Tag Archives: prevention

Heads in the Sand: Obama, the CDC and Claims of Ebola Preparedness

Thousands of people have travelled from West Africa to the US in the last 6 months.  While the CDC and others throughout the Obama administration continue to reassure everyone that the US is 100 percent prepared for an outbreak,  potential cases and exposures continue to surface all across the country.  In Dallas, the first confirmed case of Ebola remains in critical condition.  Even more concerning is the fact that the patient initially presented to the Emergency Room with a fever at Texas Health Presbyterian Hospital (and even though he provided a high risk travel and exposure history) we was sent HOME.  Initially, the hospital blamed the fact that he was sent home with high risk features (his records documented the fact that he had just travelled from Liberia) was that there was a “technical glitch” in the electronic medical record and that physicians were unable to access the data obtained by the triage nurse.  Days later, the hospital rescinded their comments and admitted that the data was there for anyone involved in the case to see but in fact, no one even noted his West Africa travel history and released him from the ER.  These missteps resulted in the potential exposure of nearly 100 contacts AND the isolation of several family members.  But today, the director of the CDC, Dr. Tom Frieden, continues to proclaim on the national media that the US is well prepared and that all local healthcare agencies have policies and procedures in place to avoid major outbreaks and exposures.

Really?  Its Time for the CDC and our administration to get its collective head out of the sand!  

According to the WHO, the number of Ebola cases is expected to continue to rise sharply in the month of October.  The CDC estimates that there may be as many as 1.4million cases before the current outbreak is over.  Others worry that the disease is now so far out of control in West Africa that it will soon become endemic.  Currently, most families in West African countries actually spend nearly 80% of their monthly income on food–now prices are increasing and food is becoming even more scarce.  As West African nations become increasingly economically challenged by the outbreak, it is likely that many will flee the country illegally (and untracked and unscreened)–resulting in further spread of disease and wider contact with individuals from other nations.  The first US case admitted to lying on his immigration forms before fleeing Liberia and would have been considered high risk due to close contact with family members with documented Ebola.  At this point, the CDC and its leadership continue to proclaim that they are “looking at possible actions” to help prevent the entry of Ebola into the US.  However, there are no specific plans in place and no real travel protocols have been established.  US air carriers admit to confusion about what to do and how best to screen passengers.  One particular airline has told its employees to treat all bodily fluids on flights as potentially infectious.

Now certainly, we should not panic.  I agree that the US is better equipped to handle an outbreak of an infectious disease than any other country in the world.  We have state of the art isolation facilities, an abundance of medical resources and the wisdom of many of the worlds’ brightest physicians.   Our advantages in treating any potential Ebola cases in the US are huge—However, we must put policies and procedures in place NOW–not after more cases appear stateside.

What steps can we take to prevent Ebola spreading in the US?  First, we need to make sure the virus does not arrive here–and when it does we must have a plan in place to isolate and contain any potential carriers

 

  1. Initial standardized screening of people travelling from endemic countries must be set into place now.  We must consider travel bans and Pre Flight 21 day quarantines prior to travel to the US in order to ensure that no patients with disease are inadvertently admitted to the US.
  2. Airline personnel must have standard protocols in place should a passenger become sick–isolation equipment and protective gear must be readily available and crews should be provided with specific training designed at protecting themselves as well as other passengers.
  3. Improved education for healthcare providers, emergency department personnel and first responders.  We must put protocols for response in place that are easily implemented when confronted with a suspected case.  Travel history and exposure history must become the first line of defense–we cannot afford to send a high risk patient home again.
  4. Immigration and Passport control should also screen all high risk travelers (from endemic countries) upon entering the US as well.  Those that are considered to pose a risk must be quarantined upon arrival for 21 days.
  5. Private industry resources must be focused on the mass production of vaccines such as ZMAPP and other potentially life saving drugs. While government should play a role in development and deployment, the private sector should be leading the charge in order to avoid the inevitable slow downs associated with government led initiatives.  These drugs should be fast tracked and studied while being put to use in West Africa.  While the science behind their effectiveness is solid thus far, there have not been nearly enough clinical trials and standard safety and efficacy trials put in place.   However, these drugs must be tested in practice in areas of outbreak.  We do not have time to await months to years of clinical trials in healthy subjects.

So, where is our government in all of this?

At present, both the Obama administration and the CDC continue to downplay the threat of Ebola in the US.  I fear that while government rhetoric continues to highlight the absolute preparedness of the US in the case of an outbreak, the reality of Ebola cases in the US (the one documented case thus far was sent home from the Emergency Room with a fever) are quite concerning.  I wonder if we could quickly coordinate an effective response should more cases arise?  The situation in Dallas–while contained now, had the potential to spread to more than 100 people during the initial presentation of the patient.  Today, the President will meet with the director of the CDC.  It is my hope that we will soon put policies in place to protect Americans from the spread of the disease.

We must Act rather than discuss.  We must Prevent rather than respond.

Unknown

 

Changing the Mindset in Medicine To Improve Outcomes: Prevention Rather Than Reaction

Much of my medical training in residency and fellowship was all about learning to react to particular clinical situations.  Long nights of call with exposure to a high volume of patients allowed me to quickly recognize common signs and symptoms, develop a working differential diagnosis and initiate testing and therapy right away.  This rapid fire exposure to disease was incredibly important in my development as a physician.  Moreover, the ability to react to clinical findings is essential in providing quality medical care as well as producing positive outcomes.

However, very little of my training focused on prevention.  Even today, residents and other physicians in training spend far more time treating disease rather than figuring out how to derail the disease process (even before it begins).  Certainly, we all learned about proper timing of routine screening tests for colon cancer, breast cancer, prostate cancer, etc.  In contrast, we did not spend much time learning effective ways in which we could counsel patients about lifestyle modification and risk reduction.  We did not talk much about how to educate patients about potential diseases that they may be at risk for and the potential negative impacts these diseases might have on an individual patient’s overall health status and quality of life.

Today in the Wall Street Journal, an article detailing a new report of an overall reduction in preventable cardiovascular death in the US today was published.  On first blush, this sounds like a very positive report–fewer Americans are dying of heart disease.  However, on closer examination, the data becomes quite disturbing–the largest reduction in preventable death was in the older population (greater than 75).  In the younger population (age less than 65) the decline was much less impressive.  Subgroup analysis revealed significant racial and geographic disparities as well–African Americans had a two fold higher rate in preventable cardiovascular death.  Residents of the southern states were also found to have much higher rates of preventable death.

Why is this?  What can we do to impact the large number of preventable cardiovascular deaths?

Based on this data, it seems to me that we are now seeing a large number of younger patients who are at risk for cardiovascular disease that are not being aggressively screened, evaluated and treated.  Many of these younger patients are not seeking medical attention until they experience their first (and often fatal) cardiac event.  According to the CDC nearly a quarter million of the 800K annual cardiovascular related deaths are preventable.  Long standing cardiovascular disease and its myriad of complications are expensive…in terms of dollars and in terms of human life.

The solution is all about prevention.  As cardiologists we must be more vigilant and screen young at risk populations more aggressively.  We must treat hypertension, hyperlipidemia and diabetes in younger patients.  We must spend more time counseling patients about lifestyle modification–not just smoking cessation.  Other healthcare providers in both primary care and in other specialties must also redouble their efforts on prevention.  We must all work together and refer patients who are at risk to the proper provider.  In addition, we must pay extra attention to higher risk groups such as minorities and we must focus efforts in geographies such as the south with higher than average preventable death rates.

Most importantly, we must all work to change the mindset in medicine.  Clinical competence and the ability to think on our feet and react is certainly essential and should remain a cornerstone of training.  However, we must also look a little deeper.  Obviously, we all love to be cast as the hero in the medical drama and save a life with an emergency procedure–however, it is just as heroic to prevent the emergency in the first place.  We must strive to train physicians who not only are able to react to disease and its presentations but who are also adept at recognizing risk and counseling patients to prevent negative outcomes later in life.

Ben Franklin had it right way back in the 1700s.  Even though we didn’t listen to Ben then, we have a real opportunity to listen and act now!  Remember–”an ounce of prevention is worth a pound of cure!”  Now that’s a low cost way to reduce the costs of healthcare AND save lives in the US today.

220px-BenFranklinDuplessis

Improving Health Status in the US Today: An Ounce of Prevention Is Worth a Pound of Cure…

As Americans we spend more money on healthcare per capita than any other nation in the world.  We have the latest medical innovations and for decades have been able to provide cutting edge therapy without regard to cost.  However, as a profession, doctors are not doing nearly enough when it comes to prevention of disease.  Certainly, costs will be reduced if we are able to prevent chronic illness and associated complications.  By focusing on better health on the front end, we may be able to significantly impact cost on the back end.

An article this week in the New York Times highlights the issue with the American lifestyle and the widespread lack of individual responsibility when it comes to health and wellness.  In the article, author Sabrina Tavernise explores the change that immigrants experience in their health status after living in the US for an extended period of time.  Research has shown that the longer immigrants live in the US, the higher their rates of high blood pressure, heart disease and diabetes becomes.  Scientists have looked at these data and have postulated that much of the change in health status for immigrants is related to the adoption of common American habits such as smoking, drinking, high calorie/low nutrient diets and sedentary lifestyles.  In addition, areas where large populations of immigrants reside often contain large numbers of fast food restaurants–providing easy access to poor food choices.

I believe much can be learned about preventative health from lifestyle research.  Most importantly, studies such as the ones discussed in the New York Times emphasize the significant impact lifestyle choices can have on the overall health of a populations.  As a nation, we must work diligently to reinvent our healthcare system and contain costs.  It is readily apparent that physicians must spend more time providing preventative counselling and promoting better health choices.  Here are my Top Five Points of emphasis for prevention:

1. Education:  It is imperative that we educate patients on risk factors for illness and how they may go about modifying risk.  Patients need to understand the consequences of poor health choices and how these choices may negatively impact them and their families

2. Assessment:  Physicians must spend time in the office with each patient and carefully assess their individual risk.  Diagnostic testing and screening for disease in high risk individuals is warranted. Once testing and assessment is completed, a frank discussion with patient and family is required in order to promote positive lifestyle changes.

3. Empowerment:  Healthcare providers must empower patients to take control of their own healthcare.  Patients must become active engaged participants in the journey to better health in order to impact outcome.  Patients must understand that they MUST take individual responsibility for poor lifestyle choices and work to effect individual change.

4. Encouragement:  Changing lifelong habits can be incredibly difficult.  Patients may resist change and deny risk.  However, physicians must help patients to set reasonable goals, cheer them along their journey and celebrate victories–no matter how big or small.  We must work hard to promote a positive attitude along the way.

5. Reassessment:  Certainly, once lifestyle changes have been made and goals met, it is important to reassess risk.  This may require follow up testing and may result in new goals and other potential therapeutic changes.  However, it is essential to communicate with the patient and continue to motivate them to make positive lifestyle choices.

It is clear that as a nation, we make poor lifestyle choices that may significantly contribute to the development of chronic diseases and increase healthcare costs.  Studies such as the one discussed in the New York Times demonstrate the powerful effects of culture and lifestyle on one’s health and susceptibility to disease.  When citizens from other countries or cultures move to the US, it appears that our lifestyle has a negative impact on their health.  Individual responsibility and patient engagement are critical to prevention of disease.  It is essential that we begin to focus more on prevention in order to gain control of healthcare costs and ensure that all Americans have access to care.

Unknown