Healthy-Waters.org: Quick Quiz

Posted on | May 13, 2016 | Comments Off on Healthy-Waters.org: Quick Quiz

Boreal Forest Vulnerability: Part of the Healthy-Waters.org Story

Posted on | May 11, 2016 | 3 Comments

From "Drops of Life".

  Mike Magee

In 2005, in a piece addressing the health of the “planetary patient”,  I wrote, “Water – it’s movement, forms, availability, and transportability – has directly shaped and continues to define the future of this planet and all of its inhabitants…As we have grown in numbers and in concentration; as we have built and infiltrated among, and at times, in opposition to other life forms, we have created future health challenges that must now be addressed.”

At the time, I saw water – its scarcity and unequal distribution and inaccessibility – as the most important planetary health issue of the day. I hit the road with a traveling show called “The Drops of Life”, a multimedia program prepared with the help of the Duarte Group which had produced Al Gore’s “An Inconvenient Truth”. What I discovered is that most health professionals considered the issue a low priority. Water was as inconvenient as global warming.

I began focusing on other issues, and “Healthy Waters” lay dormant. Then recently, I was in Syracuse, NY, to talk to 150 PA students of Dept. Chair Mary Springston and faculty at LeMoyne College. I spoke on leadership and change. In the address I touched on the case of three chemical engineering PhD students at Virginia Tech, who, with the support of their professor, uncovered and revealed the Flint, Michigan, poisoning of public waters with lead. Some months later, they published their story, citing the engineering code of ethics which pledges a commitment to societal responsibility, and to protecting individuals above all else.

After the address, over lunch, Dr. Beth Mitchell, the Department Chair of Biological Sciences, asked me what had become of the Healthy Waters movement (the site was down). I explained that I had tried, but there had been little traction. She gently suggested, in the wake of Flint, Michigan,  that I might try again.

As I was preparing to relaunch the new site, President Obama visited Flint, just as air filled with smoke and carbon-laden soot was beginning to approach the Midwest from fires in Fort McMurray, in northern Alberta. The juxtaposition nicely illustrates the urgent need for each of us to be better informed on our planetary health and critical issues like water. Let me explain.

By now, we all know that the lead in Flint’s water leached out of ancient pipes, made vulnerable by an engineering mistake. Less known is that 2000 other water systems in the US currently have dangerous lead levels. Cause and effect are clear. The will and resources to rebuild ancient infrastructure is less visible. It seems part of our populace would prefer to build a wall.

The situation in Alberta, Canada, is more convoluted, but inter-connected with planetary health and water as well. A few facts:

1. Alberta, Canada, is part of a heavily forested area in the Northern Hemisphere known as the Boreal (Northern) Forest, a belt of evergreens just below the Arctic Circle which includes Alaska, Canada, Scandinavia and Russia. The forest is made up of mostly resin producing, cone-bearing trees

2. For two decades, scientists have been predicting large scale fires and loss due to drying trees caused by increased temperatures, early snow melt, and secondary insect infestations. Temperature rises are greater in this Northern hemisphere belt than anywhere else on Earth.

3. The Boreal Forest represents 1/3 of all tree cover on Earth, and its capacity to absorb carbon is enormous.

4. In the last three years, both Russia and Alaska have had record breaking forest fires. The fires secondary impact, the deposition of heat absorbing soot onto the Greenland ice sheet, has accelerated the sheet’s disintegration. If we lose it, sea levels will rise 20 feet.

5. These are also heavy mining regions. As with Fort McMurray, mining leads to settlements, and their inhabitants carry an increase risk of accidental forest fires. These outposts generally do not have adequate forest fire fighting equipment or personnel, nor adequate exit plans. In Fort McMurray, 90,000 inhabitants had to be evacuated on a single highway.

Scientists see in the Boreal Forest multiple layers of vulnerability. Loss of the forests eliminates a critical carbon sink, while also acutely releasing large amounts of carbon into the atmosphere. The soot itself can magnify surface warming. The mining interests pollute surface and ground water reserves, while raising the risk of human caused fires, without adequate infrastructure to manage the calamity.

In 2005, in addition to the focus on integrated water cycles, I addressed the Water Crisis, Water and Health, Water and Agriculture, Water and Industry, Water and Energy, Water and Cities, and Natural Water Disasters. My timing was off. Healthy-Waters.org is again live, and “Drops of Life” has been updated. Whether we are ready or not, what recent events dramatically demonstrate, these issues are urgent and demand every citizen’s attention.

In 2016, Denial of Global Warming Persists.

Posted on | May 7, 2016 | Comments Off on In 2016, Denial of Global Warming Persists.

The science was clear in 2007. It hasn’t changed in the decade since. But deniers persist.

Iglehart and Thompson: Does the AMA Need “A Different Model of Advocacy”?

Posted on | May 3, 2016 | Comments Off on Iglehart and Thompson: Does the AMA Need “A Different Model of Advocacy”?

John Iglehart and Jeff Thompson MD

The AMA’s vigorous opposition this week to the FDA’s consideration of mandating training for opioid prescribers to curb the current opioid epidemic (which the AMA’s liberal policies toward specialty designation and pharmaceutical underwriting helped create), called to mind the words in 2009 of Gundersen-Lutheran neonatologist and CEO, Jeff Thompson in an interview with John Iglehart.  They said:

IGLEHART:  “One thing that has always struck me about physicians, and I suppose I’m particularly sensitive to it having written for a medical journal, the New England Journal of Medicine, for many years, is that physicians are generally leading citizens in the communities where they practice.  They are respected, they bring authority and credibility to their tasks as doctors. Yet when physicians have gathered in various collections, whether it’s the American Medical Association or countless other medical organizations, when they gather in Washington and try to harness their authority and respect, it just breaks down, and it mostly breaks down because the issues that they bring to Washington are largely economic and pertain to their incomes.  This has always struck me as odd and perhaps presents a challenge for organized medicine to figure out a different model of advocacy that would not only serve their own interests but those of the larger community and society. Do you also see a disconnect here?”

THOMPSON: “That’s a great observation, John. Here’s my answer back to you in a question. Why is it that 85 or 90 percent of pediatricians belong to the American Academy of Pediatrics, but probably less than 15 percent of practicing physicians belong to the American Medical Association?… I have always been a member of the American Academy of Pediatrics for the very reason that you state, because I knew where their priorities were. The AMA by contrast has been so embarrassing at so many times, it’s why at my age and behind me, the percentage of people that have engaged and paid dues has been tiny.  Time after time the AMA has screamed about their finances and so they have lost their credibility in Washington and with the public.”

Integrating Our Way Toward Universal Health Care in America

Posted on | April 29, 2016 | 1 Comment

Source: Consumerist

Mike Magee

Would you be willing to subject yourself to a 3.3% payroll tax (and your employer to a 6.7% payroll tax) to gain access to reliable simple universal health coverage – one that provided choice in and out of network, one that would cover all citizens, and one that has drawn the active opposition of health insurers? That’s the $38 billion dollar question facing Colorado voters in the near future.

Colorado supporters have arrived at this point through a rational process that began with advantaging Obamacare with the expansion of state Medicaid rolls, and navigating bronze, silver, gold and platinum options. But in the end, as the system attempted to  move toward low cost/high quality goal posts, which contractually continued to include insurer middle-men draw downs and embargoes on drug price negotiation, all roads led toward universal care and universal management as simpler, better, and (for almost everyone) cheaper in the long run approach, supporters said.

A similar process was proposed this week in a JAMA article titled, “Toward an Integrated Federal Health System”. In it, the authors review the facts, including:

• The federal government spends $1.3 billion a year (40% of all health care spending), on health care.
• This budget funds coverage through the departments of Health and Human Services, the Department of Defense, Veterans Administration, and the Department of Homeland Security.
• The payments channel through a bewildering array of mechanisms and middle men – through private insurers, private health professionals and organizations, and direct services to covered patients.
• The complexity is mind-boggling. For example, 42 programs exist across 6 federal agencies for ambulatory transportation of the elderly and disabled, each with their own rules.
• Drug payment levels vary widely. DOD pays 67% more for generic drugs than the VA for example.
• Double payments are not uncommon. Approximately one million citizens are now simultaneously tapping in to both VA and Medicare Advantage payments with losses estimated at $3 billion a year.
• Brick and mortar duplications, and in-patient underutilization is legendary.
• The DOD and the VA electronic medical records are moving forward toward integration this year – which should allow inter-operability and mobility/virtual choices for services to proceed.
• HHS expects that 50% of Medicare payments will have been converted from fee-for-service to “value-based models” (bundled payments with quality performance incentives) by 2018. Seven states will apply this approach to their Medicare Advantage plans beginning in 2017.

If all of this sounds complicated, multiply it by 50 states, and you begin to understand why supporters in a state like Colorado are seriously considering pulling the plug and going with a simpler universal solution.

Are we approaching some consensus? Will integration morph eventually into universal and cut the middle men out of the deal? Where are the consensus points emerging? Here are four areas:

1. Eliminate “fee-for-service” payment methodologies.

2. Move toward universal coverage, eliminating low benefit scam plans. 

3. Integrate patient-focused EMR’s regionally, then nationally.

4. Favor non-profit solutions, and integrated delivering systems whose mission incorporates individual, population and community health.

The Physician Psyche – An Existential Crisis of Our Own Making

Posted on | April 23, 2016 | Comments Off on The Physician Psyche – An Existential Crisis of Our Own Making

Mike Magee

The medical journals these days are replete with analyses of the latest health reform measures, and their negative impact on the physician psyche. It would be easy to simply connect the dots, and say that physician discontent is the result of ill-advised organizational changes. But, in reality, this problem has plagued the profession for some time, and is existential in nature.

Over the past two decades, our health care system in the United States has been actively transforming. Health is rapidly becoming synonymous with reaching full human potential. Health care provision is increasingly being redefined as a right carrying with it responsibilities for individuals, families and community. Provision of care is now a collaborative effort with individual providers giving ground to health care teams, and consumers joining hands with providers in strategic health planning and mutual decision making.

The role of ‘professionalism’ in training of physicians and in the delivery of care has been heralded by major scientific bodies including the AAMC, Institute of Medicine, the ACGME and the ABMS. Their listing of desirable attributes in health care professionals is helpful. But absent the context of rapid environmental change, the modeling of new approaches to care that are emerging from both the consumer and provider side, and the integration of the latest social science concepts which impact human planning, development and potential, physicians will predictably under perform in the modern world and not fully realize either the professionalism they desire or their full leadership potential in the future.

As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His thoughts on the topic, published under the title “A Flag In The Wind: Educating For Professionalism In Medicine”, are highly relevant to today’s medical educators and our nation’s health professional community.

After listing the profession’s ideal values and character qualities, he states:

“While we in medicine might see these as our lists of the desirable attributes of professionalism in the physician, as the father of an Eagle Scout I know that Boy Scout leaders use a very similar list to describe the important qualities of scouts: ‘A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, reverent (respecting everyone’s beliefs).’ I make this observation not to descend into parody, but to make a point. These various descriptions are so similar because when we examine the field of medicine as a profession, a field of work in which the workers must be implicitly trustworthy, we end by realizing and asserting that they must pursue their work as a virtuous activity, a moral undertaking.”

Later in the report, he shares: “The processes of formation include experience and reflection, service, growth in knowledge of self and of the field, and constant attention to the inner life as well as the life of action. ‘Who am I becoming as I move towards this life of service?’ is a critical question in formation, as disciplinary acculturation and expertise increases. Acknowledging that the educational process in medicine changes – in some substantive sense – who we are as well as how we relate to others, may be the key to understanding why we need to be mindful, articulate, and reflective about the process.”

“Who am I becoming?” is the right question. But equally important (perhaps more) is “Why am I becoming that?” In the same year when Dr. Inui was doing his AAMC fellowship, John Inglhart, founding editor of Health Affairs, interviewed Steven Schroeder, who had announced his coming retirement as CEO of the Robert Wood Johnson Foundation. Schroeder said, “If physicians and nurses, who are central to the operation of the system, however care is financed, are dissatisfied and feel undervalued, I grieve for that system because that is a system in trouble.” Here we see a shift, away from “I” to “it”. It is the “system”, not an individual or even an individual’s teachers, that is “in trouble”. “Bad people or bad design?”, Deming, the father of re-engineering systems,  might ask.

But increasingly, I believe that the systems that are evolving are largely a reflection of the current values of physicians and the organizations that represent physicians. Eli Ginzberg predicted this outcome thirty years ago in his classic article, “The Monetarization of Medical Care”.  The recent manmade opioid epidemic, made possible in part by the AMA Federation’s liberal approval policies  of  “specialty organizations” in “pain management”, as well as the rapid fire prescribing of oxycontin by the nations doctors and dentists, is proof positive that we have wandered far afield of our original mission, into a positioning that is so deeply conflicted by our own and others business interests that our identities as physicians and self-regulating ethical professionals have become fundamentally compromised. To my mind, the “Medical-Industrial Complex” now largely owns the soul of medicine. And for physicians to regain possession of their professional values, and quiet our inner voices of discontent, we will be required to do  some serious soul searching, and exhibit a bit of backbone as well.

“Zika” meets “Bayh-Dole Act” meets “Twitter”

Posted on | March 30, 2016 | 8 Comments

Mike Magee

Few on the planet remain unfamiliar with an infectious disease threat that was invisible to most a year or so ago – the Zika virus. It’s association with microcephaly and original concentrated appearance in Brazil (home to the 2016 Summer Olympics) has created the image-driven, news barrage that publicized the threat. All of the above has created a sense of urgency among scientists to discover and unleash a technologic solution.

The blood sucking carrier of Zika is well known – Aedes aegypt. The mosquito not only spreads Zika, but also yellow fever, dengue fever and chikungunya, a miserable infection that attacks the joints. In short, there is little sympathy for the mosquito. But it is its’ association with birth defects that makes it a unique and pressing public health emergency since at least 1/2 of the planet’s pregnancies are unintended, and exposure to Zika early in pregnancy carries a high chance of conceiving a severely disabled child.

There are quite a few scientists out there who are experts when it comes to Aedes aegypti, and not surprisingly, there have been a range of views on how to halt its’ scourge. But nearly all lead back to the genetic structure of this mosquito, and altering it in a manner that sterilizes or limits the growth of the mosquito or the reach of its vector.

We tend to think of our scientific community as integrated and unified, especially when confronted with a urgent challenge of this magnitude. One envisions a emergency meeting in Bethesda, a defined action plan with timelines, and plenty of funding. But the truth is, and has been since 1980, that America’s scientists are an independent, entrepreneurial, competitive, and patent-conscious lot that can be difficult to herd. As Rockefeller University mosquito expert, Leslie B. Vosshall, put it to a New York Times reporter, when commenting on defining the bug’s genetic code, “For a long time, I think we all thought the map was somebody else’s job.”

Now there is an Aedes Genome Working Group, but it wasn’t pulled together in Washington. It began with a Twitter post from Vosshall that read, “The Aedes aegypti mosquito is infecting millions with #Zika and #Dengue, but we still haven’t put all the pieces of its genome together”.

The subsequent professional chatter led to a coalescence of experts who eventually managed to scrape together a bare minimum of funds to start the process. They weren’t starting from scratch – but almost. There was a genetic mapping of the mosquito back in 2007 – but it is fragmented and so compromised as to make it relatively useless. To be clear. This not an easy task. The Aedes has only 3 chromosomes in its nucleus, but they contain an estimated 1.3 billion “letters” in their DNA sequence.

The good news is that DNA sequencing technology has come a long way since 2007. Still, it’s a challenge, which is why the work group is pursuing three different approaches in parallel, not certain which will unlock the code fastest and most accurately. What all members agree on is that genetic mapping is key to addressing the challenge.

Finally, there is the issue of what to do with the map once you get it. Do you attempt to genetically engineer future sterility into the breed? Could you direct the mosquito to avoid biting humans, and engineer a preference for other animal species? What happens if the engineered gene jumps species, and escapes human control? Quickly then, science technology morphs into science policy.

There was a time when scientific progress was highly centralized nationwide, when any discovery partially funded by a federal grant became the intellectual property of the U.S. government. But this approach discouraged profit seeking organizations from developing real-life applications for the discoveries.

In fact, by 1978, 28,000 scientific patents sat dormant on shelves in the U.S. Patent Office in Washington.(58) On December 12, 1980, all that changed when an outgoing Jimmy Carter signed the Bayh-Dole Bill giving academicians and their institutions (and subsequent corporate investors) control over applied discovery profits.

The response was dramatic. While 380 patents were granted to them in 1980, that number soared to 3088 by 2009. According to one estimate, the resultant impact on the nation’s Gross Domestic Product (GDP) reached $47 billion in 1996, and soared to $187 billion a decade later. Since 1980, 2,200 new companies appeared and generated more than 1000 new products. As important, the new technologies spawned entirely new industries in the United States including the field of biotechnology.

Twenty years later, The Economist commented that: “Possibly the most inspired piece of legislation to be enacted in America over the past half-century was the Bayh-Dole Act of 1980….More than anything, this single policy measure helped to reverse America’s precipitous slide into industrial irrelevance.” But that very same publication rescinded its glowing portrayal, just three years later, in an article titled, “Bayhing for blood or Doling out cash?”(78)

As that article states, “Many scientists, economists and lawyers believe the act distorts the mission of universities, diverting them from the pursuit of basic knowledge, which is freely disseminated, to a focused search for results that have practical and industrial purposes…it makes American academic institutions behave more like businesses than neutral arbiters of truth… Researchers (and particularly their minders in university patent-licensing offices) are increasingly reluctant to share materials and knowledge with others unless such sharing is accompanied by legal agreements about ‘reach-through’ royalties on potential findings and the right to restrict publication of results.”

And so, the fate of women of child bearing age, at risk from Zika, relies on the good will, brilliance and drive of individual entrepreneurial scientists who somehow manage to discover each other…sometimes, as in this case, on Twitter. As our planet becomes smaller, and our problems larger and more complex, such a free-wielding approach may be fatally flawed.

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