Ebola, risk, and the public's health

My friend Allen Perkins received a text from his college-student daughter asking if she should be worried about the Ebola virus. His reply, discussed in “Ebola virus and the dread factor” in his excellent blog, “Training Family Doctors” was “Are you considering moving to west Africa?” This was wise and profound fatherly advice, based upon an understanding of the epidemiology of disease. While is it obviously a serious problem in West Africa (particularly Liberia, Sierra Leone, and Guinea), it is not in the United States. Many other things are much more of a threat in the US, including, as Allen points out, “death from bee stings” (100 per year in the US).

Ebola might someday become a significant problem in the US, but it is unlikely and is not now. Many other health problems are. College students like Allen’s daughter should be sure that they have all their recommended immunizations for diseases that can be prevented by vaccine, including HPV and meningococcus, a very serious and often deadly cause of meningitis that can become epidemic where young people live together in close quarters, like college dormitories (and army bases). Yet, many do not receive these immunizations for reasons that range from passively not getting it done (less of a problem in schools where it is required) to having beliefs, or having parents who have beliefs, that vaccines are dangerous and should be avoided (in some cases this can trump school requirements). They are, by the way, wrong. The net benefit far outstrips the risk. Having your child get meningococcal meningitis and die or have serious brain damage, or get cervical cancer, is not something you want.

But focusing on conditions over which we have little or no control, rather than the ones we do, is fairly epidemic in this country (and likely others). Dr. Perkins focuses on the “dread factor”, about how news reports (not to mention thriller movies) whip up fear about these diseases. On the other hand, mostly what we can do is fear them, while the diseases which we individually might be able to have an impact on would require us to have to maybe do something hard: change our diet, start exercising, stop smoking, not drink so much or at the wrong times. I have written in the past about a patient who had a terror of breast cancer, a disease for which she was not at an increased risk based both on her youth and lack of family history. On the other hand, she did not seem particularly worried about the health risks of her uncontrolled high blood pressure, smoking two packs of cigarettes a day, or having unprotected sex with several different men.

Most of us can see that this is not logical, and maybe even snicker a little about her poor decision making. But it is only a little extreme. Many, perhaps most, of us, could do a better job of eating right, of exercising, of not smoking or drinking excessively (which for many people is “at all”). If not Allen’s daughter, many of her classmates are at much greater risk from going out and getting drunk on a weekend night, increasing their risk of motor vehicle accidents, sexual assault, poor judgment in choosing voluntary sexual encounters, and long term habituation for those with a predilection for or family history of alcoholism, just for starters. But taking action to prevent such bad outcomes is hard, requires effort, and often means not doing things we like in the short term, such as eating tasty-but-unhealthful foods, drinking with friends, smoking when we are addicted to nicotine, driving when we (or the driver) is only a “little drunk”, or having to do unpleasant exercise. Or it can conflict with our self-image: wearing a bicycle or motorcycle helmet, eschewing doing things that our friends are doing. Worrying about things that we can do nothing about, like breast cancer or Ebola, may be a little irrational, but it is in some way comforting because if the bad thing happens we are an innocent victim.

In addition, there are actions a society can take, that could make even more of a difference from a public health, population health, point of view, saving more lives, but these require political will. Sadly, this is often more lacking than individual will. Guns are the prime example; many state legislatures and legislators make it a point of personal pride to advocate for there being no restrictions at all on what kind of guns (e.g., automatic weapons) and ammunition (e.g., armor piercing bullets) people can have or where they can carry them (everywhere, open or concealed). Helmets and alcohol regulation are other areas where opportunity for prevention is often missed. Car safety has been increased by car and highway redesign and tobacco has been increasingly regulated (against the opposition of the industry, it should be noted, in both cases) for the benefit of public health, but many opportunities remain.

Indeed, expanding health coverage to all those below 133% of poverty by Medicaid expansion continues to be opposed by those who want to be seen as against Obamacare. This may be irrational from a public health point of view, but in many states it is rational, if offensive, for being re-elected. The most unjust and inequitable part of it all is how the effects of poor public health policies most affect the most vulnerable, poorest, least empowered people in our society, or indeed any society. Public health education campaigns tend to focus on diseases that have well-funded advocacy groups and affect the majority population; a recent qualitative study of African-American women found that they were very aware of the threat of breast cancer, but hardly at all of stroke – a disease statistically more likely to affect them.

Speaking of public health, it is gratifying to see some newspaper coverage of Ebola that is not sensationalist or scary. “U.S. Colleges See Little Risk From Ebola, but Depend on Students to Speak Up”, by Richard Pérez-Peña in the NY Times, August 30, 2014, addresses the small but real risk that may affect colleges from students who have (unlike Allen’s daughter) actually traveled to West Africa. Even better is “Leadership and Calm Are Urged in Ebola Outbreak” by Donald G. McNeil, Jr., which presents a rational, thoughtful, public health approach, and discusses public health strategies which have been used in the past in major crises and are beginning to be implemented in West Africa. These strategies center around the use of local, respected experts who can effectively communicate with the people in their countries, rather than international aid agencies. The goal is to help people to utilize appropriate prevention and protection measures rather than panic. Again, as in the case of the other personal behaviors described above, this can be hard for people, especially when it contradicts cultural and religious values (such as how the dead are buried). But having voices who are local, who understand the culture, and have both medical/public health credentials and individual credibility, is extremely important. Of course, unlike the Ebola “scare” articles, these were both on page 8 of the newspaper, but have a more prominent position on that day’s Times homepage.

So what are the lessons? Understanding risk is not always easy, especially when an epidemic with a hugely high mortality rate threatens.  Doing something is harder than not doing anything, and it can thus be tempting to worry more about the things that we can’t do anything about rather than those we could reasonably take action on. The same is true for public health issues that need to be addressed at a societal level.

And, of course, it is always the most vulnerable who suffer the most.

Medicaid expansion or not: everyone needs coverage

In an echo of my blog post of November 17, 2013, “Dead Man Walking: People still die from lack of health insurance”, the New York Times’ lead article on November 29, 2013 was “Medicaid growth could aggravate doctor shortage”. The main point in my blog was that, to the degree that there is a doctor shortage exacerbated by increasing the number of people who have health insurance (from Medicaid expansion or insurance exchanges or any other reason), the shortage was already there. If the reason that it was not felt earlier was because people, not having health insurance, did not seek care, does not change the fact that these people were here and were as sick as they were or are. To the extent that they were not getting health care because they were uninsured is a scandal. If anything, that people will now have coverage and thus seek care is an unmasking of an extant but unmet need.

The Times article looks particularly at Medicaid because many doctors will not see Medicaid patients since the payments do not cover their costs (or, in many cases, because they can fill their schedules with people who have better-paying health insurance). Those physicians who do accept Medicaid often feel that they will not be able to take more Medicaid patients for the same reason, and it is unlikely that those who are already not accepting Medicaid will begin to. The problem is significant for primary care, even for institutions like Los Angeles’ White Memorial Hospital that already care for large numbers of Medicaid patients. In the NY Times article, my friend Dr. Hector Flores, Chair of the Family Medicine Department at White Memorial, notes that his group’s practice already has 26,000 Medicaid patients and simply does not have capacity to absorb a potential 10,000 more that they anticipate will obtain coverage in their area.

The problem for access to specialists may be even greater. There are already limited numbers of specialists caring for Medicaid patients in California and elsewhere, for the reasons described above: they have enough well-insured patients, and Medicaid (Medi-Cal in California) pays poorly. It is also possible that some specialists have less of a sense of social responsibility (even to care for a small proportion of patients who have Medicaid or are uninsured), and their expectations for income are may be higher. The San Diego ENT physician featured at the start of the Times article, Dr. Ted Mazer, is one of the relatively small number of subspecialists who do take Medicaid, but indicates that he will not be able to take more because of the low reimbursement.

Clearly, Dr. Mazer and Dr. Flores’ group are not the problem, although it is likely that they will bear a great deal of the pressure under Medicaid expansion; if their practices have been accepting of Medicaid up until now, they are likely to get more people coming. The Beverly Hills subspecialists (see: ads in any airline magazine!) who have never seen Medicaid, uninsured, or poor people up until now are unlikely to find them walking into their offices. And, if they call, will not schedule them. So what, in fact, is the real problem?

That depends a bit upon where you sit and how narrow or holistic your viewpoint is. From the point of view of doctors, or the health systems in which they work, the problem is inadequate reimbursement. As a director of a family medicine practice, I know that you have to pay the physicians and the staff. For providers working for salaries, it is the system they work for that needs to make money to pay them. The article notes that community clinics may be able to provide primary care, but does not note that many of them are Federally-Qualified Health Centers (FQHCs) which receive much higher reimbursement for Medicaid and Medicare patients than do other providers. The Affordable Care Act (ACA) will reimburse primary care providers an enhanced amount for Medicaid for two years, through 2014, and yet not only is there no assurance that this will continue, but in many cases has yet to be put into place. And the specialists are not receiving this enhanced reimbursement (although the truth is that many of them already received significantly higher reimbursement for their work than primary care physicians).

From a larger system point of view, Medicaid pays poorly because the federal and state governments that pay for it (although the federal government will pay 100% of the expansion for 4 years and 90% after that) want to spend less. However, they do not want to be perceived as allowing lower quality of care for the patients covered by Medicaid, so they often put in requirements for quality that increase costs to providers which increases the resistance of those already reluctant to accept it. Another factor to be considered is that Medicaid has historically not covered all poor people; rather it mainly covers young children and their mothers, a generally low-risk group. (It also covers nursing home expenses for poor people, which generally consumes a higher percent of the budget.) Expansion of Medicaid to everyone who makes 133% of poverty means that childless adults, including middle-aged people under 65 who have chronic diseases but have been uninsured, will now have coverage.

While the main impact of Medicaid expansion is in states like California that actually have expanded the program, even in states like mine (Kansas), which have not, Medicaid enrollment has gone up because of all the publicity, which has led people already eligible but not enrolled to become aware of their eligibility (called, by experts, the “woodwork effect”). The Kansas Hospital Association has lobbied very hard for Medicaid expansion, but this has not occurred because the state has prioritized its political opposition to “Obamacare”. The problem for hospitals is that the structure of ACA relies on the concurrent implementation of a number of different programs. Medicare reimbursements have been cut, as have “disproportionate share” (DSH) payments to hospitals providing a larger than average portion of unreimbursed care. This was supposed to have been made up for because now formerly uninsured people would be covered by Medicaid (that is hospitals would get something); however, with the requirement that piece removed (thanks to the Supreme Court decision and the political beliefs of governors and state legislatures), the whole operation is unstable. That is, the Medicare and DSH payments are down without increases in Medicaid.

From a larger point of view, of course, the problem is that the whole system is flawed, and while the ACA will help a lot more people, it is incomplete and is dependent on a lot of parts to work correctly and complementarily – and this does not always happen, as with lack of Medicaid expansion. A rational system would be one in which everyone was covered, and at the same rates, so that lower reimbursement for some patients did not discourage their being seen. These are not innovative ideas; these systems exist, in one form or another in every developed country (single payer in Canada, National Health Service in Britain, multi-payer private insurance with set costs and benefits provided by private non-profit insurance companies in Switzerland, and a variety of others in France, Germany, Taiwan, Scandanavia, etc.). If payment were the same for everyone, empowered people would ensure that it was adequate. Payment should be either averaged over the population or tied to the complexity of disease and treatment (rather than what you could do, helpful or not). We would have doctors putting most of their work into the people whose needs were greatest, rather than those whose reimbursement/difficulty of care ratio was highest. There are other alternatives coming from what is often called “the right”, but as summarized in a recent blog post (“You think Obamacare is bad…”) by my colleague Dr. Allen Perkins, they are mostly, on their face, absurd.

Our country can act nobly and often has. ACA was a nice start, but now we need to move to a system that treats people, not “insurees”.

Alabama, “illegals”, and hate: We must take back the narrative

The state of Alabama has outdone Arizona with an anti-immigrant law that is even more anti-human in its degrading approach to and impact on people who are immigrants, visitors, and native Americans with Spanish surnames or who “look” Hispanic. H.B. 56, documents Allen Perkins, MD, Chair of Family Medicine at the University of South Alabama in Mobile in his blog, Training Family Doctors, “…requires schools to check and report the immigration status of their students. It instructs police to demand proof of immigration status from anyone they suspect of being in the country illegally (if stopped for another reason), even on a routine traffic stop or roadblock. It also invalidates any contract knowingly entered into with an illegal alien, including routine agreements such as a rent contract, and makes it a felony for an unauthorized immigrant to enter into a contract with a government entity.”

 He also notes that “…there were some really hateful provisions written in but enjoined as non-enforceable at this time (but liable to be enforced in the future): ‘It is a crime to harbor or transport unauthorized immigrants; unauthorized immigrants cannot enroll in or attend public universities; it is  a crime for unauthorized immigrants to apply for, solicit, or perform work; it requires that schools check and report on the legal status of their students and their students’ parents; and lastly, it is a crime to be without status in the United States.’” In a later blog entry, he describes specific incidents of harassment by regular people (e.g., store clerks) of – regular people, even American-born, because of their ethnicity. In other words, H.B. 56 has given folks in Alabama a license to be racist, which many in the state feel is particularly shameful given its history of slavery, Jim Crow, and opposition to civil rights.

Dr. Perkins worked to get the 2013 national conference of the Family Medicine Chairs’ organization, the Association of Departments of Family Medicine (ADFM) to Mobile, which he considers a diverse and vibrant city that was also in need of some economic boost, particularly given the recent hurricanes and more recent oil spills that have ravaged its shores. The agreement for the conference was all signed when H.B. 56 became law, and many members of the organization protested. This included Latino chairs, who felt that, in addition to opposition to the law, they might well be in personal danger. The conference will be moved, at considerable expense to the organization – and to the city of Mobile. Dr. Perkins includes in his blog a political cartoon (reproduced here) from the Mobile Press-Register, which also had a strong editorial about it.

The Alabama law does not stand in isolation, nor do Alabama and Arizona together. Both laws were, as it turns out, largely written by an ambitious attorney and law professor from the University of Missouri-Kansas City who now is serving as Secretary of State for Kansas, Kris Kobach. Kobach’s work is only one of the most recent chapters in a 30-40 year effort funded by incredibly wealthy right-wingers such as the Koch brothers of Wichita, Richard Scaife, and others, to rewrite American values. They have used the vehicles of conservative “think tanks”, talk radio and TV outlets such as Fox, funding individual organizations, and paying for lots of messaging (including the Super-PACs now thriving in this election season thanks to the Supreme Court’s Citizens United decision allowing unlimited corporate funding of political advertisements, one of the greatest “victories” of this effort) to create a narrative that, while essentially false, is widely believed by many Americans.

The development, implementation, and impact of this narrative as regards immigrants was the topic of discussion by Oscar Chacon, Executive Director of the National Alliance of Latin American and Caribbean Communities (NALACC), who gave the Matthew Freeman Memorial Lecture on Social Justice at Roosevelt University in Chicago on March 8, 2012. Our history in the US includes immigrants of all national backgrounds being vilified, persecuted, and demeaned (see, as just one instance, my discussion of some of the events surrounding the Boston police strike of 1919 described in Dennis Lehane’s novel “The Given Day”, Immigration and the US: Happy New Year, December 30, 2010). African-Americans, brought here as captives, along with our only non-immigrants, American Indians, have occupied a special places of discrimination and oppression. Nonetheless, during and after World War II we began to see ourselves as a “nation of immigrants”, symbolized by the beckoning torch of the Statue of Liberty, and its inscribed sonnet "New Colossus" by Emma Lazarus. We realized that the US had grown strong by this continuing infusion of the boldest (they emigrated, right?) from other nations prospering in this land of opportunity (the continuing oppression of African Americans and American Indians notwithstanding).

Mr. Chacon noted that, in 1970, immigrants of Latin American origin (which term he prefers to “Latino” or “Hispanic”, words not used outside of the US) were a minority of immigrants, and Mexicans a minority of those. The perception of Latinos in popular culture was generally positive, represented by handsome, suave, and debonair actors such as Cesar Romero and Ricardo Montalban and the character of Ricky Ricardo portrayed by Desi Arnaz. (Of course, many of those without accents, such as Anthony Quinn, Raquel Welch, and Martin Sheen felt the need to change their names, a practice also common among many minority performers such as Jews and Italians.) Since that time, immigrants from Latin American have become the majority (over 50%, but still less than 60%) of immigrants to the US, with Mexicans becoming the majority of those (over 30% of the total). The narrative that has been purposely developed over this period has served to redefine them as less than human, swarms coming to our shores who would all be here if they could, who are all Mexicans (Chacon, who is from El Salvador, is often asked what part of Mexico that is in!)

The narrative has created the term “illegals” to refer to people, when in fact only things or acts, not people can be illegal. People can do illegal things, including entering the US without official permission, or stealing, or committing assault, or driving over the speed limit and running red lights, but they do not become illegal people. This type of narrative serves to dehumanize them and thus makes it easier to oppress them. It has long been a common strategy adopted by the powerful to convince a portion of the powerless (say, Euro-Americans) to side with the rulers against other powerless people. It was very successfully done with Africans to make it acceptable for them to be slaves, and it has been a very conscious strategy to change the perception of immigrants of Latin American origin.

This narrative, pushed by right-wing ideologues, led to the passage of “IRA-IRA”, the “Illegal immigration and immigrant responsibility act” of 1996 – before 9/11 and under Democratic President Bill Clinton. In addition, major funders of the demonization have been the for-profit prison companies such as Corrections Corporation of America, that make huge amounts of money, paid for by US taxpayers at rates several hundred percent higher than their costs, to “house” arrested “illegals”. Latinos are arrested for “being illegal” but they also commit crimes and are imprisoned; their time served is, on average, less than that for African-Americans or even whites not because their sentences are shorter, but because they are regularly deported.

Has this narrative been successful? Read the news. Read this quotation from an article in the NY Times Magazine about an undocumented student (a young man who journeyed “…from cleaning windshields at stoplights and sleeping under a bridge in the Honduran city of San Pedro Sula to attending the sixth-largest university in the United States,”) who ran (and lost) for student body president at Texas A&M University: “…[a] professor, discussing the growth of Hispanics in Texas, said the state could have a Hispanic governor in the future. A number of students in the class hissed.” Note that the professor was not talking about an undocumented immigrant, or even an immigrant, just someone of Hispanic ethnicity.

This well-funded narrative is not limited to immigration of course. It has been largely successful in changing the words and terms of discussion in reproductive rights, women’s rights, and the entire vocabulary of liberal-conservative. And of course they have major impact on people’s health; after all, should we provide health care services to “illegals”? There is of course opposition to all these mythologies, and that opposition is growing. It is not as well-funded by the incredibly wealthy -- who are the real beneficiaries of suspicion and animosity among the 99+% -- but the Occupy Movement was and is real.

Alabama doesn’t need politicians passing laws that validate a new form of racism as it still struggles to move forward from its Jim Crow past. Nor does Arizona. Nor does Kansas, or Oklahoma, or any other part of the US, or the US as a whole. We must take back the dialogue, take back the words, and make the values of diversity and inclusion the ones that America and the American people represent.