Category: Medicine

Well, I’m back from a great vacation, and buried under an avalanche of work. Just to give you a hint of what an internist actually does…

My office schedule is full—really full. Everybody needs to see me, plus the various sick people I have to squeeze in. It’s great; being busy is fun, but it’s time consuming.

Then there’s my desk. It is covered in lab results, home care orders to be signed, hospice orders, medication refills, prior authorizations…

And of course, back to teaching, including evaluations, etc.

So, it may be a bit quieter around here for a while, but I wanted to point out a few interesting things. MarkH is finally getting around to practicing some real medicine, that is, internal medicine, and he has discovered what I love about it—the mysteries (and it ain’t House, folks). One important point in particular he raised is how sick medical patients really are these days:

The more realistic medicine patient would be someone over the age of 50 with at least 5 or 6 chronic problems, and just one (or two, or three) that has put them over the edge requiring hospitalization.

Hospitalized patients are much sicker than they used to be. This may sound a bit odd, but many diseases are now successfully managed outside the hospital. Also, as hospitalization has become more costly, you have to be pretty sick to get in the door. For example, 25 years ago, it wasn’t unusual to admit someone for a “work up” of one kind or another. Now, patients must meet certain criteria of “intensity of service” and “severity of illness” to have an admission qualify for coverage. This usually isn’t a problem, but sometimes it is. Just something to think about.

As the death toll in the immediate aftermath of Cyclone Nargis becomes clear, new dangers loom. Complete breakdown in essential services and sanitation will conspire to kill thousands more via disease unless the world moves quickly (and maybe, even if we do).

Arthropod-borne diseases such as malaria and dengue fever are likely to flourish as standing water serves as breeding ground for mosquitoes. Malaria kills around a million people a year. Dengue is most often a disabling illness characterized by fever and severe pain, but in endemic areas it can lead to dengue hemorrhagic fever, a fatal illness resembling Ebola and Marburg viruses (but not as contagious).

Diseases related to lack of clean water, such as diarrhea, cholera, and hepatitis A can be especially nasty with little fresh water available for rehydration.

Tetanus, acquired from wounds, is a particularly grizzly death, and was seen frequently in victims of the Pakistan earthquake.

As bad as the initial death toll is (perhaps around 100K), it can get much worse quickly. Hopefully the world will respond as it did after the Great Tsunami, and hopefully the Burmese Junta won’t stand in the way. If they do, they may not have much left to rule over.

GINA, the Genetic Information Non-discrimination Act, has been passed by the House and the Senate, and will be signed by the president. Others have explained some of the implications of the bill, but the need for the bill is a grave sign.

GINA is a symptom…a symptom of a diseased health care system. Health insurance works by pooling risk. Ideally, an insurer will take as many people as possible, regardless of their health histories, and the premiums of the healthy will support the care of the unhealthy few. Of course, insurance companies aren’t stupid. They would rather have the healthiest people possible…every penny the don’t spend is profit. That is why a small business, such as mine, will see rates skyrocket if someone gets sick. The risk isn’t being widely pooled, and the cost is being passed on to a few.

GINA isn’t necessary in most of the world (forget for a moment that most of the world doesn’t have money to spend on genetic testing). Most industrialized nations have some sort of universal health care—risk is pooled widely, in fact the pool includes the entire population. There are problems with this, but one of them isn’t discrimination. Under our current system, people are penalized for being sick, poor, or unemployed. It is inefficient and expensive.

Surely we can do better. If we make GINA irrelevant, many of our health care problems will also fade.

In this space, we have explored some real conspiracies, using as an example the tobacco companies’ war on truth. Smoking, and smoking-related disease, continues to be a significant burden on the health of Americans. For example, chronic obstructive pulmonary disease (COPD) affects between 10-25 million Americans. This disabling illness, which includes emphysema and chronic bronchitis, is horrifying to watch, and worse to experience. Smoking is also one of the strongest risks for heart disease which kills over half-a-million Americans yearly.

But it seems that smoking is on the decline, at least in my rarefied world of home/office/hospital. Even as I go to the coffee shops, book stores, and restaurants around town, I see very few smokers. So it was a shock when I arrived here in Key West on vacation that I found everyone smoking—not just at the bars and open air restaurants, but a huge number of people just walking down the street. What gives?
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The World Health Organization has declared today World Malaria Day. Why “World Malaria Day”?

World Malaria Day is an opportunity for malaria-free countries to learn about the devastating consequences of the disease and for new donors to join a global partnership against malaria.

World-wide there are about a million deaths yearly from malaria, mostly in young children. Here in the States, we almost never see malaria. That wasn’t always true. When Franklin Roosevelt founded the Tennessee Valley Authority in 1933, malaria affected about 30% of the population in the TVA region. With the use of pesticides and drainage of wetlands, malaria was effectively eliminated in the U.S. by 1951. DDT was used extensively—it was sprayed judiciously, on the interior walls of rural houses, and not-so judiciously on breeding grounds. DDT can be a very effective tool to combat malaria. When malarial mosquitoes bite, they then rest on the interior wall of the victim’s house. It takes only a small amount of DDT on the wall to kill these mosquitoes. (DDT later became an environmental disaster when it was used in a non-judicious fashion on crops. For more on the interesting and controversial topic of malaria and DDT, see this).

A very effective and affordable tool to prevent and control malaria is the insecticide-treated bed net. These nets have actually been shown to decrease all-cause mortality where they have been studied.

Malaria is nasty. Healthy adults who contract it often suffer terrible relapsing fevers. But many victims, especially children and pregnant women, suffer much more severe disease, including cerebral malaria, severe hemolytic anemia, liver and kidney failure, and death.

Several years ago, I admitted a businessman to the hospital. He was terribly ill—fevers, jaundice, kidney failure, low blood pressure. He reported having traveled to West Africa on business, and he did not take malarial prophylaxis. He had classic “blackwater fever“. It took all the resources of a modern American intensive care unit to pull him through, and just barely. Imagine the same patient thousands of times over in Africa.

World Malaria Day is an opportunity for those of us in the malaria-free world to learn about how to help stop one of the worlds largest killers of children. Link it, blog it, make some noise.

A new study this month in The Lancet examined the health impact of domestic violence (of women by men). This was a very large WHO-funded study looking at multiple physical and mental health problems in abused vs. non-abused women. This is necessarily an observational study, but appears to be well done, and included a large and diverse sample of women.

A few findings are worth a specific mention.

First, intimate partner violence is very common across cultures, with numbers ranging from 15-71% of women who had ever been partnered with a man.

Next, mental health problems, which were self-reported using standardized measures, were much more common in abused women.

Finally, physical injury, including loss of consciousness, as a result of intimate partner violence was very common (about 22-80% of respondants).

It is impossible to entirely prove causation rather than correlation in this type of study, but the authors have done a good job trying to parse this out in the discussion section.

In their own words:

…violence is not only a substantial health problem by virtue of its direct effects, such as injury and mortality, but also…might contribute to the overall burden of disease as a risk factor for several other serious health problems. The extent to which the associations between partner violence and reported ill health in women are consistent across sites both within and between countries in striking. This observation suggests that experiences of physical or sexual violence, or both, by a partner are associated with increased odds of reports of poor physical and mental health, irrespective of where a woman might live, her cultural or racial background, or the extent to which violence might be tolerated or accepted in her society or by herself. In addition to being a breach of human rights, the high prevalence of partner violence and its associations with poor health–including implied costs in terms of health expenditures and human suffering–highlight the urgent need to address partner violence in national and global health-sector policies and programmes.

This is not the first study done on domestic violence, but the size and quality of the study are a damning. One of the biggest public health problems in the world is domestic violence. They correctly frame this as a human rights issue. If half the human population is suffering mental and physical ill health due to preventable actions by members of the other half, we are doing something terribly wrong.

Despite the lessons of the holocaust, genocides continue. But we recognize them as genocides, and sometimes we actually do the right thing. This study screams out for action. The health and welfare of half the human population is at risk due to violence in their own home. Even if we can’t eradicate domestic violence, we can elevate it to the level of malaria, AIDS, and genocide as one the world’s most urgent public health problems.
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Ellsberg, M., Jansen, H., et al, . (2008). Intimate partner violence and women\’s physical and mental health in the WHO multi-country study on women\’s health and domestic violence: an observational study. The Lancet, 371(9619), 1165-1172.