Wednesday, October 29, 2014

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?

Monday, October 27, 2014

Uncertain Health in an Insecure World - 3

“Relieved, unrelieved or dead”

Statistician Florence Nightingale (1820-1910) so summarized the possible outcomes of the 19th 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 21st 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.

Friday, October 24, 2014

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

Wednesday, October 22, 2014

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