Sex, Drugs, and Public Health

July 25, 2009

First the Numbers, now the Patients

Filed under: Uncategorized — cbmosher @ 4:24 am

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.

May 2, 2009

SWINE FLU DEJA VU

Filed under: Uncategorized — cbmosher @ 6:31 am

“Doctor, the National Inquirer is on the phone.”

Oh, oh.

But I had to take the call, of course.  It was 1976 and I had been placed in charge of the Swine Flu campaign for the state of Georgia.  Dealing with “the press” was part of the job.

“Doctor, we heard that someone up in the mountains of Georgia was found dead in a pig feeding trough last week.  Could we get a quote from you about him, seeing as how he’s the first victim of this Swine Flu of yours?”

‘ My ‘ Swine Flu ?

“Sorry,” I answered, trying to be firm. “But, that gentleman was a farmer who died of a heart attack.  It was NOT – I repeat, NOT Swine Flu.  But, thanks for the call.”

That was a long time ago, but today’s news awakens the memories.  However, there are differences.  We are not doing a mass vaccination campaign this time (there is no vaccine for the current “Swine Flu” strain) and we are at the end of the flu season, not the beginning.

So what do we do with this H¹N¹ Swine Flu?

First, we are doing surveillance.  Physicians country-wide are being asked to send samples from suspect patients with illness that looks like Influenza so we can find Swine flu as soon as it crops up.  So far, there are many parts of the world where no cases have been found.  But we expect it to continue spreading, and need to know when it arrives.

Next, we are asking that you follow these guidelines to prevent the spread of Influenza:

 

  • Stay home if you are ill.    “At the first sign of the flu – – – staying home is the thing to do.”

 

  • Wash your hands frequently, especially after blowing your nose or touching someone who is ill.

 

  • Use alcohol-based hand cleanser (like we use at the hospital).

 

•        Use sneeze and cough etiquette, which means use a handkerchief or          Kleenex to cough or sneeze or blow your nose, or cough / sneeze into the elbow of your sleeve.

 

  • If you have been exposed to a family member who is ill with flu, avoid any unnecessary contact with others until it is clear that you are past the incubation period (seven days) and did not become ill.

 

  • The use of masks will not protect you. If you are worried about catching the Flu from crowds, avoid crowds.

 

Remember:              “At the first sign of the flu – – – staying home is the thing to do.”

March 7, 2009

Mrs. G. and Her Zorro Loco

Filed under: Short Stories — cbmosher @ 9:27 am

 


 

         Mrs. G. had been here a long time – long enough that the road she lived on bore her last name.  Or, more accurately, that of her long dead husband.  So she probably felt that she, not the fox, owned the place.

But there he was again, just like the previous three mornings, wandering over her grass, not spooked at all when she tapped on the kitchen window.

“Shoo!  Go away!” she said in her loud voice, holding the phone receiver away from her mouth for the moment.

“Sorry, Dear,” she said into the phone, “I had to frighten away a pesky fox in the yard.”

“Oh, like most of them, he’s got a red coat and a grey trail.  Well, yes, it could be ‘she’.  I can’t tell from here.  What’s that?  You know my hearing’s bad, could you please say again?”

She watched the animal meander toward the woods again, at the far end of her grass, but it stumbled before it got to the trees, and, in struggling to regain balance, turned toward the house.

“That’s very sweet, Dear, but I’ve already told you, I’m quite happy  here, in this house your father and I built, on the land your grandfather claimed for ranching.  My hip is healing just fine right here.  I just couldn’t live in that city where you are – too many dangers like auto accidents and  — what are they called?  — ‘gang-hangers’.  And the TV said just yesterday: people cheat you in the stores there.  I’m just fine right here.

“But you can come any time and bring that cute red-haired grandson of mine.  He can play with some of my animals – the chickens, Fluffy the rabbit – – –  Shoo!

“What’s that?  No, no.  It’s that fox.  I want him to leave before he scares my cat to death.  You know, his hair is almost the same color as your son’s.  He’s very beautiful.  Just a little clumsy.  Think about July 4th weekend, ok?”

She replaced the receiver and hobbled on her cane to the sliding glass door that looked out over the lawn.

“Here kitty.  Where are you?  Watch out for the fox,” she sang to her cat as she opened the door for her feline companion.

Suddenly, there was the fox, right at the door.  Startled, she stepped back, and almost lost her balance.

“Not on my new hip,” she thought, and protected the surgical work of that nice doctor from the city down in the valley by catching herself with her cane.

When she looked up again, that fox had just strolled right through the door, into her house.  What nerve!  There he stood, on her nice clean carpet, rolling his head left and right as if trying to see clearly.

“Stand up straight!” she admonished the animal, much to her own surprise.  What was it to her if he wanted to stand there with his legs too far apart for a self-respecting fox?

It slowly raised its head toward the sound of her voice and she saw something abnormal – and very distant – in its eyes.  A string of saliva dangled from its mouth, and fell onto her carpet.

“Look what you did!” she scolded him.  “Well, that’s enough.  Out you go,” and she poked at him with her cane to push him back out into the yard where he belonged.

Snap!  Its teeth chomped onto her cane so quickly, she nearly lost her grip. It began to shake the stick with its neck muscles and head, but she held on.

“You let go!” she yelled.

Saliva ran down the cane, dribbled onto the carpet, and sprayed into the air when the animal shook its head. After a few seconds of violent head shaking, the fox stopped moving, re-set its legs to regain its balance, and just held the cane tight in its jaws, its eyes focused somewhere far away.

“You don’t belong here!” she scolded it.  “And you’re acting very badly for a fox.  You get out!”

She disliked getting upset.

She pushed the cane hard, and it rammed into the fox’s throat.  It made a gargling noise and staggered backward, fell onto its side, but quickly, clumsily, struggled to its feet, and turned toward the open doorway.  It bumped head-first into the glass door, but a swat on its rump from the cane drove it left, and it staggered out into the yard.

Mrs. G. slammed the glass door closed and locked it.

She called me to report the encounter.  “I hear the Health Department is the place to report unusual things,” she said.  “Otherwise I would have waited ‘til my appointment with my orthopedist.”

“I’m glad you didn’t wait,” I told her.  “Close all the doors, and stay inside.  I’m going to call the Animal Trapper.”

It took the Trapper an hour to get up there, but much less time to find the fox and catch it.  He hadn’t wandered too far.  While it’s head was making its way through the delivery service to the laboratory, I was examining Mrs. G.

“Did it bite you?”

“Heavens, no.  I kept him away with my cane.”

“Did any of its saliva get on the cane?”

“Oh, yes.  All over it.  But I wiped it off.”

“What did you use to wipe it off?”

  I asked, fearing I already knew the answer.

“Well, these of course,” she held up her hands.  “And his drool made the carpet all wet.”

“Did you clean that up, too?”

“Of course,” she looked at me as if I’d asked whether she had been breathing today.

Her hands were the thick, hard hands of a woman who’d been splitting her own firewood and building her own chicken coops for 65 years.  Her palms had deep cracks, tattooed black by time and work.

When she came back to my office for her third rabies shot, she showed me a photo of her grandson.

“I’m thinking of taking my daughter’s invitation to move in with them.  I’ll miss the ranch but she said I could bring my cat.”

“Good,”

I said to keep her talking as I pushed the needle a bit harder than I have to for most people.  She had tough skin.

“Maybe it won’t be so bad in the city after all.”

 

*     *     *     *

If you were a rabies virus, just trying to find food and raise kids, some warm blooded animal would be your planet.  It would be in your own best interest – and your offspring’s – to keep your host planet healthy, so that you and yours could have a long life there.

But, if you were, in fact, a rabies virus, that’s not the way your genetic coding would have you play it.

You would take a boat ride on an ocean of saliva from, say planet “fox” where you’d been establishing your dominance, and you’d ride that saliva down into the wound made by the fox’s teeth.  Suddenly, you’d find yourself on (or “in”) a new planet, injected there with the saliva on your old host planet’s teeth.

Deep within the warm, moist interior of the new host, you’d slowly search for the tissue you like best – a nerve.  Small, thin, like a tiny wire, you’d attach yourself to it and make a home.  You’d reproduce.  Your offspring would crawl, slowly, up the nerve, to bigger, thicker nerves, all humming with electricity sending and receiving signals.

Unfortunately for your host, this propagation and up-the-nervous-system progression would cause damage in its wake.

Ultimately, your descendents would reach their “promised land” in this planet: the host’s brain.  There, a flurry of reproduction and associated destruction would wreak havoc on your host, and it would become rapidly ill.  Like climate change, the planet you and your descendents had colonized would become uncomfortably warmer (fever), and stop repairing itself and growing (i.e. stop eating).

Your host planet would be dying, carrying you and your rabies virus babies with it.  Your only chance to escape sure doom and extinction would be … to hop ship.  Find another host.  Another planet.

So, in addition to making the brain you inhabit sick, you would also make it – – – crazy.  Aggressive.  Then you’d scoot down the nerves into the host’s salivary glands, and get ready for the Big Flood.  Ready, like Noah, to ride the waters to a new land.  A new host.

And start all over again.

Well designed, don’t you agree?

We in Public Health traditionally say that the most successful parasites (including viruses in this global category of “parasite”) are those that don’t kill their host, but live long periods in a mutually balanced partnership.  Like Herpes virus or the Tuberculosis bacterium.

So the Rabies virus should be viewed by those of us in Public Health as one of the most spectacular failures as “parasite” since almost no host ever survives the full-blown infection.  But, with its creative answer to the problem, inducing the dying host to transfer the virus to a new, healthy host, you have to hand it to the little guy.  He’s definitely watching out for himself quite effectively, at the expense of his host planet. At the expense of us.

 

 

February 12, 2009

Beer and Bubblegum in the Shadow of the Amazon

Filed under: Uncategorized — cbmosher @ 6:30 am

 

The good news was, I would spend the final three months of medical school in exotic South America, studying rare tropical diseases; the bad news?  The medical organization there was run by missionaries – no drinking, no smoking, no girls.

So I thought.

“Charlie,” the missionary doctor rasped down at me from his elevated position six and a half feet off the floor, “Get your jacket and Spanish dictionary – we’ve got a house call to make.”

He sucked so hard on his Marlboro that the room’s air whistled as it rushed between his lips.

“Where we going?” I asked, bracing for the toxic cloud of his exhalation.

“Over across the Ruta.  We’ll walk.”

The “Ruta” was the major highway that snaked through this sprawling grasslands and remaining islands of hardwood forest.  It was “major” only because it was paved.  All other roads including the town’s streets were either dirt paths or mud slides, depending on the weather.  A depression in the main street remained a puddle for days after a rain, and was home to a large pink sow who moved for no bicycle, motor bike, or truck.

The Ruta was also a steady source of emergency patients to our little hospital.  It brought us the chainsaw accident victims and women in labor from miles away where people were clearing the forest to create new lives as farmers. It aimed careless truck drivers and drunk motorcyclists into sudden collisions.  Although most were low speed collisions compared with the U.S. variety, they were ugly because motorcycles usually carried entire families at a time.

I could hear the Ruta at night, when the clamor of this frontier town surrounding the hospital ebbed. During brief silences in the cicadas’ songs,  it hummed with a low roar that crescendo-decrescendoed as trucks loaded with mahogany logs roared away from the frontier, and trucks loaded food, beer, cigarettes and other essentials of frontier life roared into town.  Lacing the edges of this low roar, like embroidery on a dishrag, was a tinkling of loud music, obviously blaring and shrill at its origin, but muted over the distance between the Ruta and us.  Aside from the initial drive into town two weeks earlier, I hadn’t been to the Ruta.

“What are we gonna do there?” I asked my mentor as I arose from my after dinner siesta.

“Told ya,” the lanky West Virginia physician said in a cloud of smoke.  “House call.” His long bones were so loosely hung on him that he lurched more than walked through the door into the fading light of dusk.  

“I didn’t know there were any houses over there,” I trotted to catch up to his ambling silhouette.  “Just stores and gas stations and bars, I thought.”

He stopped, turned, and showed me his teeth through a mischievous smile.  “Depends on your definition of a ‘house,’ doesn’t it, Charlie?  Come on.”

We found a dirt path that wound into the stand of palm trees, reduced now by dusk to shadows against a sky which glowed blue-black from a sliver of moon.  Insects buzzed so loudly on either side as we walked that my eardrums hurt.  Some bird up above let go with a fusillade of caws like a machine gun.  Then I thought: “Snakes” and looked down to find my feet, but they were swallowed into the darkness of the path.  I was walking by Braille.

Just as I took a breath to say something, he rasped, “You bring a flashlight, Charlie?”

“No.”

He clicked on his.  The path before us materialized from the darkness.

“You should, you know.  There are creatures out here at night.”

“Really?” I ran a couple of steps to get closer to the illumination.  “Doesn’t bother me.”

“Oh, good,” he laughed.  “I like that.  To be a doctor around here, best to be macho.”

A glow ahead silhouetted the tree trunks.  The distant cacophony of musical notes became louder as we walked.  It was connected to the glow, which also intensified as we approached.

When we emerged at the edge of the Ruta, the blaring of tin quality music smothered the droning cicadas.  Behind that noise was another: a gasoline generator, driving the turntable and loudspeaker system wired together somewhere.  Stark electric light bulbs, bare and swaying in the evening breeze from wires hung at roof edges, were as harsh as the music.

Four small square buildings of crude plank lumber and thatched roofs randomly sprouted at the other side of the Ruta.

“Where we going?” I asked.

“La Mariposa,” he pointed at one of the buildings which had a faint pinkish hue.  “The Butterfly.”

“Why?”

“Already told ya.”  He started across the road.  I followed him into the  glaring din.  The flashlight was no longer necessary.

Inside the one room building, the “music” was so loud it was unrecognizable as something produced by instruments.  There were four or five small tables of thick wood, about the size of card tables my parents utilized to play bridge in more genteel surroundings.  A bare light bulb dangled from the roof above, flooding the center of the room like a stage, and casting the walls into shadow.  We sat on crude wooden chairs at the table he chose.

From the shadows, a girl appeared.  Short black hair, ebony eyes, skin-tight top low cut to cover half her breasts (until she bent over), and a skirt that ended mid thighs.  She was barefoot, I noticed.  And her feet were broad – splayed actually – as are those of half the people here who live in such intimate connection with the soil.

“Cerveza,” the missionary requested of her, lighting another cigarette.  “Dos.”

She looked at me, smiled – or was it a leer? – and said something to him in Spanish too rapid for me to comprehend.

He chuckled.  “The joven is a doctor,” he told her.  “Recently arrived.  Be sure to be — nice — to him.”

She tossed her hair back in a maneuver meant to be sultry, I suppose, and walked away.  Wiggled away.  Jiggled away.

“Pay attention, Charlie.”

I whipped my head around to face him.  “Yea.  Sure.  Okay.  Attention to what?”

“To what you see around you.”

“Been doing that.  What did she say?”

“Said she hadn’t seen you before and wanted to know who you were.”

“What did you tell her?”

“The truth.  Here’s our beers.  Only place we can get beer this time of night.  All the stores in town are closed.”

For some reason, it had taken two girls to bring both beers.  For some reason, they also brought chairs and joined us.

“We’re not alone,” I said taking a sip from the bottle.  I was nervous, trembling a little for some reason.

“You noticed?” he guffawed.  The two girls giggled with him.

“Good,” he continued.  “You’re paying attention.”

The second girl was more attractive.  She was blonde, which is unusual here, and looked older.  Wiser.  More relaxed and sure of herself.  Her eyes, however,  were as black as the other girl’s, and burned into me.  She said something.

“What’s your name, Charlie?” the Marlboro man said.

“That’s really kind of a dumb question,” I blurted, “for a couple of reasons.”

He guffawed again.  This time with a head back, all teeth showing, spontaneous gesture.  The girls laughed with him.

“Yeah, I suppose it would be,” he said once he gained control of himself again,  “if it were me asking. But I was just translating for you.  Margarita asked.”

“Who’s Margarita?”

The blonde smiled broadly and lowered her eyelids demurely at the sound of the name.

“Blondie.  Tell her yours.”

“I am called Carlos.  Please I am to meet you,” I repeated the phrase I’d memorized best.  I had to scream it above the blaring cacophony.

Then there was more Spanish, half of it drowned by the “music”, the other half too fast for my primitive knowledge of the language.  It pinballed among the other three with occasional sentences aimed at me to which I merely smiled and/or nodded.

At first my mentor translated a few phrases, but he eventually abandoned English.  I had the tone of the conversation by then.  It wasn’t deep.  It wasn’t philosophical.  It was, unfortunately, mostly about me.

“Rosita thinks you’re cute.”

“Cute?”

“Yeah, you know, handsome.”

“Margarita wants to know if you’re married. They want to know what state you come from. Do you have any questions for them?  They are asking.”

Half way into beer number two, I became aware that the two girls were no longer sitting across from me and from him.  They were on either side of me.  They were laughing and tousling my hair.  Margarita’s bare thighs were rubbing against my pants.  Rosita was blowing big bubbles from her gum and we all laughed as she peeled the pink slime from her face, time after time.

“What are they saying now?”  I asked the hospital’s medical director.

He blew out a dense cloud of blue smoke that enveloped his brain-shaped skull.

“They gave you a nickname – ‘Choco Clinudo’ – ‘cause of your brown hair.  They think you’re cute.”

“Yeah, yeah.  I know.  They wouldn’t think I was so cute if I was broke, I betcha.”

“You’re right about that,” he said, taking another swig of beer.

Then, a flurry of fingers in my hair propelled by girlish giggles and squeals.  Their brown thighs jumped as they teased me.  “Hey, you’re messing me up,” I objected, grabbing their wrists and pulling them off me.

“They like you, Charlie,” he beamed, then threw back his head, laughed and guffawed and bellowed and let loose enjoying himself like I’d never seen him in the hospital where he played the role of American mentor to fledgling Latin interns and the dedicated nurses who actually did the work.

When he finished his laugh, he said something to them.  The two got up, shook my hand politely and said the “glad to meet you” phrase I understood. They dissolved again into the peripheral shadows.

“Let’s finish up and get home,” he said swigging the dregs of his beer.  “It’s late.”

“What about the girls?”

“We’ll see them again at the clinic,” he said.  “Thursday.  V.D. check day.  We need to test them every month.”

“So they come in once a month?”

“Not always,” he said reassembling his lanky frame into an upright position.  “These two have missed a couple of times, but they’ll be there Thursday.”

“How do you know?”  I waited for him to finish lighting another cigarette.

“Because,” he flicked off his lighter.  “I told them you’d be there.  Let’s go.”

We crossed the Ruta, dropped down to the palm tree thicket, and he flicked on the flashlight again.  As I followed him down the path, I raked my fingers through my hair to re-comb it, and snagged a wad of bubblegum with my fingernails.  My hair was deeply entangled in the thick, sugary wad.

“Shit!” came shooting out.  “Hey,” I called up to him, perhaps a little more aggressively than I should have.  “What exactly were we doing back there?”

His answer came floating back to me in a cloud of Marlboro smoke:

“Public Health, Charlie, Public Health.”

« Newer Posts

Blog at WordPress.com.