Where does disease come from?

Political determinants

 

The bugs can’t do it alone. For them to cause the greatest possible harm they need our help and unfortunately we seem to be giving it, increasingly so. For example, this month the U.S. Senate refused to extend government health insurance for the nearly 9 million kids and roughly 370,000 pregnant women it protects.

The polite term used in the medical literature for aiding and abetting disease is “the political determinants of health.” The British Medical Journal puts it this way: “Health is a political choice … health is unevenly distributed, many health determinants are dependent on political action, and health is a critical dimension of human rights and citizenship.” (My emphasis.) Thus, if health is a political choice, then so is disease.

Unusual insight into what this means was provided over the weekend in a series of heartfelt tweets (below) from pediatrician Chad Hayes (@chadhayesmd) who practices in rural South Carolina. When you read what Dr. Hayes has to say, keep in mind that it’s well-established in the literature that two other politically-influenced factors, poverty and crowding (e.g., in homes, hospitals, schools, prisons, and shelters) increase the rates of MRSA and other bug-driven infectious disease.

Before I went to medical school, I had little interest in politics. I grew up in a conservative upper-middle class family with two working parents, went to private school for several years, and faced relatively little adversity. (1/x)

I was vaguely aware that there were people who struggled, but rarely encountered them personally. It was children that changed my mind. Not my own, but the ones I care for at work. Kids who, due to a variety of societal problems, aren’t set up for a great future. (2/x)

Today, I woke up yet again in a country where our government has failed to #PutKids1st. We have placed the interests of corporations and the wealthy above those of families who are struggling to survive and children who must strain their eyes to envision a promising future (3/x)

(4/x) It has been over two months since Congress failed to reauthorize CHIP, presumably because the money is needed to fund tax breaks for those who will never have to worry about how to pay their medical bills. We are failing children and putting our nation’s future at risk.

(5/x) I am no longer a conservative. And I am now quite political. And to the politicians who voted for this tax bill, I extend an open invitation to spend my lunch hour in my pediatric office in rural SC, as I struggle to find help for a teen mom with severe depression,

(6/x) a family with 10 people in a single-wide trailer because the house where half of them lived burned down and they have no money to rebuild or replace their belongings, or families where the biggest concern is not whether to contribute to their child’s IRA or college savings,

(7/x) not which private school to use, or which luxury SUV would be the best way to get them there. Their concerns are buying food and infant formula, paying for gas to get to the doctor, and hoping the power company doesn’t shut off their heat this winter.

(8/x) Many are necessarily so concerned about providing for their children today that they have little time, energy, or money to devote to the future. And they are the ones that we are trampling in to minimize the tax burden of people who could lose millions without noticing.

(9/9) I respect that not everyone shares my political views, but for anyone who doesn’t see a problem with this, I’d encourage you to spend some time with the less fortunate. They have changed my perspective, and they may change yours as well. Happy holiday season.

MRSA, PTSD, and Your Family

Eighteen-year-old MRSA survivor Bethany Burke: “These things on my face were taking over. It’s like my face was being invaded. I looked like I had been stung by some venomous insect. They were all over. They were swelling. And it seemed like the more I was taking antibiotics it was like feeding these things on my face. They just kept getting bigger and eventually the one on my eye became so large that I couldn’t open my eye anymore.”

 

 

As Sanjay Gupta, MD, reports, Bethany’s ordeal began at age 15 when she developed an irritation on her forehead. After being diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) at a local emergency room, Bethany was treated with several different antibiotics, and the skin abscesses had to be lanced and drained. Health issues related to the infection persisted for the next two years.

“I missed so much school,” says Bethany, then a freshman at Southwestern University in Texas. “Just getting dressed would exhaust me so much that I didn’t have any energy left. While other girls were taking bubble baths, I was checking my body for abscesses and taking diluted bleach baths.”

Although they got the infection under control “it left some pretty deep scars, physically and emotionally,” Bethany says. In fact, she was eventually diagnosed with post-traumatic stress disorder. “Not being able to control what’s going on with your body… nothing makes you feel more helpless.”

And Bethany wasn’t the only one diagnosed with PTSD – so was her mother. “I looked at her and could not believe what I was seeing,” her mother Mary recalls. “The blemish on her forehead was now just enormous. They also spread to her nose and eyelid.”

There’s a saying in the cancer field: when somebody gets cancer, the whole family gets cancer. “Cancer moves in, like a rude and unwanted guest. And, as the patient, you have to understand – as hard as that might be – that it’s not just you alone who has to cope with the disease,” cancer patient Dana Jennings wrote in The New York Times.

It’s easy to see how “MRSA” and “Cancer” are interchangeable in Jennings’ statement, especially since MRSA is contagious. For example, how would you cope when the MRSA patient is your partner with whom you so intimately share living quarters? Or if you’re infected with MRSA and have children, how do you cope with the possibility of infecting them? Or worse, what if, like with the flu, family members started contracting MRSA, one after the other?

A few years ago, the Centers for Disease Control and Prevention conservatively estimated that there are over 80,000 “severe” MRSA infections in the United States each year. However, maybe a better way to understand what the CDC is telling us is this: Each year in the U.S., over 80,000 families are infected with a severe case of MRSA.

 

 

 

The Post-Antibiotic World: “If I need one of these [Antibiotics] down the road is it going to have the effect I need it to? I don’t know the answer to that.”

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“If we are not careful, we will soon be in a post-antibiotic era,” said Dr. Tom Frieden, then director of the Centers for Disease Control and Prevention (CDC). “And for some patients and for some microbes, we are already there.”

If you want a glimpse into that post-antibiotic world, take a look at the case of Nicole Scott (pictured above). After a fall she had reconstructive surgery to her left shoulder. The procedure itself went fine but during recovery an excruciating pain set in signaling an infection: “It literally looked like I had a softball sitting on top of my shoulder and I mean I just barely touched it and my shoulder just ruptured,” she said.

Surgery was needed to open and clean the site followed by a night of IV antibiotics. Underneath her skin her doctors found a large pocket of infection that spread from her shoulder to – but not into – her heart.

Weeks later the stitches were removed and the wound was covered till her next follow-up. At the follow-up her bandages were removed and they were shocked to find that the tiny pinpoint hole at the site of the infection had become a hole the size of a quarter – the infection had eaten through the tissue and her skin. That required yet another surgery – and more antibiotics.

The CDC conservatively estimates 2 million such antibiotic-resistant infections in the US alone – every year. Each case will vary in its detail but what happened to Nicole Scott illustrates some of the broad themes: hospitalization, multiple surgeries, pain & disfigurement – and living with the dread of going through it all again.

That dread is what Nicole lives with: Have too many antibiotics taken after her surgery created a harmful tolerance? “If I need one of these down the road is it going to have the effect I need it to? I don’t know the answer to that.”

Nicole Scott is interviewed in this compelling video, which also nicely covers the a, b, c’s of when to use antibiotics. Be sure to click on the full screen icon.

 

The Responsibility to Protect

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Vaccinations protect more people than just those who are vaccinated – they also protect the unvaccinated. Health authorities call this protection “herd immunity” (people around us are referred to as our “herd”). But there’s a catch: there has to be a threshold number of people who get vaccinated before this collective immunity takes effect. Conversely, low levels of herd immunity are often associated with epidemics, such as the measles outbreak in 2014 – 2015 that was traced to exposures at Disneyland in California.

Tara C Smith, PhD, of Kent State, wrote a popular essay this month explaining how vaccination and herd immunity go together. Note that the necessary level of (herd) immunity in the population isn’t the same for every disease:

For measles, a very high level of immunity needs to be maintained to prevent its transmission because the measles virus is possibly the most contagious known organism. If people infected with measles enter a population with no existing immunity to it, they will on average each infect 12 to 18 others. Each of those infections will in turn cause 12 to 18 more, and so on until the number of individuals who are susceptible to the virus but haven’t caught it yet is down to almost zero. The number of people infected by each contagious individual is known as the “basic reproduction number” of a particular microbe (abbreviated R0), and it varies widely among germs.”

For instance, the R0 of pertussis (whooping cough) is 12-17; polio and smallpox 5-7; mumps 4-7; HIV 2-5; influenza, including the 1918 influenza pandemic 2-3; and Ebola 1.5-2.5.

Here’s the thing. If you know how many secondary cases to expect from each infected person, you can figure out the level of herd immunity needed in the population to keep the microbe from spreading. Tara Smith:

This is calculated by taking the reciprocal of R0 and subtracting it from 1. For measles, with an R0 of 12 to 18, you need somewhere between 92 percent (1 – 1/12) and 95 percent (1 – 1/18) of the population to have effective immunity to keep the virus from spreading. For flu, it’s much lower — only around 50 percent. And yet we rarely attain even that level of immunity with vaccination.

Based on that arithmetic, the following table shows what percentage of the population needs to be vaccinated by disease to prevent its outbreak:

R values

Notice that the higher the R0 value, the higher the percentage of people in the community that need to be vaccinated.

Which brings us to the question of who it is that we need to protect – who are the unvaccinated? In general it’s people who are immune-compromised. For example, children who cannot be vaccinated because their immune system is too immature to develop the adaptive immune response that the vaccine is supposed to illicit. Infants who have not yet been vaccinated or have just received a vaccination. The elderly who, because of their age, are often immune-compromised. The sick, whose immune systems can’t withstand the dose of a weakened virus in a vaccine. Those for whom the vaccine didn’t take. And here’s a detailed eye-opening list provided by the CDC that pairs a particular vaccine with health status and warns against vaccination in such cases. All told, we’re talking about a huge swath of people that need protection from infectious disease through herd immunity.

In other words, vaccination campaigns for the flu and other diseases are about much more than individual health. They’re about achieving a collective resistance to disease that involves the whole community.

In the field of international relations there’s a UN doctrine called the Responsibility to Protect. It says that if a nation can’t or won’t protect its own people from harm, then other nations have a right and an obligation to step in and do so. Similarly, on the level of community relations, we know that the very young, the old, and the sick, can’t protect themselves from harm – disease – through vaccination. And so it falls on each one of us to do so: to vaccinate, thereby protecting not just the vulnerable but ourselves and our families at the same time.

Key Vaccination Effect: It greatly reduces the need for antibiotics

We know that vaccines are “incredibly effective” against illness (chart below). Yes, sometimes there are minor short-lived side effects such as swelling at the infection site, but serious side effects are “extremely rare.”

But for those unwilling to vaccinate because of those side-effects, there’s something else to consider that we’ve only recently acknowledged: vaccines reduce the chances that a child will need to be treated with antibiotics. And according to this groundbreaking paper by Alice Callahan about how vaccines reduce our dependence on antibiotics, this matters for three reasons.

Side effects from antibiotics, including diarrhea, rashes and allergic reactions, are generally more common and severe than those from vaccination. “I see far more harm from antibiotics than I do from vaccines, by a huge margin. It’s not subtle,” says one expert.

Second, antibiotics indiscriminately kill bacteria needed for good health, and without them our microbiome  becomes out of balance. Such “dysbiosis” is associated with a number of illnesses including inflammatory bowel disease, multiple sclerosis, diabetes (types 1 and 2), allergies, asthma, autism, and cancer.

And with the good guys out of the way, bacteria that proved resistant to the drugs – the ones that survived – grow and thrive. That makes for more antibiotic-resistant infections, which are harder to treat or which can’t be treated at all.

Take measles as an example. You chose not to vaccinate your child so he or she gets sick. Since measles is bacterial-driven, your child has to take an antibiotic notwithstanding the risks of side effects, upsetting the gut microbiome, and giving rise to drug-resistant bacteria. Further, a measles infection weakens a child’s immune system for up to three years, thus risking further infection and the need for yet more antibiotic treatment.

Perhaps the best example, though, is this vivid illustration of how the pneumococcal vaccine has reduced our dependence on antibiotics. Pneumococcus bacteria can cause pneumonia and invasive blood and brain infections, but it’s also a major cause of ear infections, which are one of the biggest reasons that children are prescribed antibiotics.

 

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Ideally, says Alice Callahan, we want to protect our kids from deadly bacteria without disturbing the good ones or worsening the trend of antibiotic resistance. And this is exactly what vaccines do. But when parents choose not to vaccinate their kids, they’re increasing the kids’ chances of not only becoming seriously ill, but also of needing antibiotic treatment and other medical interventions down the road.

In other words, vaccines are a tool for decreasing medical interventions.

 

What Killed Hugh Hefner?

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On September 27 this year, Hugh Hefner “died of natural causes at the Playboy Mansion in Las Angeles,” read the headlines announcing his death. And while that’s true, there’s also a deeper story in play that increasingly involves all of us: Antibiotic Resistance – the bugs are beating our drugs.

The way to understand what happened to Mr. Hefner is to look at his death certificate – excerpted above; in full here – and read the four-step chronology that led to his demise like four dominos that fell:

(1) The problem began when Mr. Hefner contracted a strain of E. COLI that was HIGHLY RESISTANT TO ANTIBIOTICS, which led to

(2) A life-threatening bloodstream infection, SEPTICEMIA, where the blood conveys E. coli to bodily organs which the bugs then attack, which led to

(3) RESPIRATORY FAILURE, where the lungs were attacked and succumbed, compromising their ability to move oxygen, resulting in

(4) CARDIAC ARREST, the “immediate cause” of death.

In other words, what drove Mr. Hefner’s death was an antibiotic-resistant E. coli infection that he contracted, the certificate shows, six days before his death. The fact that this strain of E. coli was “Highly resistant” means they threw every drug they had at it yet it beat them all back – that’s antibiotic resistance in action.

It’s crucial to understand that while Mr. Hefner’s age may have factored into why E. coli proliferated in him in the first place – bypassing his body’s natural defenses – his age had nothing to do with why the many antibiotics they gave him didn’t work: that’s a function of the (biochemical) interaction between the bug and the drug.

Earlier this year the World Health Organization published its first ever list of antibiotic-resistant “priority pathogens” – a catalogue of 12 families of bacteria that pose the greatest threat to human health – and E. coli was nowhere to be seen. So as bad as E. coli can be, there’s at least 12 other groups of pathogens out there that are worse (Staph aureus is in the group posing a “High” risk to our health).

There’s one more thing to notice about Mr. Hefner’s death: the only reason we know about the infectious disease component is because California, unlike many states, lists the underlying causes – plural – of a person’s death, i.e., (1) to (3) above. This matters because that’s exactly how infectious disease so often shows its hand – as an initiating factor: but for the infection, there wouldn’t have been a death.

This issue was the focus of a major investigation by Reuters last year, “The Uncounted,” which found that because death certificates are poorly written – asking only for the immediate cause of death – tens of thousands of “superbug” deaths in the U.S. are going uncounted every year.

But that wasn’t the case with Mr. Hefner: His death, like his controversial life, counted.

 

 

 

 

 

 

 

 

 

Report Card on Fast Food Restaurants

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Cheating catches up with you.

We’re seeing that now in how we raise food animals – cows, chickens, pigs, and turkeys – on our factory farms. We routinely feed them antibiotics not because they’re sick, but to speed their growth (thus saving costs) and to prevent disease outbreaks (illness can spread like wildfire between the animals because of their densely packed living conditions). To understand how wrong this practice is, imagine if we raised children this way: sure, we’re different species, but the biological effect would nonetheless be the same.

And the biological effect is this: antibiotics kill off susceptible bacteria in the animals, leaving the resistant bacteria to thrive: they’re now reproducing and filling the niches formerly occupied by the now dead bugs. The problem for us is they don’t stay there: these antibiotic-resistant bacteria in the guts of the animals begin to move through the environment and enter other animals and people. Result: the CDC says a few million Americans become severely infected with these “superbugs” and at least 23,000 of them die – each year. Which raises a troubling question: if we agree this is the case, then are we not knowingly engaging in the manufacture of disease?

Yet despite this knowledge, and unlike in Europe, US and Canadian governments refuse to put a stop to it. To fill the breach, public interest organizations have banded together to put pressure on 25 fast food restaurant chains to stop buying meat from producers who misuse antibiotics. These chains are singled out because they’re huge buyers of meat and poultry; McDonalds, for example, is the largest buyer of beef in the United States. The explicit threat is that consumers and shareholders will take their dollars to restaurants that don’t put the public health at risk.

And so each year a report card is prepared that ranks America’s 25 largest fast food chains on their antibiotic policies. Released yesterday, here it is. You know what to do.

 

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After the Hell and High Water: You have to engage in medical self-defense

Harvey’s gone, Irma’s coming, others will follow. But after the hell and high water, like night follows day, comes disease: a veritable one-two punch. And so it’s every bit as important to protect yourself during those long days as it was during the furious days of the storm.

You may be dealing with, for example, “Infectious diseases [that] could sweep across Texas as Harvey floods Houston … turning entire neighborhoods into contaminated and potentially toxic rivers … [and] the city into a sprawling, pathogen-infested swamp.” Or, because the pathogen count in general is so high there’s “the potential for sewer plant malfunction or sewer plant continuing to discharge untreated or partially treated waste.”

So we’re reprinting a terrific article from Medscape Infectious Diseases that lays out the A B C’s of medical self-defense in the aftermath of a natural disaster. But first, to get a better feel for how a hurricane can turn “entire neighborhoods into contaminated and potentially toxic rivers,” – and thus the need to protect yourself – check out this revealing Times video that winds you through a flooded Houston neighborhood (be sure to click on “Watch in Times Video”).

 

 

From Medscape:

                                             What patients Should Know and Do

As people are able to return to their homes, here’s what they can do to help protect their health, officials say.

Threats in the Water and Air

A woman trudges through the water in Texas.

Floodwaters carry germs, so anything that’s come in contact with those waters could harm your health, according to the CDC.

Exposure to bacteria and germs in floodwaters can cause diarrhea, wound infections, and conditions such as trench foot, the CDC says. Traveling through standing water can make you more likely to be exposed to hazardous chemicals. Floodwater, too, is a breeding ground for mosquitoes, which can transmit disease. Use insect repellent.

Your tap water may not be safe, either. Turn to local officials or the news to see if you can drink tap water or use it for washing. If you need an alternate source:

  • Use bottled water if you can.
  • If you have access to a stove, bring water to a rolling boil for one minute. Or, you can add 1/8 teaspoon of new, unscented liquid bleach to a gallon of water and stir. Let the water sit for a half-hour before drinking it.
  • Use water-purifying tablets, following the maker’s directions carefully

Clothes that are exposed to floodwaters must be thoroughly cleaned. Some clothing may have to be thrown away, especially if exposed to hazardous chemicals, sewage, or fiberglass insulation.

Before using your washing machine, make sure the water supply is safe and sewer systems are running. Run the machine for a cycle with no clothes but with detergent and bleach to sanitize it. Wash clothes on the hottest setting recommended, and use bleach if fading is not an issue. Use a pine-oil disinfectant instead of bleach on colored clothing.

Threats in Food

When possible, take inventory of your food.

  • If power is out, keep the freezer and refrigerator doors closed as much as possible; put a block of ice in the refrigerator if possible.
  • Food that has partially thawed can be cooked or refrozen if you can see ice crystals or if it is still at a temperature of 40 F or lower.
  • Discard cans that have opened or are damaged or bulging. All undamaged cans must be thoroughly washed and disinfected.
  • Throw away all medicines, cosmetics, and other toiletries exposed to floodwater.
  • Throw out food that smells strange or has an odd color or texture.
  • Be especially careful to keep meat, eggs, fish, poultry, and leftovers cold to avoid spoilage.

Other Threats in Your Home

 Once the storm has passed and cleanup is possible, be aware of major threats to your health around the home, such as gas leaks, electrocution, and mold. Here’s how to manage these threats:
  • If you suspect a gas leak, go outside right away. Do not turn appliances or electrical switches on or off. If you turned your gas off, you need a licensed professional from the gas company or elsewhere to turn it back on.
  • Do not touch any electrical equipment while you are wet or in water; instead, call an electrician to evaluate your system. Stay away from downed utility lines, and always assume the power there is live and dangerous.
  • Before cleaning up, get the gear you need, such as hard hats, heavy work gloves, waterproof boots, and earplugs or headphones if you are using noisy cleanup equipment.
  • Be on the lookout for mold, which needs to be cleaned up quickly to prevent health issues. Ideally, if possible, clean up and dry out your home within 24 to 48 hours after the storm passes. To clean mold, mix a cup of household bleach with a gallon of uncontaminated water. Or, lightly mist mold spores with rubbing alcohol. In some cases, you might need a professional mold service.
  • Open all doors and windows to air out your home, and use fans to dry wet areas.
  • For kids’ toys exposed to floodwaters, mix a cup of bleach with 5 gallons of uncontaminated water. Clean the toys and let them air dry. Throw away stuffed animals and toys that can’t be cleaned.

Minding Your Mental Health

Once your house and life are back in order, you may still feel emotionally “spent,” and mental health experts say that’s not unusual. Disasters such as hurricanes are typically sudden and unexpected, and that can be overwhelming, according to the American Psychological Association. Among the common responses, the group says, are:

  • Feeling anxious, nervous, or filled with grief. Moodiness and irritability can happen, too.
  • Changed eating and sleeping patterns — either sleeping more or less, or eating more or less
  • “Triggers” that remind you of the event, such as heavy rain, and feeling anxious
  • Trouble getting along with family, friends, and co-workers
  • Physical problems such as headaches or nausea, or existing medical conditions that seem to be worse

While there’s no “typical” timeline for feeling better emotionally after a disaster, you might speed things along by talking about your experience, joining a local support group, focusing on healthy habits, and getting back to regular routines as soon as possible.

If things are not back to normal within a few months, consider getting professional help from a mental health expert.

Hurricane Harvey: A “slow-motion rolling disaster” of disease has just begun

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“Infectious diseases could sweep across Texas as Harvey floods Houston … turning entire neighborhoods into contaminated and potentially toxic rivers … [and] the city into a sprawling, pathogen-infested swamp,” reports Newsweek.

Natural disasters turn real estate into virtual playgrounds for pathogens. Numerous factors combine: Advancing dirty floodwater – sewage, chemicals, tiny sharp objects of metal and glass – eventually becomes a stagnant, breeding ground for mold & bugs. A boil water advisory issued this week means tap water is contaminated – but many people won’t hear about it. Large swaths of power outages began last weekend and so air conditioning & refrigeration are gone and food will be lost. Stores are closed. Roads are underwater. Public transportation = a boat. People are unable to work and earn an income. Homes are destroyed. People are scared. All this and more at a time of sub-tropical August heat & humidity during – of all things – mosquito season.

And so the usual suspects will get to work: E. coli, Shigella, Vibrio illnesses (cholera-like illnesses), mosquito-borne pathogens like Zika and yellow fever, and even Legionnaire’s disease, inducing intestinal illness in the form of diarrhea, vomiting, fever, stomach pain and dehydration. Now imagine life in an overcrowded shelter if one of these illnesses took root. Or in your home where it’s sweltering and there’s no air conditioning and running water. Then multiply that over the whole neighborhood: that’s Newsweek’s concern of a city turned into a “pathogen-infested swamp.”

 

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There’s more. Science journalist @Maryn Mckenna who grew up in Houston and covered Katrina, wrote an eye-opening thread on Tuesday observing that: “Natural disasters have a long, long tail.… The result is a slow-motion rolling disaster in which people lose care and lose the proof they’re entitled to care, while they get sicker.” Lost is access to clinics, hospitals, pharmacies, medical records and doctor’s orders that people depend on to stay healthy – and stay alive. For instance, those requiring cancer chemo, or transplant care, or people with COPD or diabetes.

Mckenna gave special mention to dialysis patients:

Out of my experience covering Katrina and the aftermath, here’s what’s haunting me today: the average time between dialysis treatments … Houston’s floods began three days ago. That’s a normal time between treatments for someone on dialysis. Missing treatment = getting sick … In Katrina, bus convoys of dialysis patients drove out of the city to get to places where they could continue treatment uninterrupted … These were people who were not flooded out, who still had working cars (though sometimes no power, and the water in Nola wasn’t safe) …

 

She was backed up by a Houston physician speaking with NPR the following day: “If they don’t dialyze three times a week, they … can become very, very sick.” Muscles, including the heart, can stop functioning correctly. “Over so many days, they can’t survive.” Even if patients do make it to the clinic they may not be treated: “Many of our nurses are locked in, flooded out of their homes, and they’re either somewhere else, or they can’t get out of our neighborhoods…. As a consequence, we don’t have enough nurses to dialyze the numbers of patients that are coming here.”

Many others are at risk too: trapped seniors, disabled, and the bedridden; children separated from parents; mental health patients who run out of meds; stranded pets & other animals; and so on.

All told, this is “one of the largest disasters America has ever faced,” said Texas Gov. Greg Abbott, as he warned against expecting anything resembling recovery any time soon, or a return to the way things were. “We need to recognize it will be a new normal, a new and different normal for this entire region.”

The new normal is rapidly unfolding. Just this morning The New York Times reports a whole new kind of public health threat: a series of small explosions – “and a threat of additional explosion remains” – at a chemical plant in Crosby, Tex., about 30 miles northeast of Houston. More than a dozen Harris County deputies went to the hospital after inhaling fumes. Residents within a 1.5-mile radius have been evacuated.

Similarly, Democracy Now reports that “an environmental crisis is unfolding as oil and chemical industry spew toxic pollutants into air.” One specific case: “… gas leaks … in La Porte [30 mi. E. of downtown Houston; pop. 34,000] that resulted in a very, very dangerous chemical, anhydrous hydrogen chloride, and this gas mixed with the moisture in the air to produce hydrochloric acid, a corrosive that can damage respiratory organs, eyes, skin and intestines.”

Since Houston is home to the country’s largest refining and petrochemical complex this is an issue to watch.

As we move into the Labor Day weekend there is something we can do – help Harvey victims with a donation. ABC News is reporting that up to 40,000 homes have been destroyed and more than 32,000 people are in shelters. The Times has an excellent article on how to help, called “Where to Donate to Harvey Victims (and How to Avoid Scams),” available here.

 

Closing the Courthouse Door on Nursing Home Residents

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The Trump administration has drafted a binding arbitration rule that prevents nursing home residents from having their cases heard in a court of law. The Trump rule reverses Obama era policy forbidding nursing homes from doing this on the grounds that it preys on the elderly. His team was influenced by the death of 100-year-old Elizabeth Barrow.

In 2009, Mrs. Barrow (pictured above) was found murdered at her nursing home in South Dartmouth, Mass., strangled and suffocated, with a plastic shopping bag over her head. Her 97-year-old female roommate was charged with the homicide, but because of her dementia she was deemed unfit to stand trial and committed to a state hospital.

Her family didn’t have a problem with that: “It’s like charging a 2-year-old who happened to take a gun off a table and shoot a sibling,” her son told The New York Times. But he did want justice for his mother’s death because, among other things, he said the nursing home knew the roommate was dangerous. For example, file notes described her as being “at risk to harm herself or others.”

So he filed a civil suit on his mother’s behalf alleging wrongful death. But the court refused to hear the case because his mother’s contract with the nursing home contained a clause that forced any dispute into private arbitration; i.e., no judge or jury – the “judge” is some private entity, typically a law firm – and the proceedings are hidden from public scrutiny. So the case was referred to arbitration.

However, the notoriety of the case coupled with the industry wide practice of requiring vulnerable people to give up their right to sue if they want into a nursing home, resulted in the Obama administration enacting a rule forbidding the practice.

But that was then. This past June the Trump administration decided to make America arbitrate again on the basis that it’s simpler, fairer and faster for all parties concerned.

Fairer? The CDC says that about half of nursing home residents have Alzheimer’s disease or other dementia. Second, the arbitration agreement may be just one page in a voluminous contract of 30 to 40 pages. Thus, according to one federal court judge who blocked enforcement of an arbitration contract:

Most of the people who come to me have no idea they’ve even signed an arbitration agreement…. the practice of executing arbitration contracts during the nursing home admissions process raises valid concerns … since many residents and their relatives are ‘at wit’s end’ and prepared to sign anything to gain admission.

 

There’s an important infectious disease tie-in because nursing homes are a hotbed for infections, especially drug-resistant ones. For instance, according to James A. McKinnell, MD, an infectious disease specialist at the Harbor-UCLA Medical Center and the Los Angeles Biomedical Research Institute:

Current data suggests that here are nearly 3 million infections in nursing homes every year, resulting in 150,000 hospital admissions and 30,000 deaths.  As the US nursing home population is expected to increase from 3 to 5 million by 2030, we can expect to see a larger burden of these types of infection.

 

Mckinnell’s research also found that: (1) Almost half (47.5%) of the people in nursing homes are colonized with at least one drug-resistant bacterium (2) Nursing homes themselves are awash with superbugs: 88% of the rooms are contaminated with at least one, and (3) The big dog is Methicillin-resistant staphylococcus aureus (MRSA). They were found in almost 2/3 of the rooms (65.2%).

 

So what legal mechanism best protects our health: the age-old one of full access to a court of law, or the newer one of binding arbitration that’s forced on you – or you’re denied admission to the nursing home – at a vulnerable time in your life?

Elizabeth Barrow knows the answer. The arbitrator ruled against her and in favor of the nursing home. However, according to a report in the Times, only later did the Barrow attorneys learn something outrageous: the private firm running the hearing had previously handled more than 400 arbitrations – everyone of them for the very same law firm that represented the nursing home.

 

 

 

 

 

 

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