Uncertain Health in an Insecure World – 16

“Open Access, or The Highway?”

The first known scientific journal, Philosophical Transactions of the Royal Society, was published 350 years ago in 1665. As noted on the frontispiece below, its pages gave an “account of the ingenious in the many considerable parts of the world”.

The 15-year old Bill and Melinda Gates Foundation’s current endowment is $43 billion. Their money funds ingenious educational and health care research. Its official blog is called Impatient Optimists because Bill and Melinda, once naïve (by their own admission) to the ways of the world of giving, have come to understand that deep pockets & big ideas alone are insufficient conditions for global game change.

Even geniuses must learn as they go. 

Effective January 2015, the Gates Foundation will require that its funded researchers submit their results to open access online journals, like the OMICS Group and the Public Library of Science PLOS ONE. By 2017, all of the research funded by the Gates Foundation must be initially published in open access journals, without the typical constraints to information sharing associated with big publishing house costs and embargoes.

In addition, the Gates Foundation has stipulated that articles funded by their grants have a Creative Commons Attribution 4.0 Generic License (CC BY 4.0), allowing published content reproduction for both scientific and commercial uses.

So from now on, it’s full, free and immediate information access, or ‘The Highway’, for researchers planning to accept prestigious Gates Foundation money.

These publishing strings are spun from Bill and Melinda’s personal values web. They want health care workers in poor countries and emerging economies to have early access to credible research results, without expensive journal subscriptions & article reproduction fees, or other information dissemination barriers.

Fair enough! After all, it is the Gates’ money, so they can dictate the funding terms as they see fit.

The Gates Foundation’s open access online-in-the-sand looks like a game changer for lucrative multinational scientific publishing conglomerates, like The Elsevier Group. Through its data warehousing subsidiaries like Research Intelligence, Elsevier tracks impact factors for individual scientists and research journals alike, tied to the frequency that their peer reviewed publications are cited by others working in the field.

Ironically, impact factor information is highly influential within the research community for one very important reason - it is grounded in a rigorous peer review process. Impact factors can also parallel and even predict the future commercial value of an idea or patent – so-called intellectual property.

High impact scientific journals like Nature and Science do not support the Gates Foundation’s CC BY 4.0 stipulation, arguing that readily reproduced research materials can be altered or misrepresented for commercial interests, to the detriment of a researcher’s and/or a journal’s reputations.

Neither camp’s position is without merit. 

But what would the Gates say if a less robust piece of research, released without major publishing house expert review into the open access architecture, harmed patients?

And what is The Lancet’s explanation for its failed peer review of the 1998 Dr. Andrew Wakefield MMR vaccination-autism link paper, retracted in disgrace in 2010?

So, “Who is right?”

Can a global medical profession sworn to “Primum Non Nocere” (First, Do No Harm) make the compromises necessary to attain the best of both worlds for the underserved, when neither is perfect?

And if “perfection is the enemy of good” in the developing world, then aren’t pricey developed world publishing house practices simply colonialism under another book’s cover?

For us in The Square, the more germane question to both camps may be “What is wrong?”

Uncertain Health in an Insecure World – 15

“Planning for World Domination”

                                                                             

Human attempts at world domination come in many forms.

Kaiser Wilhelm II (1859-1941) led Germany into World War I in support of Austria-Hungary. While he was both King of Prussia and German Emperor, the Kaiser's domestic policies were vacuous and his wartime leadership ineffectual. He lost The Great War and his crown on November 11, 1918, living out his life in exile in the Netherlands.

Henry Kaiser (1888-1967), an American World War II shipbuilding magnate, assured that his employees & their families received health care at a 10-bed Kaiser Field Hospital opened in Richmond, CA in August 1942. The first Kaiser Permanente Hospital was established by his foundation in Oakland, CA in August 1944, where the company still maintains its head offices.

Today, Kaiser Permanente (KP) operates a largely western U.S.-anchored niche market health care plan.  For more than seventy years, KP has relentlessly pursued its successful integrated care and insurance coverage business model, which is now closely linked to an aggressive disease prevention program. Within the ~9,500,000 KP plan membership group, chronic disease avoidance through illness prevention has been shown to be highly cost-effective.

The key unanswered question: Can the KP ‘Total Health’ best-in-class chronic disease prevention model be exported into other countries?

Total Health remains an unproven global commodity outside KP’s U.S. markets.

KP International (KPI) is working hard to share what it has learned in sunny California with the rest of the world. My Global Health Leadership Forum (GHLF) colleague, Molly Porter, is an unreserved proselytizer for the Total Health mantra. Tyler Norris, KP vice-president for Total Health Partnerships, believes too, telling me recently that, “Total Health is a state of complete physical, mental and social well-being for all people… to address the whole person… and apply every lever we have – from paying living wages to implementing local and sustainable purchasing practices”.

I’m totally inspired!

But as of today, KP lacks evidence to support the dominating impact of Total Health around the globe. On behalf of KP, Tyler Norris has thrown down a proper organizational gauntlet: “Any community or national health system can do this, if they make the leadership commitment”.

Beyond developing motivated leadership, just what are the major barriers to Total Health adoption in the less developed countries of the world?

Care integration – communicating collective organizational goals; aligning and coordinating patient-related efforts to help achieve shared goals.

Complexity – managing the interdependence of sequential tasks, and the reciprocal effects of chronic diseases within systems of care.

Organizational direction – motivating employees & enrollees about what to think (i.e. mindset), mutual respect, and knowledge on how acquiring new skills fosters innovation.

Change – connecting today with tomorrow; getting ahead in a strategic way that is problem-focused, avoiding crises management.

Boundaries – moving beyond the health care sector, crossing into the social services sector including education, housing, childcare, etc.

KPI's Answer: the very same factors that determine Total Health's success in the U.S. will predict its successful adoption globally.

By value process mapping, pinpointing opportunities, keeping pace and coordinating relationships, KP has positioned itself to move offshore and morph its Total Health platform to meet other countries’ chronic disease mitigation needs.  

Not unlike Kaiser Wilhelm II's vain attempt to dominate early 20th century Europe, this is not going to be easy. The dis-integrated health care systems of politically fractious developing countries, where generally unhealthy populations abide, are more of a challenge than wartime industrialist Henry Kaiser ever imagined.

But KP is totally committed to spreading the gospel of Total Health internationally, and confident that it can overcome these real-world adversaries.

It's Kaisers we're talking about, so stay tuned!

The Square salutes those who take up a grand campaign.

Uncertain Health in an Insecure World - 14

“Definition-itis”

Sir Bertrand Russell, British philosopher, ethicist and social critic said, “Everything is vague to a degree you do not realize until you have tried to make it precise” (The Philosophy of Logical Atomism, 1919).

Definitions of widely used terms vary widely.

Excessive definition variability causes a pathological inflammation of essential organ systems – a.k.a. “definition-itis”.

International medical and public health communities are increasingly interested in global health. Unfortunately, these actors have widely differing and overly complex definitions for global health.

Global health is defined as research and practices that prioritize improving health and achieving health equity for all people in the world. Because these issues transcend national boundaries and domestic governmental capabilities, they are often the purview of non-governmental organizations (NGO’s) like the World Health Organization (WHO), the United Nations (U.N.), the World Bank, etc. High income countries with well-established public health institutions are home to these global health NGO’s (WHO Geneva, Switzerland, U.N. New York City & World Bank Washington, DC). 

Other definitions of global health call communities to action around the planet to collaborate effectively to make global health promotion research & evidence-based actions a trans-national policy priority. The 2007 Oslo Declaration identified global health as "a pressing foreign policy issue of our time'". 

Still others suggest that public health is actually global health for the public good (c.f. the 1978 Alma Ata Declaration of “health for all”).

International health, including tropical medicine, is not global health. It emphasizes public health solutions for infectious diseases and maternal-child health issues in low and middle-income countries. National governments often embed international NGO’s within their ministries of health in order to more effectively channel medical aid and humanitarian assistance.  The U.N. Children’s Fund (UNICEF) has 190 country programs and national committees. UNICEF country offices facilitate foreign aid efforts by developed countries, exerting a public health benefit through field work inside developing countries.

What could be wrong with the lack of a shared definition for global health?

This space has become muddy, and definitions get bent out of shape to suit the actors' purposes. If these related terms really have different meanings, then why isn’t there an effort to make that clear? Are there common core ideas that  help to explain the continuing overlap? 

Is there anything wrong with defending the use of two related terms?

It has been asserted that a common definition of global health is essential to shaping national strategic direction, which can then inform actions by the global health community. In 2009, an expert panel led by Jeffrey Koplan reached a consensus on a common definition for global health through natural language processing of the extensive published literature. Among other G-8 countries, Canada was an early adopter of this definition as a to guide their national global health strategy in 2011.

Bravo!

If the core relevance of global health is being widely misunderstood, then related research and actions may end up being less potent, despite the best intentions of the actors.

So let's be perfectly clear.

The global health Square is not located in Babel.

Help stamp out "definion-itis"!

Uncertain Health in an Insecure World - 13

“The Vaccination Games: Mockingjay”

Some of my best friends are vaccine scientists – call them ‘Capitals’. They'd likely follow Capital President Snow.

They devote their professional lives to developing vaccines to prevent a variety of potentially lethal infections. Whether these colleagues work in open labs or one of the world’s fifteen secure biosafety level (BSL)-4 containment facilities, their discoveries are converted into useful medicines at a higher rate than any other type of research. They believe in the Center for Disease Control (CDC) Vaccine Advisory Committee, despite some member ties to vaccine makers. 

Some of my best friends think that vaccinating children is harmful – call them ‘Mockingjays’. They'd follow District 13 President Coin.

Despite the seriously flawed 1998 Lancet study linking measles-mumps-rubella (MMR) vaccine to autism, which was retracted in 2000, they worry. They’re convinced that there is a link between diphtheria-pertussis-tetanus (DPT) vaccination and sudden infant death syndrome (SIDS). They ignore news of rubella outbreaks in MMR-unvaccinated enclaves of Europe and North America. They just don’t trust vaccination, or the system.

A twenty-something colleague was just diagnosed with whooping cough (pertussis), after hacking her lungs out for three weeks. She saw multiple doctors before one finally made the connection to this childhood disease. Her DPT-induced immunity had simply flagged over the years. Some believe in the “leave it to nature” approach, touting better survival through disease-induced immunity. But the alternative to vaccination is a risk of dying from measles encephalitis or H. Flu meningitis, before the body can mount an effective immune response.

Rebellion is not without its consequences – District 12 was destroyed by the Capital’s bombs!

The 2011-2020 World Health Organization (WHO) Global Vaccine Action Plan (GVAP) has been endorsed by 194 member states as a strategy to prevent millions of deaths through equitable access to vaccinations. Whether through village-centered or nation-wide vaccination programs, millions will reap a health benefit, individually and through so-called ‘herd’ immunity, which is achieved when >95% of a community has been vaccinated.

Many rebel fighters believe that herd immunity is a myth.

Outbreaks of Group A meningococcal meningitis occur every 7-14 years in the so-called 'meningitis belt' of Africa, between the sub-Saharan Senegal to Ethiopia. According to WHO, the 2009 epidemic killed 5,352 people.

That’s more deaths than from the 2014 Ebola outbreak!

Once a disease largely confined to military barracks in developed countries, Group B meningococcal meningitis is flaring up in college dorms. The U.S. FDA and CDC monitor the safety of all routinely used vaccines, and recently approved the use of a Group B meningococcal vaccine after serious outbreaks at Princeton and the University of California Santa Barbara.

But my college freshman won’t get infected.

There are over 100 human papilloma virus (HPV) sub-types; the most commonly used HPV vaccine (Gardasil) is active against HPV-6, 11, 16 and 18.  The National Health Service (NHS) estimates that 40% of annual U.K. HPV cervical cancer deaths would be prevented by routine vaccination of 9-13 year old girls who might becoming infected after sexual intercourse. Vaccination is now recommended for boys & young men aged 9-26 years who may have sex with other men, to prevent genital warts.

Of course, my teenager won't become sexually active.

Until your child is selected to represent their district in the Hunger Games, parents can’t imagine it. But unlike Katniss Everdeen's record, only one tribute survives.

So to the Capitals and the Mockingjays, you have 3 survival options: watch helplessly while viruses kill youths for sport, rebel against the system, or vaccinate your children.

And to all those walking in The Square, I say, “If they burn, we burn with them”.

Uncertain Health in an Insecure World - 12

“Terror’s Toll”

The greatest weapon in a terrorist’s arsenal isn’t a hijacked airplane or a ground-to-air missile or an explosive vest.

It’s fear.

When humans are subjected to the threat of terror, and nothing deadly actually occurs, the terrorists are still winning.

Their victims feel powerless.

It is not surprising that individual survivors of terrorist attacks (9/11, 7/7, The Boston Marathon bombing, Mumbai, etc.) experience early post-traumatic stress disorder (PTSD) at rates twice that among motor vehicle accident survivors (38% versus 19% in a 2005 study). A minority develop chronic PTSD, often in response to continuing stress. Repeated terror acts in countries such as Israel cause psychological distress in the affected communities, with measurably elevated PTSD prevalence.

The World Health Organization’s (WHO) 2005 analysis of 57 million global deaths tallied 35 million deaths from chronic diseases, 17 million deaths from infections (HIV/AIDS, malaria, tuberculosis) and 5 million deaths from terrorism, civil war and one-sided violence (i.e., genocide).

I did not know that!

There is a growing body of evidence that another long-term consequence of being chronically fearful and powerless is higher mortality & morbidity related to substance abuse in conflict-affected populations.

Why is that?

Terrorism & violence damage health and economic infrastructures. Health care services are disrupted (electricity, water, sanitation) and health care workers often flee. During armed clashes in Somalia in 2013, basic health services such as polio vaccinations suffered. Agriculture and food rations (other than home brewed alcohol) dissipate. Forced resettlement marches and refugee camp overcrowding exacerbate these strains.

Not surprisingly, witnesses to extreme personal or family violence are deeply traumatized.

A 2013 report comparing pre-2000 to 2002 substance abuse disorder disability-adjusted life years (DALY’s) in 182 WHO member countries showed that a 1% increase in deaths due to terrorism & violence was associated with a 0.1% increase in alcoholism and a 0.12% increase in drug abuse. If there were 50,000 more terrorism & violence deaths beyond the baseline, there would be 220,000 more DALY’s lost due to alcoholism and 83,000 more DALY’s lost due to drug abuse.

   

Fifteen to 44 year old males are most negatively impacted by terrorism & violence.

While the alcoholism and drug abuse gender gap continues to close in episodic terror-afflicted affluent nations (Europe, U.S., India, etc.), the gap in terror-afflicted developed nations like Syria, Pakistan and Indonesia remains wide. In these continuously violent countries, the diminished social status of women seems to perversely favor their health.

All this begs the question, “Does the war-on-terror body count consider terror’s indirectly affected victims?”

Of course not!

To walk in The Square, we must confront these terrifying paradoxes.

Without fear...

Uncertain Health in an Insecure World - 11

“The Agony and the Ecstasy”

In both 15^th century art and modern bio-medical research, these are inseparable.

In 1410 Florence, Donatello revealed his wooden crucifix at the church of Santa Croce to his contemporary Brunelleschi, who countered with his own creation in the Santa Maria Novella. Michelangelo saw both carvings, preferring Donatello's plowman Christ to Brunelleschi's more ethereal figure, which "was so slight that it looked as thought it had been created to be crucified".

With great art, the eye of the beholder is the crucial variable.

Whether in the film adaptation of Irving Stone’s 1961 Michelangelo biography, or in the translation of fundamental laboratory research into new treatments for patients, transformation is fraught with few successes and many failures.

True genius is rare.

Just what does the world get for its annual US$240 billion investment in science? Not much, according to Nobel Prize winners and high-impact research journal publishers. A 2009 Lancet article claimed that 85% of this investment is wasted.

Does science need a forensic audit?

In a rush to generate a "health dividend", thereby achieving profit or re-election, the private and public sector sponsors of bio-medical research pervert the slow deliberate process of discovery.

Science is a marathon, not a sprint.

 

Academics assume that bio-medical literature publishing is methodologically sound… innovative… reproducible. However, the 2013 Nobel Laureates in Medicine & Physiology have recently boycotted so-called “luxury journals” (i.e., Nature, Science, Cell) due process integrity issues.

That’s a troubling sign.

Like Renaissance artists competing for a wealthy patron’s eye or critical acclaim, scientists see the selective peer-review vetting process as noble… cleansing… robust…  The 2013 Nobel Laureate in Physics described himself as an “embarrassment” to his university for having so few research papers published.

Several funding fundamentals are wrong.

The average age of researchers receiving their first National Institutes of Health (NIH) operating grant is now over forty years. Only 60% of NIH-sponsored clinical research trials are published within 3 years of completion, at a cost to publish of more than US$200,000 per paper. The impact of a research paper is measured by the number of times it is cited by others - the cost of generating a citation now exceeds US$11,000!

Increasingly, academic rewards are misdirected and difficult to connect to true quality.

The very essence of top quality bio-medical research – what renders it important work – is often lost in the seeing for a lack of careful looking.

So whether you're standing in Piazza Santa Croce or in The Square, keep a critical eye!

Uncertain Health in an Insecure World - 10

“Bored to Death”

Circa 2000, a groggy post-Millennium world awoke to a chronic disease pandemic.

Unless you’re a global public health maven, there hasn’t been a lot of excitement about this rapidly expanding threat.



The World Health Organization (WHO) calls chronic diseases ‘non-communicable diseases’ (NCD). Dr. Douglas Bettcher, WHO Director of NCD Prevention & Control, recently warned us that, “In this globalized world, we cannot isolate ourselves… from either Ebola or NCD’s”.

Unlike Ebola, you can’t “catch” a chronic disease.

Chronic diseases are defined as incurable illnesses present for >1 year that require ongoing medical care and that may affect a person’s daily life. The main chronic diseases are coronary heart disease & stroke, type-2 diabetes, cancer and chronic lung disease.

Boring!!!

But in 2005, the Agency for Healthcare Research & Quality (AHRQ) reported that 80% of American >50 years old had one chronic disease – that adds up to >60 million Americans. In 2005, the World Health Organization (WHO) estimated that 35 million people would die of chronic diseases, and projected that figure would increase to 41 million by 2015!

Once a chronic disease causes organ damage, it’s almost impossible to reverse.

The longer people around the world live, the greater their proclivity towards one or more vital organs – heart, lungs, pancreas, liver and bone marrow – failing them. We have discussed “brain failure”. More than 83% of dementia patients also suffer the profound effects of co-existing chronic medical conditions during the average 7-10 years before death.

Associated health care costs adversely affect undeveloped country economic growth & development, thwarting aspirations of developed nation status.

Once largely the selective burden of developed nations, chronic diseases are now negatively transforming the less developed world. This growing scourge visits 80% of global chronic disease deaths on low and middle income countries. In poor countries, maternal-fetal malnutrition and low birth weight predict future chronic diseases.

Of Americans aged >70 years, 90% have at least one chronic disease.

Developed nation health care systems burdened with the rising cost of caring for patients living with chronic diseases are actively exploring the potential benefits of chronic disease prevention. Singapore spends only 5% of GDP on health care by focusing on social interventions in their 70 year old “Auntie Jane” population.

Nepalese public health educator/advocate, Lonim Prasai Dixit, espouses the WHO ‘ABCDE’ life plan for reducing the burden of chronic disease – Avoid alcohol, Be physically active, Consume limited salt & sugar, Don’t use tobacco, and Eat plenty of fruits & vegetables.

Sounds quite simple…

But it’s incredibly difficult (and often financially unfeasible) to motivate seemingly un-sick, asymptomatic people to adopt these lifestyle changes.

Other experts call chronic diseases “lifestyle diseases”.

Wherever you live on Earth, the wear & tear of life (high blood pressure, type-2 diabetes, environmental & ingested toxins, and obesity) is taking its toll.

The chronic disease behemoth is steadily advancing on The Square.

High time to wake up!

Uncertain Health in an Insecure World – 9

“Brain Failure”

Forty million people world-wide have some form of what Dr. Sube Banerjee of Brighton & Sussex Medical School calls “brain failure” – more commonly dubbed dementia. The World Health Organization (WHO) estimates the global dementia prevalence doubling time at twenty years – from 35.6 million in 2010 to 115.4 million in 2050.



Sadly, many Gen ‘Y'ers’ will become the fodder for Gen ‘D’… the Dementia Generation.

The burden of "brain failure" is being acutely felt by global economies.

The current annual global cost of caring for dementia patients’ dependence & disability tops $600 billion, or 1% of global GDP. Dr. Banarjee notes that this “bucket of money” exceeds that being spent on more cost-effective killers – cancer, stroke and heart disease.

Previous posts have introduced you to a political leader who died of Alzheimer’s disease.

You may have a relative who is afflicted or who has succumbed to some type of progressive illness that has sapped cherished memories and cognitive functions. The fear of such a terrifying neurological decline contributed to the world’s greatest comic, Robin Williams, tragically taking his own life.

For centuries, doctors have studied other organ failures.

Heart, liver, kidney, bone marrow, and pancreas failure research have led to new medicines and to the capacity to safely transplant failed organs with healthier donor organs that prolong and improve lives.

But “brain failure” is a medical brick wall – essentially untreatable and uniformly terminal. There is no near-term likelihood of solid organ brain transplantation, although stem cell therapies hold great promise for regeneration of selective areas of damaged neurological tissue.

Dementia patients stay at home to avoid the confusion & panic of being out in the world.

Their unspent disposable income impacts the economy. The British have calculated that the unspent “dementia pound” amounted to £11 billion in 2014, and project that this figure will double to £23 billion by 2030. Financial institutions recognize the risk of dementia, betting that memory chip & personal pin cards will allow customers to bank independently for longer.

Dementia disrespects the boundaries between health care and social services.

The U.K. Alzheimer's Society has created 'dementia friendly communities' where taxi company employees are trained to recognize confusion and panic attacks among their customers. U.K. prime minister David Cameron launched a Challenge on Dementia to improve care and fund research.

Whether your granny calls a taxi at 1 AM to get to breakfast with old friends, or your president can't recall the name of his secretary of state, our world's security - writ small or large - is at risk.   

So wear your wrist watch upside-down... and pray.

The Square can be a unfamiliar, scary place.

Uncertain Health in an Insecure World - 8

“The Needle and the Damage Done”

Neil Young’s 1972 song decried the overdose death of a Crazy Horse roadie and the heroin use by the band’s guitarist – signs of a troubling time in America, when inner city blacks were being decimated by the needle.

The developed world imports nearly all the opium and heroin that the less developed world produces. Despite decades of international police incursions, narco-terrorist threats and murders abound in Mexico & Central America. And despite Gulf wars and extended Southwest Asian military tours, the Taliban and others harvest the raw material unmolested. In 2013, Afghanistan produced more opium than the rest of the world combined (see Afghan heroin bag label).

But the gateway drugs to heroin have changed. In 1995, Purdue Pharma began marketing prescription oxycondone as OxyContin™, ostensibly to treat chronic pain. Prescription opiates quickly became the dark, slippery path to heroin addiction and death, particularly in affluent health-insured suburbia.

By the millennium, heroin was also a white persons’ problem.

In 2007, three senior Purdue Pharma executives pleaded guilty in U.S. federal courts to misleading doctors and patients by representing OxyContin™ as being less addictive than similar opiates. As Purdue’s “responsible corporate officers”, the execs bore responsibility for five years of addiction and abuse that brought billions of dollars of sales to the company. U.S. Department of Health and Human Services banned the Purdue executives from doing business with its health care payer (Medicare) for twenty years – a ruling that was recently unsuccessfully appealed.

Pick your poison.

Since 1999, U.S. prescription painkiller sales have quadrupled, and related overdose deaths have tripled. Last year’s 16,000 pain pill-attributable deaths were double those from heroin and cocaine. According to the U.S. Centers for Disease Control & Prevention (CDC), there are now >100 U.S. all-cause overdose deaths per day, making this the leading cause of injury death. The CDC reports that for every death, ten people are admitted to hospitals for substance abuse treatment.

Public outrage and policy responses have kicked in.

Grassroots local campaigns to make the opioid antidote naloxone (Narcan™) available to first responders have blossomed, saving some 3,000 lives per year in the U..S. Official state and federal efforts to regulate the number of prescription painkillers ordered via more restrictive narcotic drug schedules and a 30-day dispensing limit have received little traction.

These sobering statistics miss the point.

Blame does not lie solely with the heroin dealers, Afghan war loads or Pharma executives, but with some doctors and their professional governing bodies. Physician prescribing patterns and government-run drug coverage payment plans contribute to >12 million Americans admitting to using opiates like OxyContin™ for non-medical reasons in 2010. And doctors running illegal pill mills need to go to jail!

Most doctors are not trained to treat chronic pain.

2011 estimates were that suffering & disability from chronic back pain and cancer, fairly cited as a medical necessity for these drugs, topped 100 million Americans. In 2014, the U.S. Agency for Healthcare Research and Quality (AHRQ) concluded that the long-term use of prescription opiates for chronic pain increases the risk of “serious harm” to patients (i.e. overdose deaths, fractures, heart attacks and sexual dysfunction), with little evidence in support of a health benefit.

So, Neil Young was prescient when he stated the obvious about narcotic addiction, “I’m not a preacher, but drugs killed a lot of great men”.

The developed world has come full circle.

Sadly, the damage is being done all over The Square.

Uncertain Health in an Insecure World - 7

"What’s in a Word?"

The counterpoise of chronic disease management with acute Ebola outbreaks confuses developed world health systems.

The emerging Hobson's choice question for their patients is:
Q: Would you rather die in hospital at age 75 after thirty years of chronic disease, or die acutely in a hospital at age 45 within three weeks after contracting Ebola?

The unsatisfying answer to this tricky question is:

A: Most of the >750,000 staffed U.S. hospital beds are configured for acute (not chronic) patient care, and there are currently only 11 U.S. hospital beds judged Ebola care ready by the CDC.

To health care systems in the developed world, and now in the less developed world, there is no question as to which type of death is more cost-effective... It's Ebola.

Degraded in common usage by medical half-truths and media spin, health care confusion abounds.

So let's clear up a few of the words in the cloud...

Contamination: Medical providers who don gowns, gloves & masks for routine patient care face an immense risk of self-contamination when removing similar gear after caring for an acutely ill Ebola patient. Daily use of acute (intubation, surgery) and chronic (dialysis) life-saving measures are known risks for Ebola virus spread via contaminated body fluids. Complex decontamination protocols are much more robust than simple aseptic techniques (hand washing) for acute and chronic patient care.

Isolation: Protective isolation of medical care providers against acute (meningitis) and chronic (tuberculosis) infections is not the same as reverse isolation of patients with weakened immune systems. The near-certainty that an Ebola-infected person walking into the emergency room of a nationally-accredited metropolitan hospital will be promptly ‘isolated’ is ironically coupled with high probability that these less specialized medical facilities cannot reliably treat this illness.

Transmission: Unlike the obvious blood splatter from an open wound onto surgical scrubs, Ebola transmission is typically subtle – the virus unwittingly borne by caregivers and their personal contacts – coworkers, families, passengers (and yes, possibly their pets). Most Ebola victims cannot say how they became infected. Public health experts’ disease control and index case containment efforts are not the same as government-mandated or self-imposed personal quarantine.

 

Spending: Some of the world’s most expensive (cost per capita) health care systems struggle to control their ever-escalating acute & chronic care expenses (by “bending” national cost curves) through purchasing groups (by 'commissioning' in the UK) and incentives (by 'pay-for-performance' and 'accountable care' in the US). Looking in the mirror, the public health care system reality sounds more like, “We just buy things… We don’t do quality”.

Investing: Some of the world’s most improved and cost-effective public health care systems, such as New Zealand, have “devolved” their cost-control strategies. Their new modus operandi reflects a national belief that “Spending is palliative, while investing is hard-nosed”. Private sector investing in public health care is controversial. However, it is undeniable that such strategic partnerships - with the partners sharing financial “skin in the game” - are a powerful incentive for value creation.

The forecast is for word cloud clearing!

Plain talk is echoing across in The Square.

Uncertain Health in an Insecure World - 6

"We’re From the Government and We’re Here to Help"

Paraphrasing Ronald Reagan’s nine “most terrifying words in the English language”, health care has become a raison d’être for most jurisdictional governments. Even the most hardened trickle-down health care funders now acknowledge that the connection between socioeconomic supply factors and medical care services demand is neither nuanced nor opaque.

The International Social Survey Programme (ISSP) of public attitudes in 33 countries shows that the economy (25%), health care (22.2%) and education (15.6%) were the top ranking concerns among people around the world between 1993 and 2013.

Not surprisingly, modern political parties repeatedly run on one of two policy planks – economic growth or better health care. The interplay between the public’s desire for better health and the mounting cost of health care as a percentage of GDP is undeniable.

The average political election cycle length of between just 2-4 years does not help matters. Inevitable political transitions spawn endless acronym-laden health care policy and process reforms.
 

Beyond serving up easy fodder for health care watchdogs and the press, continuous governmental cycles of re-invention, re-organization, re-purposing and re-positioning often culminate in vote pandering and organizational change fatigue. 

Here's what we know to be true...

The common thread of publicly-financed health care system breakdowns is a lack of courageous governmental health policy. The private sector profitably manages the related collateral damage.

 

The unifying threat is massive health care system bureaucracies parsing banal governmental policies. Entrenched bureaucrats quickly conclude that they can hunker down and survive most changes.

The antithesis of real progress – institutionalized risk aversion – renders situational hopeless-helplessness the new norm. People sick of hearing alarm bells simply turn them off.

Unlike in Reagan Country, your government has not likely “signed legislation outlawing the Soviet Union. The bombing begins in five minutes”. (1985 President Reagan mike-check quip)

But like in Reagan Country, your government is probably at the heart of the problems with your public health care system.

Welcome back to The Square!

Uncertain Health in an Insecure World - 5

“The Boogeyman”

In Dr. Khaled Hosseini’s acclaimed first novel ‘The Kite Runner’, the protagonist's polio-afflicted family servant, Ali, had a “twisted and atrophied” right leg. The children of Wazir Akbar Khan neighborhood called him Babalu – The Boogeyman. Ali gamely navigated the dangerous streets of Kabul, until he died after limping onto a landmine in Hazarajat.

With the recent observance of the 100^th anniversary of Dr. Jonas Salk’s birth and World Polio Week, it is worth noting that while hundreds of millions have been vaccinated world-wide over the last sixty years, polio remains endemic in Afghanistan, Pakistan and Nigeria. The World Health Organization (WHO) has declared a wild polio virus exporting emergency in several countries, including Pakistan, Afghanistan, Syria, Iraq, Cameroon and Equatorial Guinea.

Yes… polio myelitis… febrile crippler of young bodies, diabolical spawner of the iron lung, has made a terrible resurgence in the war torn and teeming cities of southwestern Asia and Africa.

Polio is a stigma – a national mark of Cain – symbolizing the breakdown of a society.

Worldwide, the widespread use of oral polio vaccine has reduced cases from >350,000 per year in 1988 to just 416 in 2013. With only one in 200 cases resulting in paralysis, and only 5-10% of those experiencing respiratory symptoms, polio is more of a lurking health threat than a deadly epidemic. 

In his Pulitzer Prize winning treatise ‘Guns, Germs and Steel’, Jared Diamond chronicled civilization’s ascent in the face of decimating plagues and contagions, including epidemic polio which was first documented in 1840.

The same disease that struck fear into the hearts of parents for generations until the 1950’s (see the photo of 1954 vaccinations in Canada), sparing neither the rich nor the poor, has since been essentially eradicated in the developed world. Type-2 polio has been absent since 1999.

Unlike the yearly influenza vaccines that must tack to the unpredictable shifts and drifts of hyaluronidase (H) and neuraminidase (N) mutations, there is no polio “season”. In fact, polio is one damn boring virus – the three polio virus types have not mutated since the days of Salk and Sabin.

But polio is not just another debilitating childhood disease. The recent resurgence of polio, a disease preventable through childhood vaccination, is an indictment of the public health systems of the worst afflicted countries.

More modern “great vaccinators” who boldly predict the availability of millions of anti-Ebola vaccine doses by 2015, must also privately cringe at the thought of millions of children at risk failing to be immunized against polio.

 Human rights workers and relief organizations alike are eternally frustrated by embargoes and threat lists that prevent the delivery of inexpensive vaccine doses into the hands of enemies of their polio-free states.

Regional strife is the greatest impediment to the global eradication of polio.

Polio, not poor Ali, is The Boogeyman for many of the world's children.

Let's stop polio from stalking The Square.

Uncertain Health in an Insecure World - 4

"And Now for Something Completely Different" 
  

If the 1971 cast of Monty Python’s Flying Circus ran a health care system, it would indeed be “something completely different”. Some days, health care feels like fractured sketch comedy, without the humorous consequences.

“And finally, Monsieur, a wafer-thin mint”. (Mr. Creosote then explodes)

Health care’s systemic fragility is laid painfully bare in the face of a crisis. For example, emerging viral pandemics spike baseline global public health uncertainty. But any health crisis, it seems, can trigger an implosion – the world’s tightly linked geopolitical security networks and global economic markets quickly unravel. 

You know things are getting serious when your stock exchange’s trading breaks are applied on the same day that your health system’s hospital bed-blockers are removed. You can smell ‘SNAFU’ when the U.S Congress takes respected Centers for Disease Control & Prevention (CDC) leaders to the woodshed, while President Obama appoints the first ‘bad bug’ (not drug) czar. You might rightfully be perplexed when watching a patriotic BBC-1 lead story on Royal Navy hospital ships being compassionately dispatched to Sierra Leone, while reading The Times’ unsympathetic headlines about U.K. midwives striking for the first time in thirty years over a pay hike.

Failure to see the signs of something bad coming – what Margaret Heffernan calls “willful blindness” – is a recognized risk that reaches beyond Enron or British Petroleum into health care. When mental models of how things are supposed to work fail massively, as was the case at NHS’ Mid Staffordshire Hospital, vulnerable patients die. When hospital boards succumb to the biological basis of bias, becoming too comfortable with the familiar ‘self’, they can indeed be indicted for criminal corporate manslaughter.

“Look Matey, I know a dead parrot when I see one”.

John Cleese took his pet shop one-man line of inquiry with Michael Palin (Mr. Praline) to an absurd finale - 'The Lumberjack Song' - on a British Columbia river.

The likelihood of a collective response to health care system failures (or crises) is inversely related to the number of observers. Cumulatively, we run a greater risk of becoming victims of a health care “bystander effect” than being victims of Ebola.

So, are you floating merrily down the silly river?

Or are you stepping boldly into the real world... into The Square?

Uncertain Health in an Insecure World - 3

“Relieved, unrelieved or dead”

Statistician Florence Nightingale (1820-1910) so summarized the possible outcomes of the 19^th century healing arts. Blunt – yes – but very clear and hard to dispute.

A real-life story of medical clarity in the face of fear bordering on panic puts this into 21^st century perspective.

In early October, 2014, a Nigerian businessman arrived from Lagos at London Heathrow Terminal 5. Like all but 77 of 36,000 West African air travelers over the prior two months, an infrared thermometer ‘gun’ indicated that he was not feverish when he boarded the flight. Traveler 36,001 used the on-board toilet twice during the six hour flight, washing his hands both times. He slept most of the flight, and had to be roused by flight attendants to prepare for landing.

After he'd run to make his Air Canada connection, flight attendants noted the man’s sweat-drenched clothing. Midway through the nine hour trans-Atlantic flight, the man developed shaking chills. He used the on-board toilet twice for new diarrhea, without disinfecting. After landing and clearing Canadian customs & immigration, he struggled aboard an airport hotel shuttle. When stepping off the bus, he collapsed. EMT’s transported him to a university medical center where Emergency Department personnel had been alerted to “take appropriate precautions” when dealing with feverish African travelers. Wearing masks and gowns, they rolled an unresponsive patient onto a gurney and into an isolation bay.

With a 103 degree temperature and West African point of origin, the infectious disease (ID) consultants were called ‘stat’ to evaluate the patient. If they judged traveler 36,001 to be “possible Ebola”, only highly trained personnel would be allowed to contact patient 1. Blood was drawn for Ebola testing at the national lab hundreds of miles away; test results would take 36-48 hours. The senior ID consultant took a detailed medical history, and determined that the man was not a health worker, and that he had no sick or recently deceased family members. Inspecting his passport, they concluded that he had not visited the Ebola “hot zone” countries of Guinea, Liberia and Sierra Leone in the previous month.

After weighing these medical facts against the odds, the consultants determined that the man was not at high-risk for Ebola. Routine isolation was initiated along with testing for more common, potentially lethal African fevers: Lassa, tuberculosis, dysentery, malaria and HIV/AIDS. A simple blood smear revealed the diagnosis: >20% of his red blood cells were infected with malarial parasites (>5% is considered “severe”). The patient was aggressively treated with anti-malaria drugs and intravenous fluids. The next day, his fever was relieved and his condition was greatly improved.

If the consultants had become caught up in the public paranoia and media blame game regarding the spread of Ebola from West Africa to the developed world, traveler 36,001 would have been dead within 24 hours of becoming patient 1.

Statistics count. Statistics can be scary

Between December 2013 and August 2014, WHO and the U.S. Centers for Disease Control & Prevention (CDC) reported 552 malaria deaths and 4 Ebola deaths. Since then, >5,000 Ebola deaths have occurred. 

Nurse Florence Nightingale treated patients, not statistics.

And despite being well aware of the statistics, our consultants made a clear-headed unemotional choice to not label the patient out of fear of unlikely consequences, but to look first for a common condition that could be readily relieved.

Only a few surviving family members remember the name of the two-year old Ebola “patient zero” - Emile - who died in Mileandou, Guinea on December 26, 2013. Emile’s sister, mother and grandmother also died within a month.

Every CNN viewer knows the name of the only dead U.S. Ebola patient – Thomas Eric Duncan. Not unlike mass murderers, CNN included his middle name. 

The growing list of Ebola-infected health workers who were relieved after intensive treatment at medical centers in New York, Atlanta, and Omaha have each had their 20 seconds of unwanted fame.

No one can possibly know the names of the over 2.5 million unrelieved Africans suffering with a fever on any given day.

But failing to treat patients due to complex public health risk mitigation protocols can delay patients’ relief, and under some circumstances, actually cause preventable deaths.

From where I’m standing in The Square, that seems pretty un-Hippocratic.

Uncertain Health in an Insecure World - 2

"Won’t Get Fooled Again" 
(Pete Townshend, The Who)

Pandemics are proof positive of global interdependence. They demand that the developed world meaningfully engage with less developed communities.  Fragile developed world health care systems are struggling to effectively manage pre-existing chronic diseases in the face of infectious flare-ups. Long-term medical conditions are now also creating health burdens in emerging economies.

You’ve really got to “Smile and grin at the change all around”.

Communicable diseases (HIV/AIDS, malaria, tuberculosis, diarrheal diseases) kill ~10 million persons annually, mainly in low and middle income countries. The World Health Organization (WHO) categorizes TB as a global health “crisis”, estimating that 9 million people developed tuberculosis (TB) in 2013, of which 1.5 million died (20% of deaths were HIV/AIDS-associated). WHO states that, “$8 billion is needed each year to find and treat patients and to invest in better drugs and work on a vaccine”. By comparison, the 2014 Ebola death rate is approaching 5,000, mostly in three West African countries. The World Bank estimates the global economic impact of the current Ebola outbreak at $32 billion. 

More mind-boggling is the tectonic shift in the global non-communicable diseases (NCD) burden. In 2011, WHO reported that NCD deaths in developing countries doubled to 80% of global NCD deaths since 1990. By 2030, low-income countries will have 8x more NCD deaths than high-income countries. The familiar (to developed countries) risks are tobacco, alcohol, sedentary lifestyle and obesity. The predictable results are more cardiovascular disease, cancers, diabetes, lung disease and mental illness. The World Bank estimates the shocking global NCD price tag at $21 trillion over the next two decades!

This worldwide conflation of chronic diseases and pandemics generates vexing questions & answers:

Q: Can the same system that annually runs out of flu shots for millions of the vulnerable & elderly manufacture sufficient ZMapp™ monoclonal antibody doses for >10,000 Ebola victims? 

A: Pick your poison! – In population health terms, the erosive effect of dis-integrated medical care is at least as costly and socially damaging as the explosive and scary threat of global contagion.

WHO global TB program director, Dr. Mario Raviglione, recently opined “the pharmaceutical industry is less interested in developing countries, where potential gains are limited”. Less well appreciated is Big Pharma’s business model for addressing deadly co-existing chronic and communicable diseases. While aggressively growing their developed world markets +10-13%/year via high-margin diabetes specialty drugs and personalized cancer medicines, global pharmaceutical companies are also key players in the less developed world’s compassionate care of neglected tropical diseases (NTD’s) and HIV/AIDS-related multi-drug resistant tuberculosis (MDR-TB). Should Big Pharma cover the $2 billion annual shortfall in TB treatment & prevention funding in these countries by cost-shifting to the developed world?

Today, we’re all inside The Circle of risk.

So no matter where you walk in The Square, don’t be fooled again. 

Uncertain Health in an Insecure World

“All The World’s a Stage” 

(As You Like It, William Shakespeare)

After a week near London’s theater district working with health care experts from 18 countries, one health fact is painfully clear – wherever we walk about this spinning blue orb – increasingly, life has a poor prognosis. 

Key players walking in the Global Health Square are:

The actors – executives, academics, insurers, professionals & policymakers – cognoscente from the developed and developing world who struggle mightily on a daily basis to meet the growing demands of population aging, chronic diseases and lifestyle change.

The audience – patients and their families – have never known greater health vulnerability or less secure day-to-day access to quality government-directed medical care.

While the players’ perspectives vary greatly, they’re all vitally concerned about the future sustainability of global health care “systems”. Experts managing this complexity seek ‘the world is flat’ solutions by trading in Six Sigma, quality assurance and best practice assets, hoping to reverse-engineer solutions back at home. Despite their best efforts, health care users find their taxes, deductibles and co-pays growing as fast as their medical services are declining.

The recent Global Health Leadership Forum sponsored by The King’s Fund & the University of California (Berkeley) in Cavendish Square brought many health care anthropologies together. The diverse participants agreed that health care system cultures differ by necessity, and concluded that ‘one size fits all’ medicine is not the answer.  By sharing cross-boundary stories & statistics, many health care system ‘clans’ gathered to define shared ownership & accountability precepts, and to channel organizational learning & leadership on behalf of their patients. 

The World Innovation Studies in Health (WISH) recognizes the need for marathon-like commitment to task, and re-emphasizes that social determinants of health contribute up to 90% of detrimental health effects. Eschewing uniquely U.S.-/Euro-centric views of ‘good’, novel models of working across social service & health funding streams appear worthy of emulation.

Where do you stand today on the global health stage?

Where will you walk tomorrow in the Global Health Square?

First Nation's Shaman, Canada