Sex, Drugs, and Public Health

Dear Stakeholders:

This memo is an effort at Consensus Building for the Rollout of our new Program to Entirely Eliminate Public Health Acronyms and Shibboleth Terminology (PEEPHAST).

A recent Gap Analysis of Public Health’s Capacity to communicate with our Partners showed that Lessons Learned have not developed into Best Practices as fully as we’d hoped in the Health Equity Plan. In fact, we’re getting considerable Push-Back about our terminology. This is causing pain in our Asset-Based Built Environment office.

In the interest of Transparency, the process to establish a Footprint for PEEPHAST will pick through the Low-Hanging Fruit from all the Silos we call Public Health programs.

A meeting of Stakeholders (who we hope, by meeting’s end will have become the Gatekeepers for PEEPHAST) has been scheduled at a place and time convenient to Staff. At the PEEPHAST meeting, we will Drill Down through the entire Skill Set in our Toolbox. Our Over-Arching goal is to find consensus that will make Champions for PEEPHAST of every one of you.

The agenda for the meeting is still under development, but it will be Robust, and there will be little time for Physical Activity Breaks. So please come prepared to work hard and remember: PEEPHAST for Public Health!

Note: consistent with our tradition of  Cultural Sensitivity in all areas, including the culinary, we have prepared two versions of this memo: one directed to Stakeholders, the other to vegetarians. Please pardon us in advance if you receive the wrong memo.

“How we gonna get the Coloreds to take the shot?”

Spoken by a Public Health bureaucrat in Georgia State government as Swine Flu loomed.

“Don’t we just make the vaccine available, and let people decide for themselves?”  I asked in my naive, fresh-young-doctor way. It was 1976.

“Look, Sonny. Ah been in Public Health all mah life.  The State boss asked me and you to work on this here vaccine campaign, and the CDC says they want all folks vaccinated. Ah’m close to retirement. Don’t wanna look bad; Ah want big numbahs. But we got a problem with Them.”

‘Them,’ the Black Community (as it was called by some of us at that time), comprised 25% of the State’s population. And the statistics showed that, indeed, they were leery of this quickly produced vaccine. It was mostly Whites lining up to get the shots at the Health Departments and shopping malls. Where the TV cameras frequently prowled for evening photo ops.

The State officials in charge of the vaccine campaign fretted some, then decided to hold a brain-storming session. To, you know, solve The Problem. Think up something they hadn’t thought of yet. Which is to say, think of something that wasn’t just “the way we always done it.”

The brainstorming session encompassed two hours, three pots of coffee, and several good fishing stories to fill in the moments when people fell quiet.

We adjourned, coffee-charged and empty handed, with vague promises to meet again and solve The Problem. “Soon.”

“We’ve got to do something,” my boss told me as we walked down the hall to our office. “We got the dang CDC right here in our backyard. They aren’t going to be happy.”

That afternoon, a knight in shining armor called. The Health Officer of Fulton County (the County encompassing Atlanta) was on the phone. He had convinced Martin Luther King Jr.’s father to take the Swine Flu shot. The Health Officer himself would vaccinate “Daddy King” with multiple TV cameras rolling.

Everyone sighed a puff of relief and smiled. Surely the Black Community would follow Daddy King’s lead.

The day came. The sleeve was rolled up. The cameras rolled. The Health Officer – adequately serious of face – gave the inoculation. And Daddy King never flinched.

We began watching the vaccine statistics to see the ‘bump’ in shots given.

This memory floods back as I read a series of studies on vaccine acceptance. They are done as surveys, reflecting attitudes before the H1N1 vaccine is offered.

The summary of one, analyzed by race, shows a pattern that deja-vu’ed me:

46% of Whites were “worried about the (H1N1) vaccine”;

but a significantly higher percentage  of Blacks (62%) said the same.

Suspicion about a hastily produced vaccine appears to be as intact today as it was in 1976. And that distrust still varies across social and economic lines.

But it’s driven by emotion and beliefs, not by scientific fact and logic. We humans often do that.

As with this, which I heard recently:  “That 1976 Swine Flu shot killed people. Why risk taking the Swine Flu shot again?”.

Just because the H1N1 disease has the same nickname, “Swine,” doesn’t mean the same virus is involved. It’s not. So the two vaccines were made from different viruses, and are not the same. The 1976 vaccine has a tainted reputation from the concern at the time about increased incidence of Guillian-Barre disease. That association, by the way, has been studied for Seasonal Flu vaccine for over a decade, and no definitive connection between G-B disease and vaccine has been consistently shown since 1976. If there is an increased risk of G-B, it’s of the order of one case in a million shots; death from Flu, on the other hand, occurs at the rate of one death out of every thousand cases.

Or “I got sick with vomiting and diarrhea this morning. I’m sure it’s that restaurant where I ate 5 days ago.”

In my career, I’ve never heard anyone say “I think it was my mother’s cooking last night.” People’s belief systems don’t seem to admit that possibility, in spite of epidemiological evidence.

Or, more to the point, when people say “I don’t take the Flu shot. It’ll give you the Flu.”

Can’t happen. The virus in the shot is killed. Dead. What can happen is for a person to be incubating the Flu at the time of the shot. Then we make a mental association between the two events which doesn’t exist.

And, sometimes we are all just the victims of bad timing. As when, 33 years ago, the phone rang again, interrupting our enthusiastic survey of vaccination data, forty-eight hours after Mr. King had gotten his shot,. It was the Fulton County Health Officer.

“We got a problem.”

“Oh?”

“Daddy King seems to have taken ill.”

To this day, I don’t know what illness Mr. King had been incubating at the time of his Flu shot, but I do know that fear and other emotions still drive decisions. And I can’t help but wonder how many ghosts of 1976 Swine Flu Vaccine campaign haunt us, Halloween like, during this vaccine season, as we try to protect folks from the epidemic of H1N1 that has already begun.

Step right up, Ladies and Gentlemen, gaze upon what’s new, what’s high tech, what’s the latest in Public Health, here to protect you, your precious children, your lifestyle. And your salary.

Now, while everyone was still cringing after September 11, someone  with considerable sophistication (and apparently, inside access to advanced bioweapons technology)  sprinkled Anthrax spores through the U.S. Postal Service. So they (you know, “They”) shifted our focus from hijacked airplanes to something even scarier – laboratories.  Labs hidden behind hermetically sealed doors.  Labs dark at night, except for a single light illuminating the nefarious work of some twisted scientist.  Labs teeming with bizarre microbes most people don’t understand which – like everything we don’t understand – automatically makes them scary.

People demanded that Congress act.  Congress did act.  Congressmen who wish to act, really have only two options: pass a law making such activity illegal  (oops – too late – already done long ago), or throw money at the Problem.

So they backed up a fleet of dump trucks to our Nation’s treasury, and the Bio-Terrorism extravaganza was on.

Before we get to the Main Attraction, take a stroll with me past the carnival Sideshows:

“Federal funds have recently been released to your State!” the bold print blasted from one unsolicited letter. If they hadn’t been limited to paper and ink, the words would have been written in flashing neon, surrounded by an oval of glaring bare bulbs, accompanied by dinging bells and probably, a siren.

Another hawker tried name dropping:  “The CDC, FEMA, and Homeland Security all say that no one should be without – - -”

O.K. Now that they have our attention, what are they selling?

-  Biological Weapons detection devises that fit right into your pocket!

-   A pre-fab  steel plated “Safe House” for your family! (including the dog). This backyard bunker is featured in full, glossy, color, painted red, white and blue in a pattern you can guess.  Picture that next to the swing set.

-   Fever detecting thermometers shaped like credit cards which you can carry in your wallet or purse, wherever you go! Because everyone should know the instant they come down with Smallpox. “Free shipping on orders over 500.”

-   Consultants! Specializing in writing your required Plans and grant applications. So now you can use the cascade of Federal dollars to hire someone to obtain the cascade of Federal dollars.

-   Bomb scene investigation films! (Uh-h, isn’t that, like, too late?)

-   Seminars on how to put on Hazardous Materials suit and respirator. To be held in Honolulu.

And dozens – believe me – dozens more.

But the Main Attraction, from this Blog’s perspective, is the wholesale sell-off of Public Health.

The time-proven approach to providing Community-Based Health Care (which is what Public Health does) is to first diagnose the Patient. Just as your physician would. In the case of Public Health, the “patient” is your Community.  Is AIDS your biggest problem?  Are Teen Pregnancies more common than elsewhere?  Is your Community’s water contaminated?  Are you confronting an outbreak of hepatitis?

Every Community’s disease profile is different (just as each individual patient in a private Doctor’s office is different).  That’s why Public Health is best done at the local level, not by State or Federal governments.

So let’s say your Community has a higher rate of childhood brain cancer than similar communities.  That’s the Diagnosis.  If you were the Public Health Officer, having made the diagnosis, you’d next direct therapy to attack that problem.  “Therapy” in Public Health is not pills and surgery, it’s money and people organized in a creative way to address the problem.  People like nurses who can do epidemiological investigations of childhood cancer, and Environmental Health Scientists who sleuth out the culprits. Without either one of those tools, you can’t create a “Therapy” that fits your community’s specific Public Health problem.

But what’s evolved over recent years is a system where the Federal and State governments funnel money down to local Health Departments, specifically earmarked for certain programs.  Like addicts, Health Departments almost never say “no” to this money, even if the program attached to the money is not needed in that Community.  You can use the money to keep valuable employees on the job when their salaries are threatened. But those employees will need to change their program focus. So now you have nurses trained in Child Health suddenly working in Bio-Terrorism Preparedness or Environmental Health Scientists investigating cigarette smoking in public buildings. I am not kidding here.

And if a Local Health Department keeps this up for a while, soon it’s not out there “diagnosing” and “treating” the health ills of its Community; it’s running programs which were dictated to them from afar.  Programs they have to “sell” to the Community, since the Community doesn’t really need them.

What can happen as a result? In the 1960’s and ‘70’s, we discovered a handful of effective antibiotics to cure Tuberculosis. As a result, the rates of TB started to drop. So, funding for TB began to dwindle.  Less money for TB, more for sickle cell screening or for purchasing and installing specific computer programs. As the tool of money for TB withered, the tool of people skilled in TB investigation and management also shrank because their salaries dried up.  Thus, by the 1980’s and ‘90’s, most Health Departments had few or no Public Health Nurses skilled in watching for and managing TB as a Community Health problem. They were all doing some other (well funded) program.  Then, in the face of the double whammy of a new wave of immigration bringing more TB to the U.S., and AIDS epidemic devastating the exact part of the immune system used to control Tuberculosis,  drug-resistant TB erupted, creating havoc in our communities. It took several years for us to re-build the infrastructure to control it.  An infrastructure that Public Health once knew very well. An infrastructure that had been in place for over a century, but had been lost among the politically driven winds of diverted resources.

In the same way, Health Departments greedily gobbled up Bio-Terrorism money in the early 2000’s, and hired people to comb their Community for Anthrax, Smallpox and Tularemia.  Or, more accurately, to write Plans about how to comb their communities for those rare and exotic diseases.  Entrepreneurs made small fortunes selling Bio-Terrorism related trinkets.

And if  childhood brain cancer was out of control in your Community, it was suddenly getting a lot less attention as Public Health focused on the sexy Bio-Terrorism thing.

Now, when you go to your Doctor with a pain in your wrist, do you want him to give you a few samples of the latest, greatest, newest drug on the market for pain (drugs left at the Doctor’s office by salesmen, hoping for profits as your Doctor prescribes it after the samples run out) or would you rather have your Doctor diagnose your wrist problem and treat you specifically for that?

That’s what Communities should do.  Tell their Health Departments – who are the Community’s Doctor and who work for the Community – to stay focused on the local issues that are actually affecting people.  And tell their congressional representatives to fund Public Health, rather than the  categorical programs de jour which look sexy, like flashing neon.

Public Health should be your Community’s Doctor, not a circus.

Mrs. X lay in the back of an ambulance recently, IV running into her vein, rolling back and forth on the gurney. She was on a long trip to a specialty hospital, a couple of hours away.

Whatever was wrong with her, her kidneys were working just fine.  With each little road bump, her bulging bladder sent electrical shocks to her brain.

“I have to pee,” she told the Paramedic.

He braced himself with his hand against the wall, placed his feet wide apart for balance like a subway rider, and rummaged through a bunch of stuff behind a sliding panel.  He pulled out a large oval of plastic.

“Here.”

“What’s that?”

“A bed pan.”

Distain replaced the discomfort on her face.

“I need a bathroom,” she said indignantly.

“But…” the Paramedic tried to explain that they were still more than an hour from their destination medical center and that using the bedpan or holding it were her only options.

Not to her, they weren’t.  She was insistent.  Very insistent.  The Paramedic slowed down the IV.  While that move was scientifically logical, it was way too late.

The Paramedic braced himself again, one hand on either side of the rolling, sometimes lurching vehicle, and inched his way up to the front.  He explained the dilemma to his driver.

“Wadda you wanna do?” the driver asked.  “Stop at a Burger King?”

The Paramedic envisioned himself explaining that decision to a doctor, or worse, to his supervisor.

“That won’t work,” he said.

“I need to go now!”  Mrs. X’s voice was rising.  Probably her blood pressure was, too.  Not a good thing. Not while she was on his ambulance.

“All right,” relinquished the Paramedic.  He turned to his driver.

“We’ll be passing Memorial Hospital in a few minutes.  We can let her use the bathroom in the E.R., then be on our way.  An E.R. is safer.  And they’ll understand.  Radio them, would you?”

Then he inched backward, both hands and both feet braced, until he could sit next to his patient again.

“OK, Mrs. X.  We’re going to stop and let you – ”

“You need to talk to them,” the driver interrupted the Paramedic.

He started to roll his eyes, but controlled it in front of his patient.

“OK,” he said softly, confidently.

“Memorial E.R., this is Ambulance unit 24.  I have a 53 year old female we’re taking to University Med Center as a transfer from St. Joseph’s who – ”

“That’s correct.  St. Joseph’s.  We’re from the next County over, just passing through. The patient needs to go to the bathroom.”

“Well, no, we can’t go back to St. Joseph’s just for a bathroom stop.  That’s an hour back the other way.  We’d like to ask that you – ”

“She says she can’t hold it until we get to University.  That’s another hour and a half yet.  So if we could just – ”

“Yes.  Of course we have bedpans.  The patient was offered one, but refused.  Said she can’t use it.  So if we can just stop for a couple of minutes – ”

“Say again?”

Mrs. X tugged at the Paramedic’s pants and wrinkled her face in urgency.

“She has complications with her surgically implanted shunt.  So we’re taking her back to her surgeon at the Cancer Center.  She’s stable.  We’re within three minutes of your facility now, so could we PLEASE – ”

“No Ma’am.  I’m not shouting.  I just need you to quickly give me the OK to – ”

“Why can’t you let her use your bathroom?  She’ll just go, and we’ll be on our way.  I’ll accompany her.”

“You will NOT!” Mrs. X interjected.

“I’ll accompany her into the E.R.,” he spoke toward his patient, “and wait for her while – ”

“What regulation is it against?  She just needs to go.”

“But No! I mean, no.  She’s not here for care in your E.R., just to use the – ”

“What lawyers?”

“But – ”

“Look, we’ll assume all responsibility.  All she needs is – ”

“Yes, ma’am.  Understood.  Thank you.”

He slowly, with a bowed head, hung up the microphone.

“Well?” asked the patient.

“Well?” asked the driver.

He snapped out of it, became commanding again.  “Pull into the parking lot at the E.R.” he told the driver.

“About time,” muttered the patient.

“But don’t back up to the door,” he added.

“Say again?”

“Just park it!”  He lowered his voice, “like a visitor.”

“Better hurry,” her voice sing-songed.

The Paramedic took a deep breath.  “Mrs. X, we can’t use their bathroom.  But we can – ”

“What!!  What do you mean?”

“Regulations.  Legal concerns.  If you set foot in their E.R., they’ll have to process you as a patient.  Start all over, as it were.  It would take an hour or two.”

“Would they bill me?”

“Is the Pope Catholic?”

“All I need is – ”

“I know,” he interrupted her.  “I know.  But they’re afraid they’d get written up for some violation. Or maybe sued.  It’s either go through their E.R. as a patient, or – ”

“Would they let me pee first?”

“That’s out of my control, ma’am.  They’d probably want your insurance card first, then need to register you as a new patient, then – ”

“Gimme that bedpan and wait up front with your ears closed.”

When this epidemic first popped its head above the ground in Mexico, Paricutin – like, it was, of course, impossible to know if it would be a fizzler or The Big One or something, as was most likely, in between.

So we Public Health detectives watched the numbers like raptors following their prey, observing, tracking its path, trying to project where it would go.  Anticipating its behavior so we could pounce on it at the right place.

We are beyond that now.  Numbers have told us all they are gonna reveal.  They told us that the virus spreads efficiently from person to person.  That it will spread over the entire globe.  That, (darn!) it will continue to spread in places experiencing summer, like North America and Europe, which is abnormal Flu behavior, while simultaneously spreading in winter climes like Australia, New Zealand and South America (poor Argentina’s hit hard).

Now we have turned to question #2.  How will the virus behave in the human body? Like Seasonal Flu? Or something more aggressive?  To answer this question, we are now analyzing individual cases.

A 78 year old woman  became ill with Influenza-Like-Illness (ILI) on Monday, was hospitalized on Friday with bacterial pneumonia superimposed on confirmed H₁N₁ infection, and died on the following Wednesday.  She had underlying heart disease and emphysema.

Pretty much like Seasonal Flu.

A 39 year old rodeo athlete took a break from calf roping when he developed ILI on a Saturday. As he sickened, he consulted his physicians. He died at home the next Friday.

Definitely not like Seasonal Flu.

Ten people were admitted to the University of Michigan’s advanced care ICU during June for severe complications of the H₁N₁ infection.  Their chest X-rays showed “white-out,” i.e. lungs full of fluid.  A couple of them were coughing blood.  They all needed ventilators to breathe for them.  Two were placed on heart-lung bypass machines to try to keep their oxygen levels up.  Only seven of them survived.

Interestingly, bacterial pneumonia was not evident in any of these patients – it was the virus doing it all. And, of importance were their ages. The youngest was 21 and the average age was 42. The time it took for these patients to go from first symptoms to hospitalization was as short as one day.

Another interesting case is that of a sixteen year old from San Francisco who was found to have  H₁N₁ which was resistant to Oseltamivir (also called Tamiflu). Similar cases of resistant virus have been found in Europe and Japan.

It was only a month ago that every  H₁N₁ strain tested was sensitive to this drug – one of our major weapons in this fight.

A picture is emerging from these and similar case stories being reported from across the globe : the majority of cases of H₁N₁ are as mild as routine “Seasonal” Flu, largely a mild illness of a few days. Some ( the very young, the very old, and those with serious medical problems) get seriously ill, also like Seasonal Flu. But with this new virus, an unlucky few can get horribly ill with a viral pneumonia, with fluid in the lungs blocking oxygen uptake, and other complications (including blood clots and hemorrhage).  The mortality rate in this group is high.

And now the virus shows us that it is evolving very quickly, changing its genetic make-up to, at the very least, become resistant to our anti-virals. We do not yet know what other changes it is creating deep within itself.

This picture is typical of a genetically “shifted” Influenza virus – and it is a typical Pandemic pattern. Just read accounts of the 1918 and 1957 Pandemics and compare. The major difference from those earlier Pandemics will be the intensity (and professionalism) of press coverage. They’ll be all over this one. The epidemiologists will not be working alone.

First the numbers, now the Patients. The next interesting gauge of this Pandemic will be Society’s response. Watch for Public Health officials to close institutions. Watch for politicians to pontificate. Watch for comedians to mock the virus. Watch for religious gatherings to, contrary to their mission, discourage attendance. Watch for airplane ticket prices to fall. Watch, unfortunately, for counterfeit vaccine and Tamiflu to become available “ Now! For a short time only! ” on the Web. Watch for scary movies.

Wise old physicians and Public Health officials will shake their heads and wonder, as they battle this Pandemic, at how dramatically a mere virus will reveal the stuff of which we Human Beings are made.