Sex, Drugs, and Public Health

January 4, 2017

Rice Water Stool

Filed under: Uncategorized — cbmosher @ 10:42 am

One of the ironic and mildly distasteful analogies that Medicine created between food and disease entities ( Strawberry Tongue, Cottage Cheese Discharge, Chocolate Cyst, Miliary Tuberculosis).

However, it does a good job of describing the primary symptom of an epidemic which erupted among thousands of defenseless people. People who were still wandering, shell-shocked, among the after-earthquake ruins of their lives, adding misery and sudden death to injury.

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The bacteria’s point of view: the Cholera Vibrio travelled a harrowing road to reach its destination and begin having babies. It came from Asia, in the intestines of human travellers. Expelled, the bacteria had to find their way to water before dying of dehydration. Those Vibrio which survived to reach water needed to remain alive until someone swallowed them. The stomach acid of the drinker would be lethal to most of the Vibrios were it not for the bacterium’s genetic ability to cease protein production and conserve energy during this passage thru the toxic acid environment. The few surviving Vibrio next had to work their way thru the thick mucus of the small intestine to reach the cells of the intestine’s wall. Those who made it activated other genetic mechanisms to begin taking nourishment, and begin protein production again, manufacturing, then excreting an exotoxin. This exotoxin causes the intestine to secrete massive volumes of water and electrolytes (sodium, potassium, chloride, bicarbonate), the vehicle to carry baby Vibrio out into the world.

The patient’s Point of View: gushing out volumes of milky-looking fluid (Rice Water) up to 20 liters a day, the patient rapidly dehydrates and goes into electrolyte imbalance causing profound weakness and muscle cramps. The patients don’t die of overwhelming infection; they die of dehydration. Quickly.

The Epidemiologist’s Point of View: the copious diarrhea, teeming with Vibrio bacteria, contaminate water and food if there is not assiduous separation of drinking water from sewage and scrupulous hygiene among family members and caregivers. Genetic “fingerprinting” could identify the specific strain of Vibrio and probably reveal where it came from.

The clinician’s Point of View: The mortality rate from untreated Cholera is 50 to 60%. Adequate and early treatment can reduce that to less than 1%. And treatment is pretty simple, although intense and exhausting. Just replace the fluids and electrolytes as fast as the exotoxin spews them out. At the volumes we’re talking about, it’s a race.

 

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Here’s a photo of a Cholera bed. The patient lies naked on the plastic-covered mattress, pouring rice-water stool thru the hole in the mattress into a bucket beneath the bed. Measuring the volume of this fluid loss tells you how much electrolyte fluid the patient needs, either orally or by high-volume IV’s. My family first saw this arrangement in Bolivia in 1991. A ship had disgorged ballast water from Asia into the Pacific port of Lima, Peru, bringing the first cholera epidemic since the 19th century to South America. The epidemic spread rapidly, resulting in nearly 10,000 deaths.

Haiti, 2010: I arrived in Saint Marc, a city sprawled over a plain where the island’s major river, the Artibonite, flows into the Caribbean. The missionaries and I were scheduled to hold multiple clinics in churches, schools and large meeting halls at different communities scattered over the coastal plain where Haitian families grow rice in a desperate attempt to keep starvation from their homes.
The population of St. Marc area had recently swelled with refugees from the destroyed Haitian capital, living in plastic tents strewn over a large area.

Sanitation (sic): the Artibonite River drains the floodplain where families live on small rice plots. It provides water for washing, cooking and drinking, and respite from the heat for playful children.

On this half-island country of descendants from slaves who successfully freed themselves, poverty is so profound that it dwarfs what I’ve seen in Bolivia, Mexico, Honduras, Guatemala and Paraguay. Crude outhouses are often too vile or even dangerous to use.

In spite of their extreme and chronic poverty, Haitians are hard-working and classy people. In the clinics we held, nearly every adult and most of the kids arrived smelling of perfumed soap, their hair carefully braided and respectfully soft-spoken.

 

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As we drove from a clinic one afternoon, the silt-laden Artibonite churned, just beyond the van’s right windows. Children, glistening with water, cavorted, splashed and giggled in the brown foam. A woman dipped water from it into a cheap red plastic bowl, then carried the water up to her charcoal cooking stove. A barefoot man walked the bank between the river and the road. Suddenly, he stopped, pulled down his trousers, squatted, and pooped. Finished, he quickly pulled up his pants and continued walking.

The Artibonite would take care of that, too. As soon as it rained again.

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The Set-up: multiple Relief agencies had swarmed Haiti after the quake. Doctors Without Borders, Cuban Medical Brigades, Red Cross, Red Crescent, various churches, University of Miami, and the United Nations, among numerous others. As we drove the next day toward another clinic site, closer to the foothills, we passed the U N flag fluttering on a knoll atop a wide slope that flanked the River. Tents and small cabins clustered around the flag.

A few outhouses perched on the slope below.

Rain clouds were building over the mountains that separate Haiti from the Dominican Republic.

The Explosion: In October of 2010, the well respected Medical organization, Partners in Health, began to see patients with severe diarrhea. Physicians there were accustomed to treating gastroenteritis, but these cases were far more severe than they usually see. Within three days, the Emergency Room in St. Marc was overwhelmed with 404 patients (they usually see about 20). Ten percent of them died. Within ten weeks, Cholera was in every province in Haiti. Quickly, the deaths mounted to 100 a day, country-wide. As of this date, 10,000 have died. Haiti’s Cholera epidemic continues.

Epidemiologist, revisited: genetic typing showed this specific strain of Cholera to be unique to Asia. The epicenter of the outbreak was the Artibonite Valley. Shoe-leather epidemiology found leaking sewage from the U N outpost where Peacekeepers from Nepal were stationed.

Yet, for five years, the U N denied that it was responsible for introducing the first Cholera into Haiti in at least 100 years. They (and other politicized agencies) focused instead on Haiti’s horrible sanitary infrastructure and uncontrolled movement of populations following the earthquake. Those conditions certainly did facilitate the rapid spread of the disease (and many other water-borne diseases). A case of Cholera in countries where sewage and drinking water are well separated would not spread very far. But Cholera did not spontaneously generate itself in Haiti.

Once in a Lifetime Opportunity: The U N formally acknowledged its responsibility for the outbreak in mid 2016. Partners in Health, which continues to treat cases, is ready to attack Cholera with a comprehensive Elimination Plan. A project to eliminate Cholera will also control other diseases that have been killing children in Haiti for decades.

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With an infrastructure of safe drinking water and appropriate sewage treatment / disposal, not only could they eliminate Cholera, they could dramatically reduce the incidence of other diseases spread by the Fecal-Oral route: childhood diarrhea, Polio, Typoid, Salmonella, Hepatitis, parasites.

PIH has petitioned the U N for funding. So far, commitments from member countries fall short of what’s needed.

What You Can Do:
1. pressure your representative to urge both the U S and U N to see that this Cholera Elimination Plan is adequately funded.

2. donate to Partners in Health. I give to them regularly because the money they receive is well spent. There is no concern of graft or waste.

 

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July 10, 2016

Public Health and the N R A

Filed under: Uncategorized — cbmosher @ 10:07 am

Well, they did it again.

Thursday (July 7) some Democratic and Independent congresspeople tried to get the Dickey amendment language removed from the 2017 Health spending budget. This would have allowed the CDC to fund research on firearm injury and death, so that we could have solid facts on this Public Health epidemic.

Dickey himself has reversed his position on his own eponymous amendment of 1996 and recommends that we allow the CDC to study this Public Health issue (see previous BLOG of June 19). But NRA-influenced congresspersons killed that effort. And, as more Americans are also killed, accurate data – also known as the truth – will be withheld from us all.

The horrific killings in Baton Rouge, Falcon Heights and Dallas this week scream from the headlines, skewing – again – our picture of gun violence. These high-profile killings, which are a symptom of something badly diseased in the body of our society, are not the only killings from guns that we suffer.

There are also incidents like Texas mom Christy Sheats gunning down her own daughters. Sheats is alleged to have written on her Facebook page: “it would be horribly tragic if my ability to protect myself or my family were to be taken away, but that’s exactly what Democrats are determined to do by banning semi-automatic handguns.”

This pre-Dallas (Houston area) tragedy is a stark example reinforcing the findings of the now-classic 1993 Public Health study which showed that households with firearms actually experience MORE homicides than gun-free households (see previous BLOG and original article for details).

That was the study that triggered the Dickey amendment.

Aside from the death statistics related to guns (mortality rates), there’s the issue of non-fatal serious injury (morbidity). In the absence of CDC compiled data, we still have some idea of the scope of this issue. From 2010 through 2013, an average of 76,164 people went to hospitals annually for treatment of gunshot injuries. That’s 208 seriously injured people each day, more than eight every hour.

That, folks, is an epidemic.

If killings and injuries are the SYMPTOMS of this disease in the body of our society, how is the body’s “immune system” responding? Of course, our individual bodies’ immune systems are defenseless against bullets, but society’s body has responded:

1. congressfolks who profit from lobbying by the NRA have responded by maintaining the Dickey amendment, in hopes of keeping us in the dark about this epidemic;

2. investors in gun manufacturing have responded by profiting from the value of firearm stocks. In the few hours between stock market close on Thursday and the opening bell on Friday, the Dallas shooting occurred. Friday morning, Smith and Wesson stock and Ruger stock both INCREASED by 3 to 5%.

If that’s society’s immune system at work, we need a new immune system.

Skewed impressions about gun violence – which are produced in this data void of the Dickey amendment – lead us to react with overheated emotion, anger, and finger-pointing. Almost always, in my experience, fingers point away from the true cause of the disease under these circumstances.

If we want to do something that may actually work (because it’s based on logic and reason, not emotion), we need to utilize the same problem-solving process we use in Medicine every time we see a patient:

1. Examine the patient (in Public Health, we need accurate data to do this)

2. Diagnose the disease (for P.H., it’s a community-wide disease, not just one individual)

3. Treat the disease (P.H.’s main treatment is Prevention).

But we’re not doing that. So, on the day that headlines scream “First Death from Zika in the U.S. !!!” there were (an estimated) 208 serious injuries and 82 deaths from firearms.

You know what to do.

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References: Agency for Healthcare Research and Quality, CDC, New England Journal of Medicine, Daily Kos, New York Daily News.

June 19, 2016

Public Health and the Second Amendment

Filed under: Uncategorized — cbmosher @ 4:04 pm

The CDC was originally the “Communicable Disease Center.” It focused on microbial diseases like TB, Influenza, Malaria etc. which could spread from one person to another. It is now called the “Centers for Disease Control” and investigates many other society-wide maladies like Cancer, heart attack, and death from injuries.

As with other branches of medicine, we in Public Health make the Diagnosis, search for the Cause of the problem, and decide on a Treatment (in Public Health, that’s Prevention).

In addition to investigating these conditions with their own staff, the CDC also funds research and prevention of disease by many other agencies and universities. The following data reflects a small sample of accomplishments from such efforts, measured between 2000 and 2010:

1. TB: case rate down 30%; Cause – the Mycobacterium; Treatment – drugs, isolation, investigation of contacts
2. H1N1 Pandemic Flu: prevented 30,000 hospitalizations and 1500 deaths; Cause – a virus; Treatment – vaccine, drugs, isolation
3. Cancer: colorectal, breast and cervical down 2.2 to 2.8 % each year; Cause – various; Treatment – screening, early intervention, vaccine
4. Heart Disease: down from 195 cases per 100,000 persons to 126; Cause – the major one is smoking; Treatment – smoking in youth down from 35% to 19.5%.
5. Motor Vehicle Accidents: death rate down from 15 per 100,000 to 11; Cause – inadequate safety devices; Treatment – belts, air bags, better design.

In 1993, the New England Journal of Medicine, America’s most prestigious Medical Journal, published a research paper from the University of Tennessee entitled “Gun Ownership as Risk Factor for Homicide in the Home.” The study showed that homes where guns were kept were significantly more likely to experience a homicide as homes with no guns.

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Funding for the study came from the CDC’s Center for Injury Prevention.

Congress, under pressure from the NRA, produced the Dickey amendment to a budget bill, prohibiting the CDC from funding such research. Congress, no doubt parroting NRA catch phrases, accused the CDC of “promoting gun control.” The amendment was named for a congressman from Arkansas.

Over the years, with repeated affirmations of the Dickey amendment (and related budget cuts), CDC funding into firearm injury and death dried up.

As I’m sure you know, the NRA repeatedly envokes the second constitutional amendment to bolster its position. I encourage you to read it. Even though it was written in the vernacular of 225 years ago, it’s only one sentence and is quite clear:

“A well regulated Militia, being necessary to the security of a free State,
the right of the people to keep and bear Arms, shall not be infringed.”

You should probably ask yourself this question: What does a “well regulated militia” mean in 2016?

While you’re at it, ask where the NRA’s money comes from (hint: membership dues is only about 50% of its more than $300 million annual revenue).

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In the absence of solid “official” data from the CDC (collected from emergency rooms, physicians, death records etc.) a number of organizations have nevertheless provided us with some sense of this epidemic of injury and death. Numbers vary, due to lack of centralized, fact-checked analysis, but here are some samples:

1. every year in the U.S., between 27,000 and 33,000 people die of Gun Shot Wounds. At least 750 of them are children, and the number may be as high as 2600.
2. Compared with other “developed” countries (Europe, Canada, Australia, New Zealand, Japan, Korea) our GSW homicide rates are 25 times higher, and suicide rates 8 times higher. If people did not have a gun handy (recall the NEJM article discussed above), they’d either use a less lethal tool, or have a little more time to think about it.
3. 60% of all homicides in the U.S. are committed using guns, a much higher percentage than in the U.K., Australia or Canada.
4. Of those 30,000 deaths a year, what percentage involve a mass shooting? Only 2%.
5. Of those 30,000, how many deaths were due to Terrorism between 2005 and 2015? Just 71.

Thus, the vast bulk of GSW deaths never make the national press. Due to this skewed reporting (focusing on mass shootings and those where the shooter was called a “Terrorist” by someone) most of us are unaware of the scope of this epidemic.

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If the CDC were allowed to study this issue, it would most likely approach it as it has communicable infectious diseases, cancer, heart disease, and deaths from other injuries. First, it would compile nation-wide data. Next, it would look for patterns in the data which might identify where risk is highest. In certain geographical areas? Are there differences by gender or age in injury and death?

Then we could use that information to formulate a RATIONAL approach (as opposed to the current EMOTIONAL reactions).

Hopefully – very likely, I believe – using such an approach, we’d begin to show improvement in death and injury rates, just as we have with TB, Pandemic Influenza, Cancer, heart disease, and motor vehicle accidents.

This quote has been attributed to the former director of CDC’s Injury Prevention Center: “The scientific community has been terrorized by the NRA.”

An even more interesting quote comes from former congressman Dickey, written jointly with the former CDC director for Injury Prevention in a Washington Post Op-Ed: “We are in strong agreement now that scientific research should be conducted into preventing firearm injuries and that ways to prevent firearm deaths can be found without encroaching on the rights of legitimate gun owners.”

Why not obtain the facts about gun related morbidity and mortality? We wanted it with Pandemic Flu. We want it with Cancer. We have it available from the CDC for dozens of other diseases, including non-gun related injuries. What are we afraid of finding? More to the point, what is the NRA afraid we’ll find out?

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References: CDC, New England Journal of Medicine, American Psychological Association, BBC, CNN, CBS, Forbes, Washington Post, Daily Kos Gun Fail, Brady Center, Business Insider.

May 3, 2016

Dog Food Medicine

Filed under: Uncategorized — cbmosher @ 10:21 am

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Pierre calls 911 for an ambulance every week or two during the warm months when he still pans for gold. More often during the lonely winter.

“Chest pain,” he’ll wheeze the magic words. “Like a fart turned sideways.”

Just to seal it, he’ll often add “I can’t drive.”

We wouldn’t want him to. Not any time after eleven A.M. anyway. There are enough drunks on the roads during the night hours causing accidents; we don’t want the steel mining contraptions crammed into his rusty Datsun clanging into each other and shifting the wreck’s momentum as it staggers between the right lane and its usual trajectory directly into oncoming daytime traffic.

“We’re coming, Pierre,” we always reassure him.

It’s my job to bring the dog food.

Red lights plinking off the pine trees astride the road, siren wailing to warn any meandering deer, Joe, the hospital janitor, weaves around the hills and swoops us down, then up the gullies. Like a needle embroidering the landscape.

As the ambulance struggles up the final grade to Pierre’s shack on the hill, transmission slipping, medical equipment sliding to the back of the vehicle, I pull an opener from the Trauma Kit and start opening the first can. I’ve ruined a few pairs of pants from that splattered grease.

The instant we pull into the junkyard surrounding his shack, the ambulance is accosted by a half dozen raucous canines, no two of which look to be even the same species, let alone the same breed, but all of which are seriously mean and, we’re pretty sure, unvaccinated.

I roll down the window. A big black-and-brown with stinking breath and thistle-matted fur lunges his front paws onto the door, almost reaching the window. His snarling makes my ears ring.

“Ready?” I yell to Joe.

“Ready.”

I wind up, like back in Little League, and heave the can as far as possible from both ambulance and front door of the shack.

The howling, yelping, baying cacophony streaks after the can. We jump out, run to the back of the ambulance, yank out the gurney, and run for the shack.

“Got the Trauma Kit?” he asks me.

I streak back to the ambulance, grab the kit, then race toward the shack again. The black-and-brown sees me, and comes charging. We burst in, hauling the gurney and Trauma Kit, and slam the door behind us.

“What took ya so long?” he growls from somewhere within his indoor junkyard. “My friends are saying nice things about me – I must be ready to die.”

The din of dogs is a muffled tornado beyond the thin walls. We can slow down now, and be methodical.

I check his blood pressure.

“Never mind that,” his tobacco breath gargles. “Check my eyes. I don’t wanna go blind from that Immaculate Degeneration, like my brother.”

“I thought you had chest pain,” I retort.

“Yeah. It’s prob’ly from the cigars the doctor said I had.”

I’m surprised.

“You smoke? I thought you just chewed,” I try hard – in vain – not to look at the permanent brown streak of stained skin at the right corner of his mouth.

“Don’t smoke,” he mumbles. “Doctor said the X-ray showed I have cigars in my lungs.”

I listen to him breathe, stretching the stethoscope to its full distance. That close to him, I don’t want to inhale too deeply.

“There’s some mucus in your lungs. You coughing it out?”

“Can’t. I can get down to my cough, but I can’t get under it. It’s stuck. Take me to the hospital.”

We will, of course. But by the time he’s strapped securely into the gurney and we’re ready, a dozen paws scrape furiously at the door. The incessant caterwauling envelopes us.

I pull the second can from the Trauma Kit, open it, crack the door just enough, and heave again.

They all wheel and run after it. All but the black-and-brown. He stands there, snarling at me, saliva drooling from his black lips like tobacco juice from an old miner’s mouth. But then he, too, turns to chase the pack, sure of himself that he’ll get the biggest share.

We run for the ambulance, wheels bumping over the irregular earth and the scattered trash.

“Hey, slow down,” Pierre complains. “It feels like you done throwed me in the ore tumbler.”

We shove him in the back and lock the gurney in place. We just make it to our seats before the dogs come back, snarling for more.

“Don’t you feed your dogs?” Joe shouts back to Pierre once we’re safe inside.

I shiver at the sound of claws scraping down the vehicle like fingernails on my grade school blackboard.

“Sure I feed ‘em,” he yells up to the driver. “I feed ‘em ambulance guys.”

And he chuckles all the way down the hill as our red light strums the pines that straddle the road.

March 9, 2016

Filed under: Uncategorized — cbmosher @ 5:44 am

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So, I’m standing in line at the local 24 hour Stop-and-Rob, waiting behind some gum-snapping teenager to pay for my food-like products. Stuff not recommended by any Public Health officials. But I figure, if anyone asks, I can say they’re not for me and go to confession later.

Then I feel someone behind me. Not that he touches me or breathes on me, but he’s giving off a very strong – – – presence.

“Hey, Bobbie,” yells the check-out clerk over the teen-ager’s head and mine. “How you been?”

“Still alive,” the guy responds with a voice like an animal’s growl.

I’m about to turn around and be friendly, trapped as I am between the trajectories of their words. Until he finishes his thought: “no thanks to the damn DOCTORS.” He spits the last word.

He starts moving toward the counter, coming alongside me, talking directly to the counter clerk. “Doctors don’t know SHIT.”

I see him with my peripheral vision. Scruffy three-days’ beard, saliva still glistening on his lips from the words he’s spitting, his eyes narrow and predatory.

Like a snake’s.

A fog of alcohol fumes moves with him.

“DOCTORS gave my mother pills,” he seethes thru clenched teeth.

Ah. That’s what I felt when he was behind me: violence, barely contained.

“Take them pills, they said. You’ll be fine, they said.” His lips stretched out the “f” in “fine” until it sounded like a burning fuse.

It’s clear that his words and his hatred are aimed at me, but his eyes, like mine, remain fixed on the check-out clerk.

Who is his mother? Is she my patient? Or, was she?

The teenager in front is taking forever to fish out and count her nickels and pennies.

“Doctors HURT people,” the alcohol cloud blasts me again. I don’t even allow him into my peripheral vision anymore.

Maybe I should just go.

“Doctors should be KILLED.”

The teenager finally turns to leave.

“Just this,” I hold up the candy bar and can of Cheese-Whiz. I don’t want to put them on the counter, prolonging the process.

Wonder if Cheese-Whiz could function like Mace?

I give the clerk three bills and leave without my change. All the way to the door, I feel a laser boring a smoldering hole into the back of my cranium.

The door swings closed behind me, and I’m back in the community again. The community where almost everyone knows me. The community I serve. Trying to do well for everyone who comes for help. And I succeed most of the time.

But, in this business, most of the time isn’t good enuf.

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