KOLAHUN

Andreas Vesalius, M.D. (1514 - 1554)

Here we have the Physician and Surgeon’s Almanac for December 31, 2012.

It’s the birthday of Andreas Vesalius, M.D., born Andries van Wesel on this day in Brussels, Belgium in the year 1514. Descendent of a line of royal court physicians, he was the son of Anders van Wesel, court-apothecary to the Emperor Charles V of the Holy Roman Empire.

In Padua, in 1537, he became a doctor of medicine and, in his short career as an anatomist, he introduced the Renaissance to medicine, dispelled over a thousand years of accepted medical beliefs and convince us to look at our bodies with our own eyes.

Galen anatomy (left)                                                        Vesalius anatomy (right)

Military Medicine (Saturdays) - The Advance in Prosthetics

The peg-legged pirate is perhaps the earliest vision of a prosthetic limb.  In recent years, however, the advances in prosthetics, from the materials to the functionality, have leapt forward astronomically.  Some of the best advances either come directly from the military or through military funded projects, such as this Johns Hopkins multi-disciplinary effort to create multi-functional upper limbs which have neural sensors so that a person 'thinking' can direct prosthetic movements (DARPA funded).

However, as with all things military (in spite of this ridiculous Navy propaganda - 'a global force for good'!), the embrology of this interest in limb prosthetic research comes from a viscious carnage: "For every 30 service members returning from Operation Iraqi Freedom and Operation Enduring Freedom, one is an amputee. Just since Jan. 1, 1,421 amputees have returned."   Unfortunately, te rest of the world doesn't have a half-trillion dollars at its disposal to advance the care of its amputees, even though road traffic accidents could be the third-leading cause of global disease burden by 2020.  

And so, while many advances in prosthetics happen outside the military world (see this fantastic engadget compilation), it is quite instructive to see where the trends in prosthetics are going in the military world.  On the materials side, the trend obviously is to lighter and more durable limbs.  In the developing world, lack of quality materials frequently degradeds limbs withing 1-2 years, necessitating frequent replacements.  On the functionality side, newer prosthetics have accelerometer sensers and actuators which replicate the natural boost of foot-ankle stepping so that wearers don't have to work extra for normal movements.  And, as described above, the future control of these limbs may be through neuronal implants which allow the mind to 'direct' the prostheses.  

As with many of these posts on military medicine, this is again an applause to the accomplishments of the military scientists and a call for them to widely disseminate the knowledge for the benefit of everyone else.  

Logistics (Wednesdays) - Lessons From Amazon and Apple?

Last week's discussion was the futuristic dream of the 'decentralization=democratization' paradigm of health-care.  In this model,supplies are manufactured in the places where people need them.  But stepping back into the reality of the present, there must be some things we can improve in logistics to overcome the plight of, say, a polio vaccine getting to a rural child in Pakistan (painstakingly articulated by NPR) or the inability to get necessary medicines into Haiti post-earthquake.  

Perhaps two of the big four technology companies can give us insight:  Apple and Amazon (the other two of the four being Facebook and Google, though they are still mainly in the computing/internet business).  Apple is a singularly vertical company which produces all its own components and software to manufacture a final product to which users ascribe a 'halo effect.'  Its ability to negotiate with its suppliers comes from its scale and from its customers strange proclivity to be completely inelastic to price or supply shocks (a google nexus 7 isn't that inferior to an ipad mini!).  It's unclear if any international health organization has the financial clout to impose Apple-like rules of procurement on its suppliers.  Perhaps consortiums or individual organizations can negotiate improved access using the shield of 'humanitarianism' into conflict areas?  In reality - these organizations already try pretty hard to get access and it's not clear logistic lessons from Apple have anything to offer.

On the other hand, Amazon is a polyamorous giant, sprawling multiple supply vectors and financial models.  It sells products directly.  It sells products for other companies.  It supplies physical products and also 'clouded' products.  It competes with Apple and Microsoft and Google.  But it also competes with Fedex.  It has huge warehouses of server farms and also buys robots for its fulfillment centers.  In short, it does a lot of things, all of them having logistical implication.  

There are many lessons to be learned from Amazon for international health organizations - how to maintain warehouses, how to rapidly fulfill field orders, how to ensure product quality, how to track feedback, etc.  But perhaps, as this article discusses on the nature itself of Amazon, international health organizations need to continue thinking through how much of a vertical versus horizontal organization they'd like to be versus just divesting non-health related entities, like this one.  Does an NGO want to manufacture medications, warehouse them, buy planes for transport, and then actually treat patients also?  Or would it rather buy medications from a pharmaceutical, pay a logistics company to transport and house them and then finally when the supplies are in the field, treat the patients?  

Games in medicine (Tuesdays) - Learning Through Gaming

Nate Silver, he of the 538 blog fame during the 2008 and 2012 election cycles, was recently featured on the Bill Simmons podcast.  It should be noted that Nate's original fame was as a baseball nerd and so it was quite natural for him to be on Simmons' (mostly) sports blog.  

In a typically incisive comment and question progression, Simmons stated (paraphrasing) that Nate's correct prediction of the 2012 Presidential election felt "like a victory for math," but then went on to question why people don't enjoy math so much in school.  Again paraphrasing, Nate's response was that: "in English, kids get to read good books; but that in math, they only do problems and that math would be far better if everyone learned from fantasy football or something similar."  

Absolutely.  And Nate's the prime example.  He was obviously a precocious kid at math, but ended up suceeding because he started learning from what he enjoyed and built a baseball model.  Then he used the knowledge from that to gain international acclaim and be proclaimed as one of Time's 100 Most Influential Persons in 2009.  

This stuff can't be taught in school under the old paradigm of education.  In that world, information was a premium, so teaching facts was paramount.  Some educators made a cursory glance towards 'teaching how to think,' but the primary responsibility was to teach who the first president was, what was involved in the New Deal and the atomic properties of carbon.  But that shit's easy now.  

There's google.  And wikipedia.  Almost every class has a computer.  And almost every kid has a smartphone of some sort.  Knowledge is free and accessible nowadays.  It's what kids do with it that matters now.  And this applies to medicine.  Sure a medical student needs to know basic anatomy - but honestly, that stuff isn't clinically useful and if it's really true that 50% of our medical knowledge exires within 5 years, then facts are even less meaningful.

The medical community has been advancing in the 'gaming' of health-care - from using crowdsourcing to find complex answers to biological properties to using exergames for obese kids.  It would be cool to see this level of gaming be incorporated into the basic and continuing medical education and for the term 'gaming' to lose its shallow connotation.  

 

Point-of-Care (Mondays): HIV Home Testing

When the FDA approved the Ora-Quick In Home HIV test early this year, it seemed to be a huge advance for the decentralization=democratization movement in health care.  Individuals who had little or no medical access or who were too anxious to get tested at one could buy a kit (around $40 at Walgreens) and check for themselves. Time Magazine named it as one of its inventions of the year, Magic Johnson cheered its value for the minority community and scores of other activists applauded its approval.  

 Throwing some cold water on this enthusiasm, comes this editorial in the Nov 20th edition of the Annals of Internal Medicine (pay firewall) from Paltiel and Walensky.  They summarize their thoughts in this paragragh:

We are struck by the unreserved enthusiasm that the FDA's approval of OraQuick has prompted. We believe that home HIV testing may play a useful but limited part in a program of good sexual health. Expectations that it will eliminate barriers to expanded HIV detection seem unrealistic. Home HIV testing is not a substitute for routine HIV screening in health care settings, provision of which is still our best hope for identifying the 235 000 Americans who remain unaware of their HIV infection (10) and linking them to effective care.

They are wrong.  

They do make some valid points on the relative cost of the test: $40/test is prohibitive, especially in the cohort of people who already don't have access to health-care.  But this should be overcome with competition and price subsidies - why can't a NGO donate money so that people can buy coupons and buy these tests?  And they're right that there are serious ramifications for getting a false negative result and perhaps just as serious ones for getting a positive test.  Counsellors and clinicians should be made available to anyone who either does not understand what the test does, wants a confirmation of their test result or needs further treatment.  

But what they're completely missing is the larger trend of decentralization of health-care.  Much like voters consumed election news from multiple sources this year, people also consume health care in novel and decentralized ways.  For example, this Pew Survey found that:

Fully 85% of U.S. adults own a cell phone. Of those, 53% own smartphones.

One in three cell phone owners (31%) have used their phone to look for health information. In a comparable, national survey conducted two years ago, 17% of cell phone owners had used their phones to look for health advice.

Smartphone owners lead this activity: 52% gather health information on their phones, compared with 6% of non-smartphone owners. Cell phone owners who are Latino, African American, between the ages of 18-49, or hold a college degree are also more likely to gather health information this way.

In the US, a clinical trial has shown that patients can accurately perform HIV tests in an ER by themselves.  Meanwhile, in South Africa, where clinicians are scarce, this trial is trying to promote non-healthcare-provider HIV testing.  All these are singular data points on the larger vector towards decentralization and patient initiated health-care.   

The mistake that Paltiel and Walensky make is that they're clinging to an archaic model of medical care where when you're sick, you go to the building with red cross on it.  But that's not how people access health care any more.  People find information on google.  Or on disease specific communities on-line.  Or in facebook groups.  And yes, penultimately, patients who are concerned about HIV will need professional counsellors.  And ultimately, patients who test positive will need clinicians to order further tests and prescribe treatment.  

But this counselling and these tests and treatments don't need to be done in a central location.  In fact, the pivot that the medical community needs to do is to stop funneling patients into an edifice and start leaving the comfort of the clinic to engage with patients in their physical and virtual worlds.  The idea that patients can test themselves shouldn't be a cause for alarm, but rather further validation that patients have new powers in a world of democratic information and testing.  The medical community needs to accept this as a feature, not a bug, of the modern world, break out of the security of the older paradigm and starting thinking of how to improve the care of patients in this new landscape.  

 

 

New Orleans (Sundays) - Crime and Punishment

One of the saddest memories of the post-Katrina time was the picture to the right, a 'murder roll' that was listed on a wall outside St. Anna's Church on Esplanade Ave.  High crime rates had been prevalent in New Orleans before that storm and continued, or perhaps even were exacerbated, afterwards.  Seven years later, they're still very high and are getting national attention.  There are all kinds of theories out there about the cause of high crime rates, from low wages to the focus on the drug wars.

But skipping from the causality to the effect, high crime rates lead to increased incarceration (although in some senses this may be counterproductive, that's for a different post).  The city of New Orleans and the state of Louisiana have become the world's 'imprisoning' capital, as documented by Cindy Chang in this part of a Times-Picayune series.  Simultaneously, the revelations of the conditions in the prison systems has led the Southern Poverty Law Center to sue the Orleans Parish Prison (OPP) and the Feds to arrange a consent decree (basically an agreed judgement between two parties in a suit) with this same OPP to improve the prison conditions.

Lost in these legal and political dances however, is a fundamental issue of the perverse incentives built into the prison system: 

According to the Louisiana Justice Institute, New Orleans is the only major U.S. city, and one of only two jurisdictions nationwide, that finances its jail through a per diem system. This means that instead of having a fixed budget like other city entities, the Sheriff’s Office receives $22.39 per inmate per day.

WTF?  The prison gets more money the more it jails and the longer each person stays inside?  Stating the obvious, why wouldn't the prison keep prisoners longer?  What incentive do they have for making an efficient system?  In a truly perverse situation, if prisoner-on-prisoner violence happens, doesn't it just means more inmate-days...and more money to the prison?  And given that there's unlikely a 'quality-of-inmate-corrected' clause, where the prison gets a bonus for low recidivist rates, what's the incentive for spending money on rehab or educational activities? 

It's good that the SLPC, the Feds and that civic groups like the Orleans Parish Prison Reform Coalition (OPPRC) are fighting for improved inmate conditions and for a smaller jail.  But it's also incumbent upon the New Orleans city government to dismantle this awful pay-per-prisoner incentive based funding of the jail.