EXPECTING, ADDICTED TO DRUGS

March 20, 2015

Potent prescription opioids like oxycodone can be lifesaving for people with pain. However, these drugs also cause serious problems. Addicts obsess about getting their next fix to avoid the unbearable withdrawal symptoms.

There have been pharmacy thefts, illegal street sales and desperate pleas by criminal’s families for prison time so their loved one can get addiction counseling. These stories aren’t going away. Oxycodone is a huge problem for addicts.

Moreover, newborn babies are being innocently caught up in opioids’ power too. Prescription drug abuse is not infrequent among moms-to-be. In fact, rates are increasing. Infants born to addicted mothers suffer from neonatal abstinence syndrome where baby is effectively in withdrawal after birth, craving the opioid taken by mom. These newborns are irritable, jittery, breathing quickly and feverish.

First, doctors try non-pharmacological interventions like keeping baby in a calm, dark, quiet room with soothing by mom. Sometimes, they also have to use morphine to manage baby’s pain and distress until it’s weaned off craving mom’s opioid. These infants are monitored closely in the neonatal intensive care unit.

This has crept up on physicians over the last decade, many of whom didn’t have any medical training in this area. Now, they’re gaining expertise and even getting used to seeing pregnant women in this situation.

Methadone, another opioid, offers some optimism through harm reduction programs. Ideally, mom wouldn’t be on any opioids, but at least methadone gives her a chance for a healthy pregnancy.

For addicts, oxycodone withdrawal can mean vomiting, unremitting tummy pain, severe agitation, insomnia and the unending quest for more oxycodone. Methadone can treat these symptoms, and expecting moms enrolled in harm reduction programs get it regularly from pharmacists who dispense doctors’ prescriptions.

The idea is that instead of spending every day looking for the medication, and wondering how she’ll get and pay for it, mom knows exactly when she’ll have her next dose. This means women can focus on staying well.

Fear of losing her family
Now, some methadone moms are having healthy pregnancies and healthy babies who go home with them and breastfeed. The challenge however, is getting more mothers to admit their problem and then ask for addiction help.

This isn’t an easy step though, since it’s attached to guilt and shame. Moms with other children may fear losing them, and worry about how they’ll be viewed. It takes a lot of strength to see beyond peoples’ negative reactions and judgments, and make baby’s health the top priority.

WHY HOSPITALS MIGHT EVEN ENDORSE YOUR VICE

March 13, 2015

Hospitals are supposed to promote health, but are they actually sending mixed messages when it comes to human vice? Burgers, fries and soda have inundated North America even in the most unlikely places.

In fact, there’s always time to fuel your ‘Big Mac’, ‘large Coke’, or ‘Double Cream Double Sugar’ addictions, including inside hospitals. The irony is, fast-food outlets don’t force their way in. McDonald’s and Dunkin’ Donuts (or Tim Horton’s in Canada) wouldn’t be there without hospital approval.

If you didn’t know you were in a hospital, you certainly wouldn’t be able to tell from the food court. Actually, you would probably think you were at the mall. Paradoxically, hospitals are where we go to get healthy; to conquer diseases like cancer, diabetes and obesity.

The food we eat plays an important role in our health. This is particularly true for children whose bodies are still developing. However, paediatric hospitals are among the worst offenders. Florida’s Shands Children’s Hospital has five fast-food restaurants.

Hospitals are often upsetting places, but don’t we have an obligation to behave more responsibly than this? Why are we comforting patients and their families with unhealthy comfort food that we know is directly linked to the diabetes and obesity epidemics plaguing our country?

Fast-food places keep hospitals in the black, but isn’t this a conflict of interest? It’s a very mixed message that you’re not supposed to eat Wendy’s or McDonalds, but when doing so helps your local hospital’s budget it’s okay. In other words, we want you to curb your unhealthy impulses, but we’ll look the other way when it’s good for the bottom line. Sometimes we’ll even endorse your vice if that’s the lesser of two evils.

There’s no place for fast-food in hospitals because these chains aren’t interested in health. They’re profit driven instead.

VACCINATION: ARGUING ABOUT ITS MERITS IS NOT THE ANSWER

February 17, 2015

The recent measles outbreaks in Canada and the U.S. raise some important questions.

What are the responsibilities of editors and journalists when it comes to science-based topics? Those, like vaccines, rooted in scientific fact? Do they too deserve the balance we conventionally consider our journalistic standard? After all, are such stories really a debate?

The scientist in me wishes media outlets would stop giving anti-vaxxers opportunities to broadcast untruths to others. The vaccine “debate” is an example of a dialogue where both sides should not be given equal podium time and benefit of doubt.

Vaccines need to be framed differently. Rather than, ‘We are going to hear from someone in favour of vaccination’—which is like believing in Thursdays if they are something you have to believe in—and then, ‘We are going to hear from someone against vaccination’—which makes it seem like this is an even-handed subject—we should instead discuss it as a human-interest piece; ‘Why do anti-vaxxers think this way? Why don’t they immunize their children? What are the risks?’ Putting the “pro-vaxxers” and the “anti-vaxxers” head-to-head establishes an inaccurate equivalence.

Editors strive to create balance and avoid bias. Vaccination is not a question of equilibrium however, because there is nothing to equalize. One side is a thousand-ton brick, and the other a feather. Creating parity between them is impossible. Newspapers and the radio think they are engaging lively debate by including different opinions, but sometimes there is no debate.

Often, journalists’ role is to question the status quo. Despite the public’s right to do so, in the context of science, sometimes we should simply accept the facts. Vaccines are one of medicine’s greatest accomplishments. They have eradicated contagious, disfiguring and often deadly diseases like smallpox that plagued humans for thousands of years. Hard evidence over decades exists that is easy to access. If you google, ‘Does the MMR vaccine cause autism?’ and open any evidence-based health page, the answer is a resounding ‘No.’ If you then dig deeper, into someone’s personal Facebook page or blog perhaps, you will find the anecdotal evidence to the contrary. To me, those things are not equivalent.

Vaccination is science, not a political debate. Vaccines are not like discussing foreign policy where one or two or seven or nine opinions might be equally valid. Scientific consensus exists, and then there is anecdotalism that blatantly deviates from that consensus. It is not that I do not want to debate. When considering vaccines however, it is about how and what to debate.

IS GETTING CANCER LIKE LOSING THE LOTTERY?

February 5, 2015

When someone gets cancer we want to know why. We want to believe there’s a reason.

However, according to a study by oncologist Dr. Bert Vogelstein and biomathematician Cristian Tomasetti at Johns Hopkins published in the journal Science last month, the explanation is more like losing the lottery—often the real reason is not because you didn’t behave well or were exposed to something harmful in your environment, it’s just because you were unlucky.

In fact, Vogelstein and Tomasetti found that two-thirds of cancers could be attributed to bad luck rather than heredity or our environment. This bad luck presents itself as random DNA mutations, which accumulate in our bodies as our cells divide and appear to be responsible for several cancers.
Actually, 22 of the 31 cancers these researchers looked at, including leukemia, bone, brain, ovarian, pancreatic and testicular cancer, were essentially due to biological bad luck (random mutations).
Heredity and environmental factors, like carcinogen exposure, played a more significant role in nine other types of cancer, including colorectal, skin and smoking-related lung cancer.

Early detection in research
Overall, Vogelstein and Tomasetti attributed 65 per cent of cancer incidence to these random gene mutations, which can drive cancer growth. There’s no particular reason for these harmful mutations aside from randomness as our stem cells divide.

These results suggest that lifestyle changes like quitting smoking might help prevent some cancers, but may not affect others. Therefore, more research and resources need to focus on finding ways to detect these cancers early when they’re still curable.

Vogelstein and Tomasetti did not cover all cancers. They excluded breast and prostate because of unreliable stem cell division rates.

No. 1 DR. SOKA MOSES

February 2, 2015

No. 1 Dr. Soka Moses

Sometimes, the person who influences you most comes when you least predict it. But when it happens you know it. You can feel your heart grow bigger. You can feel yourself step up a bit, because you just want to be a better person after you meet them.

I love that the person who influenced me the most is the youngest of the group. Dr. Moses was only two years out of finishing his medical internship when he was put in charge of an Ebola Treatment Unit in Liberia. He worried about the risks, but he took the job anyway. He saw mentors and protégés die, not to mention hundreds of patients. He risked his life staying in protective gear hours past the accepted international limits, because it was the only way to care for his patients.

Dr. Moses is a natural leader: he pays attention to everything from the way his unit’s supply system works to how long a patient is in triage. Seeing him at MOD1, you know this guy could run a huge medical center anywhere in the world. And to top it off, he sings when he is getting dressed in protective gear.

Dr. Moses may be embarrassed by this posting, but when someone inspires you I think you need to share it. Here is to Dr. Moses who believes that every life has value, and understands it takes systems and leadership to make that happen. To an inspirational young leader, to a man who makes me want to be the best person I can be in 2015: Dr. Soka Moses.

NO. 2 DR. LARRY BRILLIANT & DR. JERRY BROWN

January 31, 2015

NO. 2. Influencers. OK for no. 2, there are two people:

Dr. Larry Brilliant, Senior Advisor to Jeff Skoll
The Yoda of Global Public Health, Larry is a philosopher and a connector. He connects people in medicine, technology, business, government; the east with the west. For Larry, public health is about moral choices, our collective moral choices. But he is also a guy with a mischievous sense of humor (Yoda again) as witnessed by the electronic banner he is wearing below.

Dr. Jerry Brown, Medical Director ELWA, Liberia
Jerry is the doctor we all wish we could have—gentle, focused, always working to get his patients the best care. Frankly, he couldn’t care less about media or a film crew. Sometimes you could see that he wanted to run in the other direction, a few times he literally did. But he loves being a surgeon so much that once you get him talking about medicine, he keeps talking. Jerry is also a proud Liberian. He wants, he expects, his fellow citizens to improve life in Liberia. When I think of Jerry, I think of the definition of decent: moral, honest, kind.

NO. 3 MARK SMOLINSKI

January 30, 2015

As we are roaring into a new year, I wanted to write about those people whose work is changing the way I approach 2015…the people who last year filled me with hope, inspiration, and passion for what can be done THIS YEAR.

NO. 3: Mark Smolinski, head of pandemics, Skoll Global Threats

Somehow it is appropriate that the guy who believes that mobile is a key to helping us combat epidemics was captured on their cell phone on a bus in the tech capital of the world: San Francisco. Mark moves around the world setting up mobile disease tracking systems from Brazil to Thailand, from Tanzania to the US. He opened our team’s eyes to the connection between animal and human disease—the importance of tracking both and the connection between animal and human health. He is also one of the happier people I know, which in itself is contagious. So here is to connection for good, embodied by Mark Smolinski.

PALLIATIVE CARE BEFORE PHYSICIAN-ASSISTED DEATH?

January 3, 2015

It’s a common belief that patients, particularly those with terminal cancer, would choose death if their pain became unbearable because of inadequate palliative care. The argument is as follows: enhance palliative care access, adequately control pain and watch society’s support for physician-assisted death erode.

But, should palliative care come before doctor-assisted death, or do these go hand in hand with helping patients achieve the “best” death possible?

One concern is that legalizing physician-assisted death makes it an easy option. In other words, that once it’s legal, patients immediately choose it after receiving a terminal diagnosis, which in turn leads to inadequate funding to improve palliative care and opting for doctor-assisted death out of desperation because of palliative care’s poor quality.

However, the evidence does not support this. In fact, countries where physician-assisted death is legal are also world leaders in several palliative care metrics. For example, the five states (Oregon, Vermont, Washington, Montana and New Mexico) in the U.S. where doctor-assisted death is legal by statute also rank in the top eight regarding the availability of palliative care in their hospitals. This may be because legalization has been accompanied by increases in palliative care funding, as well as official palliative care policies.

Moreover, physician-assisted death is not only a medical issue but also a societal issue involving complex social questions. Doctors should not lead the way in making these choices because they impact all human beings. This is not something that physicians alone should or can decide. If the laws are going to change that has to be understood, and all of us need to be actively involved in this process.

In an ideal world doctor-assisted death would be legal and palliative care quality improved and physicians would have the right to conscientious objection (refusal to perform physician-assisted death) when they believe this is the right choice.

MEDICAL RECORDS

December 8, 2014

Why can’t medical records be as easily accessible as your bank information? It is startling in this technological age how far behind almost every part of the medical system is in regards to accessing your health information.

How can we expect patients to be a partner in their healthcare if we make it time consuming and even expensive to access their medical information? A recent New York Times article: Top Secret describes how personal health information is almost held hostage by providers. One patient profiled spent six weeks and 100 dollars not to mention numerous phone calls and the time it took to fill out forms and send them in by regular mail in order to get a single detailed copy of his bill for a back operation.

With 80 percent of hospitals and doctors offices now converted to electronic medical records (something that only really begin in full force in 2009) there should be no excuse for giving patients easy access to their personal medical information. Beginning next year, a new government mandate will require health providers to show that they are using electronic medical records to better share information with patients and one another. Doctors, hospitals, and clinics should view this mandate as an invitation to rethink their relationship with patients’ access to personal health information.

Among medical professionals, I have heard comments like patients won’t understand their records or bills. Many parts of medicine are still left in an old paternal, or self-protective, model.

Frankly, the do not understand argument simply doesn’t hold water. We would never say a client shouldn’t get access to their bank account, loans, stock or 401K records because they “wouldn’t understand.” The medical establishment needs to enter the 21st century. We live in an information sharing age—not just with big data for clinical research, but also with individual patient information. Both the lives of individual patients and the practice of medicine will be better if the healthcare system learns to share financial and medical information in a convenient manner with patients.

LAWS CAN ONLY BAN "SAFE" ABORTIONS, NOT ABORTIONS

November 25, 2014

This month was the New York premier for Vessel, a documentary about Women on Waves (WoW). It’s a sad reality that an organization like WoW is needed today.

Dutch physician, human rights activist and artist, Rebecca Gomperts, founded WoW in 1999 to perform safe abortions and support desperate women in countries where this procedure is illegal.

Stationed on a ship, Gomperts’ crew uses the laws governing international waters to bring abortions and contraceptive services to women with no other alternative.

Despite legal, political, religious and logistical hurdles, Gomperts and her team are persevering with creative solutions that enable them to educate and empower women around the world to have more say in the policies that are being made about their bodies.

Although abortion is legal in the United States, with mounting restrictions surrounding it and women’s contraceptive rights, WoW may be sailing our way soon.

Additionally, individual states can restrict abortion policy. Texas, for example, has been severely affected by controversial anti-abortion law.

Before the 1973 Roe v. Wade decision, illegal abortions harmed and killed many women in the U.S. According to one study, one in four deaths among Caucasian women and one in two among African American women were caused by abortions in the early 1960s.

WoW’s message is simple: we need to put the power back in women’s hands. Making abortions safe, legal and accessible should be our goal.

THE SICK DOCTOR

November 20, 2014

It’s difficult to receive a serious diagnosis. Sometimes, it’s even harder to tell the world about it. This is challenging for the patient, and the doctor.

How does the clinician decide to reveal a diagnosis like Parkinson’s Disease or Bipolar Disorder? When should the doctor stop practicing?

Doctor ethics
Is it ever acceptable, or possibly even necessary, for the clinician to deceive the patient?

Sometimes it takes the doctor years to accept and admit what’s going on inside her body. There’s an additional, unique level of complexity for the clinician—her diagnosis can compromise the patient’s care.

The sick doctor feels weak, wounded and unable to carry out her tasks. Being the subject of conversation feels unnatural for the clinician who is used to the patient fulfilling this role.

The doctor’s colleague is often too polite to say anything even though she knows there’s something wrong. In fact, it’s often the patient who offers the clinician advice: “You look like my grandfather who had…”

What does this say about the culture of medicine? Does the patient feel empowered to say these things while the doctor does not?

The clinician may be reluctant to look at the faults of her colleague because this could unveil something about her own faults as well. The doctor may wish to share her diagnosis with the patient but choose not to since this would expose her weakness, and that seems unacceptable.

There’s an ongoing, ethical debate about the extent to which the clinician should admit her day-to-day frailties when she’s about to do something really important that affects the life of the patient. This is a factor for the doctor who is sick as well as the tired, sleep-deprived surgeon who was up all night on-call and is now operating on her patient the next morning.

The regulatory College requires the doctor to disclose conditions that may affect her ability to practice medicine safely. As painful as this is, it’s something every clinician needs to think about.

When does the doctor cross this line? How does the clinician know when she has reached the point where she’s possibly doing harm to the patient, or needs to ask for help?

The doctor may be afraid to ask for this help. Yet, she needs to be aware of this deficiency and willing to admit it to her colleague. In turn, the colleague needs to support her emotionally, and help the clinician make sure she’s practicing safely.

DOCTOR, LISTEN…

October 30, 2014

Some might describe the doctor-patient visit as a transaction: the patient comes with a problem and the physician gives her an answer. But does this fulfil the patient’s needs? Not always.

Asking the ICE (ideas, concerns, expectations) questions can help the doctor understand the patient’s point of view: ‘What do you think is going on?’ (ideas), ‘What are you most worried about?’ (concerns) and ‘What do you think I can do?’ (expectations)

Tapping collaboration
Mostly, the patient wants a two-way relationship with her physician. She wants to work with the doctor and actively contribute to her care.

The patient is not always forthcoming though, and sometimes the physician wishes she could tell her to be more clear. The doctor is not a mind reader. The patient is supposed to prepare, be concise and accurate. The physician expects her to describe the nature of her problem: When did it start? What makes it better or worse? What contributes to it?

But where does the responsibility lie?

Sometimes, the patient is reluctant to share information: she does not want to interrupt, she might defer to the doctor’s expertise, or she might not be asked.

The physician plays a critical role as an educator, but the patient can also inform the doctor by asking direct questions. These can be a starting point for informed collaboration on diagnosis, treatment and prognosis.

Empathy’s weight
The patient’s health problem is the fact. The rest are her feelings. Those feelings need to be explored and acknowledged: What keeps her awake at night? What is she angry about? What does she fear? What is the best way to support her?

The physician ought to address these concerns because they are legitimate and must be recognized whether or not they are justified (in the doctor’s opinion).

Empathy is the physician’s ability to understand the patient’s experience and supportively communicate this to her.

A 2011 analysis of empathy published in The Canadian Medical Association Journal cited a study of oncologists who were filmed speaking with their patients. Moments when the patient expressed an emotion like, ‘I’ve got nothing to look forward to,’ were tracked. The oncologists responded in an empathetic way only 22 per cent of the time during these “empathic opportunities”.

Empathy is a clinical skill. It gives the doctor the information she needs to provide AND show care.

Attunement or agreement?
Expectations are complex because they differ depending on the patient. Each person’s unique makeup affects her attitudes around every aspect of her life, including health care.

Some expectations concern treatment and prognosis: ‘What will happen to me next?’ Others relate to what the patient hopes will happen. Still others revolve around how the patient wants to be involved in decisions about her care.

Asking the patient, ‘What are your expectations of me as your physician?’ is a valuable starting point. By listening to the answers, the doctor can confirm that she is on the same page as the patient. The physician provides the best care when she understands, respects and helps manage these expectations.

A lot has been written about the patient’s ideas, concerns and expectations. A 2009 study in The British Journal of General Practice looked at 36 family doctors in Belgium. It aimed to discover how often ideas, concerns and expectations came up at the physician-patient encounter, and to determine any correlation between these questions and prescriptions.

When ideas, concerns and expectations were addressed, medication was prescribed less frequently. As the authors write, “Identifying and eliciting ICE components are key competencies related to shared decision-making”.

Understanding the patient’s responses to ideas, concerns and expectations facilitates attunement over agreement. Asking these questions says, ‘I hear you, I understand you and I respect what you are saying.’

The doctor will not always agree with the patient’s ideas, share her concerns or meet her expectations, but these questions help the physician and the patient understand each other.

BREAKING THE SILENCE

October 14, 2014


Source: Mikael Häggström

Every year, thousands of families in the United States and Canada mourn the death of their babies.

About 26,000 pregnancies end in stillbirth in the U.S., according to the American College of Obstetricians and Gynecologists. That’s about 1 in 160 pregnancies, and more than one-third of these deaths are never explained. In 2011 alone, 23,910 infants died before their first birthday.

In Canada, 2,818 babies were stillborn and 1,810 infants died within one year after birth.

While the numbers are staggering, often families grieve in silence.

Stigma surrounding childhood death prevents society from speaking about its devastating effects on parents and their families. While there is an open dialogue about some forms of death, this is often not the case for babies and infants who have passed away. What types of support are available to bereaved parents?

“A person [who] loses a partner is called a widow. A child who loses a parent is called an orphan. But there is no word to describe a parent [who] loses a child, because the loss is like no other.” [Unknown]

October 15th is Pregnancy and Infant Loss Awareness Day. This day is recognized nationally in the United States, and although it is honored in parts of Canada (British Columbia, Manitoba, Saskatchewan and the Northwest Territories), this hasn’t made it to the federal level yet. Not only is October 15th a day for grieving families to come together, it is also a day for creating awareness for the wider public on how to help support those who have experienced this devastating loss.

Bereaved parents face tremendous challenges after the death of their baby. Their grief is a lifelong process. The grieving experience might change over time, but the child will always be missing and major milestones like the birth of a sibling can bring back painful memories of loss. Grieving parents and their families learn to live with their feelings of sadness and happiness simultaneously.

A general tendency in our society is to focus on the positives in life—expressed through statements such as “You can have another child” or “At least you did not get to know your child too well, which would have made it harder”—which can be inappropriate and hurtful.

Simply being present, listening to the parents, crying with them, allowing them to speak about their child and acknowledging the babies, the mother and father as parents and the birth experience (if applicable) may be what’s truly needed.

MORE TRANSPARENCY, SAFER HEALTHCARE

October 2, 2014

Taxpayers support tremendous amounts of research and development (R&D) through organizations like the National Institutes of Health (NIH) and other government agencies that go into funding medical research. Yet, this information is not readily available publicly—although it’s easily accessible to doctors, it’s often extremely difficult for patients to find. In fact, the answers patients are looking for might not even exist.

For example, how would you find the best hospital for your child to have open-heart surgery? Despite the fact that a lot of information exists about specific heart defects some children are born with, outcomes across institutions are often not compared. Consider buying a car—would you get one without looking at Consumer Report ratings, or comparing prices across different dealers?

We effectively buy healthcare without the freedom to do comparison-shopping because huge variation amongst doctors and hospitals does exist. This applies not only to results, but also to procedures. Not having this data means that patients cannot make informed choices.

Culture of Secrecy
How are patients heard? It is time to create more comparative care to allow patients to choose good outcomes. The system as it stands now expects patients to do the heavy lifting—to look for the best surgeons and hospitals by interviewing doctors and healthcare facilities they’re considering.

In 2013, the National Health Service (NHS) in the U.K. published the world’s first comparison data on surgeons, including everything from how many operations they perform, their outcomes and mortality rates. The Canadian Institute for Health Information (CIHI) does comparison reports on hospitals across the country, and is working on doing these for individual surgeons, but there is pushback.

While some hospitals and physicians are in favor of these changes, others prefer keeping their performance information private. Some doctors want to know how they compare to their colleagues, but not necessarily release this information to the general public.

However, access to this data should not be insider information where physicians know who is performing well and who is not, while leaving patients in the dark. The healthcare system should be based on transparency.

However, as is the case in the U.S., the Canadian medical system is based on hierarchy and autonomy, which are not conducive to transparency. It may not be sufficient even for doctors to look at their own numbers to determine how they’re doing since you need comparative data to understand the quality of care you’re providing.

But if patients cannot access this information, how would healthcare quality truly improve? Your Health System, an interactive website launched by CIHI earlier this month, which provides hospital and regional comparisons across 15 performance standards, is a big step towards healthcare transparency in Canada.

Pressure to be perfect
Dr. Teodor Grantcharov, a general surgeon at St. Michael’s Hospital and associate professor at the University of Toronto, is dedicated to transparency. He is currently developing the world’s first operating room black box, which makes his patients confident because they think it’s unlikely he has anything to hide if he’s willing to be open about his mistakes.

In fact, Dr. Grantcharov maintains a database of his procedures and outcomes. He has done this since he started practicing and knows exactly how many of each surgical procedure he’s performed as well as the number of patients who suffered complications. He can look back on his performance and understand what went wrong and why.

Practicing like this raises tough questions for him, but as professionals, should doctors not reflect on their own performance before their patients do? Physicians cannot improve if they don’t understand why something went wrong.

There is anxiety and concern among patients as well as a tremendous desire for transparency. This is critical because the doctor-patient relationship is based first and foremost on trust.

Medical professionals like Dr. Grantcharov are changing a culture that expects physicians to be perfect, an ideal that begins prior to medical school. Doctors need perfect grades to get into med school and then into a residency program. On top of that, they are expected to never make mistakes or forget anything. Consequently, those expectations have had a tremendous impact on quality improvement and implementing safety initiatives.

The culture of medicine may not favor transparency, and may even feel threatened by it, but we owe it to our patients and ourselves to provide the best healthcare practices.

EBOLA: OUR FAILURE

September 24, 2014

This past February, I traveled with Dr. Peter Piot, one of the co-discoverers of Ebola, and the current director of the London School of Hygiene and Tropical Medicine to Yambuku, Democratic Republic of Congo. Yambuku, in the center of the DRC, was ground zero for Ebola, the site of the 1976 outbreak, which killed 280 people including 2 Belgian nuns. Yambuku was where Ebola was first identified.

What was deeply disturbing to see in Yambuku was that the health care system has actually deteriorated since the 1976 outbreak. The hospital has no phone, no mobile coverage, not even a working radio. There is no running water and only minimal electricity.

In Yambuku, we met an Ebola survivor. Sukato Mandzomba had been a nurse in 1976, particularly vulnerable to catching the disease like all healthcare workers. But he had also been lucky and survived. He now runs the hospital lab.

Every workday morning, Sukato heads into his makeshift lab. He works by himself carefully hand dying slides to identify infectious diseases like malaria and TB. His handwritten records are meticulous.

In 1976, the best and the brightest descended on Yambuku from the CDC in Atlanta, from WHO in Europe. They came in planes and military helicopters. They brought fancy equipment and a passion to identify a terrifying new virus.

So how could it be that nearly four decades later, Yambuku was in worse shape? How could it be that in a place where we know infectious diseases are rampant, that the hospital has received no essential drugs for two years? Instead the staff buys basic drugs at the weekly private market.

What I found particularly heartbreaking is across the board the local residents: nurses, doctors, schoolteachers know they have been abandoned. They say people come but they do nothing. They are right.

Sadly, things aren’t a lot better in Congo’s capital, Kinshasa, a city of almost 9 million people. In Kinshasa’s main public hospital Mama Yemo, we saw gauze being rewashed and hung in the courtyard because the hospital doesn’t have enough money for supplies. Not everyone in surgery was wearing gloves.

In 1995, a patient with Ebola managed to travel via plane from Kikwit in the Congo, where there was a second major Ebola outbreak, to Kinshasa—a harbinger of the Ebola patient traveling from Liberia to Lagos, Nigeria last month. In 1996, the Congolese team, led by Dr. Jean-Jacques Muyembe, managed to contain the Kikwit patient so he didn’t infect anyone else. In Nigeria, they weren’t so lucky. Patrick Sawyer who flew into Lagos from Liberia infected 15 others; 4 have died.

Like Lagos, Kinshasa is a megacity, and like Lagos, it has multiple flights a day to Europe. Both cities are places where epidemics could spread widely, so what happens in Mama Yemo Hospital in Kinshasa matters to all of us. Mama Yemo is a front line in the war against infectious diseases.

Unless we establish robust early detection and early warning systems, unless we strengthen health care systems around the world, we will continue to face epidemics that could become pandemics. What happens in the Congo will affect us, not every time, but it will ultimately affect us.

Take Yambuku. In 1976 as Ebola was brutally killing people in Yambuku, another deadly virus was already circulating. A number of years later, blood samples taken at the time of the original Ebola outbreak were analyzed to see if HIV-AIDS had been present in 1976, long before it had emerged on the world stage. It turns out that .8 percent of the population of Yambuku was HIV-AIDS positive in 1976.

A few years later in Kinshasa’s Mama Yemo Hospital, a brilliant cardiologist, named Dr. Bila Kapita started collecting case file after case file of patients that were dying savagely of strange opportunistic infections; they were of course dying of HIV-AIDS.

So just when the world thought that Ebola was the most terrifying epidemic, another far deadlier epidemic, a true global pandemic was burrowing in for the long haul, an unseen enemy moving between people, moving via ship and plane around the world.

HIV-Aids would go on to kill not thousands, but 36 million people on six continents. And Dr. Peter Piot, who 38 years ago worked to identify Ebola, would find himself trying to contain a true pandemic, as executive director of UNAIDS.

As we left Yambuku I asked myself, if the healthcare system had actually gotten worse, what is happening right now in the Congo, that we don’t know? What unseen enemies, unseen viruses and bacteria, are we missing?

We have failed the people of Yambuku, the dead and the survivors. Rushing in was not enough. We need to strengthen health systems and put in place better disease detection systems. The scope of the current Ebola outbreak in West Africa is a result of our failure.

Our global connection now puts us at increasing peril. But it can also be used for good, to create global change. The choice is ours.

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