Chronic obstructive pulmonary disease (COPD) exacerbations and respiratory syncitial virus--maybe a huge problem?

We're having a curtailed winter and early spring here in the inland northwest, or so it seems. We could still get a snowstorm or two, but the crocuses are blooming and the redwing blackbirds are singing by the unfrozen ponds. Despite the mild temperatures and sunny skies we are still having an influenza epidemic and many of our patients with chronic lung disease are becoming sick with wheezing and low oxygen levels. We have rapid tests for influenza and for another lung infection, respiratory syncitial virus (RSV) and I am presently seeing less flu and more RSV.

I have never routinely checked my patients with asthma and COPD exacerbations for respiratory syncitial virus. I thought that it was one of  those tests that would take so long to come back from the lab that the patient would be well before I ever found out the result. It is possible, though, to get a result back from a rapid antigen detection test (much like a home pregnancy test) using a sample of mucus from the back of the nose, in 30 minutes.

Last week two patients with severe wheezing and uncontrollable cough who were in the hospital with worsening of their COPD tested positive for RSV. Yesterday another one did. It is RSV season. In fact, it is even more RSV season than it is flu season. We are smack dab in the middle of RSV season which stretches from January to April. RSV is best known as the virus that causes acute lung disease in infants and children. In the US alone, over 80,000 children are hospitalized each year due to this virus and worldwide it kills more children under the age of 1 than any other infectious agent with the exception of malaria. More high risk adults, such as those with lung disease or immune suppressing diseases, contract RSV than they do the flu.

RSV is, for most of us, just a cold. It causes a stuffy runny nose and a cough, sometimes a fever. In small children or people with lung disease it can cause respiratory failure. It is very contagious. It is most often contracted by directly touching an infected person or objects with infectious secretions, even when they are dry. It is very important to avoid transmitting it in the hospital, and since we don't routinely test adults for it, we are probably very efficiently spreading it from infected to uninfected patients. The time from exposure to symptoms is 2-5 days. There is no vaccine, and people who get RSV can get it again, even during the same season, though perhaps more mildly. In very susceptible babies, a monoclonal antibody, Palivizumab, can be given monthly to prevent disease, but it is terribly expensive. For a baby it might run $1000 to $3000 per dose, but since it is dosed by weight, it would probably cost around $30,000 per dose for the average size adult. Not an option.

Prevention involves good hygiene, avoiding exposure to infected people, handwashing, and avoiding cigarette smoke which can make a person more susceptible. There is an antiviral medication, ribavirin, which is  active against RSV and sometimes used, primarily for immune suppressed patients like those with bone marrow transplants. Ribavirin costs about $30 a pill, would be dosed twice daily, has a black box warning for causing hemolytic anemia. It is not known if its use improves symptoms.

I think that it is likely that many of the winter adult lung disease admissions that I see are related to RSV. It is much more common than I believed. Since there are no really useful pharmaceuticals to treat it, none of the economic forces that lead to mass education are at work to raise awareness of its importance in the aging and chronically ill population that we internists see in the office or hospital. There is talk of vaccine development, but if natural infection does not give long term protection, it is unlikely that a vaccine will. It would certainly be nice if we knew whether ribavirin helped improve symptoms. Old fashioned and low tech prevention is probably the key to reducing its impact. I certainly need to be checking for it more often and thinking about taking precautions to avoid spreading it in the hospital or waiting room!

Nursing homes: what are we paying for and what are the alternatives?

The US population is getting older. There are about 9 million Americans who are over the age of 80 and about half of them need some kind of help in the activities of daily life. About 1.3 million Americans live in nursing homes. The average yearly cost to live in a nursing home is over $80,000, but that varies hugely by location. In San Francisco, the average cost of a year's stay is $144,000. In my state, which is notoriously cheap, if you live in a small town away from the big universities and population centers, it would cost closer to $68,000. This is quite the deal, but still more than double the average yearly salary for a working person. The total costs associated with nursing homes and assisted living in the US was $255.8 billion in 2013, according to the Medicare data.

Expensive, and...

What do you get for all that money? It varies, but generally nursing homes are older buildings and rooms are shared and often cramped. There is a hospital bed for each patient, sometimes a mattress on the floor if the patient is at risk of falling out of bed due to being demented and wakeful at night. That sounds a little barbaric, but it is actually a great idea when compared to bed rails or pads on the ground next to the bed, which can just make things worse. There is usually a shared private bathroom, with toilet and sink, sometimes a shower. There are 3 meals a day and snacks, like ice cream or pudding. There is a registered nurse available around the clock, but he or she may be responsible for 50 patients or more. There are licensed practical nurses available as well, and the ratio is a bit better for them, maybe 1 per 5 patients. There are nurses aids, less well trained, who help with dressing and toileting and cleaning up messes, and are spread pretty thinly. For-profit nursing homes, which make up the majority, have worse staffing ratios than state or non-profit facilities, and better staffing ratios correlate with better care and outcomes. There is often physical therapy available in a nursing home to help patients walk better or have less pain or regain function after an injury. Some nursing homes have speech therapy specialists who help improve swallowing and help patient learn to communicate after strokes. There are often activity directors who devise ways to make the time pass more pleasantly with games or crafts or music or movies.

People often end up in nursing homes when their health takes a sudden downturn, such as after an illness or injury that leads to hospitalization. After an acute illness older people are often profoundly weak and have lost the self confidence to return to their homes. Injuries such as fractures of the leg or hip may require that a person not bear weight, leaving them stuck in a wheelchair, needing help to get to meals or the bathroom. Many of these problems are temporary, but sometimes they are part of a cascade of events leading to no longer being able to function independently. When patients no longer require hospitalization, they may be transferred to a nursing home or "skilled nursing facility" (SNF or "sniff," for short.)

You can't always get what you want...

My patients tell me that nursing homes are, in general, terrible. Some patients are grateful and satisfied but most really dislike living in nursing homes. A large proportion of residents can't express themselves well enough to have an opinion that can be heard. What the ones who talk about it say is:

1. The food is bad. Usually it is mass produced and bland. In any case, people like their own special ways of making food, and this can't happen in an institutional kitchen.

2. It takes a really long time for a nurse or aid to come when a resident needs them. If this is to use the potty, often they are wet or soiled by the time help arrives, then they feel sorry and embarrassed. I think there is such shame attached to this that I only hear about a tiny fraction of it. If the problem is pain, the resident is often in such a state when the relief arrives that medicines don't work as well and they become irritable, alienating staff.

3. Mistakes are made. One of my patients, who was labeled a trouble maker, told me that 30% of the time he received his medications, there was some kind of error. Not necessarily large, but stuff like forgetting the aspirin, or giving him a whole rather than a half pill of something. The vast majority of mistakes like this would go completely unrecognized, not even showing up as a cause of morbidity, since most nursing home residents don't check to make sure their medications are correct.

4. Other residents are loud or rude or are just so sick that being near them is demoralizing. It would be nice if we could all be compassionate to our less fortunate or less polite peers, but many people need refuge, especially when they are old and vulnerable.

Like being in a sub-optimal summer camp as a child, people usually do adjust to living in a nursing home, but a large proportion of them, when they have returned home, tell me that they do not want to go back.

How about DIY?

It seems crazy that it should cost so much to live like this, when many nursing home residents were able to survive on a tiny social security check before they were admitted. What if they just arranged for the important part of this care without going to an actual nursing home? It sounds like a great idea, but the math doesn't work out that well. The average nursing home cost of $80,000 a year is what we have to beat. If we just start with the 24 hour care, it costs over $80,000 to pay someone $9.50 an hour for 24 hours a day, 365 days a year, and that isn't even a living wage. Compared to this cost, stuff like rent and food barely need mentioning, but $1000 a month for rent and utilities plus $400 a month for penny pinching groceries adds about another $17,000. Sharing the expense with a spouse starts to be comparable to the cost of a nursing home, but reliable home help that will not call in sick or smoke or mismanage money is extremely hard to come by. 

People have, for years, come up with creative ways of dealing with the process of aging. Before going further, I should mention the fact that humans have devised state and federal programs, Medicaid and Medicare, to help pay nursing home costs, since few seniors have enough money to pay their own nursing home costs. Medicare pays a large proportion of nursing home costs for patients who are expected to return home, but need a relatively brief nursing home stay after a hospitalization in order to do so. Medicaid will pick up the bill for nursing home costs when a senior can prove that they no longer have the resources to pay their own way. But there are also non-nursing home options that many people make work.

Living with family
As long as humans have existed, old people were taken care of by their extended families. This is shockingly inexpensive, since the very old don't eat much and already have all the clothes they need and rarely have expensive hobbies. Unfortunately not everyone has an extended family, and American lifestyles are not focused on having someone with time on their hands hanging out at home all the time. Even when family is available, things can go very wrong. About a year ago I saw a pair of sisters, one 96 and the other 102, who lived with their son in an apartment. They were hungry, thin and dirty and, according to the emergency medical crew, slept on a mattress together without sheets and just a grubby blanket. Their son wasn't cruel or abusive, just not much of a homemaker. There was shock and outrage among our hospital staff, but the sisters eventually went home with him because that was what they wanted.

On the very much more jolly end of the spectrum, one of my patients took her mother out of a perfectly fine nursing home to where she had prepared a room at her monastery. Her mother became more active and always had a novice assigned to her, who learned compassion by practicing it. She ate healthy food and complained about it, but she had complained worse about the nursing home. She got healthier and needed less medication. She eventually succumbed to old age, with hospice attending her at the monastery. 

Adult Family Homes
Since staffing is the biggest cost associated with care of the very old or disabled, adult family homes have arisen so that the cost can be shared among several clients. These are large private homes that have 24 hour staff, some of whom live there, and care for several older adults. Some of these are great. Near my home, there is a family home care place run by a family from Kenya, and I've been told that they are wonderful. One of the great benefits of a place like this is that staff turnover can be quite low. If staff live in the home or are close friends of the owners, they really get to know the residents and they get good at what they do. Also there are a smaller number of clients to take care of than in nursing homes, which means that care is more personal. Some of these places have come into the spotlight for providing terrible care, which is made more possible by there being less regulatory oversight.

Foster care
Adult foster care homes usually have one or very few clients, and caregivers need to have the basic knowledge necessary to care for their clients, but don't need to be nurses. If the chemistry is right, these can be great. I don't know of a clearinghouse for foster care providers, and in my experience these arrangements tend to happen when somebody knows somebody who is willing and able to do it.

Just a little bit of help at home
For people who don't need 24 hour care, staying at home and having help come in is much more affordable. Medicaid will even pay for this, in some cases. Some people remodel to make room for a roommate  and can trade rent for care duties. The patients of mine who have done this often have a long lasting solution that also can solve the problem of being isolated. They do, though, need to have contingency plans for vacations and illnesses and such. 

Out-sourcing--care tourism
What about out-sourcing? There are cultures that do personal care better than we do in the US, and at a much lower cost. Thailand, for instance. The last time I was in Thailand, there were professional massage places everywhere, and they cost maybe 5 or 10 dollars. Service in hotels was amazing and the staff actually seemed to enjoy doing their jobs well. The food was delicious. As it turns out, there are at least 2 nursing homes in Chiang Mai which are geared toward clients from Europe and the US. The very old in Thailand, and there are increasing numbers of them, are almost always cared for by their families, though there are a some facilities that cater to Thai seniors.  One of the ex-pat focused nursing homes is called The Care Resort and is pretty high end, with multiple levels of care and big beautiful grounds and outings to see elephants, or so it appears on the website. I can't find anything about cost on the website, but an article about it in the UK Daily Mail says that a year's cost is about 21,000 British pounds, which is about $35,000. Another such nursing home, which appeared on the website actually to have some Thai clients, is at the McKean Rehabilitation Hospital, which was a home and hospital for lepers when I spent time there in the 1980's, after finishing my residency. It was a beautiful place then, a bit outside of the city, with shade trees and open wards and a wonderfully creative approach to all aspects of leprosy as a chronic disease, but not a death sentence. The staff was cheerful and caring and there was an affiliation with the Presbyterian Church. The website makes it look fine, but not opulent. No prices are mentioned. The extended grounds still house some aging patients with leprosy (a disease which, despite its reputation, is not very contagious) who have no other home, and there is a strong outreach program to serve and rehabilitate people with all sorts of disabilities. 

Going to Thailand in one's great old age would have various benefits, not least of them elephants and tropical fruit. It is never cold, which would be good for those waning years when it is hard to get warm. There is a cultural kindness. On the not so bright side, though, family and friends would hardly ever visit. Medicare and Medicaid would not pick up the bill. Emergency hospital services would not compare favorably to the US. The recent movie, the Best Exotic Marigold Hotel, tells the story of some aging British people who move to India to live at a place that is trying to figure out how to provide assisted living for seniors, and portrays some of the drawbacks and benefits of outsourcing elder care. Moving to Asia is probably impractical for most aging Americans. Relocating would take a very committed friend or family member and a physically pretty intact potential nursing home resident and a hefty dose of courage and flexibility. 

Retirement Communities
Some people are wealthy enough and forward thinking enough to become part of continuing care retirement communities. For a chunk of money, which can range from $100,000 to over a million dollars, it is possible to have an independent house or duplex with the option to move into assisted living or a nursing home on the same grounds as the need arises. High end places of this type probably offer better staffing ratios and probably lower staff turnover than standard nursing homes, and it is certainly easier on couples who can live in close proximity even when one of the pair needs more help than the other.

Co-housing solutions
Cooperatives and co-housing offer another alternative to the corporate approach to aging care. This requires immense planning by community members, but is a way to deliberately and intentionally create an extended family with whom we can age.  

Having the conversation
So what should we do about the fact that we will all, with any luck, grow old? In the year 2050 it is estimated that 1 in 10 people will be over the age of 80. Perhaps half of them will require care of various levels of intensity. I will be 89 years old, if I'm not dead. The majority of people reading this will be 80 or older, or, possibly, dead. I venture to say that none of us wants to be in a nursing home. Are we really doing the hard work of remaining healthy and alive only for the opportunity to spend a small fortune living in a small fusty room with a roommate who may or may not be a suitable companion, waiting for a nurse's aid to come help us? Some solutions may involve technology, unloading overworked personal care givers by having robotic solutions to bedpans and med passing. Perhaps technology will unload everyone's job, and personal care will be one of the only jobs that still requires the work of a human. 

I think that it is mostly important for a conversation to begin, involving not just seniors who are vulnerable if they complain, but all of us who dread dependence and institutionalization. Those of us not yet old need to recognize that it is very unlikely that we will die before this issue becomes relevant. It is very inconvenient to say that the nursing homes we have now are an unacceptable solution to the problem of growing old. If we say that, we have to actually do something, because 1.3 million people need what nursing homes supply, and most of us are unwilling or unable to provide those services ourselves. 

Staying strong and useful
Besides actually planning for our years of dependency, perhaps we not-quite-yet-old also need to think about policies that make us less dependent. Most people dream of retirement, but the reality of not being useful or needed does not usually make us happy. I came upon a link to Thailand's initiatives on the elderly while looking at the nursing home situation there. In 2003 they passed The Elderly Act which, in addition to guaranteeing healthcare and basic food and shelter needs to older citizens, also grants them vocational training and support to become involved in community networks. I don't think we are doing that in the US. It might be a really good idea.

Vaccinations, measles outbreak and reasonable and civil discourse

Lately there has been an outbreak of measles, a vaccine preventable disease, along with an outbreak of people yelling at each other. There have been angry exchanges between people who would like all children vaccinated according to the recommended guidelines and people who support the rights of parents to choose which vaccines to give their children, if any, and when to give them. There has been much focus on the assertion, particularly, that the Measles/Mumps/Rubella vaccination (MMR) might cause autism. There is no believable evidence to support that assertion, but the questions of whether vaccination is safe and whether it should be required are much more interesting.

Yay Vaccines!
I am a big fan of vaccination as a means of fighting disease. It is an ingenious concept. The recipient of a vaccination gets an injection or oral dose of a weakened virus or bacterium or an inactive part of one, which causes the body's own immune system to produce cells that will recognize and kill the real virus or bacterium if it enters the body at some future date. Vaccinations are so much more elegant than antibiotics, which are chemicals that are broadly active against a whole bunch of different agents and only last until the body inactivates or excretes them. Vaccines stimulate the body's own very complex and amazingly effective systems for fighting infection in much the same way that natural infections or exposures would. These systems are then available to prevent disease whenever the need arises.

Herd immunity--that's how vaccines eradicate diseases
Vaccines are ingenious at the individual level, but they are even more ingenious on the level of populations. A vaccine raises an individual's resistance to a disease, but each individual is still somewhat vulnerable to that disease because the body's defenses are not absolute. Some vaccines are more effective than others, and some people have a more robust response than others. Infectious diseases persist in our communities because they move from one person to another. If the vast majority of people in the community are immune to a disease, as can be achieved with vaccination, the disease cannot be transmitted and will die out. The few people in the population who are not immune are protected by the many who are since the likelihood of coming into contact with someone with an active infection in such a community is very low. This effect is known as "herd immunity" and is one of the primary reasons that we should care about whether other people get vaccinated.

Curing smallpox
The word "vaccination" comes from the word root for cow, since the first vaccine in common use was derived from cows to fight smallpox. It had been observed that dairy maids who were infected with cowpox, a pustular disease, from touching the udders of infected cows did not get smallpox. In 1796 the physician Edward Jenner created a vaccine from that virus which became widely used. In 1979 smallpox, which killed as many as 500 million people in the 20th century alone, was declared eradicated. The vaccine was mandatory for school children, and I'm pretty sure I got it when I was a kid. It usually left a little scar on the upper arm but otherwise only rarely had side effects. Once in awhile, when a child had something that predisposed him or her to more serious infections, the vaccination would cause an overall body pustular rash which was very nasty. The vaccine is no longer in common use, but still exists, especially for preventing the tropical disease monkeypox which is similar to smallpox but milder.

Goodbye, polio
Other vaccine successes include polio, which was a virus that primarily infected children via the fecal-oral route, and caused paralysis, which was often fatal or disabling for life. The first vaccine was produced by Dr. Jonas Salk and was an injectable dead virus, and the second, close on its heels, was an oral vaccine that was a live attenuated virus (meaning it resembled the active virus but didn't cause polio.) Polio has been wiped out in most developed countries now due to vaccination, though it still breaks out in countries where vaccination is less common.

Measles, mumps and rubella
The measles vaccine was first licensed in 1962 and improved in 1968. It was combined with vaccines against mumps and rubella to create the MMR in 1971. It is estimated that the vaccine, in its first 20 years, prevented 52 million cases of measles, 17,400 cases of mental retardation due to measles effects on the brain and 5200 deaths. Measles causes fever, runny eyes and nose, a cough, a typical spotty rash and sometimes sore throat and spots in the mouth. I saw a case in Africa in a very miserable infant who probably had measles related pneumonia and had a reasonable chance of dying of the disease. Globally, measles vaccination has had a staggering impact. In the year 2000 it is estimated that over 700,000 people died of measles, primarily children, making it the 5th leading cause of death in kids. With a UNICEF backed measles immunization strategy, measles infections and deaths were reduced by 74% by the year 2010. Africa and India are major measles hot spots. There is no specific treatment for measles, so the only thing physicians can do is support the patient with fluids or oxygen if necessary and try to make sure the disease doesn't spread to others who might be vulnerable. Measles is very contagious. The vaccine, however, is very effective in preventing the disease. Rubella is another spots and fever disease, and can cause serious birth defects if a pregnant mother is infected with it. I had that one when I was a wee child and it didn't seem too bad, but I hope I didn't infect any pregnant people. There was no commonly available vaccine at that time. Mumps is a virus that causes swelling of the lymph nodes and can infect a young man's testicles, sometimes resulting in infertility. The vaccine is quite effective in preventing it, but not nearly as good for mumps as it is for measles.

Autism connection? Nope.
MMR is the vaccine at the center of the present controversy. In 1998 Andrew Wakefield, a gastroenterologist in England, reported 8 cases of children who developed autistic symptoms and gastrointestinal symptoms within 1 month of receiving the MMR vaccine. He proposed that the vaccine was causative, despite the fact that there was no obvious reason why it should be and there was no increase in cases of autism in the period after the MMR vaccine was introduced in England. His data was later questioned and thought to be fraudulent and the paper was retracted. Many studies have been done since then and have not shown any believable evidence that MMR causes autism, yet there are many people who still believe the vaccine/autism connection. Autism does present in early life and vaccines are given in early life, so a reasonable parent with a child who develops autism might suspect that the vaccine caused the autism, even though it did not.

But wait...not necessarily all good
Although it seems pretty clear that MMR doesn't cause autism, vaccines are not all benign and there are many diverse vaccines in common use. In the first 18 months of life the Centers for Disease Control recommends that a child receive about 24 immunizations, if I am reading this chart correctly. If successful, the vaccinations might prevent pneumonia, hepatitis, meningitis, chickenpox and the shingles that can follow in later years, tetanus, which can be fatal, whooping cough, most ear infections and rotavirus gastroenteritis. Also, of course, measles, mumps and rubella. But this is a lot of shots. Each one might cause muscle aches, listlessness and injection site redness and swelling. Children also often cry really hard and want never to go back to the doctor's office. The shot that prevents whooping cough can occasionally cause high fever and seizures and sometimes, though rarely, results in a temporary floppy unresponsive state that can't be a good thing. The reformulated version of this, which has been available for decades now, is less likely to cause these side effects, but the reactions still occur. The rubella part of the MMR can cause chronic arthritis in adults who are rubella immune if they receive MMR to boost their measles immunity.

Other vaccine greats
There are also immunizations for older children and adults which are just as miraculous and just as much of a concern with regard to side effects. These are recommended for various subgroups and situations, but not required for school aged children.  This is a list of all of the vaccines available in the US. One of my favorites on this list is the chickenpox vaccination. I must have been an odd and solitary child because I never got chickenpox. My twin got it when she was in her 20s and was really sick. She still has scars from it. Chickenpox is usually an annoying skin rash, with lots of small blisters that scab after a few days, but those little blisters can occur in the mouth and esophagus which makes eating and swallowing very difficult, and the virus can cause severe pneumonia. When I was in my thirties they released the chickenpox vaccine and I got one. Since that time I have been exposed to chickenpox, which is incredibly contagious, many times without getting the disease. This means that I, and the generation of children that have gotten that vaccine will never get shingles, which is a reactivation of chickenpox which causes pain and skin lesions, sometimes with lifelong pain and scarring. Despite the fact that the flu shot is sometimes disappointingly ineffective, I happily submit to it yearly because the flu is such a nasty disease and vaccination lowers my risk of getting it or makes it less severe if I do. The human papillomavirus (HPV) vaccination is also a winner. It is indicated in girls and boys to prevent genital warts that can cause cervical and penile cancer. It is still expensive and hasn't been embraced universally yet, partly because genital warts can also be prevented by having only one sexual partner for life and making sure that he or she has never had sexual contact with anyone else. Some parents forego the vaccine for their children because they believe that this will be achievable.  Cervical cancer kills 4000 women yearly and results in fertility threatening surgery and treatments in many more. The HPV vaccine could prevent these outcomes and potentially also make the dreaded pap smear obsolete.

Yellow fever: not without its problems
The yellow fever vaccine is both wonderful and terrible. In the 1600's yellow fever came from Africa to the Americas and eventually to Europe with captured African slaves. Yellow fever is so named because it causes liver failure with jaundice. It also causes nausea, vomiting, kidney failure and diffuse bleeding. It killed more soldiers in the Spanish American war than battle injuries. It slowed work on the Panama canal and infected people in Boston and other US port cities. In the early 1900's it was found to be caused by the bite of the Aedis aegypti mosquito and mosquito control led to significantly better control of the disease. It was still a considerable problem in places where mosquitoes could not be controlled so a vaccine was created in 1930 which has been very effective in reducing disease. Travelers to parts of South America and Africa are still at risk, as are residents. Unfortunately the vaccine can rarely cause a version of yellow fever in some people and can cause a fatal inflammation of the brain. The newer version of the vaccine is less likely to cause these side effects, but they can still occur. Despite the known side effects, travelers to many countries need to provide proof of vaccination in order to enter if they are arriving from an area with known risk of yellow fever.

The Swine Flu debacle
In 1976 there was an outbreak of swine flu (H1N1 influenza) in Fort Dix, New Jersey. One army recruit died, and there was fear that this virus, which was similar to the one that caused the influenza pandemic in 1918, would spread across the country. In fact, the only infections were at Fort Dix and 40 million Americans were vaccinated against it, resulting in quite a number of cases of Guillain Barre syndrome, an immune mediated paralysis that can result from both infections and vaccinations. On the bright side, apparently immunity from that vaccine did last until the most recent pandemic in 2009, so the folks who got that vaccine were less likely to come down with our most recent H1N1.

Where do we stand, legally?
The laws about vaccinating children differ by state. All states require some vaccinations in order to attend school, but some states offer exemptions, not just on the basis of medical issues such as immune system diseases, but on the basis of parents' religious or philosophical beliefs or values. With the recent measles outbreak, children who did not receive measles vaccination are being kept out of school, and some schools in California have reported up to 65% of students not being fully vaccinated due to their parent's objections. Some suggest more stringent requirements for vaccination, eliminating exemptions on the basis of religious or philosophical beliefs. West Virginia has already taken this step and several other states have only medical and religious exemptions.

Stupid people? Not so fast...
So are "anti-vaxxers" stupid and selfish? I don't think so. At least not necessarily more so than anyone else. Some of their concerns are not really valid, like worrying about the presence of tiny amounts of mercury as a preservative in some vaccines (hardly any now) and the possibility that multiple vaccines given at the same time will overwhelm the immune system (it's actually built for that: picture what happens when a child eats a handful of dirt.) There are some reasonable arguments against vaccinating ones children, even though I may not agree with them. Since vaccination protects the population and because it can be a big money maker for clinics, pharmacies and drug companies, it would not be surprising if we didn't hear much about occasional side effects. So suspicion is not entirely unwarranted. As a loving parent it is hard to be a party to 24 immunizations before the age of 18 months, especially since most of them involve sticking a needle into tender baby flesh. When a disease, like measles, seems to be vanishingly rare, how wise is it to expose one's children to an immunization which definitely has associated side effects (though not autism)? Some of the parents who reasoned in this way now have children with measles and many more have children who aren't able to attend school because they are not vaccinated. Are they selfish? They probably didn't think they were, but the vaccine isn't 100% effective and it isn't given until after a child's first birthday, so infection with measles does put other children, especially babies, at risk of measles and its complications.

Civil discourse--perhaps we should give it a try
How do we, as a society, want to deal with this issue? Americans are fiercely individualistic compared to many other countries, and we usually tell the government that they have no jurisdiction when it comes to our personal decisions. We draw the line (but it's a very wiggly one) at personal decisions that put our children or other people at risk. That's how our rules about vaccination came about in the first place. We, as physicians and nurses, now tell people about side effects of vaccines at the time they are administered, but we don't, in fact, allow them to refuse them for their children unless they also want to opt out of public school, except in the case of religious or philosophical beliefs. Do we want to close those loopholes as well? What we really ought to do is have civil and respectful conversations. We should carefully weigh both the value of controlling vaccine preventable and otherwise untreatable diseases against the actual observed side effects of vaccines. We want to support scrutiny by organizations that have as little vested interest as possible, such as the CDC. We want both sides, vaxxers and anti-vaxxers to avoid black and white thinking.

Health and Human Services announces push to end fee-for-service payments for Medicare

On January 26, 2015, the department of Health and Human Services (HHS) reported plans for a sustained effort to end "fee for service" in medical care. Fee for service is a model of payment we are all familiar with and it works really well when we get our car fixed or our dog groomed or our baby babysat. In these situations we want to pay for what we get, and if we aren't satisfied, we don't come back. If the dog's hair looks terrible a week later, we won't just go back to the same groomer and if any of the other people who do us service perform it in a way that makes us need ever more service we will go to someone else who gets the job done better.

Doctors and other medical service providers are primarily paid "fee for service" but most patients don't pay them directly and they don't have a good grasp of whether the job of doctoring is being done right, and they don't usually blame it on the doctor if he or she tells them that they need to keep coming back and keep getting things done in order to be healthier. The result is that doctors make more money by providing a service that keeps patients coming back for yet more treatment. A dermatologist is not financially rewarded for diagnosing and removing a potential skin cancer in one visit and calling us on the phone with the results, despite the fact that most of us would prefer that. He will make much more money by diagnosing the spot one day, having us return for a biopsy, then return to have the stitches out and to discuss the results, then again for the excision and then to review the pathology report. If I, as a primary care provider, treat a condition and in so doing make you sicker or more insecure, resulting in more visits, I will be monetarily rewarded. The economics of fee for service make medical care more expensive and more time consuming and don't encourage good health.

Payers, especially Medicare, have worked hard to reduce this tendency to make more money by doing more things, rather than by giving better care. Years ago they began bundling payments for hospital stays, paying by the diagnosis rather than the intensity of the treatment provided. Doctors' fees, though, have been relatively spared, as have costs of individual surgical or diagnostic procedures. With the introduction of the Affordable Care Act, Medicare has been phasing in the practice of not paying for preventable readmissions, which provides a strong incentive for hospitals to keep patients for long enough to ensure they are well enough to go home and stay at home. Some patients are too unstable, either socially or medically, to stay out of hospital long, which makes this strategy far less than perfect.

What HHS would really like, though, is for the health care system to provide appropriate and efficient service without significant oversight. This would cost them less and allow them to focus their attentions on something more interesting, like human services, whatever that entails.

In their January 26th announcement HHS has characterized the evolution of Medicare payment as a series of 4 steps or categories. The first is fee for service, which we are transitioning away from, at least sort of. The second category is linking fee for service to quality--we will still be paid according to the volume of work we do, but we will be paid better if patients are made healthier with better efficiency in how we use resources. The practice of not paying for preventable readmissions and not paying for the treatment of preventable complications is an example of this. Category 3 is paying us a little differently than fee for service while maintaining some of our present structures. The most talked about model is the Accountable Care Organization (ACO) which brings doctors and other service providers together to care for patients in a coordinated manner which will presumably save money, some of which will be given back to the providers as a bonus for doing such a good job. The other model, which works for smaller organizations, like clinics, is the Patient Centered Medical Home (PCMH). This pays physicians at a higher scale when they keep track of patients better, including having care coordinators for complex or high risk patients and making sure preventive health care is actually done. Both the ACO and the PCMH are total bears to set up, expensive, and require computer systems that function at a really high level and practitioners who know how to use them. The up front costs are amazingly high and the administrative support required is huge. Because of the massive amount of detailed data gathering and manipulation required to make these things fly, they burn doctors out and make us spend even more time looking at computer screens and less time talking to patients.

Category 4 is good, though. Category 4 is population based payment, and is the system that would reduce the need for HHS oversight. Clinicians or organizations would be paid to provide care to people for, say, a year. The incentive, then, is to make patients as healthy as possible with as little intervention as possible so that we can reduce the intensity of the medical care they need. Providing good, high quality care would mean patients are less likely to need expensive hospital stays or procedures.  This system provides an incentive for the dermatologist to take care of the little skin cancer in one visit and encourages me, as a primary care provider, to give you just the care that makes you healthy and confident. Some people actually like going to lots of doctors appointments and getting lots of tests, and they may not be pleased with population based payment. Care that makes patients a little happier for a lot more money tends to thrive under our present fee for service system,  especially with insurance paying the bills. This kind of care would happen less frequently. When better treatments do arise, there will be strong incentives to find ways to make them less expensive. Population based payment's natural tendency to improve value would definitely bring down healthcare costs. There will also be a tendency to stifle astronomically expensive innovation, which has been far more common than low cost innovation in our profit driven system.

HHS says that they hope to have 30% of Medicare patients in category 3 or 4 by 2016 and 50% by 2018.

Changing the way things are paid can be really difficult, however. This category 3, with the ACO and PCMH requirements, is so complex as to be almost impossible and maybe not even a good idea. Paying for population health sounds to physicians a lot like managed care, which we tried years ago and sometimes made us feel like jailers, denying patients care that was expensive but right for them. If patients have adequate input into what is valuable to them (it looks like the medical establishment is moving in that direction) some of those problems may be allayed. But one of the biggest hurdles is that if private insurance continues to pay fee for service, we will continue to have systems set up that push for us to do more rather than better. If we get good at taking care of a patient's needs in one visit rather than several, we may feel penalized if insurance companies other than Medicare now pay us less. HHS has decided to set up Learning and Action Networks to interface with private insurance and other payers to encourage them to adopt population based payments, which would save them money as well.

Population based payment is where I would like to see health care move, but it will be a painful transition, if it works. A huge amount of the money that goes into health care (I've heard figures as high as 50%) is spent on billing and all of the record keeping relating to that. If doctors and hospitals are paid by the number of patients for whom they provide care, we will not be billing insurers for what we do.  As lovely as it is to think of a system without billing, those people, doing that work, will lose their jobs. At least most of them will. As we reduce overdiagnosis and overtreatment, which would be a natural consequence of population based payment, hospitals will lose revenue and some of them will close, unless they can re-tool to help healthy people stay healthy. Radiology technicians and lab technicians will also lose their jobs, because much of what we do in medicine is based on an exaggerated idea of what is needed, shaped partly by generations of being paid fee for service. It will be particularly awkward to move from the very high administrative burden of category 3 to the simpler and more focused category 4 of population health and population based payment. Bureaucracies like to be large and tend to grow. At some point in this evolution they will need to shrink. Something like 17% of our gross domestic product goes into healthcare, which is a sizable chunk of our economy. The money we expect to save on more efficient health care is huge and may have a very large positive effect on something, Transitioning health care jobs to ones that are life sustaining rather than ones that react to disease and dysfunction could be beautiful, but it is not at all clear what it will look like on the way to that goal.

Thanks HHS for keeping us focused on a payment system that provides an incentive to keep people healthy, but do take it slowly and please prepare for the consequences.

Treating the flu: does Tamiflu (oseltamivir) work and does it have side effects?

The flu season has really gotten into gear now with 46 of our 50 states reporting widespread influenza activity as of January 3, 2015. Influenza is a virus that infects the respiratory tract, causing sore throat, runny nose, fever and cough. Rarely people with the flu will have nausea, vomiting and diarrhea, but this is not "stomach flu" which is a term some of us use to describe any one of a number of viruses that give us intestinal symptoms. Influenza is the one where you hurt all over, you have a high fever and cold symptoms, then you start coughing and you can barely get out of bed for days. Sometimes it's milder than that, but it can also be more severe, affecting brain function and sometimes requiring oxygen or life support with a ventilator. It also kills people, on the order of about a half a million worldwide every year, either directly by the destructive effects of the virus or by setting the stage for a devastating bacterial pneumonia.

Flu is very contagious. A person with the flu can spread it to others for 1-2 weeks, and it frequently runs through whole schools resulting in as many as 1 in 3 children being absent from classes. The very best way to reduce the spread of flu is to have people with the flu stay away from people without the flu. Hand washing is also good. Epidemic flu usually lasts for about 13 weeks each year, tapering off toward the end of the season, and usually it's pretty much gone by March. This year we are starting with influenza A which is usually the most severe type, and the genetic signature is not one that is well covered by the present flu vaccine. The Centers for Disease Control (CDC) posted an article detailing the present flu situation. They estimate that the vaccine is 23% effective, but that is based on an odds ratio calculated by comparing a group of sick people who did or did not have the flu when tested and looking at whether or not they were vaccinated. What they mean is that if you are sick enough to be tested for the flu, you are 23% less likely to actually have the influenza virus if you got the vaccination. But the vaccine is still recommended because there will be influenza B coming around later as well as the non-seasonal flu, H1N1, which should be covered by the vaccine. There is also a chance that the influenza A you are exposed to could be one that has not genetically drifted, which might mean the vaccine would make you more immune to it.

This year's flu is a pretty nasty one, with many people getting sick enough to need hospitalization. It is not the most terrible we have seen, and is similar in how sick it makes people to the 2012-2013 season, 2 years ago. Because the vaccine is less effective this year, though, the CDC is recommending that physicians be very generous about prescribing one of the two influenza antiviral medications. These are oseltamivir (Tamiflu) and zanamivir (Relenza). Oseltamivir (which is not available as a generic) is a capsule or liquid which is dosed twice daily and costs a bit over $100 for a 5 day course. Zanamivir (also still on patent) costs a little less and is inhaled, twice daily, and is contraindicated in asthmatics since it can make them wheeze. The Cochrane Collaboration, an organization which reviews scientific data in an unbiased fashion, says that neither drug does much for healthy people infected with the influenza virus, and there is no really good data to determine if it helps people who aren't otherwise healthy or who are desperately ill with it. They both tend to make the symptoms a little less severe and shorten the duration of illness by 1/2 to 1 day. I have been prescribing them generously for years to my patients with the flu, since I know how nasty it is and have always figured that they could use all the help they could get.

A few days ago a friend asked me if I had heard anything about mental effects of Tamiflu. She said that an acquaintance of hers had a son who had committed suicide after being started on it. His girlfriend had just left him, but he was a very psychologically stable person, and this wasn't like him. She said that she had heard that the drug could make people mentally unstable. I thought that it sounded like hogwash, so I checked my handy dandy iPhone Epocrates app and found that behavioral effects and self injury were quite high on the list of serious side effects. Today I looked further into it and found that in Japan, where Tamiflu is used more commonly than in the US, they reported quite a few cases of psychological side effects, including delirium, primarily in children and adolescents within the first 48 hours that they took the drug, with something like 70 deaths. The Food and Drug Administration reviewed side effects, especially during the 2009 pandemic when Tamiflu was widely used and found that there were some psychological side effects reported, but pretty rarely. There were also some severe skin reactions, even resulting in death. There were more case reports, including a girl who had manic depressive symptoms that resolved only after a few months, out of South Korea. Tamiflu also makes about 1 in 9 patients vomit.

In general oseltamivir (Tamiflu) is safe and the influenza vaccine is safe. They are also both somewhat, though not gloriously, effective. Both are lucrative for the companies that make them. The flu is a huge public health issue, causing death and disability and work and school loss, and it repeats itself yearly, with varying intensity. Because control of the flu, even shortening illness by a day or decreasing transmission just a bit, is so very important on a population level it is likely that the down side to an individual will tend to be minimized. As an individual and as a member of a human herd, I will continue to get yearly flu vaccines and nudge my dear ones to do the same. If I wake up feeling like I got hit by a truck and then nanobots have attacked my mucus membranes with sandpaper I will probably take one of the anti-flu drugs (but maybe zanamivir since it is cheaper and probably won't make me jump off a balcony.) These are decisions, though, that individual patients should make after being fully informed of both effectiveness and potential side effects.

Bedside ultrasound in the developing world: what is it good for?

In the last year and a half I've been able to go to Africa 4 times and Haiti once, for which I give thanks that the world still produces abundant fossil fuels. That much airplane travel does make me feel a bit guilty, even though I'm not actually vacationing.

Going to far away places to practice medicine has always been something I hankered after, and it turns out that knowing how to do and teach ultrasound is a good way to get invited to exotic places. I think if I could do cleft palate surgery or eye surgery or had a traveling dentistry practice I could also be useful in foreign lands, but as an internist it is more difficult to find something that I can do well in a hit and run fashion which actually benefits people. Bedside ultrasound, particularly teaching it, fits the bill.

Forgive me for repeating myself if you've already heard the story, but when I quit my regular primary care practice, I learned to do bedside ultrasound. I fell quickly in love with the ability to see inside people, sharing with patients their living anatomy, quickly making appropriate diagnoses and designing appropriate management, following patients' response to therapy. I learned how to ultrasound the heart, lungs, liver, gallbladder, kidneys, bladder, spleen, intestines, great vessels, and also how to teach other people. It's been exciting and time consuming and tons of fun, and has become an integral part of my practice as an internist and hospitalist. I've written many blogs about how ultrasound has changed my practice, but I still get the question, "what's it good for?"

What it's good for varies according to the setting. A bedside ultrasound is usually done with a machine that is small enough to carry in one hand. Mine, a General Electric Vscan, is about a pound and has a screen that is just a few inches across. It gives surprisingly good pictures, but they are nowhere as good as the big ultrasound machine in the radiology suite. If that big machine was pocket sized, I'd be like the doctor on Star Trek. Because the bedside machines are smaller and less expensive than the full size ones, their resolution is a little bit worse, so they are best for asking relatively simple questions. Also bedside ultrasound is performed by doctors who also do things other than imaging and haven't spent the extensive amount of time radiologists have in learning subtleties of reading radiological images. At my hospital in the US I can answer questions with my small ultrasound machine like, "is there fluid in the peritoneum?" or "are there gallstones?" or "is the heart squeezing OK?" or "are the kidneys/ureters blocked?" I can feel confident about whether the bladder is over-full or whether there is fluid or infection in the bases of the lungs. I can see pulmonary edema and amounts of pleural fluid that are too small to be seen on x-ray. I can follow the course of intestinal distress such as gastroenteritis or obstruction. Sometimes I can't see enough to say anything, most often if the patient is hugely fat or is plastered with bandages or stickers that I can't remove. If I need to really know what is going on inside a patient who I cannot image with a bedside ultrasound, I can order a radiological study and usually get my answer in a reasonable time period. When I can look myself, though, my treatment decisions are more fluid and timely.

In the developing world there are less x rays and CT scans available, less official ultrasounds, and having the ability to do bedside ultrasound is pretty magical. There are many ultrasound machines in these out of the way places, and what is mostly needed is training. There could be more machines, of course, and when it becomes more clear how useful the technology can be, more resources may be focused in that direction. I have ultrasounded in Tanzania and South Sudan and the island of La Gonave, off the coast of Haiti, and the procedure, quick, painless and free, was profoundly influential. Last month while I was in South Sudan there was a war on nearby, and there were freshly and not so freshly wounded soldiers, which was a new thing for me. Here are a few cases of exactly what ultrasound has been good for in the developing world:

1. Young man with a gunshot wound to the leg. Is it broken? Is there a pus collection? Ultrasound is really good for ruling out long bone fractures and finding subcutaneous fluid collections. The wound was only in the muscle and a little cleaning and bandaging did the trick. No need to transfer this one to a higher level of care.

2. Different young man was injured in the face with shrapnel. He is unable to see out of one eye. Is the retina damaged (a bad sign)? Ultrasound is quick and efficient as a tool for looking at the eye, especially if the patient is unable to open it for an exam. This guy did have a thickened and abnormal retina with evidence of blood in the posterior chamber and a metallic foreign body. He is not likely to get his sight back in that eye.

3. Little boy shot in the chest and short of breath. Is it a punctured lung? A burst blood vessel bleeding into the chest? Is the heart damaged? For this boy it was none of these things, but a contusion of the lung, which looks a bit like pneumonia on ultrasound. A chest tube would have further compromised that lung and the boy avoided this procedure. Where is the bullet? It would have been great to have an x-ray to find that out!

4. A young woman with vaginal bleeding after three months of thinking she was pregnant. Is she having a threatened miscarriage or is this just an irregular period? Ultrasound is wonderful for seeing a uterus and whether there is a baby hiding inside. We saw many of these cases. Sometimes there was a baby, sometimes not. The treatment, bedrest vs. normal activity, was very different and knowing which was indicated could profoundly impact the whole family.

5. A little baby with an enlarging lumpy area on the lip. I could just imagine all of the creepy things it could be. The ultrasound showed it to be made up of blood vessels, so it is a cavernous hemangioma, which is a common benign tumor in infancy and usually goes away or shrinks by itself, and sometimes requires medications to help it go away.

6. A young man has been getting weaker, with swollen legs and a barrel chest. Is it heart disease? Perhaps something he was born with? These might be treatable with medications. Unfortunately it was not. There was a huge tumor obstructing blood flow to the heart and lungs. Good to know, though heart wrenching.

7. An old man, failing to thrive. He has back pain. Ultrasound shows he has a large bladder tumor which is blocking his kidney. Caught this late, and in a war zone, this is not treatable. Knowing helps his family to make plans.

8. An uncharacteristically pudgy woman with recurrent abdominal pain. Is it an ulcer? Actually no, her gallbladder is full of stones and is tender to push on. Surgery will help, and this lady lived in a place where that was safe and available.

9. A young woman with pelvic pain. Is it a tubal infection? A bladder infection? It is not hard to visualize the abdomen and pelvis with ultrasound, and this person had a ruptured ectopic pregnancy with blood loss into the abdomen. She will die without surgery and she will likely do fine with it. She was rushed, appropriately, to surgery.

10. A woman with a full term pregnancy: she hasn't been feeling the baby move. Is it in trouble? Ultrasound is absolutely wonderful for looking at babies, since they float around in a big balloon of water. This woman's baby looked healthy. Good news.

11. A woman acutely short of breath, with some chest pain: is it asthma (common) or her heart? Strangely enough her heart wasn't squeezing very well and her lungs looked wet. She responded well to medications for pulmonary edema and was fine the next day. I have no idea what that was about, and can't find out further because I'm home and she is probably lost to followup.

12. Pyomyositis: people get collections of pus in their legs and sometimes arms for no obvious reason. Then they get very sick and if the pus is not drained, they die. When a leg is swollen up it's pretty hard to know where to cut to release the pus unless something like an ultrasound tells you where it is. We doctors love draining pus. The young man in question, a retired child soldier, had relief of his condition and will get well.

13. A soldier, clearly sick after being shot in the belly: Has the bullet injured a blood vessel or vascular organ? Is there a significant amount of free air to suggest a major intestinal perforation? The FAST scan (focused assessment with sonography in trauma) looks for fluid, usually blood, in the belly and can determine whether a patient needs emergency surgery, if available, to avoid bleeding to death. Lots of free air looks like air anywhere, with air artifact and multiple parallel horizontal lines. This young man had peritonitis, with thickened bowel walls, fluid filled bowel loops and small amounts of fluid between the intestinal loops. He was transferred to a higher level of care after receiving antibiotics and fluids.

Also...babies with loud heart murmurs, young men with testicular swelling, the worried well...
Ultrasound in the developing world is great!

Just got back from South Sudan--thoughts about tropical medicine

I just returned a few days ago from the Republic of South Sudan, where I spent about 3 weeks. Jet lag is fading, and in time I may even stop complaining about how incomprehensibly bad the Juba airport was. Overall the experience was great, though.

My intention was to spend 2 weeks with my friend Jill Seaman, a doctor who has been working in Sudan for decades, primarily fighting tuberculosis and visceral leishmaniasis by establishing  and pushing treatment protocols. Jill now helps run a community hospital in the (usually) tiny town of Old Fangak, on the Zeraf River. The hospital serves a community that usually numbers a few thousand along with anyone who can make their way there, but now Old Fangak has become a busy metropolis of over 30,000 people because of the many people who have fled their homes due to fighting. My job was to help out with patient care and teach bedside ultrasound. The other week of my three week trip is how long it takes to get to and from Old Fangak. I only got 10 days there, as it turned out, since the government has become more strict about flights to and from that area because it is a hot spot in their civil war. South Sudan is a new country, having gained its independence from Sudan in 2011. There was relative peace until last December when violence broke out in the capital between supporters of the ousted vice president and the president over policy disagreements. Since the vice president was from the second largest tribe, the Nuer, and the president was from the largest tribe, the Dinka, the disagreement became a tribal conflict in outlying regions which has been bloody and destructive. South Sudan has had lots of civil war, and this situation is more the norm than peace, which was sort of present for 2 years after independence.

My last visit to South Sudan was a year ago, right before the new civil war broke out, and my timing in leaving was close to perfect, since the whole place became hellish a week after I departed. This time the war was pretty close to Old Fangak, but its isolation, with no passable roads and only access by river, made travel there pretty safe. Still, much of the medicine this trip had to do with wounded soldiers. There was also the usual constant stream of the medically ill and occupationally injured, with their tropical ulcers, parasitic diseases, diarrhea and fevers.  Complications of starvation will set in more substantially due to disruption of farmers and cattle herders, but presently food aid from organizations such as the World Food Program is keeping this partially at bay.

When I got back, the Christmas holidays were quickly approaching. Family from far away were going to descend on our house, and I had piles of journals and notes and bills and certificates on important horizontal surfaces. While taking care of these, I found the notes I took from a brief DVD course in tropical medicine, released by the Mayo Clinic, that I took last year. I don't actually have a place to put hard copy notes where I will see them again and learn from them, other than coffee tables which would look way better without stuff all over them. So I am going to combine what I learned in South Sudan in Old Fangak with my notes as a way of remembering stuff. Here goes!

Poor nutrition, homelessness, poor sanitation and stresses underlie most of the conditions we saw. The vast majority of illness and injury we saw were preventable by clean and adequate water supplies, food and shelter security, good prenatal care, waste disposal and non-violent problem solving. There were almost no uncomplicated conditions. We saw patients in several situations. There were the inpatients, who had beds or pads on the floor of the hospital buildings and were given mosquito nets. They were usually the sickest patients, with problems that were life threatening and sometimes without easy solutions. There were patients with wounds, who were living either somewhere in the compound or in the surrounding village and would come in for dressings and sometimes minor surgical procedures. There were clinic patients who came to the morning, afternoon and evening clinics, staffed by local clinicians (nurses, clinical officers and community health workers) and sometimes by a doctor. Patient visits in clinic numbered around 200 per day. Some of these became inpatients. There were patients with conditions that required less intensive observation but which required long treatment courses, such as tuberculosis, nephrotic syndrome, Kala Azar and Brucellosis. These are exotic and rare in the US and common as dirt in Old Fangak.

Malaria is the most likely cause of high fever. It is the treatable cause which needs to be ruled out first. The test we use is a "paracheck" which is a rapid diagnostic test based on presence of malaria antigens. A drop of blood from a fingerstick is placed on a plastic stick with absorbent paper inside, a drop of fluid is added and lines appear in a few minutes indicating a diagnosis of malaria. This is similar to a urine pregnancy test and can be done in the clinic or at the bedside while the patient waits. The commonest form of malaria by far in Old Fangak is Plasmodium falciparum, the most severe and acute variety. It can present with metabolic acidosis, shock, coma, renal failure, even ARDS. In Old Fangak it can have all kinds of associated symptoms especially nausea and vomiting with diarrhea. Most cases can be treated with oral Artemisin combination therapy though cerebral malaria and other severe presentations are treated with intravenous medications. Somewhat less severe versions of malaria are caused by Plasmodium vivax, ovale, malariae and knowlesi (usually in southeast Asia) and these have different fever patterns. The Anopheles mosquito transmits malaria and is controllable with elimination of standing water (mostly impossible) and use of insecticides. Since these mosquitoes primarily bite as evening falls, use of mosquito bed nets, especially for children, drastically reduces malarial disease. Pregnant women are treated monthly during their first trimester with Fansidar (Sulfadoxine/Pyramethamine) because they are more susceptible to the disease and because it can cause miscarriage.

Visceral Leishmaniasis, also known as Kala Azar, commonly presents with prolonged fever, enlarged spleen and liver, sometimes with diffusely enlarged lymph nodes, and bone marrow involvement which can lead to anemia and low platelet and white cell counts. It often coexists with HIV infection, though not so much in Old Fangak where HIV is still relatively rare. It can be diagnosed with a rapid diagnostic test which detects rK-39 antibodies and is about 80% sensitive. If this is negative, a DAT (direct agglutination test) is performed which should detect 95% of cases. A lymph node aspirate can detect the actual organism, which is helpful when the immune response is not vigorous, like with HIV coinfection. It is about 60% sensitive, and can be used for detection of recurrence, unlike antibody and agglutination tests. Spleen aspirates, also useful in recurrence, have sensitivities as high as 95%. The lab staff is capable and confident in performing lymph node aspirates, which in the US would be a great big deal, and splenic aspirates are performed at the bedside in patients without significant bleeding risks, quickly and nearly painlessly, with vanishingly rare complications. The specimen is smeared on a slide, giemsa stained and examined for the tiny protozoans which look like an eyeball with a dot and are about the size of a platelet. The disease is usually treated with sodium stibogluconate (SSG) and paromomycin injections for about 3 weeks, which often cause nausea and vomiting an can also cause fatal heart arrhythmias and kidney problems. A less toxic but much more expensive option is liposomal amphotericin B which is given intravenously on an intermittent schedule, usually over 21 days. This is used for resistant or recurrent cases and in patients who don't tolerate the SSG/paromomycin regimen.

Back pain and tenderness, prolonged fever with weight loss, chronic arthritic joints in children, unexplained chronically enlarged lymph nodes, especially with fluid collections inside and cough with fluid around the heart or lungs is usually tuberculosis and requires prolonged residence at or near the hospital compound for directly observed treatment. Treatment of TB is effective and lifesaving and most patients comply with medication therapy which is impressive. Worries about contributing to multi-drug resistant tuberculosis slowed the development of programs to treat the disease, but at Old Fangak people are getting appropriate therapy along with nutritional support, blankets, mosquito nets and sometimes shelter and are being cured of their TB.

Nausea, vomiting and diarrhea could be anything, but is often Giardia. In many areas of Africa good sanitation has made this uncommon, but it is pretty rampant at Old Fangak. Despite aggressive latrine construction, babies and children, especially those with diarrhea, leave Giardia parasites everywhere, and though both Sudanese and Americans are clean and tidy in their own homes, the hospital compound seems to be covered with a thin layer of filth. Most floors are dirt. The floors that aren't dirt are mopped daily, but walls are not and small islands of cleanliness do not make a huge overall difference in infection control. Giardia is treated with tinidazole which tastes horrible and is slightly nauseating. It seems that, improbably, most children actually take it when it is prescribed.

Schistosomiasis is probably nearly universal, since most people swim and bathe in the river, which carries the parasite to the skin of the human host, which it penetrates to cause infection. Schistosomes are blood flukes which can affect most body systems, but schistosomiasis is usually either assymptomatic or associated with symptoms that are hard to notice, such as discomfort with urination or fatigue from chronic iron deficiency. The two types present in Africa are mansoni and haematobium. Mansoni is famous for causing portal hypertension with symptoms of liver failure, but more commonly causes chronic intestinal distress and intestinal blood loss. Haematobium is known for causing scarring and sometimes cancer in the bladder. The eggs can be identified in urine or stool, but in Old Fangak it is most often treated when patients present with classic symptoms, since most people are likely chronically infected. Reinfection is nearly impossible to prevent, though in some countries routine and repeated blanket treatment has been tried. Praziquantel, as a single dose, is usually effective in clearing the disease, and is sometimes used prophylactically for children at high risk.

Tapeworms and roundworms are surprisingly rare in our little community, but with the influx of internally displaced people that equation may be changing. These are pretty easily treated with a single dose of a pleasant tasting tablet, albendazole. They can cause intestinal distress and malnutrition and are associated with poorer school performance. I did see one case of an overwhelming infection with Strongyloides stercoralis, a roundworm, in a young woman who was chronically ill with kidney failure and vomiting who had tiny worms in her urine. Despite appropriate treatment, she died. Once this infection becomes so widespread it is hard to eradicate and usually implies an associated immune dysfunction. Malnutrition and kidney failure might have been what made her vulnerable.

Brucellosis is a disease carried by cows and dogs and transmitted to humans primarily through contact with their urine and feces. The cows, which are a common form of wealth and currency in South Sudan, are heavily infected. A vaccination program could be very effective in reducing cow morbidity (primarily abortion and infertility) as well as human disease but hasn't been tried. Ongoing civil disruption due to war gets in the way of all sorts of good ideas. Brucella causes recurrent fevers with nausea and vomiting and overall feeling miserable and can persist for years, causing chronic arthritis of the large joints and the back. Most infection is assymptomatic. It can affect the skin, with rashes, the eyes, causing inflammation and blindness, bladder, testicles and ovaries, lungs and brain. It is diagnosed in the lab with a serum agglutination test and treated with 6 weeks of doxycycline along with 2-3 weeks of gentamicin, which is usually given as a rather painful intramuscular shot. It frequently recurs.

Chronic kidney disease with nephrotic syndrome is surprisingly common and probably related to ongoing immune system activation by repeated infections of various kinds. This is treated with a slow taper of prednisone, which sometimes works. Patients usually present with facial and leg swelling along with frequent urination and fatigue. There is a fingerstick monitor of the creatinine level, something I haven't seen in the US, which is the only available way to document the status of a patient's kidney function. High blood pressure is treated appropriately which helps in recovery or at least to slow the progression of disease. Endstage kidney disease is right now a terminal diagnosis since there is no available dialysis or kidney transplant available to these people.

Late stage cancer is surprisingly common. There was a 17 year old boy with a tumor in the chest that had displaced his heart to the right chest cavity and obstructed blood flow into the heart. It was likely a mediastinal germ cell tumor, since this is not terribly uncommon in young men. It is quite sensitive to chemotherapy, even curable, but this person presented at such a late stage that he would have been lost even in the US. He had been in bed close to a year, had deep bedsores and legs which no longer would straighten. He had devoted parents and a winning personality. He died after a week in the hospital. There was a man who came in unable to swallow. This had progressed over a year, but his esophageal cancer (visible on bedside ultrasound) had now completely obstructed his swallowing and, though he would receive some intravenous hydration, there was nothing we could do for him. In the US he would likely have died, but would have had palliation with radiation therapy and a feeding tube. Esophageal cancer is common in East Africa. A woman returned to clinic after having received radiation and chemotherapy for a tonsillar cancer that turned out to be a lymphoma. With advice from doctors who were friends of Jill's, she received appropriate therapy and was free of disease when she returned. A beautiful young man had a deep and fungating wound of the right groin that was foul smelling and liked to bleed. It appeared to be a squamous cell carcinoma, but we did biopsy it and results are pending from Nairobi. He could get radiation therapy for palliation if transport could be arranged and if he is able to survive that long.

Tropical ulcers are very painful and appear usually on the lower legs after minor trauma. They are inhabited and probably caused by a collection of bacteria and can cause bone infections and even cancer if untreated. These are very common, and are treated with dressing changes, debridement and antibiotics. Presently we are using gentian violet topically which seems to speed healing. War wounds often cause extensive tissue damage and are treated with dressing changes and sometimes delayed primary closure once they are clean and healing. They can be disfiguring and painful. I tried a combination of guar gum (a component of many high tech wound dressings) with powdered antibiotics for some of the more weepy wounds. This was popular with the patients but I wasn't there for long enough to see if it improved healing. It did appear to reduce evidence of infection.

Pneumonia, especially in kids, and diarrhea with dehydration in babies accounted for a reasonable amount of sickness. Most pneumonia is treated, successfully, with amoxicillin, some with ceftriaxone, and diarrhea was treated with oral and sometimes intravenous rehydration, with treatment for the specific cause if that became at all clear, often with antimalarials or antibiotics. Runny nose with runny eyes, especially in the presence of rash was measles and often quite a severe disease in small children. Most medical missions take vaccination of children quite seriously, but most remain unprotected.

In the US I normally see complications of heart failure and vascular disease, primarily related to smoking and obesity, diabetes and its sequelae, chronic lung disease, again related to smoking and infections that are often complications of IV drug abuse. I also see the devastations of extreme old age with dementia worsened by urinary tract infections or pneumonia. None of this is common in South Sudan. In the hospital at Old Fangak the common conditions are about as diverse as I see at home, but the options for diagnosing and treating them are much more limited. For me there was quite a steep learning curve. 

Staff from the community who have little or no formal medical training do a tremendous amount of the work, including diagnosing and treating very significant and, for me, exotic diseases. This is made possible by protocols developed by generations of doctors, including ones working with Doctors Without Borders and especially Jill Seaman who has been doing this kind of thing for a really long time. When no Americans are present, Kala Azar, tuberculosis, brucella and many other diseases are treated effectively and followed appropriately by South Sudanese health workers. They could certainly use more training, but I am in awe of their skills. I saw one of them put an IV in a dehydrated baby with no difficulty which I doubt could have been done with such skill in a US hospital. With access to medical and nursing school, which they do not have, their potential would be tremendous.

Working in Old Fangak is something that doctors dream about. It is expensive to travel there and disruptive to my work schedule, and there are all kinds of diseases that are easy to pick up. There are grouchy people with AK47's wandering around looking twitchy. The medical care requires flexibility and is often incredibly frustrating when lack of resources makes it impossible to solve a problem that is so very soluble if only the situation were different. Still, the company was excellent and the patients were great and the attitudes and skills of people working there were inspiring. It was deeply fulfilling, I learned a ton and have a bunch of great stories. Also... hooray, I didn't die!