Week 3 Potpourri

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Week 3 Potpourri

• Stuart Henochowicz, M.D., M.B.A., F.A.C.P.

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Deadly TB strain sweeps Kyrgyz prisons

• A drug-resistant and virtually untreatable form
  of tuberculosis is spreading from prisons in
  Kyrgyzstan to the general population.
• http//news.bbc.co.uk/2/hi/asia-pacific/7307398.st
  m

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• Colony 19 is a rundown, Soviet-era prison just
  outside Kyrgyzstan's capital Bishkek.
• Four hundred prisoners live inside its crumbling
  walls. Conditions are cramped and dirty, there is
  little water or electricity.
• But the worst threat here is invisible.
• Dr Maxim Berdnikov is an infectious diseases
  doctor with the ICRC. His regular visits to
  Kyrgyz prisons have led to an alarming
  discovery.

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• "Levels of tuberculosis in Kyrgyzstan's prisons
  are the highest I have seen in my entire career,"
  he says.
• "I've worked in the Caucasus, where TB is very
  prevalent too, but here it is higher. It is very
  worrying."
• Today Dr Berdnikov is screening new arrivals for
  TB, but his equipment is poor - a 40-year-old
  truck, with X-ray equipment that is even older.

5

• The ICRC says Kyrgyz prisons have become
  breeding grounds for tuberculosis. Around 40 of
  screened prisoners are found to have TB, and over
  a third of those have the new, and highly
  dangerous, multi-drug resistant (MDR) variety.
• TB is the leading cause of death in Kyrgyz
  prisons, and the rates of MDR TB are among the
  highest in the world.

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• There are many reasons for this - overcrowded,
  poorly ventilated prisons, malnourished
  prisoners, and, especially in the case of MDR TB,
  inefficient treatment.

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• "I got TB when I was in prison," recalls Damir.
• "And I did get medicine for it. When I was
  released they said I was getting better and I
  would probably improve on my own, so I didn't
  need to take the pills anymore.
• Instead of getting better, the interrupted
  treatment meant that Damir developed MDR TB.
• Just a few months ago he was close to death, but
  now, thanks to a new project, he is one of a
  handful of prisoners who are being treated.

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Colony 27, which is now reserved for TB
patients.
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• TB rates among Kyrgyzstan's general population
  are already 10 times higher than in western
  Europe, and rates of MDR TB are increasing
  rapidly.
• "The latest figures show that in Bishkek around
  25 of all new TB cases are MDR," says Maxim
  Berdnikov.

10

• 'People migrate'
• Dr Berdnikov's biggest headache is trying to keep
  track of his MDR TB patients once they are
  released from prison, and to make sure they still
  have access to medicine.
• Of nine recently released, one has disappeared -
  no-one knows where he is, or whether he is
  continuing his treatment.

11

• http//www.nytimes.com/2008/03/25/world/africa/25s
  africa.html?scp1sqsouthafricatbstnyt

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Spreading the Safety Net Obstacles to the
Expansion of Community Health Centers

• John K. Iglehart
• New England Journal of Medicine
• Volume 3581321-1323 March 27, 2008

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• Amidst this partisan standoff, however, Bush
  has remained resolute in fulfilling one early
  campaign pledge that most Democrats
  enthusiastically embrace doubling the number of
  community health centers (CHCs) over a 5-year
  period, so that millions more people who lack
  insurance or have limited access to private
  medical care can be treated at publicly funded
  facilities.

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• The CHC initiative, launched in 1965 as part of
  the Lyndon B. Johnson administration's War on
  Poverty, was largely the brainchild of Dr. Jack
  Geiger, who drew inspiration from a South African
  movement that had fostered the creation of
  facilities where poor workers could receive both
  public health services and medical care.

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Numbers of Patients and Visits (Panel A) and
Annual Federal Appropriations (Panel B) for
Community Health Centers
Iglehart J. N Engl J Med 20083581321-1323
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• Reflecting this "power to the people"
  philosophy, the funding mechanism for CHCs
  consists of federal grants that bypass state
  governments and flow directly to these nonprofit,
  community-based organizations.

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• The commitment of Bush, a former governor, to
  expanding CHCs therefore seems out of political
  character and contrasts with his preference for
  promoting private insurance by issuing tax
  credits. Nevertheless, the commitment is an
  implicit acknowledgment that expanding insurance
  coverage and increasing the number of CHCs are
  complementary strategies and that both are
  required in order to improve access to care.

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• Two thirds of CHC patients are members of racial
  or ethnic minority groups, and many lack
  proficiency in English. More than two thirds live
  on incomes at or below the federal poverty level
  (20,650 for a family of four in 2007), and more
  than 92 have incomes below 200 of this
  threshold.

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• Because their population is relatively young
  overall and is disproportionately made up of
  young women and children, there is a high demand
  for primary care services, but many centers also
  offer assistance in applying for Medicaid and
  SCHIP coverage, health education, and translation
  and transportation services.

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• CHCs, which participate in policy activities
  largely through the National Association of
  Community Health Centers (NACHC), are striving to
  attract more physicians through myriad channels
  at the national, state, and local levels.

21

• These efforts include a call for expanding the
  National Health Service Corps, which places
  primary care clinicians in communities with the
  greatest need the offering of internships to
  medical students and residents and contacts with
  medical schools and teaching hospitals that may
  be interested in collaborating with
  community-based organizations.

22

• Hawkins points out that "CHCs meet the
  definition of a medical home' as developed by
  primary care medical organizations, but we will
  not be able to reach our expansion goals if we
  cannot attract a greater number of clinicians to
  these centers and more federal support from
  Washington.

23

• Despite good intentions on both sides of the
  aisle, it remains uncertain whether Congress or
  the new administration will see the continued
  expansion of CHCs as a vital step toward
  reforming the health care system.

24
Rising Public Health Risk Seen As More Parents
Reject Vaccines

• By JENNIFER STEINHAUER GARDINER HARRIS
  CONTRIBUTED REPORTING FROM WASHINGTON.
• Published March 21, 2008
• New York Times

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• In a highly unusual outbreak of measles here
  last month, 12 children fell ill nine of them
  had not been inoculated against the virus because
  their parents objected, and the other three were
  too young to receive vaccines.

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• The parents who objected to their children being
  inoculated are among a small but growing number
  of vaccine skeptics in California and other
  states who take advantage of exemptions to laws
  requiring vaccinations for school-age children.

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• Children who are not vaccinated are
  unnecessarily susceptible to serious illnesses,
  they say, but also present a danger to children
  who have had their shots -- the measles vaccine,
  for instance, is only 95 percent effective -- and
  to those children too young to receive certain
  vaccines.

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• Measles, almost wholly eradicated in the United
  States through vaccines, can cause pneumonia and
  brain swelling, which in rare cases can lead to
  death. The measles outbreak here alarmed public
  health officials, sickened babies and sent one
  child to the hospital.

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• ''I refuse to sacrifice my children for the
  greater good,'' said Sybil Carlson, whose
  6-year-old son goes to school with several of the
  children hit by the measles outbreak here. The
  boy is immunized against some diseases but not
  measles, Ms. Carlson said, while his 3-year-old
  brother has had just one shot, protecting him
  against meningitis.

30

• 'When I began to read about vaccines and how
  they work,'' she said, ''I saw medical studies,
  not given to use by the mainstream media,
  connecting them with neurological disorders,
  asthma and immunology.'

31

• 'The very success of immunizations has turned
  out to be an Achilles' heel,'' said Dr. Mark
  Sawyer, a pediatrician and infectious disease
  specialist at Rady Children's Hospital in San
  Diego. ''Most of these parents have never seen
  measles, and don't realize it could be a bad
  disease so they turn their concerns to unfounded
  risks. They do not perceive risk of the disease
  but perceive risk of the vaccine.'

32

• While the picture of an unvaccinated child was
  once that of the offspring of poor and uneducated
  parents, ''exempters'' are often well educated
  and financially stable, and hold a host of
  like-minded child-rearing beliefs.

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• Vaccine skeptics provide differing explanations
  for their belief that vaccines may cause various
  illnesses and disorders, including autism.
• Recent news that a federal vaccine court agreed
  to pay the family of an autistic child in Georgia
  who had an underlying mitochondrial disorder has
  led some skeptics to speculate that vaccines may
  worsen such conditions. Again, researchers say
  there is no evidence to support this thesis.

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• There are differences within states, too. There
  tend to be geographic clusters of ''exempters''
  in certain counties or even neighborhoods or
  schools. According to a 2006 article in The
  Journal of The American Medical Association,
  exemption rates of 15 percent to 18 percent have
  been found in Ashland, Ore., and Vashon, Wash. In
  California, where the statewide rate is about 1.5
  percent, some counties were as high as 10 percent
  to 19 percent of kindergartners.

35
To the Editor George L. AnesiCleveland, March
22, 2008 NYT

• Parental objections to vaccines highlight the
  fundamental ethical dilemma inherent in all
  public health initiatives the often conflicting
  values of seeking better societal health and
  preserving individual liberties.
• Virtually any action taken in the name of public
  health such as mandating vaccinations cuts
  into the individuals right to make such a
  decision for him or herself.

36
To the Editor George L. AnesiCleveland, March
22, 2008 NYT

• The vaccine debate is further complicated
  because the decision to abstain from vaccination
  has strong negative externalities. It is not a
  simple decision about ones own health or ones
  familys health, but rather a decision that may
  also affect the health of those with whom the
  unvaccinated interact.

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To the Editor Carl Baum NYT

• It seems the parents who reject vaccines have it
  all figured out theyve done their research
  and claim to understand the risks and benefits
  of exempting their children from vaccines.
• One question remains Whom will they sue when
  their children die of preventable diseases?
  Themselves?
• The writer, a pediatrician, is director of the
  Center for Childrens Environmental Toxicology at
  Yale-New Haven Childrens Hospital.

38
To the Editor Axel Duwe NYT

• Vaccines, the most cost-effective drugs ever
  developed, have saved the lives of countless
  children. Smallpox, diphtheria, whooping cough,
  tetanus, polio, measles, mumps, rubella and Hib
  meningitis have been 99 to 100 percent
  eradicated. But as with all drugs, there is
  always the possibility of rare side effects, and
  some children may even have a genetic
  predisposition for these.

39

• As an immunologist who has a family member with
  Aspergers syndrome, I do not believe that this
  is a good rationale for exemption from
  vaccinations. No scientific studies have shown an
  increased risk of autism associated with
  vaccines.

40

• If someone elses child is infected with measles
  (even if that child has been vaccinated but the
  vaccine did not provide full protection) and
  suffers neurological damage or death, the parents
  who sought an exemption should be considered
  negligent and liable for the resulting injury.

41
To the Editor Athalia ChristieAndrea Gay NYT

• You report that a growing number of parents in
  the United States are refusing to have their
  children vaccinated against measles because of
  personal beliefs. But in many developing
  countries, parents do not have this choice.

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• Factors like poverty, poor health infrastructure
  and a lack of information mean that families
  cannot get the immunizations they need. As a
  result, measles is still one of the leading
  killers of children worldwide.

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• Since 2001, the Measles Initiative has been
  working to change this situation. In
  collaboration with local ministries of health,
  the initiative has supported the vaccination of
  more than 500 million children in 50 countries.
  This has been a major contributor to the dramatic
  reduction in measles deaths.
• It costs less than 1 to vaccinate a child. Until
  families everywhere have the opportunity to
  immunize their children against measles, children
  will be under threat and many more will get sick
  or die from this disease.

44
To the Editor Laura Colby NYT

• When my nursing and crawling 6-month-old son
  went limp, refused to nurse and couldnt raise
  his head for 36 hours after his third diphtheria,
  pertussis and tetanus shot, you bet I educated
  myself about the true risks that accompany
  immunizations.

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• With guidance from a new doctor, I stopped all
  immunizations except for polio, knowing that the
  diseases my son would face were unlikely to kill
  or irreparably harm him and that if he contracted
  any of them, I would be able to care for him to
  ensure his recovery. I was simply unwilling to
  risk losing or injuring my son to these imperfect
  shots.

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• I relied on New York States medical exemption
  as my son went from child care through college.
• Until the medical community can guarantee parents
  that these shots wont kill or injure our
  children, I stand firmly behind the decision I
  made for my 6-month-old now a grown man capable
  of making his own medical decisions.