This week on Diagnostocracy, Ti and Keifer welcome students Jennifer Fields and Jesse Aquino to review the March for Science and the inevitably partisan role of science in politics. Jennifer and Jesse then discuss their experience advocating health policy while at DO Day on Capitol Hill earlier this month.
I went into medicine with the full intent of serving the less fortunate. However, I didn’t discover street/homeless medicine until after college, and I quickly fell in love with it. During the last four years, I discovered that most people — especially my peers — don’t know that street medicine is a field. So here I am, armed with a laptop and the effervescent desire to share my passion and educate (or rather, I now have an outlet to rant forever and ever without seeing the glazed look in your eyes).
I’m starting a Street Medicine series on Diagnostocracy in which each article will cover a different aspect of medical care for the homeless, since there is so much to talk about. Through the series, I want to not only open your eyes to a special field of medicine but to also to reverse the stigma that weighs so heavily and unjustly on homeless individuals. Diagnostocracy is about promoting change, whether it be medical, social, intellectual, or spiritual. Ideally, I’ll tap at least the surface on all of those with this series.
Homelessness in Paradise
All right, let’s jump to it.
When we think of Hawaii, we think of paradisiacal beaches against a soft sunset glow, some guy setting your alcoholic drinks on fire at a tiki hut bar, or an intimate honeymoon getaway. (I’ve never been to Hawaii, but this is what the ads tell me.) What’s cast in shadow behind all of this is the fact that Hawaii has the highest rate of homelessness in the country.
One of Hawaii’s representatives, Senator Josh Green, is also a physician, and he recognizes that homelessness isn’t just a social problem; it’s a medical one, too. In January 2017, he co-introduced legislation titled “Declaring Homelessness to be a Medical Condition in the State for Purposes of Medicaid Eligibility and Recognizing that Housing Instability is a Major Health Factor that Negatively Affects Homeless Individuals’ Health and Well-Being.” I’m going to call it by its other name, SCR4, for short.
SCR4 has a couple of lines that encapsulate the aforementioned concept that homelessness is the intersection between an extremely simplified medical vs. social Venn diagram:
“…according to the National Alliance to End Homelessness, ‘[h]omelessness both causes and results from serious health care issues, including addiction, psychological disorders, HIV/AIDS, and a host of order [sic] ailments that require long-term, consistent care’”
“… because housing instability detracts from regular medical attention, homeless individuals’ conditions often get worse, which allows these medical conditions to become more dangerous and costly”
Supporters of the SCR4 measure see homelessness as an illness and housing as a treatment, and it’s easy to see why. Homeless individuals are more susceptible to substance abuse and medical co-morbidities, such as HIV and cardiovascular disease. A study found that the mortality rate in homeless individuals is three to six times higher than that of their housed counterparts.
As future healthcare professionals, there are some things we should think about.
- Since homelessness is tied to a decrement in health, should we be able to use public insurance, like Medicaid, to fund housing?
- What are the shortcomings of starting social intervention before medical treatment and vice-versa?
- How do we approach this issue if housing is just correlated with, not a cause of, a decline in health?
- With whom can we collaborate outside of medicine to derive a solution?
- What kinds of biases or other limitations do we have that may be holding us back from tackling this problem effectively and efficiently?
I talked to a homeless patient who tried to stay overweight to appear bigger and therefore intimidating to others on the streets as a defensive measure. What can we do about this battle between health and safety?
How You Can Help
I’d like to ask you to distribute water bottles, food, hand sanitizer, bug spray, hats, and/or sunscreen as you see homeless individuals during your drives or walks. The weather is warming up, so let’s think of ways we can help alleviate the discomfort of our fellow human beings.
I like to keep my articles short and to the point, but sometimes, it’s difficult with a topic that I love talking about. With that being said, please contact me via email, through the Diagnostocracy contact page, or catch me at school if you’d like to know more about homelessness as a medical condition. I have much more to add, some of which I hope to eventually incorporate in this new Street Medicine series, so please stay tuned!
Image: Al Jazeera
Welcome to Diagnostocracy’s first podcast episode! Today Ti and Keifer introduce you to the pod. Then their fellow classmate, Leigh Graziano, joins them as they discuss the American Health Care Act (AHCA) and the court battles happening in Arkansas over lethal injection.
On March 10, 2017, the Accreditation Council for Graduate Medical Education (ACGME) increased the limit on continuous resident hour shifts from 16 to 24 hours. Especially in the context of increasing rates of physician burnout, reactionary opposition began to spill into editorials, headlines, and podcasts. But before we break out the pitchforks, let me say that there is more than one way to view this situation.
Why It’s Bad
In 2003, the ACGME imposed shift restrictions after the premature passing of Libby Zion, an 18-year-old college student. Her death was attributed to the resident’s continuous 36-hour shift (although you can probably also argue for lack of supervision, according to the The Washington Post). In the wake of the 2017 reform, many physicians voiced their concerns about why sleep-deprived residents are a danger to both themselves and their patients.
Why It’s Good or Might Not Matter
To support the new regulations, advocates have been frequently citing the conclusion of a study from the New England Journal of Medicine on surgical residents:
In surgical settings, most studies have shown no difference or a worsening in patient postoperative outcomes and resident education after duty-hour reforms. However, many studies have suggested that duty-hour reforms resulted in improved well-being and less fatigue among surgical residents.
This finding is controversial, because we also have to weigh the scale between the health of the patient and of the resident. The study also begs the question of whether we should have shift restrictions at all. Additionally, Johns Hopkins researchers argue that shorter shift times lead to an increased number of handoffs, which jeopardizes patient safety.
Of course, we still need to consider other factors. For example: specialty, location of practice, hospital/clinic bureaucracy, and individual expectations (e.g. I need time for naps daily…emphasis on “need”). These all chip at the balance between physician competence and patient safety. More studies and other means of evidence-based input are needed to better gauge the repercussions of instituting the reform (or removing it completely) on residents of different fields, their colleagues – including nurses, PAs, and others – and patients.
Medical professionals, especially osteopathic physicians, are trained to look at patients holistically. But are clinicians truly assessing an individual’s needs and their goals?
We should challenge the textbook notion that autistic patients require supervision. An apartment complex in Pittsburgh, PA is set to open doors to those diagnosed with autism spectrum disorder (ASD). The project emerged from a shared vision of facilitating independent life for people with autism through affordability and special architectural design. Sweetwater Spectrum, a development of shared homes in California, had a similar idea and was built with acute attention to accommodation, which includes on-site support staff:
It has a community center, farm, greenhouse and pool. The homes have noise-dampening ceilings and quiet heating and air conditioning systems for residents who are hypersensitive to loud sounds.
These apartments parallel the backdrop of a rise in autism rates. According to the CDC, we are at a historic high for the number of people diagnosed with ASD.
Here’s the part that gets – unfortunately – tangled up in a mess called politics. Medicaid is currently the main payer for ASD management, but the Trump administration plans on transitioning Medicaid to a block-based grant system, and then to halt Medicaid expansion altogether. This means that despite the prevalence of autism, we may see a decline in funding for its treatment/management.
Should Medicaid’s possible fadeout worry you, the future health practitioner, and your ASD patients or others who rely on Medicaid? To this, I would say, “Hey, I know of this FANTASTIC blogcast called Diagnostocracy, which will cover the turbulence and impact of the public insurance system in the future, so stay tuned…because it’s a great site.”
Our focus should shift focus to being better at “medicine outside of medicine.” As a society, we have tunnel vision for the next breakthrough in technology or easy pharmaceutical quick-fix, but we should lend ourselves to simple yet effective out-of-the-box thinking (like building a heart pump with supplies from Home Depot). Prescribing personalized housing to facilitate an autistic patient’s well-being goes beyond the clinic room.
With that being said, let us continue to reassess our definition of patients’ needs and goals and what practicing medicine really means.
(Just wanted to give a quick thanks to Keifer W., Leigh G., and Roy L. for editing this post!)
We’ve all seen the commercials. “Prevagen, a dietary supplement shown to improve memory, contains a unique ingredient originally discovered in jellyfish.*” What we often miss is the clarifying asterisk, that “these statements have not been evaluated by the Food and Drug Administration (FDA)” and that “this product is not intended to diagnose, treat, cure or prevent any disease.” The truth is that the supplement industry is built on the premise that you can equate supplements wit FDA-approved drugs which have been subjected to the rigors of research, development and clinical testing (or at least that you won’t be able to distinguish between the two).
Like Prevagen, only some of these false claims are charged as fraudulent—and often years after many hopeful Americans have been conned into buying the product. An article in The Atlantic this week discusses the booming dietary-supplement industry and its unencumbered sprint to free-market success at the cost of both credible science and our wallets. Dr. James Hamblin explains the case that many supplemental companies make when selling their product:
A metabolite that no one could ever get from food, and in which nearly 100% of people are deficient, represents a big market. And while consumers are waiting for clinical trials to play out, people don’t need to wait to buy [it].
What’s scary is that supplements are treated more like foods than like drugs by the FDA. They can go straight to market without requiring evidence of efficacy. When provoked, the men in suits pushing supplements will admit that their product is not a drug, but will often continue to make the argument that it is better than food. Again, Dr. Hamblin:
I reacted by asking him about broccoli and salads, and why those aren’t medical foods. They make people with diabetes and heart disease less sick, when used regularly. Conversely, chronic abuse of Pop-Tarts and Pepsi contributes to lethal disease. Eating mostly whole plants will protect most hearts more effectively than the most widely prescribed cardio-protective pharmaceuticals, statins, and yet food is not medication.
So a product that is treated like food—while claiming to be better than food—lacks credibility to be a drug. What can be done?
The future of the dietary-supplement industry might lie in the hands of Dr. Scott Gottlieb, President Trump’s pick to lead the FDA. Gottlieb has received criticism for taking millions of dollars from nearly 20 biopharma and health firms while vowing to fight the opioid crisis. He stands for a libertarian, regulation-free approach and even accused the FDA of evading the law.
But how can a free-market approach to supplements succeed when consumers in the marketplace are unable to tell when a product is actually helpful? As a future physician, I am terrified by the idea that a low-budget commercial for a product with no clinical evidence for efficacy can bear the same weight as my own medical advice developed over years of grueling education.
I’d like to believe that the answer is adequate patient education and more deliberate communication. I learned a lot about the power of “fake news” recently; but unfortunately, convincing those around me that the facts still matter may be one of the toughest tasks in my own career down the road.
Image: Harvard Health
This week, Katie Falkenberg, a photographer for the LA Times, was named a Pulitzer finalist for Motherhood in the Time of Zika. Not only is her work stunning, but it captures the very honest, everyday tragedy of an incurable and unpreventable disease.
Zika infection is usually harmless in healthy adults and children. The risk of fetal developmental disorders like microcephaly strikes fear in pregnant women and devastates those affected, as described in Falkenberg’s Times profile:
As many as a third of mothers are unmarried in [Brazil], where the rate is highest in impoverished rural villages and crowded slums. Even mothers who have a partner have found themselves suddenly abandoned as their relationships crumble under the emotional strain, economic burden and social stigma that come with raising a child who may require almost constant attention. Many [of these babies] develop severe cognitive and physical disabilities that require expensive therapy and monitoring by specialists.
Meanwhile, Washington endured an embarrassing fight over a spending bill to provide relief in both domestic and international efforts to handle Zika. The Obama White House requested emergency funding when the World Health Organization declared the outbreak a Public Health Emergency of International Concern. Over the next 6 months, these funds were held hostage in a bill that also addressed things like defunding Planned Parenthood and allowing Confederate flags to be flown at cemeteries. That is, the Zika outbreak fell victim to the reality of 21st century U.S. politics: sometimes even tragedy and epidemic are insufficient pressure for political action.
Now, nearly half a year after the $1.1 billion bill was finally signed into law, the first live-attenuated vaccine candidate was found to show complete protection from Zika infection. Pei-Yong Shi, author of a study published in Nature:
A successful vaccine requires a fine balance between efficacy and safety. Vaccines made from attenuated live viruses generally offer fast and durable immunity, but sometimes with the trade-off of reduced safety.
Shi’s study shows what he believes is sufficient safety testing to warrant further development of the candidate vaccine. There are dozens of Zika vaccines in the pipeline, but most require several rounds of shots—a potential obstacle in countries like Brazil where access and delivery may be difficult.
Such live-attenuated vaccine has the advantage of single-dose immunization, rapid and strong immune response and potentially long-lived protection. Therefore, a safe live-attenuated vaccine will be ideal in prevention of Zika virus infection, especially in developing countries.
In the U.S., nearly every state has at least one expecting mother with the disease. Now that we’re on our way into spring, many high-risk areas like southern Texas are taking extra precautions to defend against the mosquito-borne disease. This week, the Texas Department of State Health Services recommended testing all pregnant residents in certain counties and all residents showing certain symptoms of Zika infection.
Twice in the past month, President Trump has called for crippling cuts to the budget of the NIH, the primary funding agency for health-related research in the U.S. Research in medicine is patchwork, and the message of its results is often muddied by conflicting studies. But adequately funding these projects helps us to answer questions that give context and hope to Falkenberg’s images.
Image: Katie Falkenberg