A “CODE BLUE” Moment – Crisis In A Broken Health Care System.

Posted on | March 12, 2020 | 2 Comments

Mike Magee

In the opening pages of “CODE BLUE: Inside the Medical Industrial Complex”, I wrote:

 “When Donald Trump expressed his cluelessness—’nobody knew that health care could be so complicated’—before a meeting of state governors in February 2017, he was exposing a pattern of both arrogance and ignorance that is now on full display.

Most Americans awaken today forced to acknowledge the absurdity of our convoluted system of third-party payers, and the pretzel positions our politicians weave in and out of as they try to justify it, reform it, then un-reform it. Congressional loyalists continue to find solace in telling themselves, “Well, we still have the best health care in the world.”

In point of fact, we’re not even close to having the best health care in the world. As legendary Princeton health economist Uwe Reinhardt prophetically remarked two years prior to COVID-19, “At international health care conferences, arguing that a certain proposed policy would drive some country’s system closer to the U.S. model usually is the kiss of death.”

It is at times of crises like these that system weaknesses expose themselves. The inability to swiftly and efficiently test a population for COVID-19, share those results, and rationally plan a swift, coordinated, and effective response is a reflection of the gross inadequacies of our health care system. So is a leaky and disjointed supply system that can’t manage demand for cue tips, let alone ventilators.

In a review of CODE BLUE last year, John Rother, President and CEO of the National Coalition on Health Care wrote, “Code Blue will make you mad, but it will also make you better informed and better able to understand what we need to do as a country to fix it. I can’t think of a more persuasive book on the need for change.”

The need for change that John forecasted not only included matters of justice, planning, and equitable distribution of health care resources, but also the capacity to respond to a global public health event of the magnitude of COVID-19.

How broken must a system be when our nation can’t keep up with nations like South Korea and Italy in testing for the virus? What does our “patchwork response”, variable across states and communities, lacking any private-public planning and coordination, and absent clarity on pricing, access, eligibility and prioritization, and raft with confusion even on what protections are necessary for health care workers collecting samples, tell us about our need for a fundamental restructuring of our health care system?

God Bless Anthony Fauci, but is our system so fragile that the fate of Americans rests on a single individual having the temerity to speak truth to power in the face of executive incompetence? And how are we to reconcile a Presidential veto on testing kits months ago. And the solution now? The President turns to his son-in-law’s family for advise on what to do next.

A half-century of systematic underfunding of public health, planning and prevention in deference to entrepreneurial scientists in pursuit of profit and patents over patients and families, ends here – in crisis. We will survive this “Code Blue” calamity, but we need to assure through new leadership and deliberate action that it will never happen again.

For now:

1. Self-isolate the family.
2. Test if you can.
3. Trust and believe in each other.
4. Ignore Trump and Pence. Trust your state leaders for now.
5. Vote with your head, not your heart (or your gut), in the next cycle.

For All Health Professionals Now: “Connect the ‘DOTS’, Dump the ‘Hunch’ “

Posted on | March 9, 2020 | Comments Off on For All Health Professionals Now: “Connect the ‘DOTS’, Dump the ‘Hunch’ “

Mike Magee

There isn’t a health professional (or financial professional for that matter) out there who didn’t shake her head last week when Dr. Trump expressed his “hunch” about Covid-19. Crises and panic breed in an environment of ignorance, loose lips, and misshaped priorities. “Hunches” make all responsible leaders shutter.

Britain’s Adam Kucharski’s new book, “The Rules of Contagion”, recounting the mathematics of 1918 Pandemic, makes clear the critical roles of scholarship and leadership during a health crisis.

Rather than “a hunch”, he explains “DOTS.” As Joe Biden would say, “Here’s the deal.” The critical question we face today, as circuit breakers shut down our markets, and “South by Southwest” (a festival critical to the Austin, Texas livelihoods of thousands since 1987) is cancelled, is: “How worried should we be about infection from Covid-19?”

As Kucharski explains, the answer to that question is packaged in a number – R, for reproductive rate. But to calculate R,  you must know four other numbers signified by the acronym, “DOTS.”

“D” is for “duration”, that is, how long someone is infectious. It appears that with this virus, the answer is one to two weeks.

“O” is for “opportunity”, that is, the number of people an infected person comes in contact with during the period that they are actively infectious. “Social distancing”, self-isolation, eliminating hand shaking are all limits placed on opportunity.

“T” is for “transmission probability”, that is, the chance that the virus will pass from one human to the next during an interaction. For Covid-19, transmission seems most common in close-knit communities, and large gathering situations.

“S” is for “susceptibility”, that is the likelihood that the virus will find a welcoming environment in the contact individual. If and when we develop a vaccine, susceptibility would go way down. So far, children appear least susceptible to this virus. In contrast, the old and frail in some cases appear to have fatality rates in the range of 10%.

“D” x “O” x “T” x “S”  =  “R”

If  we are to bring this pandemic under control, we have to decrease “R” or the reproductive rate to less than one. What the means is that you can’t pass the virus on to more than one person, otherwise the numbers, and population vulnerability continue to explode exponentially.

For all health professionals listening: “No hunches now, just the facts – clear, calm, and consistent!”

The Mask – When Not To Cover Up and Why.

Posted on | March 5, 2020 | 1 Comment

Mike Magee

If you want to know what American consumers are obsessing on these days, just check out Amazon searches. There you will discover that the tag “N95 mask” has had more than a million hits over the past month.

It seems we have transferred all of our fears, and hopes of protecting ourselves and loved ones from COVID 19, to some form of this iconic, to the point that health professionals in hospitals and outpatient settings are nervous about their own dwindling supplies.

Obvious missteps and trust gaps related to our President and his administration haven’t been helpful. Health professionals in and out of government, through various communication work-arounds, have tried to settle things down – sometimes clumsily. For example, Surgeon General Jerome Adams tweet “Seriously people- STOP BUYING MASKS!” felt a bit like it had come out of the Mick Mulvaney “GET OVER IT!” school of crisis communication.

That said, masks can be a bit confusing, and that comes from someone who spent more than a few years wearing one as part of his daily stints in operating rooms. So here are the quick facts:

1. Two types of masks: There are a) surgical masks that fit loosely and prevent transmission through large droplets emitted by sneezing or coughing; and b) respirator masks that fit tightly, requiring sizing and adjusting, and can prevent transmission of smaller microorganisms like the ones that cause measles and chickenpox.

2. Who should make priority use of a mask?  Two types of people: a) Health care workers who are in frequent contact with infected individuals; and b) patients with symptoms of respiratory infection, and suspect or proven COVID 19 patients.

3. If not masks, than what? The basics are now essential:

a) Frequent hand washing. Soap and water for 20 seconds is very effective, more so than hand sanitizers.

b) Stop touching your face – that’s harder than it sounds, but quite essential.

c) Keep surfaces at home and at work clean and sanitary.

d) Avoid  close contact with sick individuals – challenging during the flu season.

e) Isolate yourself if you are sick. Stay put – close to home and limit non-essential travel.

Last piece of advice for doctors, nurses and other health professionals who are charged not only with caring for all of us, but also help all Americans process their fear and worry during these worrisome times. Deliver equal measures of knowledge and reassurance.

Coronavirus – an Opportunity to Pursue Global Health, Societal Justice, and Progress.

Posted on | February 25, 2020 | Comments Off on Coronavirus – an Opportunity to Pursue Global Health, Societal Justice, and Progress.

Mike Magee

The emergence of the novel coronavirus, and its evolution into a pandemic threat, are sending shock waves across the globe. The discussions between government, academics, non-governmental organizations and industry reflect the common belief that no one sector can address such a complex challenge in isolation. 

The rapid advance of technology and human migration have accelerated globalization, regionalization and the rate of change in social institutions while virtually disintegrating geographic boundaries.  Success in forming stable and productive cross-sector relationships will largely determine the extent to which we are able to ensure global health, societal justice and progress.

Without new cooperative approaches, we find ourselves at cross-purposes and at risk. For paradoxically, expanding the flow of information and creating the expectation, and in time the reality of free and equal access to knowledge, has placed the spot light on glaring inequalities and human needs that are no longer politically tenable.   

Human health requires optimistic leaders with the expertise and willingness to commit, and a reservoir of good will among the players to support both innovation and implementation of the common vision, structural integration, joint governance and ongoing civic engagement.

Human health requires accurate information and baseline data that clearly define the challenges and serve as a foundation for future reasonable outcomes.  It is not enough to marshal human resources.  There must be an established organizational capacity, processes, and oversight to ensure that the human effort translates into a highly coordinate and effective service result.

Human health also demands long-term sustainability. A lack of clarity undermines operational execution, measurement, communications, and long term planning.  The prejudice should always be toward early organization and prevention, health consumerism and relationship based care, elimination of health disparities, and an integrated vision of health as the leading edge of development.

The obstacles to success in combating coronavirus are a microcosm of global health challenges writ large. These include absence of top level leadership, basic disagreements on the fundamental scientific underpinnings, absence of strong prevention programming, hidden political agendas, exclusion of key sectors, and failure to identify a key issue and address it proactively.

Government, business, academics and non-governmental organizations are increasingly overlapping in the areas of social purpose. Addressing coronavirus effectively is both a challenge and an opportunity.  The ability to significantly organize their varied and often complimentary skills and resources could significantly benefit societies worldwide.

Young, Liberal, Silicon Savvy – Why did they join Juul?

Posted on | February 7, 2020 | 4 Comments

Mike Magee

In late 2018, young tech-savvy future entrepreneurs streamed into the offices of e-cigarette start-up Juul. Four thousand strong, they were attracted by the $38 billion valuation and the promise of stock sharing in the high-flying techie new business with moral cover – a mission to make cigarette smoking obsolete. At their Christmas party in the San Francisco Giants baseball stadium, all agreed, morale couldn’t be higher.

Nine months later, their vaulted CEO, Kevin Burns, formerly of Chobani, stepped down. Valuation had sunk by over 2/3s to $12 billion, leaving those sign-up stock bonuses highly devalued, and 16% of the staff were fired as the new CEO pledged to cut $1 billion. What happened?

Reality bit! Juul was a 2017 spin off from cannabis vape manufacturer Pax Labs. CEO Burns engineered aggressive expansion into Europe and Asia, sold a 1/3 stake to tobacco giant Altria, and embraced teen friendly marketing tactics and flavored pods. The latter delivered in more ways than one.

Yes, 1 in 4 high schoolers are now hooked on nicotine (1 pod has as much nicotine as a pack of cigarettes, and a 4 pod pack costs $15.99). But in return for massive profits, Juul is now public enemy #1 in the eyes of concerned parents, school boards and progressive legislators.

Juul has now pulled its ads and their most popular flavors off the market. But that’s not the worst of it. Over 50% of employees are tied up in an all-hands-on-deck effort to deliver to the FDA a “pre-marketing tobacco application” (PMTA) due May 12th that will expose ingredients, components, manufacturing processes, and health and environmental impacts of their product. As one anonymous employee posted, “We’re going to get the PMTA or die trying! Lol…do we have a plan b? No.”

The executive team has a Plan B – Hire former FDA Officials. That includes former lead toxicologist at the agency’s Center for Tobacco Products, Roxana Weil, and FDA tobacco inspector, Gabriel Muniz, who signed up recently as director of regulatory compliance.

It isn’t as if we weren’t warned. Back in 2018, Jonathan Winickoff, former chair of the American Academy of Pediatrics Tobacco Consortium, said: “Juul is already a massive public health disaster.” But others saw addicted adults, not kids as the real problem. David Abrams, former director of the Office of Behavioral and Social Sciences Research at the NIH, commented blithely “It changes your heart rate a little bit. The AAP is doing its job. And we should be protective of kids. But there are adult lives at stake, too.”

A recent executive order has put a temporary federal ban on flavored vaping products. But health advocates note that the pronouncement is filled with intentional loopholes. The West Coast workforce is predominantly Silicon savvy, young, liberal, and have one foot out the door. As one employee put it, “To be sort of beholden to Trump and Republicans for the existence of our industry is disheartening.”  

Coronavirus: Best Seat On My Flight?

Posted on | February 5, 2020 | 4 Comments

Mike Magee

Flights of US air carriers Delta, American and United to China have been cancelled until further notice, and travelers who have been in China within the past 2 weeks have had their entry into the US curtailed. But for the rest of us who are going to fly, what’s the the best spot to seat yourself?

Let’s put this specific virus aside for a moment, and share a few facts:

There are now more than 3 billion airline passengers a year worldwide, and spread of communicable diseases has been well-scrutinized including specific studies of SARS and H1N1 Influenza. Those studies revealed that coach-cabin passengers were at a 3.6% to 7.7% increased risk of contracting the virus if they sat within two seats of someone actively infected. Sitting in the first class lowers the risk, but only slightly.

Since these viruses are transmitted through the air primarily in droplets, or through touching contaminated surfaces, confined locations – whether crowded restaurants, subways, theaters, grocery store lines – all represent an increased risk. But one thing to note: Viruses prefer low humidity, and when you fly at 30,000 feet, you’re in a low humidity environment.

Most air travelers perceive the risk to be greter than it actually is because of misperceptions regarding air circulation. Modern planes utilize High-Efficiency Particulate Air (HEPA) filters, and compartmentalize their air return delivery system. That means that air collected in your immediate vicinity, after collection and filtration, is distributed back to your section. Translation, you are not continuously exposed to the germs of all the passengers. And your regional air is filtered 30 times per hour, removing 99+% of bacteria infections-treatment.com, fungi, larger viruses, and virus clumps.

So if you do decide to fly, what preventive steps make sense?

1.General: Clean hands, cover mouth when you cough or sneeze, avoid close contact with large groups. (Note: one study found that part of the risk of flying was in the queuing for boarding and disembarking; and after the doors have been secured but the ventilation system has not yet been turned on.) Facial masks are not currently recommended.

2. Limit movement: As much as possible, limiting movement limits exposures. Studies show that window seats are safer than aisle seats primarily because only 40% of window sitters get up from their seat during flight while 80% of aisle sitters are up and about. On the average flight of 3 to 4 hour flight, ½ of passengers never use the lavatory, and 40% use it once.

3. Your seat: Keep your hands clean and hydrate. Avoid seat back pockets that have stored tissues and who knows what else. If you are going to use your tray table, clean it with a disinfectant. Open your air vent fully and direct the flow to hit in front of your face. This creates air stream away from you.

4. Travel advisories: Check WHO and CDC sites for travel updates

5. Novel Coronavirus cases are fast approaching 25,000 with approximately 500 deaths or a case fatality rate of approximately 2%. Compare that with the 2003 figures for 8422 cases of  SARS and a case fatality rate of around 10%, and you can see why we’re not yet in a full blown panic.

6. Diagnosis and Treatment: Below is the best advice on surveillance and diagnosis from JAMA today adapted from the CDC. As for treatment, their is no vaccine as yet, and the effectiveness of anti-virals is as yet unknown but is being actively studied.

When The Wool Is Pulled Over Your Eyes (Again) … IT’s Not Exactly “Breaking News”!

Posted on | February 3, 2020 | Comments Off on When The Wool Is Pulled Over Your Eyes (Again) … IT’s Not Exactly “Breaking News”!

Mike Magee

In this age of hucksterism and “fake news”, we Americans need to accept the fact that we’re too easy a mark, too naïve, too corruptible. And don’t blame our elected leaders – they’re simply a reflection of us.

Just take a look at our health care system, overrun with profiteering, one of only two nations in the world that allows direct-to-consumer advertising, a world where a man like Arthur Sackler could be honored in the Medical Advertising Hall of Fame and have his name brandished on the top medical education conglomerates across the nation.

The fix we’re in is self-made and chronic. Consider the fact that tobacco companies (and that includes modern-day vapers like Juul) have been well acquainted with the profession for many decades. Through the 1930’s and 1940’s, when money was tightest because of the Depression, cigarette manufacturers were a major source of revenue to the two top medical journals in the country – the Journal of the American Medical Association (JAMA) and the New England Journal of Medicine published by the Massachusetts Medical Society. Not only were they a major source of advertising revenue to these organizations, but they also were grand sponsors of the organizations’ medical meetings.

Cigarette companies have always been inventive and integrative public affairs marketers. And that was clearly evident at the time. Take for example how they played to the doctor’s ego in an ad in 1939 with the tag lines “Every doctor is a doubter”. The argument, straight from the finest minds of the finest PR agencies in New York City said, “If you advise patients on smoking – and what doctor does not – you will find important data in the studies listed below. May we send you a set of reprints?”

RJ Reynolds upped the “Public Affairs” ante on Philip Morris in 1942 by creating the Medical Relations Division (MRD). Not to worry that the MRD was directed by A. Grant Clarke who had no medical or scientific background whatsoever, but rather was in advertising; nor that all mailings were being processed, in and out, by the William Esty Advertising company.

Phillip Morris was an expected presence at the AMA’s 1942 Annual Convention in Atlantic City. Their convention floor exhibit drew quite a crowd, thanks in part to their ad in JAMA which solicited doctors to visit their on-floor, smoking lounge where they could “Drop in, Rest…read…smoke…or just chat.”

During those years, Philip Morris took a more direct approach. They placed themselves in the AMA and its members shoes, fighting for respect and autonomy, fearful of President Truman sponsored “socialized medicine”, and short on cash. Without even being asked, they ran a full blown public relations campaign on behalf of American doctors.

A wartime doctor ad in 1944 read: “He wears the same uniform. . . . He shares the same risks as the man with the gun. . . . Yes, the medical man in the service today is a fighting man through and through, except he fights without a gun. . . . [H]e’s a trusted friend to every fighting man. . . .[H]e well knows the comfort and cheer there is in a few moments’ relaxation with a good cigarette . . . like Camel . . . the favorite cigarette with men in all the services.”

Was the doctor being commended or exploited? One ad so effectively mines nostalgia, it could bring tears to the eyes of any doctor (including me) who has had to drag his tired ass out of bed in the middle of the night. It shows a pajama clothed, middle aged male, phone in hand, black bag an arm’s length away, ready for service, and the explanation: “24 hours a day your doctor is ‘on duty.’…When there’s a job to do, he does it. A few winks of sleep. . . a few puffs of a cigarette. . and he’s back at the job again.”

Health professionals, like elected federal officials last week, were targeted not for their individual buying powerful, but rather for their influence on larger group purchasing – whether that be tobacco or vaping capsules, or votes.

And its not that we Americans today are more ignorant than other peoples around the world, but we do seem to be remarkably slow at realizing we’re being played for suckers. “Not Willing To Hear Evidence” may have been last week’s dominant headline, but it wasn’t exactly “Breaking News.”  Burying our heads in the sand can have a cumulative effect. With Democracy, let alone health care, in the balance, it’s time to finally shake off our complacency, pay attention, seek the truth, and be responsible citizens of this great nation.

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