Sunday, August 27, 2017

No Man is an Island

As another hurricane has hit Texas causing flooding and loss of life, I think it is important to look at how we, as a society, treat the less fortunate.  Texas declined the medicaid expansion of the Affordable Care Act, and so its citizens are chronically at risk. This morning I read a review by Danielle Ofri, MD, of the book, "No Apparent Distress," by Rachel Pearson, MD (https://www.nytimes.com/2017/08/25/books/review/rachel-pearson-no-apparent-distress.html?_r=1).  In it, Dr. Pearson's stories about those who fall through the cracks are described.

I have spent most of my career working in "safety net" hospitals. Yet, even here, there are requirements for copayment. In the case of scheduled surgeries, copayment may be required in advance. Sometimes, this may be more than $2000. Clearly, a fee this high might cause a patient to question if they should wait. And many do. Sometimes, the disease will progress, and be more costly to treat. But, this usually affects primarily the patient and their family. And, often the taxpayer.

Medical diseases like diabetes and hypertension can also be far more costly if treatment is delayed. A common medication for hypertension costs less than $10 per month, yet a hypertensive brain hemorrhage may require a week in ICU at over $2000/day, followed by weeks of rehabilitation, and perhaps never returning to the pre-hemorrhage level of functioning. And, at the time of the hemorrhage, care is mandated by EMTALA (the Emergency Medical Treatment and Active Labor Act). So, again, we must all bear the increased costs of delaying care. While this is an unfunded mandate, doctors and hospitals must either recoup the costs or decide to go out of business, so they don't need to provide the care. But, closing Emergency Rooms affects anyone who needs one. So, this may affect all of us.

Infectious diseases pose even more of a threat to all of society. When I was a medical student, many of the homeless had been exposed to a non-toxin producing variant of diphtheria. Thus, if the typical toxin producing variant developed in the area, they and those who had received the DPT vaccine (https://en.wikipedia.org/wiki/DPT_vaccine) would be best protected. Since a booster is recommended every 10 years, many healthy adults would be unprotected simply because they didn't keep up with revaccination. But, this is just theoretical.

About 20 year ago, I took care of a toddler who had tuberculous meningitis. He was neurologically devastated by it. His infection was traced to a daycare provider with a chronic cough. This worker couldn't afford to take time off to spend at least half a day at a public clinic to have the cough checked out, so continued to work with children, who are the most likely to be devastated by tuberculosis. And, yet, how many of us pay for childcare? And, do we always check on the workers? Since these workers often are low paid, many are immigrants. 

Cysticercosis is another disease that may spread from the less fortunate. It is a pork tapeworm often encountered in third world countries. But, humans can have both gut and tissue, such as brain or eye, involvement. The gut involvement is caused by eating infected meat. The tissue involvement is caused by eating infected feces. Yet, pay for both agricultural workers and food service workers is low, so many are immigrants. In the field, workers may have no toilet facilities or bathroom breaks. Food service workers may also not have optimal hygiene. Health education is scant for such occupations with low pay and frequent turnover. Testing and treatment is rare. So, such workers may not only have tissue involvement, but, also gut involvement. So, all of us are at risk. In 1992, several Orthodox Jews were reported to have cysticercosis (http://www.nejm.org/doi/full/10.1056/NEJM199209033271004#t=article). 

We do not exist as islands. We interact with other people. We may eat meals prepared by others. Our children may be cared for by others. The most affluent may be able to have their domestic help tested and treated for various infectious diseases. Less affluent people likely can't insist on this. But, most of us, at least occasionally, eat food grown and prepared by others. So, if the least fortunate can't afford care, the more fortunate may also suffer. It is not only ethical for a society to help the less fortunate; it is also beneficial for the more fortunate.

Thursday, August 10, 2017

Fire and fury

This week marked 72 years since the first uses of nuclear weapons at the end of WWII. Yet, once again, it seems that their use may be being considered again. I recently saw a video (<iframe src="https://www.facebook.com/plugins/video.php?href=https%3A%2F%2Fwww.facebook.com%2Fnamelesstv%2Fvideos%2F1759173391042313%2F&show_text=0&width=476" width="476" height="476" style="border:none;overflow:hidden" scrolling="no" frameborder="0" allowTransparency="true" allowFullScreen="true"></iframe>). The Department of Homeland Security posts the same advice in text format (https://www.ready.gov/nuclear-blast). These both suggest there is a reasonable hope to survive.

Recently, rhetoric has intensified between North Korea and the US (http://www.cnn.com/2017/08/10/politics/trump-north-korea/index.html, https://www.cnbc.com/2017/08/10/us-only-option-on-n-korea-nuclear-threat-wesley-clark-commentary.html).

North Korea has tested small nuclear weapons already and has threatened to strike Guam (https://www.washingtonpost.com/world/national-security/north-korea-now-making-missile-ready-nuclear-weapons-us-analysts-say/2017/08/08/e14b882a-7b6b-11e7-9d08-b79f191668ed_story.html?utm_term=.fb122dcb1f37), and may soon be able to reach the western US mainland, and maybe further into the US. Certainly, even if they have 60 nuclear weapons soon, a number which is miniscule compared to the US or Russia, who each have over 100 times more, and more sophisticated weapons, this could result in millions dead, initially on the Korean peninsula, and with the possibility of extending further, even while still remaining local, to other nuclear powers.

The information on surviving a nuclear blast suggests listening to radio and TV to hear public service announcements on where to go. Yet, it is likely that TV and radio would be functioning, at least initially, due to the electromagnetic pulse which accompanies a nuclear blast (http://www.businessinsider.com/nukes-electromagnetic-pulse-electronics-2017-5). This would also affect the systems used by emergency services to direct any rescue efforts and the rescue vehicles themselves, as they, like most other modern vehicles are heavily dependent on their onboard computers. So most of the survivors would be left to care for themselves. Similarly, even if one could walk to a hospital, the hospital would be similarly affected. And, they would likely be overwhelmed by the numbers of casualties. And, then, fallout would continue as radiation falls on neighboring areas, determined by winds. During a war, there may be multiple blasts, each with the same consequences. How fast the emergency services could be brought back to service is a question.

Survivors may have neurologic dysfunction, nausea, vomiting and diarrhea which may lead to dehydration and nutritional problems, bleeding, damage to the immune system which may lead to life-threatening infections. Those who survive the early period are at risk for various cancers, especially leukemia and thyroid. Other cancers including breast, esophagus, colon and lung are also increased. Survivors of Hiroshima and Nagasaki still are suffering and dying from radiation related illness (https://www.icrc.org/eng/assets/files/2013/4132-1-nuclear-weapons-human-health-2013.pdf).

The dust thrown up into the atmosphere would have yet another effect--a nuclear winter. A regional nuclear war could still devastate the environment and lead to worldwide suffering (https://www.sciencedaily.com/releases/2006/12/061211090729.htm, http://climate.envsci.rutgers.edu/pdf/acp-7-1973-2007.pdf). This research was based on simulations involving only 50 Hiroshima sized weapons (compared to North Korea's estimated 30-60 weapons, each on the order of twice the size of the weapon used at Hiroshima). This is estimated to be worse than the cooling produced by the eruption of Tambora in Indonesia in 1815, which caused the year without a summer in 1816 when people starved in Europe, China and even the United States.

The mass starvation would cause social disruption, as it did in 1815-1816, from the drought and severe el Nino which caused the Chumash Indians to abandon their settlements on islands off the coast of California (http://californiamissionsfoundation.org/articles/agriculturedroughtandchumashcongregation/), to riots in Europe and Asia, to unseating 70% of representatives in the 1816 election in the United States, to migrations from village to city with a subsequent pandemic beginning in Bengal (http://boris.unibe.ch/81880/7/tambora_e_web.pdf). Later, there was migration from Europe to the Americas and Russia, and westward in North America (http://boris.unibe.ch/81880/7/tambora_e_web.pdf). Some of my ancestors left Germany during this time period. They left because they hoped for a better life.

The nuclear winter after even a small nuclear war would likely lead to similar or larger scale societal disruptions, as people flee both war and famine. So, survivors of a nuclear war would have all these problems to contend with, and might die of the sequelae of the conflict. It is likely that their lives would be very different than they had before.

I remember that, during the Cold War, when we had "duck and cover" drills at school, my parents told me to pray to die in the flash, to be vaporized leaving only a shadow on the sidewalk. They said it would be far better than surviving. In a nuclear war, there are no winners. Everyone is a loser.




Thursday, November 10, 2016

Kristallnacht

Seventy eight years ago, the evening of November 9 was the beginning of the large scale arrest and imprisonment of Jews in Germany and Austria. Called Kristallnacht because of the large amount of broken glass from the windows of Jewish owned businesses. It was justified as a reaction to the murder of a German official, in Paris, by a 17 year old Polish Jew, distraught over the deportation of his family from Germany. Nazi officials claimed that the Jews were to blame for the riots, so 30,000 Jewish men were arrested, and the Jewish community fined for the damages. (https://www.ushmm.org/research/research-in-collections/search-the-collections/bibliography/kristallnacht) 

This was 5 years after the first concentration camps were founded, in 1933. Initially, many of the prisoners were political opponents of the Nazi regime, as Hitler sought to consolidate his power. (https://www.ushmm.org/wlc/en/article.php?ModuleId=10005263)  


The disabled were seen as having "lives not worth living," a burden to the state, and so were killed. Families were not told the truth about how their family member had died. Many of these patients, as well as prisoners, were dissected by German anatomists and pathologists. (http://www.slate.com/articles/life/history/2013/11/nazi_anatomy_history_the_origins_of_conservatives_anti_abortion_claims_that.html)


Homosexuals were seen as deviants and so were imprisoned in concentration camps, starting in 1933. They were treated poorly by guards and other prisoners, and so had a 60% death rate. (https://en.wikipedia.org/wiki/Persecution_of_homosexuals_in_Nazi_Germany_and_the_Holocaust)

Later, during the war, other groups--Poles, Roma, Soviet prisoners of war--became victims of the Nazi regime.

Lutheran Pastor Martin Niemoller, who was imprisoned in 1937, wrote,
"First they came for the Socialists, and I did not speak out—Because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out—Because I was not a Trade Unionist.
Then they came for the Jews, and I did not speak out—Because I was not a Jew.
Then they came for me—and there was no one left to speak for me."
(https://en.wikipedia.org/wiki/First_they_came_...)

On this anniversary of Kristallnacht, we must again affirm, "Never Again." Never again should any people be persecuted or killed because of their religion, or race, or ethnicity, or sexual orientation. Because as Niemoller says, we have the duty to stand up for each other. 


Monday, August 29, 2016

Information Age

We live in the age of an information economy. Trading in information is now seen as a way to make a living. Information clearly has economic benefit in the corporate world, so one can get a "jump" on the competition. In a similar way, governments have long been involved in seeking to know what an adversary is doing, or planning. Over recent years, there have been a spate of movies about the codebreaking efforts of WWII. 

Initially, the German Enigma code was broken by Polish mathematicians, Marian RejewskiJerzy Różycki and Henryk Zygalski, working for Polish military intelligence. Just ahead of the invasion of Poland, bomba (mechanical codebreaking machine) were provided to the French and the British. This was the basis of the work during the war at Bletchley Park. Unfortunately, although the Poles had been first to break the code, they were deemed to be to high a security risk to work at Bletchley Park. 

Later, the same concept was applied and the British then built bombes for use at Bletchley Park. They were different in design than the Polish bomba, but, used the mathematical concepts developed by the Poles. The Polish contribution has been more recently acknowledged, as demonstrated by the plaque below.


CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=460477

Discovering the secrets of others, through codebreaking or other means, has long been a major function of intelligence services.  Another approach has been the planting of false information. This has been used, not only to influence governments, but also to influence electorates.

In the 1980s, there was a Soviet disinformation campaign aimed at blaming the US government for developing the HIV/AIDS virus, and suggesting that it was to be a genocide of Black people (https://en.wikipedia.org/wiki/Operation_INFEKTION).  It had some effect, leading many to question what the origin of the virus was and led to further distrust of the American health care system.

More recently, there have been efforts at influencing public opinion regarding international events, such as the shooting down of a Malaysian jetliner over Ukraine. There have also been efforts at influencing election outcomes, presumably to get a result more favorable to the country which is interfering, whether in a referendum, such as Brexit, or election of political figures. (http://www.nytimes.com/2016/08/29/world/europe/russia-sweden-disinformation.html) This involves not only releasing factual information, but, making lies appear to be the truth. 

As someone who feels it is my duty to be an informed voter, it is increasingly difficult. There is no easy way to distinguish what is true and what is not. And, for many voters, there seems to be a trust in beliefs rather than facts. But, is this really unreasonable, when one can't trust "facts." So, it just seems easier to "trust" someone who seems "trustworthy" rather than attempt the seemingly Herculean task or sorting out what is true and what is not. To me, it seems most reasonable just to ask, "Who benefits?" and, "Do they have friends who would be able to construct a plausible reality?" To me, this is the greater concern, as authoritarian government is frightening to me, whether from the left or the right.



Tuesday, August 9, 2016

All Politics is Personal

August 9 is the anniversary of two important events. The first was the second use of nuclear weapons. Nagasaki. Coming three days after the first use.

My family was involved in the Manhattan Project. Many scientists and engineers were. But, after use of the bomb, many were plagued with a sense of responsibility. I discussed this more in my posts about President Obama's visit to Hiroshima. 

The second anniversary is that of the resignation of a President. Watergate. Adding "gate" to various other words has since come to suggest scandal. But, let's look back. The first election I voted in was 1972. The year of Watergate.

The Watergate scandal began when the DNC headquarters was broken into on June 17, 1972 (https://en.wikipedia.org/wiki/Watergate_scandal). It was in an office complex named Watergate, hence the name of the scandal. Investigation of the perpetrators lead to the Committee for the Reelection of the President, the aptly named CREEP. The ensuing scandal led to the resignation of the President Richard Nixon late on August 8, 1974, as the Watergate investigation led to Nixon's close aides. Gerald Ford then became President.But, first, Nixon tried to block the investigation by asking that the Special Investigator be fired. The Attorney General and a Deputy Attorney General both resigned, rather than comply, in what was called the Saturday Night Massacre on October 20, 1973. The Solicitor General then fired the Special Investigator at Nixon's bidding. Yet, Nixon could not stop the investigation.

I did not know of the resignation until August 9.  At the time, I was studying in Poland. A popular joke there, at the time, was that of an American, a Frenchman, and a Russian drinking together. The Frenchman commented that the best evening of his life was the evening spent with Brigitte Bardot (a popular French actress of the time). The American then said that the best evening of his life was an evening spent with the President. At this, all the Americans started laughing. And the Poles told us we hadn't heard the punchline. They then told us that the Russian then said that the best evening of his life was when two men came to his door and asked, "Are you Ivan Ivanovich?" He told his friends that he had said, "No." And then, he said, they left. That was the punchline. And, this joke, like so many others, expressed the truth that the Poles knew.

Years later, I interviewed a young woman, who was growing up in Washington at the time of Watergate. It was very interesting to hear the story told from the perspective of someone who had witnessed some of the events as a child. And, how those events impacted her and influenced her politics and choice of career.

The differences in reaction to the joke exposes the difference between the Americans who were, at the time, embarrassed by the Nixon and the events that led to his resignation. The Poles, on the other hand, had experienced the nighttime visits, and the visitors who didn't leave, but rather escorted the occupant out. My grandfather's second wife was given 15 minutes to pack for her family. Only two of them survived their two years in Siberia. None ever returned to their home in the Kresy, but rather had to wander for a while before finally making a home in the United States.

Tip O'Neill said, "All politics is local." But, I would suggest that it is personal. Each of us begins with the attitudes shared by our families. They have been shaped by their experiences. And, then, our personal experiences modify our political beliefs further.







Monday, July 11, 2016

Black Lives Matter, Blue Lives Matter

With the recent news of the shootings in Louisiana, Minnesota and Texas, I think about gun violence. I need to disclose that I am a middle aged white female. Yet gun violence and the fear of it have been part of my life.

At 15, I visited Prague. I went with a student group. We spent most of our summer in Germany, yet crossed to the East twice, once in Berlin, and then a few days in Prague. A beautiful city with so much history. Yet with fresh evidence of the suppression of the Prague Spring. Some of the leaders were still loose. And, the hard line authorities wanted to capture and punish them all.

As we were leaving Czechoslovakia, I was pulled off the bus, then queued up again, to have the same happen two more times. Then the officer began to question me. In Czech. I knew no Slavic languages except the bits of Polish I heard when we visited my grandparents. I asked him to repeat his questions in one of the languages that I knew. Yet this questioning was done with three young men with guns pointed at me. I dared not flinch, for fear that one of the soldiers might shoot. Meanwhile, I prayed that if they arrested me, for what I didn't know, they wouldn't send me to Soviet Union. I had heard bits of my grandmother's experience there working in a Siberian labor camp for the crime of being Polish. I knew I was too soft. Finally, I was allowed to board the bus, and leave the country. Then, the driver, who had understood the exchange told me that I looked like one of the student leaders. I never heard what happened to my twin. I hope she is well.

While in residency, I came to know my neighbor, who was a police officer. At first he was on medical leave. He had killed a man. His partner had also been killed in the shootout and my friend and neighbor injured.

My next experiences came when I worked in an inner city hospital. Gangs were active. There, I cared for hundreds of victims of all ages, from infancy up. But, usually, they respected those who cared for them. A colleague had his shoes stolen at gunpoint, but wasn't injured, because, "Doc, we might need you someday." A few times we were threatened that if a certain patient died, we would, too. And, once, we had a SWAT team in the hospital. We had to walk past them and their bullet proof shields to care for our patients, and worried that we might be caught in the crossfire.

Another threat was after I had been speaking out about gun violence after I cared for a young boy who had been shot on the freeway. He was one of about 20 shooting victims my hospital received on a typical Friday or Saturday in the mid-90s due to gang activity. This child was deemed different. He was middle class, from the suburbs, just driving home from a Dodger game with his cousins. So the press was interested. I spoke out, testified on the costs of gun violence to committees of city and state government. Thus, my photo was in the paper. And, a copy of my photo was sent to me with a target drawn over my face. Scary, but I knew that my activities were having an effect.

During this time, I also learned from colleagues the issues of "driving while Black," "running while Black," etc. It was something that had not been part of my experience until then. Instead, I had been told, even by Black and Hispanic colleagues, not to drive through certain neighborhoods.

Later, I had an alarm that triggered a "home invasion" alarm. I was home alone, by then middle aged, working on my computer, when the police came, with guns drawn, wanted proof that I was who I was. They looked through my home, following me, but finally left after I got my ID, showing this house as my address.

I realize that people are violent. But, guns increase the lethality of that impulse to violence. I don't have a solution, given the millions of guns in the hands of the American populace. I have worked in an area where gang violence was rampant. I have seen far too many lives destroyed by violence. I have worked to save and rebuild some of those lives.

I can understand that police may be afraid, but, I have seen reasonable control by well trained officers when we had the terrorist shooting in San Bernardino, not adding to the toll at the Inland Regional Center. I can understand that the people are afraid, especially Black men, but am impressed by the overall peaceful nature of the recent protests. I hope and pray that we can come together to end the violence. So that I don't have to try to patch up any more shattered victims.

Sunday, June 19, 2016

Juneteenth

Today is Juneteenth, the commemoration of the day the slaves in Texas were freed (http://www.juneteenth.com/history.htm; https://en.wikipedia.org/wiki/Juneteenth). Even though the Emancipation Proclamation freed the slaves in the Union on January 1, 1863, slaves in the Confederacy continued to be enslaved. After the surrender at Appomattox Court House on April 9, 1865 (https://www.nps.gov/apco/index.htm), news spread slowly through the Confederacy. Union soldiers led by General Gordon Granger arrived in Galveston on June 19, 1865, and brought the news. There was shock and jubilation. Some slaves left their plantations to find family in other states, or even if they had no where to go. June 19, or Juneteenth has become a time of celebration in the African American community. It is also a time of prayer, and focusing on education and self-improvement. Unfortunately, it is little known among whites in the US, though some suggest it is a second Independence Day (http://www.huffingtonpost.com/entry/juneteenth-photos_us_57640f77e4b0853f8bf08d36).

Unfortunately, June 19, 1865, did not end slavery. It continues to the present day. Walk Free estimates that 45.8 million people continue to be enslaved (https://www.walkfree.org/modern-slavery-facts/). Despite being illegal, slavery exists in nearly every country on earth. This year, attention has been directed to the slaves used in fishing, especially in international waters. One center of this is Thailand (http://www.theguardian.com/global-development/2016/feb/25/slavery-trafficking-thai-fishing-industry-environmental-justice-foundation).

Forced labor may also continue with governmental support, as is the case of cotton picking in Uzbekistan and Turkmenistan (http://www.antislavery.org/english/campaigns/cottoncrimes/forced_labour_in_uzbekistan_background.aspx). Brick making and garment making in India also often employ the use of slave labor (http://www.antislavery.org/english/slavery_today/what_is_modern_slavery.aspx).

Over half of slaves are women and children. Nearly 1 in 3 victims are children, often trafficked by someone they knew (https://www.walkfree.org/modern-slavery-facts/). Natural disasters, such as the earthquake in Nepal, lead to the trafficking of more children. Closer to home, only last year did Los Angeles County stop arresting children for prostitution, and begin treating them like victims (http://www.latimes.com/local/lanow/la-me-ln-sheriff-children-sex-trafficking-20151021-story.html).

So, on this Juneteeth, let us not only remember the past, as all Americans should, but work toward the elimination of slavery throughout the world today.