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.

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.