “moves through the brain, it seems to cause little gas bubbles to form. When they pop, it leaves a cavity. So you are littering people’s brains with these little holes.”

U.S. physician Susan Okie thinks that the combination of a blast wave followed by a sudden drop in pressure is the culprit.

Psychiatrist Evan Kanter of the University of Washington argues that explosions disconnect the amygdala, or emotional part of the brain, from the frontal lobes, which control planning and decision-making.

And Dr. Ibolja Cernak of Johns Hopkins postulates that blast waves generate powerful vibrations of major blood vessels in the chest and abdomen, which transfer that energy to areas deep in the brain, such as the hippocampus. Cernak says the damage eventually leads to premature aging of the brain.

A recent Army study downplayed the seriousness of mild TBI (MTBI), suggesting that the health problems associated with MTBI were largely a result of PTSD and depression.

But a careful reading of the study reveals that researchers failed to directly link PTSD to MTBIand that “These data should not be construed as suggesting that mild traumatic brain injury is not a serious medical concern.” Solders who suffer MTBI, especially those knocked unconscious or who experience it multiple times, “were at a very high risk for physical and mental health problems.”

UCLA’s Hovda even questions the term “mild.” He says, “I don’t know what makes it ‘mild,’ because it can evolve into anxiety disorders, personality changes, and depression.”

Besides the acute symptoms of TBI, there is a tapestry of psychological syndromes that victims can suffer. “Even mild brain trauma shakes up the entire body,” says Dr. Landau. “Many doctors and therapists just don’t see this.”

One problem, says Landau, is that MTBI can produce such a wide variety of systems, from disrupting the female hormone system to irritable bowels.

One of the major effects of TBI is what Landau calls the development of “identity ambiguity: people who were decisive become indecisive. People who were charming become withdrawn. They may have trouble reading. They may fly into rages.”

Landau says this can be devastating for those around TBI sufferers. “The family is excited that this young person is coming home [from the war] with no major injuries. They left as a good son, a good father, and a good husband. Suddenly they start hitting their children, can’t have sex, start drinking too much, talking too loud.”

Mary Watson, RN, DSM, a psychiatric nurse at a Cleveland VA hospital, says TBI sufferers can “seem to be perfectly normal and then spontaneously become confused and irritated, suddenly set off by something in their surroundings, and start yelling and cussing.”

Pennsylvania Psychologist Barry Jacobs, author of “Emotional Guide for Caregivers,” says TBI victims may lose their ability to empathize with others. “It is like a stranger has suddenly shown up.”

Jacobs says he is particularly concerned about MTBI. “Mild injuries are most at risk,” he says, “because the symptoms are subtle and may not be recognized as neurological. But while the symptoms may be subtle, the consequences for family, friends and coworkers “may be severe,” he says.

According to Landau, “There is a 70 percent chance that relationships will break down after TBI.”

Treating TBI is tricky, not just because it can be both subtle and stubborn, but because military culture resists admitting to problems. A Pentagon study found that 60 percent of the soldiers who suffered from the symptoms of TBI refused to seek help because they felt their unit leaders would treat them differently. Some 55 percent refused help because they thought they would be seen as weak or would lose the trust of their fellow soldiers. A number feared that reporting the symptoms of TBI could prevent them from getting jobs as police and firemen once they left the military.

“Vets don’t tell the truth,” says Hovda. “They say, ‘I’m fine, I can go back into battle.” The result, however, is that TBI victims may be exposed to further damage before they can heal. “MTBI is a biochemical event,” says Hovda, that creates a crisis for the brain. During this crisis, “the brain is vulnerable to another incident. A second incident during this phase is likely to have more severe repercussions.”

The Center for the Study of Retired Athletes found that three or more concussions meant that athletes were three times as likely to have “significant memory problems” and five times as likely to suffer from depression or develop an Alzheimer’s-like syndrome called Chronic Traumatic Encephalopathy.

Whether it is sports or war, the more one is exposed to trauma, the worse the damage.

Multiple tours and longer deployments mean soldiers are exposed to more explosions. “The multiple nature of it is unprecedented. People just get blasted and blasted and blasted,” says Maj. Connie Johnmeyer of the 332^nd Medical Group, a unit that deals with psychological problems.

But with a major shortage of troops, the pressure is to get lightly wounded soldiers back into battle. Out of the 1.6 million who served in both wars, some 525,000 troops have had more than two combat tours, 70,000 have served three, and 20,000 have done five or more.

When soldiers are first wounded, says Gean, “The acute care [at Landstuhl and Walter Reed] is truly world class,” far better than most people could get in the U.S., bar a few trauma centers. But she thinks that the TBI problem “is larger than we think,” and she worries about “what happens after” they leave.

The worry is well placed. Soldiers return to find that there are few psychological resources for them, and virtually no individual therapy. “There are two things going on regarding vets,” says Col. (ret) Will Wilson, chair of the American Psychological Association’s Division 19 (Military Psychology). “One, there are not enough care providers available, and two, there are not enough people focusing on the problem outside of the military.”

The Department of Defense’s (DOD) Task Force on Mental Health concluded that “The psychological health needs of service members, their families, and their survivors are daunting and growing.” And yet the military has lost 22 percent of its psychologists in the past several years, most from burnout.

At Walter Reed, soldiers with PTSD outnumber amputees 43 to 1, but the hospital has no PTSD center. “TBI can be missed,” says Watson. “People demonstrating psychological problems can be sent to the general psych unit where they are locked up.”

Soldiers are also routinely treated with medications rather than therapy. A study by Veterans for America found that some soldiers were taking 20 different medications at once, some of which canceled others out.

Soldiers also have difficulty finding therapists because the VA pays below-market rates, and even cut those reimbursements 6.4 percent in 2007. The result is that some 30 percent of psychologists are unwilling to take on military patients. For regular soldiers, one 45-minute session once a month is not uncommon, and they may be treated by a different health professional each time.

This situation may be worse for the National Guard and the Reserves, who make up almost 50 percent of the troops deployed in both wars and who, according to the Veterans for America study, “are experiencing rates of mental health problems 44 percent higher than their active duty counterparts.” Health care for such troops may be inferior to that offered to full-time regulars.

The problem is broader than psychological services. A Harvard study found that 1.8 million vets under 65 have no health care or access to the VA. “Most uninsured veterans are low-to-middle income workers who may be too poor to afford private coverage but are not poor enough to qualify for Medicaid or free VA care,” the study found.

“The insurance situation is horrible,” says Landau.

Therapists like Landau and Jacobs point out that while TBI may affect an individual, its consequences ripple out to a much wider audience.

“You have to mobilize their [TBI sufferers] support system,” says Landau. Educating a TBI sufferer’s family is essential and “very possible to do.” But many in the military are not trained in skills like family therapy.

Watson agrees about the importance of working with families, but points out “that in many cases there is no core family” and TBI sufferers are on their own.

As grim as the current situation looks, most health professionals say there is hope for many TBI sufferers.

Gean says that when she was in school, conventional wisdom was that damaged brains couldn’t heal. “But we now know that the brain can heal. It has an intrinsic plasticity that allows it to recover, and this is particularly true for the young brain.”

On the psychological side, while recovering from TBI may take a long time—Landau says sometimes from five to 10 years—if the proper care is given, recovery is possible. Jacobs agrees the recovery period may be extensive, but, “things do get better over time.”

Rehabilitation, however, is expensive, and it is by no means clear how many victims there are. Between TBI and the kind of damage that substance abuse inflicts, Landau guesses that “40 percent of the returning vets will have physical and psychological difficulties.”

No one has put a final figure on what that will cost, but $14 billion over the next 20 years is not out of the question.

Right now the resources don’t meet the demand. “Currently the VA system cannot manage patients with TBI,” says Dr. Heekin Chee of Boston’s Spaulding Rehabilitation Hospital. Jacobs agrees: “The infrastructure that exists is not going to be able to cope.”

UCSF researcher Weiner ticks off what he sees as at least some of the solutions: “First, everyone of these people has to have access to quality clinical care, and physicians need to get educated about this syndrome. Second, we have to create a national database on this so we can figure out what is going on, and what we can learn from clinical treatment. Third, there needs to be a lot more organized research on these people.”

Weiner says the federal government has made $300 million available for research, “Which sounds like a lot of money, but really isn’t.”

Following the revelations of inadequate medical care at Walter Reed, Congress has gotten more involved in the issue.

Last July Congress passed the Wounded Warrior Bill (S 1606) to improve care for troops and veterans, and the House Energy and Commerce Committee just passed a reauthorization of Traumatic Brain Injury Act (HR 1418) to support research and rehabilitation for TBI sufferers.

Rep. Pascrell led the push for the bill. “This is not just for the military,” says Pascrell’s Communication’s Director, Caley Gray, but for TBI sufferers nationwide.

It has taken a war to put the issue of TBI on the nation’s health agenda, but the cost of that awareness in blood, flesh, and decimated relationships is high. Even if the war ends soon, there will be hundreds of thousands of soldiers and veterans who will bear the burden of TBI. Sorting out how to deal with it may well test the nation’s mettle far more than the conflicts that produced the damage.

For Gean, who has seen some of that wreckage first hand, the solution is clear: “We have to do something for these soldiers.”

Super Bug II

Registered Nurse

12-04-2007

Conn Hallinan & Carl Bloice

When a Brooklyn middle student died Oct.14 from an antibiotic resistant “super bug” he may have picked up at school, the media took notice. After a 17-year old high school football player from Virginia succumbed to the same pathogen and student deaths were reported in New Hampshire and Mississippi, the news went page one. Then the Center for Disease Control (CDC) released a study suggesting that methicillin-resistent Staphylococcus aureus (MRSA) kills almost 19,000 Americans a year—more than from AIDS—and it was the lead story on network news.

For a week, the combination of dead children and the alarming CDC report caught the press’s attention, before fading, a victim of the media’s short attention span and California’s monster fires. But while MRSA may have disappeared from prime time news, it continues to stalk the nation’s hospitals, nursing homes and, increasingly, locker rooms, gymnasiums and schools.

What caught the eye of the media in the October stories was that MRSA is no longer something you pick up in a hospital. You can get it from wearing someone else’s football pads, pumping iron in a weight room, or sharing a towel.

“The bad bugs are getting stronger and they’re getting stronger faster,” says Smithsonian Institution ethnobiologist Mark Plotkin.

In 1972, only 2 percent of Staphylococcus were methicillin-resistent. By 1995, 22 percent were classified MRSA. In 2005 it was 60 percent. The New England Journal of Medicine says MRSA is now the leading type of skin infection in the nation’s emergency rooms.

According to the Association for Professionals in Infection Control & Epidemiology (APIC), about 126,000 patients are infected with super bugs each year, ten times the previous estimates.

APIC has just completed a nationwide study of MRSA, the first to examine the prevalence of the bacteria beyond the confines of intensive care units (ICU) and operating theaters. “What we found was surprising,” says APIC CEO Kathy Warye, “67 percent of those (infected) patients were not in high risk areas, like ICUs, but in places like cardiology. It’s in all areas of hospitals.”

Besides being dangerous, super bugs cost an estimated $30.5 billion a year to fight. Warye says that the average cost of treating a MRSA patient is $35,000. “They are enormously expensive,” she says.

The CDC’s Dr. Scott Fridkin, co-author of the study, says the survey demonstrates “the need for better prevention measures” that include “curbing the overuse of antibiotics and improving hand-washing and other hygiene procedures among hospital workers,” which is thought to be a major source of the MRSA outbreak.

But while overuse of antibiotics and hygiene are clearly important, the role of staffing levels didn’t make it into recent coverage of the current outbreak.

The Harvard School of Public Health found a direct link between hospital-acquired infections and nursing staff levels. According to a study of 799 hospitals, inadequate staffing resulted in a greater number of urinary tract infections and hospital-acquired pneumonia.

Nurses may have upwards of 12 patients and hundreds of bedside contacts. That translates into at least one and a half hours of hand washing a shift, time that may be in short supply for overworked staff.

“The trend in health care is to cut staff, cut nurses, and cut cleaning staff,” says Lisa McGiffert of Consumer Union’s Stop Hospital Infection Project based in Austin, Texas.

It is a trend with deadly implications. According to Ohio nurse Michelle Mahon, RN, CLNC, the 2003 Institute of Medicine reports there were 98,000 preventable deaths attributed to insufficient staffing of nurses.

A 2002 study by the Chicago Tribune found that many hospital-cleaning staffs receive inadequate training, and there were 25 percent fewer cleaners than in 1995. McGiffert says, “We have had phone calls from cleaning staff saying, ‘It’s impossible to do this job on one shift.’”

One problem with cleaning, says Mahon, is that “some of these chemicals should be left to stand for awhile—say 10 minutes—and that doesn’t always happen.” She says cleaning crews are stretched thin, and hospitals use skeleton crews at night, “regardless of the patient load.”

Further, many hospital have contracted out their cleaning services to companies where turnover rates are almost twice as high as with in-house cleaning services, and training can be sketchy.

As a result, approximately 75 percent of patients’ rooms are infected with MRSA.

“If you spend five minutes in a room with someone with MRSA, you are going to get colonized,” says Dr. Neil Fishman, director of epidemiology and infection control at the University of Pennsylvania School of Medicine.

If patients do get colonized, current hospital policies help spread the bacteria to communities. During the 1970s, the average hospital stay was seven days. Today it is three, which means patients return to their communities before MRSA infections can be identified, thus spreading them to family and friends.

“The environment in which you work is a huge concern,” says Mahon. “You often ask yourself, “Am I bringing this home with me?’”

While many antibiotic resistant pathogens are hospital-generated— 2.1 million patients are infected each year—an increasing number of antibiotic resistant bacteria come from the widespread use of the drugs in farm animals.

“We estimate that 70 percent of the antibiotics are used in animal agriculture,” says Bris Tencer, Washington Representative of the Food and Environment Program for the Union of Concerned Scientists UCS). “This is the part of the equation that gets overlooked.”

According to the UCS, the use of antibiotics in giant feed lots pumps two trillion tons of antibiotic laden waste into rivers, streams and water tables that eventually end up ingested by consumers.

The UCS is currently supporting House Resolution 962, which would prevent the “non-therapeutic” use of antibiotics on animals if those antibiotics were similar to ones used to treat humans. The European Union instituted a similar policy and sharply reduced the number of antibiotic resistant germs in commercial meat.

Once MRSA pathogens get established in a community, they are difficult to dig out. British authorities found that using standard detergents sometimes makes the problem worse, because they end up killing all but the toughest bugs.

While community infections are a problem, they only make up about 15 percent of MRSA cases. Hospitals generate 27 percent of the infections, and health care facilities, like nursing homes and assisted living facilities, account for 58 percent of the rest.

Nursing homes and assisted living facilities are difficult to sanitize because most of them either contract out cleaning services, or use untrained and low paid staff. In many states, such institutions also don’t have to report infection rates and there is little government oversight of their operations.

This is true for hospitals as well. Only a few states require hospitals to make infection rates public. “Infection is a hot topic for patients, because there is no way to hold the hospital accountable here in Ohio,” says Mahon. As a legal consultant, Mahon says she receives up to 2,000 calls a year from patients, and a “significant portion” are from MRSA sufferers.

APIC’s Warye is strongly in favor of making infection rates public. “Transparency leads to improved outcome.” But she also points out that collecting data is not enough. “You need to use those figures to change things.”

McGiffert’s organization lobbies states to pass legislation requiring hospitals to publish infection rates. So far, she says, 19 states have such rules. Governor Arnold Schwarzenegger vetoed such a bill in California.

Controlling infections “does take an investment,” says McGiffert, “and for the people who hold the money, it hasn’t been on their radar.” But in the long run, she argues, “it saves money,” not to mention lives.

But the Tribune study found that infection-tracking units have been reduced 20 percent since 1995. According to Jill Furillo, RN, and Southern Director of the California Nurses Association, “Many facilities eliminated the position of infection nurse” during the 1990s cutbacks.

When hospitals do take an aggressive “active surveillance” approach, they have gotten results.

Presbyterian University in Pittsburgh screened staff and patients to see if they were MRSA carriers, and disinfected blood pressure cuffs and stethoscopes after each patient. They also used disposable gowns and gloves and rigorously enforced hand washing procedures.

The result was a 90 percent drop in MRSA infections. Similar results using the same procedures were registered in Pittsburgh’s Veterans Affairs health care system, and in hospitals in Boston and New Haven.

The CDC has yet to call for the mandatory screening of patients, though they urge the implementation of many of the other practices.

Warye is upbeat about defeating, or at least sharply curtailing, MRSA infections. “If every institution has a focus of zero tolerance, and implements procedures to prevent these infections, we can get on top of this.”

“This is a really nasty bug, and it’s becoming apparent that we don’t have to live with it. Now we have new techniques, and good studies to show they re effective,” says Dr. Harold Standiford, the University of Maryland Medical Center’s infection control chief.

Warye agrees: “We need to spread the success we have seen in some institutions to the rest of the nation. Infection prevention is everyone’s responsibility.”

Stalking the Super Bugs

Stalking the Super Bugs

Registered Nurse

6-23-2006

By Conn M. Hallinan and Carl Bloice

Royal Marine Richard Campbell-Smith, a buff 18-year old, was completing his basic training in Devon, England when he got a few scratches on his leg. Two days later he was dead.

Gloria Bonaffini checked into a Bridgeport, Ct. hospital for a routine bypass operation. Doctors told her husband she would be out in a week. She stayed 448 days, finally dying of an acute infection she caught during her surgery.

Three children—age 15 months, nine months, and 17 months—were admitted to a Chicago-area hospital with respiratory problems. They were all dead of toxic shock within a week.

In all three cases, the killer was the same: methicillin-resistant Staphylococcus aureus, or MRSA, a drug-resistant bacterium that first appeared in early ‘90s. Since then it has seared a lethal path through hospitals and rest homes and started appearing in day care centers, prisons, and gymnasiums. Several players for the St. Louis Rams caught it during training and passed it to opposing players.

MRSA is only one of several varieties of bacteria that have become resistant to medicine’s magic bullet—antibiotics. Formally ubiquitous or easily treatable germs like E. coli, Salmonella and Campylobacter have morphed into organisms that can be virtually immune to treatment.

“The bad bugs are getting stronger and they’re getter stronger faster,” says Smithsonian Institution ethnobiologist Mark Plotkin. “We feel like we’re looking at an almost hyper-evolutionary period.”

In 1974, only two percent of Staphylococcus was methicillin-resistant. By 1995, 22 percent were classified MRSA. Last year it was 60 percent.

Solving the problem will not be easy, because antibiotic resistant pathogens are generated by a constellation of conditions and practices, from poor hygiene in hospitals, to the widespread use of antibiotics in animal agriculture.

And to make matters worse, at the very time these super germs are on the rise, many pharmaceutical companies are abandoning the search for new antibiotics in favor of more lucrative drugs aimed at long-term, chronic conditions.

According to Dr. John Bartlett of John Hopkins, chair of a legislative taskforce for the Infectious Disease Society of America, there are virtually no new antibiotics “in the pipeline,” which means, “We’re in a bit of trouble now, and maybe a great deal of trouble in five years.”

Certainly the statistics are sobering:

According to the Chicago Tribune, 103,000 people in the U.S. die each year from these infections, making them the fourth leading cause of death after heart attacks, stroke, and cancer.

The Center for Disease Control (CDC)—which puts the fatalities at 90,000—found that hospital infections were up 36 percent over the past 20 years and, that out of 35 million admissions a year, some 2.1 million will acquire one.

While the problem is serious, and more than a little scary, getting a handle on it may not be that complex. For instance, the solution to hospital infections may have less to do with high tech labs and fancy biochemistry than old-fashioned remedies like proper cleaning procedures and keeping the patient-nurse ratio down.

The Harvard School of Public Health found there was a direct link between hospital-acquired infections and nursing staff levels. “The national study of 799 hospitals found that patients were more likely to contract urinary tract infections and hospital-acquired pneumonia if nurse staffing was inadequate.”

The other part of the hospital equation is housekeeping.

A survey by the Auditor General of Scotland found that cleaning services “play a key role in minimizing the risk of hospital acquired infections.”

However, the Tribune study found that many hospital cleaning staffs receive inadequate training, are overextended, and have fewer personnel than a decade ago. Cleaning staffs have been cut 25 percent since 1995.

One East Coast nurse, who requested anonymity, told Registered Nurse, “Hospitals are filthy. It is really incredible. The housekeeping staff at my hospital was cut by one-third several years ago.”

The nurse says that to reduce staff, many hospital workers are “cross trained.” But this means they may end up “touching the patient’s bed, and at times the patient, after doing housekeeping work.”

Many hospitals have contracted out cleaning services to workforces that may not be adequately trained, and where turnover rates are almost twice as high as in in-house cleaning services.

Pia Davis, president of the Chicago health care chapter of the Service Employees Union (SEIU), says “We have report after report showing that rooms are not cleaned every day,” she told the Tribune, “hospitals hire people and just say go in there and clean. They don’t show them what chemicals to use or not to use.”

As Nancy Foster, vice-president for Quality and Patient Care Policy for the American Hospital Association points out, “Cleaning in a hospital is a skill very different than cleaning an office building.”

As a result, according to the Tribune study, approximately 75 percent of patient’s rooms are infected with MRSA.

Hospitals and health care workers are at war with an ancient and recently invigorated enemy. Given the nature of bacteria, it is a war in which all victories are incremental.

The daily mutation rate for E. coli in human beings is 10 to the 12th power, a figure that is hard to grasp even using a computer. The phenomenal reproductive rate, coupled with bacteria’s ability to share genetic material, means that almost as fast as human beings invent something to kill them, bacteria become resistant.

The history of anti-bacterials is a history of stroke and counter stroke. Penicillin was isolated in 1939. By 1941 there were penicillin-resistant streptococci.

Human practices add to the problem. Sometimes patients don’t finish the prescribed course of antibiotics, which means it is easier for resistant germs to emerge since“what doesn’t kill bacteria makes them stronger.”

Sometimes the problem is picking the wrong drug. A U.S. Office of Technological Assessment found that up to 50 percent of antibiotics are prescribed inappropriately.

While the American Medical Association is deeply concerned about the global increase in resistance to antibiotics—a 1995 statement by the organization warns of a “public health problem of potentially crisis proportions”—it jealously guards the right of doctors to prescribe what they wish, and fiercely resists setting any national standards for the use of antibiotics.

But you don’t have to go to a doctor to get a dose of antibiotics, just chow down on some barbeque.

In a study for the CDC, L. Clifford McDonald found that supermarket chicken was riddled with vancomycin-resistant Salmonella. According to McDonald, “The widespread resistance to this drug now seen in meat-borne bacteria appears to stem from farm use since 1974 of a related antibiotic—virginamycin—as a growth promoter.”

An estimated 13.5 million pounds of antibiotics are used in animal agriculture for non-therapeutic purposes—the same kinds of antibiotics used in human medicine— according to Susan Prolman, the Washington Representative of the Food & Environment Program of the Union of Concerned Scientists (UCS).

About three million pounds of antibiotics in the U.S. are used to treat human beings annually.

The UCS says that 70 percent of all the antibiotics are used on healthy animals because they save farmers money. Thousands of animals are packed into sheds and pens which, according to Prolman, are rarely cleaned. “Chickens raised for meat live about 45 days, but their cages are only cleaned out every one or two years. They not only live in their own filth, but the filth of generations.”

Cows, pigs and fish are raised under similar conditions.

Such CAFOs (Communal Animal Feeding Operations) act as giant Petri dishes in which antibiotic resistant bacteria evolve and get passed on to workers in these establishments, as well as to consumers.

CAFOs also produce two trillion tons of antibiotic laden-waste that finds its way into “rivers and streams and water tables that affect downstream consumers,” says Prolman.

All of these antibiotic practices conspire to put resistant bacteria into the community. CAFO workers, their families, consumers, patients, and health care workers spread the pathogens to places like gymnasiums, sports facilities, and day care centers. You don’t have to check into a hospital to get a MRSA, you can go work out a your local gym.

Over the past decade there has been a dramatic increase in antibiotic resistant germs in the community. According to the Tribune study, such organisms have increased a thousand fold in Illinois.

New hospital procedures aimed at generating a rapid turnover of beds adds to the problem. In the 1970s, the average hospital stay was seven days, enough for doctors to identify and treat infections. Today the average stay is three days, which means that many patients go home before they can be properly diagnosed.

“If you spend five minutes in a room with someone with MRSA, you are going to get colonized,” says Dr. Neil Fishman, director of epidemiology and infection control at the University of Pennsylvania’s School of Medicine.

Jill Furillo, RN, and Southern Director for the California Nurses Association (CAN), points out that this is particularly important for healthcare workers, “because they are exposed and can potentially bring those germs home to their families.” From there, the bacteria can spread to the wider community.

As tough as some of these pathogens are—and many are meaner and deadlier than they were 10 years ago—most health care experts agree that MRSA is no match for hospital hygiene.

The Tribune study found that out of 103, 000 fatal infections in the year 2,000, some 75,000 were “preventable.” According to a study by the CDC and the Society for Healthcare Epidemiology of America, 20,000 lives could be saved by health workers just cleaning their hands. Hand washing “is the single most effective way to prevent transmission of disease,” says the CDC, but fewer than 70 percent of health workers follow the proper guidelines.

Fishman says he has found that nurses are better at washing their hands than doctors, and nursing students are better than nurses. “It seems like when you get your degree you stop washing your hands,” he says.

But sometimes nurse-patient ratios simply overwhelm “technique.” Depending on the unit in the hospital, nurses may have upwards of 12 patients and more than a hundred bedside contacts. “Sometimes it is a matter of time,” says Hedy Dunpel, RN, JD, Chief Director of Nursing Practice and Patient Advocacy for the CNA. “Under conditions of speedup, which do exist, people will take shortcuts.”

Because of the presence of the CNA, California has the best nurse-patient ratios in the country, ranging from 1:1 in trauma units, to 1:5 in medical surgical units. But those figures are rare elsewhere in the U.S.

According to the CDC, proper hand washing translates into an average of 1.5 hours per shift, which is not only time consuming, but may also irritate the skin.

The introduction of alcohol rubs has improved the situation some—such gels save about 15 seconds off of traditional soap and water and are less irritating—but their use may run into fire code problems. Alcohol is flammable, and some states ban its use near carpets or in closed rooms.

Many nurses work over 60 hours a week, which leaves them exhausted. Study show that tired health care workers are less likely to follow proper hand care procedure.

But hands are not the only problem. Infections are passed by clothes, food and equipment as well.

“Once, when I was working as an intensive care nurse, we began to be alarmed by the number of infections occurring on our ward,” says Kay McVay, RN and former president of CNA. “We checked everything we were doing,” including hand washing and sterilizing instruments, but still couldn’t find the source.” McVay says an infection nurse came in, watched everything, and finally figured it out. “She noticed the doctors were not wiping down their stethoscopes as they moved from patient to patient. With that discovery we were able to deal effectively with the problem.”

But according to the Tribune study, infection-tracking units have been cut 20 percent since 1995. “One of the effects of the cutbacks in nursing carried out by hospitals in the ‘’90s,” says CNA’s Furillo, was a sidelining of procedures for infection detection and control. “Many facilities eliminated the position of infection nurse.”

Tracking hospital infection rates is difficult because there are only a few states that require health establishments to make such information public. According to the Tribune study, “The health-care industry’s penchant for secrecy and a lack of meaningful government oversight cloaks the problem. Hospitals are not legally required to disclose infection rates, and most don’t.”

When they do give out information, it may be undecipherable to the average consumer. For instance, the CDC allows hospitals to use the term “nosocomial infection,” which means “hospital acquired,” but unless you are a Latin scholar or Catholic bishop, you aren’t likely to know that.

A good deal of this is about money.

Dr. Victor Yu, professor of medicine at the University of Pittsburgh and an expert on infections, says there is, in fact, pressure for hospitals not to be particularly aggressive in ferreting out infections. “Repairs to equipment or extensive cleaning can means shutting down a department or a floor. Even a few hours is a significant loss of revenue.”

McVay says her experience is that many hospitals simply do not insist that proper sterile procedures are followed. “They have little incentive to do so. People seldom sue over hospital acquired infections, and it’s difficult to prove negligence, and, therefore, there is little liability to worry about.”

And unless a nurse is protected by a union, complaining about procedures may be risky. “There are numerous forms that intimidation can take to keep nurses quiet about the problem,” says CNA’s Furillo, “and without union representation the nurses have little protection against reprisal.”

When people do get infections, treating them is increasingly a problem, because many antibiotics are no longer effective. Fishman recalls one patient with an infection that resisted all the standard antibiotics. “I finally had to give him colistin, which is very toxic to the kidneys and doesn’t work very well, but that is what I had left.”

That problem is likely to get worse, because many drug companies are disinterested in producing more antibiotics. “There is unequivocal evidence that antimicrobial research is on a steep downward slope,” says John Edwards, the head of policy at the Infectious Diseases Society of America.

Drug giants Roche and Eli Lilly recently announced they will give up making antibiotics. “Pharmaceutical companies are saying this is not a priority. They do a lot better making Lipitor,” says John Hopkins’s Bartlett.

Health activists, unions and environmentalists are moving on a host of fronts to tackle the problem, from improving sanitary procedures to sponsoring legislation on antibiotic use and hospital transparency.

One front is rigorous attention to cleaning, which seems to pay off.

Bridgeport hospital, where Gloria Bonaffini died, instituted a major overhaul in sanitation procedures, and the hospital’s 22 percent infection rate for heart surgeries dropped to almost zero. A similar program in a veteran’s hospital in Pittsburgh reduced MRSA by 85 percent, and eliminated it at the University of Virginia Medical Center.

A 36-bed surgical war in Dorchester, England was plagued by MRSA until authorities doubled the cleaning hours from 66.5 hours to 123.5 hours per week. A government study concluded, “In the long term, cost cutting on cleaning services is neither cost effective or common sense.”

The U.S. Society for Health Care Epidemiologists (SHCE) is pushing “active surveillance,” a variation of the European “search and destroy” model. This advocates that all patients be checked for infection, and isolated if they are infected, as well as increased attention to cleaning procedures.

The CDC, however, only supports using “active surveillance” in case of epidemics, rather than as standard practice.

The American Hospital Association is lobbying for the adoption of a Surgical Care Infection Policy (SCIP), which promotes standardizing antiseptic and behavior practices in all surgical situations. These include:

• Administrating antibiotics 30 to 60 minutes before surgery, and removing patients from the drugs after 24 hours if there is not sign of infections.
• Keeping surgical patients’ temperature stabilized.
• Aggressive antiseptic procedures including the regular cleaning of ventilators and filters.

According to Foster, when SCIP is implemented, “We have seen a decrease in infection rates and, for ventilator-associated pneumonia, some hospital rates have dropped to zero.”

Dunpel of the CNA argues “the causes of hospital infections and super bugs are multiple, so there is no single solution, but the starting point has to be adherence to the recognized precautionary principles.”

A number of organizations are working to keep the drug companies in the business of making magic bullets.

Bartlett’s taskforce is focusing on developing legislation that will encourage “drug companies to stay engaged,” he says. Proposals include tax incentives and giving companies exclusivity rights for a certain period of time.

The Union of Concerned Scientists is pushing the Preservation of Antibiotics for Medical Treatment Act (S-742 and HR-2562) that would halt the use of antibiotics on animals for non-therapeutic reasons, and require the government to keep records on where, and how much, antibiotics are used.

In 1997, the European Commission banned the non-therapeutic use of vancomycin-related antibiotics in animals, and a Danish follow-up study found a dramatic drop off in antibiotic resistant bacteria in meats sold to consumers. The European Union has since extended the ban to all antibiotic use in healthy animals.

But Prolman warns that the Preservation Act is “up against a powerful lobby of veterinarians, agribusiness, and the pharmaceutical companies.”

Organizations are also demanding that hospitals track infection cases and make their findings public. The American Federation of Teachers successfully lobbied the Connecticut legislature to require hospitals to publicly disclose infections; Connecticut is now one of seven states that require hospitals to release infection numbers to the public.

On yet another front there is a push to develop a vaccine for Streptococcus aureus. One vaccine currently in trials is showing promise.

Some doctors are experimenting with reducing the length of antibiotic regimes from 7 or 10 days, to just three. Medical researchers in the Netherlands have found that the shorter courses are just as effective and less likely to generate resistant bacteria.

As Dr. Wendel Brunner, director of the Contra Costa Public Health Department in California warns, “We have to do more than engage in an arms race with mother nature,” a sentiment with whichBartlett strongly agrees with, “Absolutely, we need to be working all sides of the equation.”

Fishman uses the analogy of a machine in making the point about all the different levels people need to work on in order to solve the problem: “It is only when you have all the parts of the machine coming together that the machine works,” says Fishman.

Rough Beasts & Public Health

Rough Beasts & Public Health

Revolution

7-6-2005

“Some rough beast, its time come round at last,

Slouches toward Bethlehem, waiting to be born”

William Butler Yeats

In early June, a patient checked into a Contra Costa County Health Department outpatient clinic in Richmond, Ca., with a fever of 101.2, flu-like symptoms, and a cough. The man sat in a waiting room—the clinic serves hundreds of thousands of people each year—until the physician could see him. Because the patient could not speak English, the doctor called in a Vietnamese interpreter. The rest was drill: blood pressure, ear and throat examination, listen for congestion.

But then a bell went off in the doctor’s head.

She had the translator ask the patient if he had recently traveled. Yes, he replied, he had just returned from Vietnam, presently ground zero for avian flu, a particularly malevolent virus that has killed more than 60 people and decimated chicken populations throughout Asia.

The doctor put a mask on the patient, moved him to a room by himself, and called the Health Department. Blood samples were drawn and county and state health labs went into overdrive, scanning for a molecular code designated H5N1-A. For a few scary days it looked like Richmond might be the first U.S. beachhead for the disease, but in the end it turned out to be a standard Type A influenza.

On one hand the incident demonstrated the strengths of public health. “The businessman who returns from Vietnam is going to see a private doctor,” says Dr. Wendel Brunner, Director of Public Health for the county’s health services. “A private doctor has about 12 minutes to see a patient, four of which are filling out insurance forms. They aren’t going to ask the patient’s travel history, and they are not likely to call the health department.”

On the other hand, Brunner is facing a $5 million cut in his $60 million budget, and high on the list of cuts are translators, who not only interpret, but also accompany nurses who conduct house visits. Without a translator, the Richmond doctor would never have asked the travel question.

The arrival of the next great pandemic has always been a “when” not an “if,” and firewalls for stopping it are getting thinner.

“Nobody knows how bad it [the pandemic] will be,” says World

Health Organization (WHO) General Director, Lee Jong-Wook, “but we can’t be optimistic.”

So far, H5N1-A is only a threat to those exposed to infected birds, although there are scattered cases of person-to-person transmission. But the virus has spread from domestic fowl to wild ducks and domestic pigs. The latter are worrisome, because pigs have served as a viral bridge to humans before. If avian flu mutates into an easily transmissible form, the world could be in considerable trouble

H5N1 presently has a startling mortality rate of between 47 percent and 83 percent, but most experts think it unlikely that it will maintain that level of lethality. People in Asia have tested positive for the flu’s antibodies without exhibiting symptoms, indicating that not everyone who contracts it gets deathly ill. Nevertheless, WHO estimates that such a pandemic would hospitalize 30 million people and kill eight million.

Other researchers, like Michael Osterholm at the University of Minnesota, say the death toll could range from 180 million to 360 million worldwide, including 1.7 million in the U.S. Olsterholm is the Director of the Center for Infectious Disease Research and Policy and an associate director of the Department of Homeland Security.

Even if avian flu has only the fatality rate of the 1918-19 pandemic—2.7 percent— it would have a catastrophic effect. That pandemic killed 675,000 Americans and anywhere from 50 to 100 million people at a time when the world’s population was less than a third what it is today, and when populations were far more isolated.

“If you want to see why a pandemic today will be far greater than the 1918 flu, ” says Dr. Donald Francis of Global Solutions, “just sit in a European airport and watch all the costumes walk by.” Francis, whose firm is trying to generate money for vaccines, was one of the earlier identifiers of HIV, and part of the WHO/Center for Disease Control (CDC) team that finally cornered and eliminated smallpox in 1977.

But at the very time avian flu is threatening to mutate into a worldwide killer, public health budgets in the U.S and across the globe are being systematically starved of funding.

Budget problems like Brunner’s are hardly limited to Contra Costa County.

“Each budget year those of us in community clinics have to fight for our very existence,” says San Francisco’s Nancy Lewis, FNP, MSN. “We are considered expendable,” she says bluntly. She calls the cutbacks of public health facilities and personnel “alarming.”

County and state health budgets have been declining for years, and Congress plans to cut Medicaid by $10 billion over the next five years. Medicaid is the nation’s largest health insurance program, covering some 50 million low-income people.

That will have a cascading effect on the states, many of which are already cutting recipients from the rolls. Tennessee is dropping some 300,000 people, and Missouri is cutting 90,000. For those still covered, states are proposing higher co-payments.

“State and local governments are in such a budgetary crisis that they are forced to cut things that they know are good for the public,” says occupational physician and former president of the American Public Health Association (APHA), Dr. Barry Levy.

According to public health officials and epidemiologists, cutting health care creates the perfect breeding ground for pandemics.

Public health funding seems almost designed to create a crisis. For instance, according to health writer and Pulitzer Prize winner, Laurie Garrett, one of the key things hospitals need to respond to a pandemic is ” surge capacity,” or the ability to double their ability to treat patients.

Garrett says, “What’s happened with managed care is that hospitals have eliminated surplus beds and surplus personnel. So, far from being ready to deal with surge capacity, we’re actually understaffed and we have massive nurse shortages all across the country.”

Asked about “surge capacity,” Brunner just laughs. “We don’t have surge capacity for a bad winter.” He goes on to explain that private insurers calculate that “It is cheaper to turn patients away than have empty beds.”

According to the American Hospital Association, between 1980 and 2000, some 900 hospitals were closed nationwide in the name of “efficiency.”

A scarcity of beds has consequences. The Society for Academic Emergency Medicine found that delays in getting patients into hospital beds meant greater medical complications, more patients ending up in expensive Intensive Care Units, and higher mortality rates.

If anything, the international situation is worse.

Countries like China, according to Calcutta based journalist P. Sainath, have largely defunded their health care programs, as the recent SARS outbreak demonstrated. “The Chinese saved tens of millions by closing down rural clinics, and then lost billions because of SARS,” he said. “Everywhere the rights of the poor are being whittled away, and we will all end up paying a price for it.”

During the 2003 SARS outbreak, Chinese villagers told Garrett that they didn’t seek medical care because a single day in a hospital represented a year’s income.

SARS eventually infected some 8,000 people, killing 800 of them.

According to the May 6-7 WHO conference in Manila, early intervention is the key to stopping or moderating a pandemic: “if action is delayed…it will be too late to implement effective local, national, or regional responses.”

WHO recommended a crash program on developing a vaccine and stockpiling the anti-viral drug, Tamiflu.

According to the Financial Times, however, only 12 countries have made a serious attempt to stockpile, and the U.S has only enough Tamiflu for about 1 percent of its population. In contrast, France and England can cover about 20 percent of their populations.

Nor is Tamiflu a magic bullet. “It is not clear that Tamiflu is effective,” says Brunner.

On developing a vaccine, Levy agrees with WHO’s recommendation, but warns that “We are way behind where we should be on vaccine development.”

Vaccines also have their own difficulties. “The problem with vaccine development is that vaccines don’t make money,” says Francis, illustrating his point with a chart indicating that while worldwide sales of vaccines brought in just a little over $6 billion in 2001, Lipitor and Prilosec sales alone earned pharmaceutical companies $12 billion.

When private industry does get involved, it can be costly. In 1970, WHO paid about 1 cent per dose for smallpox vaccine. When the Clinton Administration asked Dynport, the company that manufactures smallpox vaccines for the military, to ramp up production for civilians, its price was $25 a pop.

There were lessons learned from the 1918-19 pandemic. In his book,

“The Great Influenza,” John Barry notes that a Public Health Service post mortem on the disaster found, “What could help, more than doctors, were nurses. Nursing could ease the strain on a patient, keep a patient hydrated, calm, provide the best nutrition, cool the intense fevers. Nursing could give a victim of the disease the best possible chance to survive. Nursing could save lives.”

But the U.S. has a major shortage of nurses at the bedside, as does much of the world. According to Rockefeller Foundation estimates, Africa is short one million health workers and Europe has a crisis that parallels the U.S. Add to that the shortage of hospital beds, and Osterholm’s projection may not be far off the mark.

“We’re not in the preventive mode here,” says Lewis, “but the let’s-fix-them-after-the-fact mode of hospital care. Under such circumstances it would be very difficult to care for the tens of thousands of patients who would not get a necessary influenza vaccine on time.”

Keeping nurses healthy will also be a problem. “Medical workers are at risk,” says Brunner, “because they are literally in people’s faces.” He points out that the first SARS victim was a medical worker.

“New strains of influenza, particularly things like the avian flu, are the most worrisome to me and many nurses,” says Lewis. “This is especially so in light of last year’s debacle when the influenza vaccines were contaminated.”

According to Gina Johnson, RN, public health case manger at the Rolling Meadows Clinic, Cook County, Il., not enough has been done to prepare medical workers for what they may face in a pandemic. “We need to start getting education about Asian avian flu, SARS and new strains of tuberculosis as soon as possible (so that) we don’t get it thrown at us at the last minute.”

She adds, “nurses want to be given the proper tools and protection as soon as possible so in the advent of an emergency we don’t get burnout and feel overwhelmed.” Johnson has been in public health for 12 years in Illinois and Iowa.

In a pandemic situation, Osterhold predicts that “healthcare workers would become ill and die at rates similar to, or even higher than, those in the general public.”

One recent influx of money for public health comes from the Department of Homeland Security to prepare for bioterrorism. Brunner estimates the county receives about $1 million from Home Security, which he is happy to get because he says “it helps the Health Department deal with all communicable diseases.”

But others worry that Homeland Security’s concerns end up diluting the mission of public health.

“Bioterrorism distracts public health from its true mission,” says Dr. Victor Sidel, Distinguished University Professor at Montifiore Hospital in New York, and past president of the APHA. Sidel calls the spending on biowarfare “wasted funds” and says the real problem is that “public health has been starved, and is being starved.”

Brunner also wishes there were the same kind of focus and funding on “what is really killing our people, which are chronic diseases, like cancer, HIV, diabetes, cardiovascular problems, not to mention violence.” He also worries that the bioterrorism focus may “divert attention and intellectual resources from public health issues that are more important.”

Sometimes the problems seem almost overwhelming.

Francis says that “there is not the in-hospital or in-public health capacity to deal with a flu pandemic,” and Brunner agrees that the inability of U.S. medicine to respond in the way it should “is built in.”

Besides the insufficiency of beds in the U.S., according to Osterholm, there are only 105,000 mechanical ventilators, between 75,000 and 80,000 of which are in constant use. Ventilators are particularly important if a pandemic takes on the characteristics of the 1918-19 flu, in which a major killer was acute respiratory distress syndrome (ARDS).

Lewis says “The bottom line is that we are about as ready as they were in 1918 when millions died here in the US. But they had an excuse. There wasn’t much of a public health infrastructure and no vaccine. We have no excuse for not fully utilizing the resources that are available to us today.”

Levy argues, “We are in a major crisis and we need something on the order of a Manhattan Project,” adding, “the greatest threats out there to us are not military, they are disease.”

For Sidel, the solution is long-term: “What we need is a decent medical care system, a universal system that unites public health and medical care,” and points to U.S. Rep. Barbara Lee’s HR 3000 as a step toward creating a system that “will prepare us for what will surely come.”

In the meantime, Brunner successfully lobbied to keep his Vietnamese translators, and the Supervisors “restored most the cuts in Health Care.” So Contra Costa has dodged yet another bullet—for now.

Medical Outsourcing

Medical Outsourcing

CNA

Nov.-Dec. 2004

A surgeon sits at a state-of-the art computer station in Bangalore, India, analyzing a three-dimensional image of a U.S. patient’s kidney. He notes some potential trouble spots and sends his findings off by email. The transaction by Wipro Health Sciences, an Indian based company, saves a U.S. hospital 45 percent on the procedure.

A German drug firm, Mucos Pharma GmbH, contracts out the testing of a new treatment for neck and head cancer to Siro Clinpharm of Mombai, India. Siro finds volunteers to test the drug in half the time and expense the German company would encounter in Europe—and without having to first test the drug for safety.

A North Carolina man without health insurance had a life-threatening heart condition requiring a new valve, which would cost him $200,000 in the United States. He flew to New Delhi, where doctors replaced his heart valve with one from a pig for a total cost of $10,000, including roundtrip airfare.

For almost a decade, the U.S. medical industry has been outsourcing records and financial transactions to places like India, Hong Kong, Singapore, Pakistan and the Philippines. But recently outsourcing has spread beyond number crunching and word processing to basic medical services. From biopsy analysis to cardiac surgery, the health business has discovered there is gold in going foreign.

Outsourcing began in the middle-90s with medical transcriptions, a $16 billion industry that is growing at a yearly rate of 15 percent. In the old days, a doctor would write up a report and submit it to an insurance company. Now, just talk into a phone and the report goes off into digital cyberspace, to be downloaded to Europe, Asia or Latin America.

But medical transcriptions were just the toe in the door. “Telemedicine” now covers (reader, take a deep breath); medical billing; accounting; creation of patient information; patient registration; checking insurance coverage and eligibility verification; medical coding; insurance denial/rejection analysis; drug research and testing; analysis of digital lab slide images; creation of digital templates for prosthetics; and biopsy analysis.

So far, “telemedicine” has not figured out how to take your temperature, but a Swiss company called LifeWatch can monitor your vital signs from a fair distance away.

However, “telemedicine is less about cutting technology than it is about the buck. When Health Partners of Minneapolis sends a report to the Philippines, the information technology (IT) programmer works for 1/9 what an IT programmer makes in the U.S. When medical billing specialists Alpha Thought axes a $10 an hour job in Chicago, it ships it to New Delhi, and realizes a 25 percent saving.

Some firms, like Cbay Systems of Annapolis, Md.—the fourth- largest medical transcription company in the United States—send virtually all their work abroad. Cbay outsources 95 percent of its transcriptions to India and is projected to earn $100 million in 2005. Given that an American accountant can earn up to $4,000 a month and his Indian counterpart $400, it isn’t hard to see where that $100 million comes from.

Few politicians have challenged the collateral damage inflicted by outsourcing medical services, although Tennessee recently enacted a bill that gives preference in awarding state contracts to data entry and call-center firms that agree to keep jobs in the U.S. Some 30 other states are considering similar legislation, reflecting growing concerns over medical records and privacy. In California, SB 1451 was approved by the legislature in September but vetoed by Gov. Arnold Schwarzenegger. The bill would have provided privacy protection for patients whose medical records are outsourced.

National legislation has also been introduced. U.S. Rep. Edward J. Markey’s (D-Mass) HR 4366 would require a patient’s approval before any such information could be shipped abroad. There is also a Senate bill (SB 2481) to restrict the U.S. government from offshoring medical records and jobs, but given that most hospitals and all medical firms in the U.S. are private, the bill skirts the real impact of the trend: job loss.

Suresh Menon of HealthScribe, one of India’s largest medical transcription companies, put his finger on the legislation’s weakness: “Most hospitals in the U.S. are under private control and the bill does not seek to debar third party U.S. contractors from outsourcing work to Indian medical transcriptions.”

The legislation certainly hasn’t overly alarmed the Indian market. Anand Mahindra, president of the powerful business lobby, the Confederation of Indian Industry, told the Asia Times that the legislation was “unfortunate” but its impact would be “small” because U.S. federal contracts are a trifling part of the industry.

According to a study by Forrester Research, the U.S. will move some 3.3 million jobs offshore by 2019, jobs that translate into $136 billion in lost wages.

The soothing line from the medical industry is that medicine can’t really be offshored.

“General practitioners and surgeons will have a job forever,” assures TK Kurien, president of Wipro Health Sciences.

John Challenger, CEO of Challenger, Gray & Christmas, a Chicago-based “outplacement” firm, adds, “You can’t go overseas to see a doctor or a nurse or get physical therapy.”

People in the profession disagree.

“We are very concerned about outsourcing to other countries,” says Deborah Burger, an RN and president of the California Nurses Assn. (CNA). Berger argues, “If we don’t do something right now, patient care is going to be compromised. If we wait too long, corporations will control how the medical profession provides care.”

In part that is already underway. Dr. Roy D’Souza in Bangalore, who analyzed those kidney images for Wipro, is a case in point. He also downloads and studies CT scans and MRIs.

So is U.S. trained physician Prathap C. Reddy, whose Apollo Company runs 37 hospitals in India. Apollo offers cardiac surgery for $4,000, a saving of $26,000 over the same procedure in an American hospital. One reason is that a U.S. cardiologist makes $300,000 on the average, while his counterpart in India earns $65,000. More than 5 percent of Apollo’s patients are westerners and the numbers are growing.

When one factors in nurses, technicians, and support staff, medicine on the cheap does more than squeeze a few high-priced U.S. heart surgeons. Savings on hospitalization may be anywhere from 200 percent to 800 percent in places like India, according to Ames Gross and Rachel Weintraub, reporters for Medical Devicelink, the industry’ online publication.

So is our loss India’s gain? Not exactly.

Medical transcription jobs—80 percent of which comes from the United States— have indeed poured into India, which just passed the Philippines as the No. 1 recipient of such offshoring. But such jobs have little impact on the one-third of India’s poor who live on less than $1 a day, or the two-thirds of the population that lives in rural areas. Indeed, offshoring can make things decidedly worse for the locals. The Andhra Pradesh state government, for instance, is siphoning off desperately needed water from farmers in order to provide it to the Vannenburg Intelligence Technology Park’s 20-acre campus. Much of the water is used for landscaping the Park’s lush lawns and flora. The government has also raised electricity rates for hard-pressed consumers, while at the same time giving IT firms a 25 percent break on their bills.

There are also safety and environmental concerns about offshoring. Increasingly, U.S. medical firms are moving major parts of their operations abroad. Respironics, Inc., of Murrysville, Pa., is shifting its research and development, manufacturing, drug discovery and testing and health care services to China, the Philippines, and Hong Kong, according to Medical Devicelink.

Labor and materials are cheaper abroad, but environmental laws are also much weaker. Waste management may be the local river, with all the consequences that implies for local residents.

The combination of offshore savings, coupled with the Bush administration’s massive corporate tax cuts has allowed Health Maintenance Organizations (HMOs) to move from marginally lucrative in 1998 to immensely profitable today. In the last nine months of 2003, HMO profits jumped 73.3 percent, and the industry’s net worth climbed 70 percent, from $23 billion to $39 billion. Profits are projected to rise another 16 percent in 2004.

Drug companies have also elbowed their way to the tax trough. Bristol Myers-Squibb, Merck, and Pfizer successfully lobbied for a tax “holiday” provision in the recent $137 billion tax reduction bill: $100 billion in foreign drug sale profits will be taxed at a rate of 5.25 percent, instead of 35 percent. The “holiday” is supposed to be temporary, but tax “holidays” have a habit of turning into endless summers. As Martin Sullivan of Tax Notes told the Financial Times, the windfall may keep industry happy for awhile, but “as they build up profits again, it’s more than likely there’ll be another amnesty because they’ll start lobbying again.”

Instead of creating jobs, the cash the companies saved on taxes and reaped from price hikes allowed them to finance a major reorganization of how they did business. Instead of adding to their domestic workforce, they created an army of “labor saving devices” which has raised profits, but kept the unemployment rolls high. They also went foreign, using some of their newly reaped capital to finance offshore production, from building actual factories, to financing high-speed information networks.

This is why the U.S. is presently in the unprecedented situation of seeing its median household income fall 3.4 percent, at the same time, productivity is rising 12 percent. While this is a long-term trend, it sharply accelerated in recent years. According to the Economic Policy Institute, “In the 2000-03 period income shifted extremely rapidly and extensively from labor compensation to capital income.”

Part of this shift has been from the acceleration of outsourcing to low wage, non-union locations. In early October, the Business Roundtable hosted 150 corporate leaders at a $1,400-a-head conference on how to speed up the process of sending U.S. jobs abroad. The conference, according to the Asia Times, urged the Bush administration “not to be swayed by the public furor over the loss of American jobs overseas and not to espouse policies that would prevent American firms from getting jobs done cost-effectively, including outsourcing and subcontracting to countries like India and Russia.”

The medical industry is flush with cash, and cash provides clout when it comes to influencing legislation and lobbying. Most people assume the big players in politics are economic giants like oil and gas, defense and agribusiness. But according to the Center for Responsive Politics, the medical industry poured $91.5 million into the 2004 elections. Only banks, lawyers and real estate interests handed out more in an effort to influence legislation and tax policy. Almost two-thirds of those monies goes to Republicans.

The current trends suggest that medical outsourcing will accelerate over the next decade, and CNA’s Burger warns that while the medical industry may lag behind other industries in introducing new methods and technologies, there is growing concern among medical professionals about outsourcing. “We are not immune to the potential drain of jobs in our profession,” she says.

Some of that drain is not so “potential.”

The huge drug multinational, GlaxoSmithKline, recently announced it was moving one-third of its clinical trials offshore to countries like India and Poland as a cost-cutting measure. A pharmaceutical industry source told The Guardian that clinical trials can cost one-tenth of those in the west, and that GlaxoSmithKline was also moving its research to India. It has opened a research facility in Singapore as well.

Unless the hemorrhage is stanched, the medical profession could shrink dramatically. Along with that contraction will go well paying jobs, many of which have medical plans linked to them.

Over the past three years, 68 percent of the industries that have been losing jobs tend to provide health coverage to employees. By contrast, 55 percent of the job growth is in industries that do not provide health care, according to a recent Economic Policy Institute study. All but five small states are experiencing this trend.

It would be a stretch to put the growing crisis of health care coverage on the back of outsourcing, but given the projection that some 3.3 million relatively well-paying jobs will go foreign in the next 15 years—and that estimate may be conservative—it is certainly part of the problem.

One of offshoring’s central selling points is that it will lower health costs. But Burger of CNA is deeply skeptical that “telemedicine” will reduce costs or improve medicine. “Sometimes we go along with these new technologies and gizmos because they are supposed to save money,” she says, “but nothing in medicine had gotten any cheaper. In fact, costs and profits are way up.”

Burger argues that offshoring and cybermedicine are about cutting human providers out of the process, and increasing profits, not lowering the cost of health care. “When you actually work with human beings,” she warns, “you can’t cut corners.”

The Complex Terrain of Aging

The Complex Terrain of Aging

Registered Nurse

Sept. 2007

Conn Hallinan

Carl Bloice

3207 words

The earthquake that struck Kashiwazaki, Japan in July, 2007 did more than smash up houses and kill 11 people: it exposed a fault line that had nothing to do with the island nation’s unstable perch on the Pacific Ocean’s “Ring of Fire.” All of the dead were over 65

The great heat wave that battered Chicago 12 years ago made life about as unpleasant as it can get in that Midwest city, but for older people—most of whom were poor and minority—it was a killer.

No one knows for sure how many people the heat wave that rolled across Europe killed in August 2003, but in France the death toll was at least 15,000, the majority of them elderly.

Natural disasters have always had a way of shaking the glitter off systems and revealing the underlying fissures, be it inadequately maintained levees in New Orleans, or in the cases above, a systemic failure by social, political and medical institutions to deal with a demographic tsunami.

By the year 2050, the number of humans 65 years or older will increase from a little over 600 million to two billion, two-thirds of whom will be in the Third World. “Aging is affecting virtually every country,” United Nations General Secretary Ban Ki-Moon told a Tokyo conference on aging this past April. “The world has never seen such rapid, large and ubiquitous growth in the number and proportion of elderly people.”

In the U.S., the number of people over 65—currently 35 million— will double by 2030, jumping from 13 percent of the population to 20 percent.

At the same time the elderly population is climbing—adults over 85 are currently the fastest growing demographic group in the U.S.—the number of doctors and nurses who treat them is declining, and the population of traditional caregivers is either stagnant or falling.

What makes this particularity challenging is that geriatrics, the branch of medicine that deals with the diseases, debilities, and care of older people, is an enormously complex kaleidoscope of medical procedures, government policy, and demographics. If things go wrong in any of these areas it can lead to a train wreck.

For example, in the aftermath of the 1995 Midwest heat wave, researchers found that it was not so much the temperature that killed people, but poverty, isolation and fear. Many elders were too poor to afford air conditioning; they lived alone, and were too afraid to go out in the mean streets of Chicago. Isolated behind locked doors, they baked to death.

But tying together all the strands that make up the complex field of geriatrics is not a simple task.

On one level, the infirmities of age like diabetes, arthritis, incontinence, and high blood pressure are medical conditions that can be treated with drugs. But as Dr. Claudia Landau, Geriatric Curriculum Coordinator and an Associate Clinical Professor of Medicine at the University of California, Berkeley argues, when it comes to treating older people, “The medical model is not going to work.”

Geriatrics, she says, needs doctors and nurses to be as much sociologists and anthropologists as medical workers. “They have to know whether their patients are poor or rich, they need to know the total terrain. If you don’t attend to all of the elements you are not going to care for old people very effectively.”

The medical model is relentlessly pushed by an avalanche of television ads on treatments for incontinence, diabetes, and high blood pressure, what researchers Dr. Carol L. Estes and Steven P. Wallace, PhD, call the “commodification” of aging by a “medical-industrial complex” whose bottom line is money.

“Adult diapers and drugs produce significant profits for their manufacturers, creating incentives to promote these products,” write Estes and Wallace in Social Injustice and Public Health. “As a consequence, behavioral therapy, which is time consuming and not very profitable, is rarely used even though it is more effective.”

While bladder control seems like one of aging’s minor aliments, it is a major reason older people are institutionalized.

Studies show that conditions like incontinence, diabetes and high blood pressure respond just as well to exercise and dietary regimes as they do to target drugs. Indeed, many times the drugs create the problems.

Dr. Wendel Brunner, now Director of Public Health in Contra Costa County, California, recalls that when he was working in a clinic, “Old people would come in with bags of medicine. I would throw away most of it, and they would get better.”

Treating older people takes certain skills that most general practitioners and specialists don’t have. One of those skills is listening. “As we get older our homeostasis changes and doctors need to be tuned into that. You have to listen and take the time. You have to value communication,” says Landau. She calls this “cognitive medicine.”

Is an older patient disorientated because he or she is losing their mental facilities, or because of depression? Do they have an infection? (which can be difficult to spot because older people tend not to run fevers). Or is their medication wrong?

A doctor or nurse certified in geriatrics is trained to triage these very questions.

But out of 145 medical schools in the U.S., only nine have geriatric departments. There is only one geriatric doctor for every 5000 people in the U.S. Fewer than 9,000 of the 650,000 doctors in the U.S. are certified in geriatrics and fewer than 3 percent of medical students take courses in the subject. As a result, the number of U.S. geriatricians has fallen by one-third.

“It’s a problem,” warns William Satariano, a professor of Epidemiology and Community Health at UC Berkeley’s Public Health School and an expert on aging.

Doctors, for example, need to be particularly careful when prescribing drugs to elders. Diuretics are commonly proscribed for controlling high blood pressure, a chronic disease many older people suffer from. But if patients are not properly hydrated, diuretics can cause dizziness and falling. Some 350,000 Americans fall and break their hips each year, of which 40 percent will end up in nursing homes. A fifth will never walk again.

Side effects can be exaggerated when different doctors prescribe drugs without any centralized monitoring. “Multiple doctors prescribing multiple medicines cause multiple problems,” says Brunner.

Wallace and Estes found that many doctors tend to under treat older patients, with some claiming “those over 80 should receive no curative treatments…because they have lived out their ‘natural lives.’”

But a Harvard study found that when 90 year olds were put on Nautilus trainers they got better. Landau recalls advocating physical therapy for older patients when she worked in a public health clinic, only to be accused of “torturing” them by some staff members. “I told them to humor me and lo, and behold, people got better.”

One reason why there are fewer geriatric doctors is that they are among the lowest paid in the profession. While radiologists and orthopedic surgeons average $400,000 a year, geriatricians average $150,000 a year. Brunner, however, is not overly sympathetic to this argument: “It is hard to feel bad about any doctor’s income. The problem is not that we don’t pay doctors enough.”

The shortage is not restricted to doctors. Only 720 of the 200,000 pharmacists in the U.S. have geriatric certification, and the situation is only slightly better for social workers.

Bonnie Martin, RN, a geriatric nurse in San Francisco, and a member of the California Nurses Association’s Board of Directors, says the situation in nursing is “very similar.” According to Martin, “very few RNs choose to work with the elderly and very few NP (nurse practitioners) attend geriatric programs.” Much of the care for the elderly “is left to LVNs (licensed vocational nurses) and certified nursing care, in spite of the fact that the elderly need more complex nursing care than most other patient populations.”

Joan Stanley, RN, Senior Director of Education Policy of the American Association of Colleges of Nursing, and Mathy Mezey, RN, a professor at New York University, write, “The care of older adults is now the number one business of the U.S. health care system, cutting across hospitals, home care and nursing homes.”

Stanley and Mezey argue that “Evidence shows that older-person care delivered by nurses with specialized geriatric knowledge and skills improves outcome,” by improving patient assessment, reducing falls, and lowering costs.

Yet less than 1 percent of the 2.7 million nurses in the U.S. and Canada are certified in geriatrics and only 27 percent of nurses in baccalaureate programs have required classes in geriatric medicine.

Martin says the reason is that “nurses in LTC (long term care) tend to be paid significantly less, have fewer benefits and are not considered among the nursing ‘elite,’ an outgrowth of how little we value our elderly.”

Elder care is falling increasingly on aides, whose pay averages $9.34 an hour. The low pay and lack of benefits results in large yearly turnovers. What is more, the traditional pool for such aides—women age 25 to 54 with little education—is not growing to match the rise in the elder population.

Another dimension of the problem is part of Landau’s “total terrain”: class, race and gender.

There has long been a significant gap between the care that whites, as compared to minorities, receive, and who delivers that care. In 2004, a commission headed by Lewis W. Sullivan, former Secretary of U.S. Department of Health and Human Services, found that “From cancer, heart disease, and HIV/AIDS to diabetes and mental health, African Americans, Hispanic Americans, and American Indians tend to receive less and lower quality care than whites, resulting in higher mortality rates.”

Inferior care, Wallace told Registered Nurse, has a “weathering effect” on people, by which he means the “accumulated impact of being poor, living in poor conditions and the high stress of living in a racist environment,” all contributing to deteriorating health.

For instance, Wallace says that “food insecurity” among minorities is twice that among non-Latino whites, and that food insecurity is associated with a host of chronic diseases like diabetes, hypertension, and coronary heart disease.

This disparity of access to health care has an impact on what U.C. Berkeley’s Satariano refers to as “the middle years, where the accumulation of insults the poor suffer play out. It is during these middle years that we begin to lose some of our resistance to disease.”

New research finds that poverty level income—$10, 210 for a single person, $13,690 for a couple—falls short of meeting basic needs. According to the National Academy of Social Insurance, people need to earn between 150 percent to 300 percent above the poverty line “to meet basic living expenses without assistance.”

Gender creates yet another dimension to the problem. Women, age 45-55, with a family income of less than $35,000 a year, make up the overwhelming bulk of people who volunteer their labor to care for aged parents or grandparents. Some 80 percent of them hold full-time jobs. It is this “informal” labor force that keeps the crisis of elder care from going into free fall.

More than 20 million U.S. employees have ailing parents, and only one percent of the companies they work for pay for subsidized elder care. Medicare will not pay for long term care (LTC), and Medicaid will only do so once the elders’ assets are exhausted. The result of the government’s unwillingness to take any responsibility in this area means that 64 percent of LTC is “informal,” and another 28 percent is a combination of informal care and elder resources. The average informal caregiver puts in 18 hours a week.

“The problem of long term care is the elephant in the room when policymakers and planners gather to talk about health care systems,” Mary Jane Koran, a member of the National Commission for Quality Long Term Care told the House Sub-committee on Labor, Health and Human Services in February of this year.

The Bush Administration’s solution to the LTC crisis is to push market driven schemes, like reverse mortgages and private long term insurance. More than eight million Americans have purchased LTC insurance, only to find that companies throw up one road block after another when it comes time to cash in. A study in California found one in four claims were denied. In the meantime the industry has pulled in more than $50 billion in premiums.

As for reverse mortgages, they essentially wipe out one of the few assets working class people can pass on to their children.

According to the American Association of Retired People, this informal labor network is valued at anywhere from $275 to $350 billion a year, more than twice what Medicare costs.

But demographics are working against “informal” care giving as a solution to the LTC crisis because people are having fewer children. In 1955 the average family size was 3.7. In 2000 that figure was 2.1. According to a study by the Robert M. LaFollette School of Public Affairs, “The average working couple has more living parents than children.”

Because people are living longer they are more vulnerable to Alzheimer’s disease. According to the Alzheimer’s Association, by age 85, nearly 50 percent of the population will be stricken with the disease. Relatives will care for over 85 percent of those.

As for the caregivers: no good deed goes unpunished. “Women of all races tend to have jobs that either do not provide health care, are lower paying so they can’t afford private insurance, or they work part time in order to care for their family and have no benefits,” says Miller. “Therefore, by the time they become eligible for Medicare, their health may be significantly worse.”

Because women are paid less, and may end up missing work to act as caregivers, they also end up drawing less Social Security. The Academy of Social Insurance estimates that family caregivers give up about $659,000 in lifetime wages and pension benefits.

Another part of the “total terrain” has to do with where people age.

Studies show that elders do better if they stay in their homes rather than going to a care facility. Staying in place also saves money. But most homes are not designed for elders.

Satariano, the author of “The Epidemiology of Aging: An Ecological Approach,” argues that “The problems of older people require addressing things that some people think of as falling outside the realm of health care,” like the design of cars and houses. This, he says, means pulling city planners and building contractors into the mix. “How do we design more walkable communities? Can we build communities that have short distances to walk to stores, supermarkets where they [elders] can purchase fresh fruits and vegetables?”

Since up to 70 percent of diseases that afflict seniors are behavioral, not genetic, this is not just a matter of providing people better cuisine. Eating properly and exercising by walking in safe, well lighted parks, is part of the formula for what Satariano calls “adding life to years, not just years to life.”

Satariano’s “ecological,” approach argues for creating environments that are senior friendly. “Houses should be designed with a minimal number of steps, bathroom walls should be reinforced for attaching supports, and doors made wider for wheelchairs.”

Wallace told Registered Nurse the same approach to improving elder health should be applied to planning communities. Reflecting roofs, cooling trees, and parks—so-called “heat islands”—would reduce hot weather deaths. City planners and zoning boards should encourage the building of “granny units” so family can be nearby. He says these initiatives should be no more controversial than putting fluoride in the water to reduce tooth decay: “You just do it!”

“The core problem is that we don’t need more medicine, we need to set up communities so that people can become more active,” says Wallace.

“Instead of thinking what we need to do to keep people in their homes—where 90 percent of older people want to be—long term care gets caught up in cross currents and ideological debates,” says Wallace, “where free market advocates see privatization as a solution to everything.”

Martin adds a human element to LTC: “There is a huge emotional and physical toll to being institutionalized. There is a complete loss of privacy, dignity and control over your life. You are told when and what you eat. On shower days you are stripped naked, wrapped in a towel, placed in a shower chair and dragged down the hall to the shower room.”

Brunner agrees that avoiding institutionalization is important. “How do we set up a social support system and infrastructure to help old people get services at home and keep them out of nursing homes.”

Finding solutions will not easy and tend to run up against a cohort of powerful lobbyists that run the gamut from pharmaceutical companies to the insurance behemoths. On the other hand, the political power of seniors has grown over the past decade, and local and state governments, not to mention the medical establishment, are coming under increasing pressure to respond to demands to improve elder care.

At least the outlines of a solution are out there.

One is to end health disparity. “Everything links back to growing income inequality,” says Brunner, and Satariano agrees: “The issue of disparity is critical.”

Kay McVey, RN, and President Emeritus of the California Nurses Association, says income is directly related to the quality of elder care. If patients don’t have the money, they can “end up tied to a gurney or strapped in a wheelchair and stuck in the back of a facility.”

Two is to create a nation-wide health care system that coordinates care. “Single payer health care would end the idea that you can make big profits off of old people. It establishes one standard of care for everyone, whether you are in an acute care facility or a long term care facility,” says McVay. The only criteria should be: “What does the patient need?”

Three is to improve training. “ Medical schools must train students to treat older Americans,” says Brunner. “We have a right to make demands on our institutions, says Satariano. “You have to teach geriatrics,” says Landau bluntly.

Four is designing communities and programs that take into account the “ecology” of aging. “When you are elderly you need not just medical attention and medications,” says McVay, “you need good nutrition and exercise and things that challenge your mind. Otherwise it is just warehousing. It shouldn’t be that way and needn’t be that way.”

Mobilizing the medical profession, lobbying federal, state and local governments to stop turning a blind eye to the problem, and neutralizing the lobbying power of the “medical-industrial complex” will be a formidable task, and yet given the size of the constituencies involved, one that may not be as difficult as it initially looks.

In the end, it will also take a sea change in our attitude about elders, “Who are not exactly revered,” as Landau points out.

“I know it sounds sort of corny, but you have to have love and empathy. Aging is about loss—loss of independence, loss of mobility, eyesight, hearing, cognition—you need an approach that allows people to deal with loss in a collective, supporting way,” she says.