Flint, lead, medical heroes, O-rings and guns

In January, 1986, 73 seconds after lift-off, the space shuttle Challenger exploded, killing all 7 astronauts on board, including one of the first civilians to go up, New Hampshire teacher Christa McAuliffe. It was a disaster; indeed the words are now paired so that we always say “Challenger disaster”. The cause was a flaw in the design of the solid rocket boosters (“SRB”s) and in the now famous “O-rings”, flexible rubber seals, like max versions of the ones we see on a lot of home tools. It was perhaps the worst domestic disaster of its time, nine years before the 1995 domestic-terrorist white-power bombing in Oklahoma City, almost 16 years before the attack on 9/11. It was a disaster in two ways; the obvious one, the explosion, and in that it could have been prevented; NASA and the company that produced the SRBs, Morton Thiokol, knew about the problem.

Morton Thiokol engineers, and particularly one named Roger Boisjoly, had been worried about the problem for years; Boisjoly had expressed his particular concerns in 1985. Morton Thiokol managers considered telling NASA to scrap the launch, and then decided not to. After the disaster, Boisjoly testified before a commission about the problem, and about the warnings that he had sent to his bosses. In 1988 he was awarded the Award for Scientific Freedom and Responsibility by the American Association for the Advancement of Science. He was shunned and at Morton Thiokol, and resigned. He was right; Morton Thiokol and NASA were wrong, and it led to a disaster. And he was out of a job.

In 2014, Michigan Governor Rick Snyder appointed an emergency manager named Darnell Earley, for the bankrupt city of Flint. One of his cost-cutting measures was to stop buying treated Lake Huron water from the Detroit system and instead supply water from the Flint River. The river was full of corrosives, from decades of industrial discharge, and one effect was to degrade the old lead pipes in many Flint homes, dramatically increasing the lead levels in the water. And in the bodies of Flint’s children. The politics of the decision are continuing to play out, with calls for Snyder’s resignation, and it would have been corrupt and evil even if the problem had been identified and remedied earlier. It wasn’t, and thus became a disaster. Good piece on it in Rolling Stone.

Again, we have a hero, a Flint pediatrician named Mona Hanna-Attisha. Dr. Hanna-Attisha had heard that a team from Virginia Tech had found high lead levels in Flint’s water, and noted that she was seeing a rise in the number of children with high lead levels. She led a team doing “the easiest research project I have ever done”; because Medicaid requires children to be tested for lead at 1 and 2 years of age, she was able to compare the prevalence of high levels from 2013 to 2015.  The percentage of children with elevated lead levels “doubled in the whole city, and in some neighborhoods, it tripled. And it directly correlated with where the water lead levels were the highest” she noted in an interview on “Democracy Now”. She announced it at a press conference, and was immediately attacked by the powers-that-be (I call them the “PTB”); in this case both the political leaders of the state and the state health department.

Well, that evening, we were attacked. So I was called an "unfortunate researcher," that I was causing near hysteria, that I was splicing and dicing numbers, and that the state data was not consistent with my data. And as a scientist, as a researcher, as a professional, you double-check and you triple-check, and the numbers didn’t lie. And we knew that. But when the state, with a team of like 50 epidemiologists, tells you you’re wrong, you second-guess yourself. But that lasted just a short period, and we regrouped and told them why, "No, you were wrong." And after about a week and a half or two weeks, after some good conversations, they relooked at their numbers and finally said that the state’s findings were consistent with my findings.

There is a long and distinguished tradition of doctors making breakthrough discoveries that helped cure or prevent disease in thousands or millions of people. Some of the most storied are Edward Jenner, the 18^thcentury physician who invented the vaccine to prevent smallpox, 19^thcentury physicians John Snow, who discovered that the contaminated water from a particular pump in London was the cause of a cholera outbreak, Ignaz Semmelweis, who showed that doctors washing their hands could prevent deaths in post-partum women, Rudolf Virchow, the “father of social medicine”, who showed an outbreak of typhus among miners was the result of the social conditions they lived in, Louis Pasteur, Robert Koch, and Joseph Lister who proved that germs caused those diseases, and 20^thcentury doctor Jonas Salk, who found the vaccine against polio. Does Mona Hanna-Attisha’s work rise to this standard?

Well, it may not in terms of the total lives saved, although it is worth noting that, like the work noted above, it is about public health, about populations, not individual interventions, and thus has a great impact on so many (despite the fact that in the US at least 95% of all “health spending” is on individual medical care, not public health). But she is heroic in that she stood for the truth and for the health of the children in defiance of the powerful who were trying to minimize or cover up the problem, and who tried for a while the “best defense is a good offense” strategy of attacking her, shamefully. Indeed, this is what it takes to be a hero, to not only do something important that has an impact on many, but even more to do it when you have to stand against the establishment, the PTB, the powers-that-be. This takes a great deal of courage, as well as commitment.

In Kansas, the legislature legalized concealed-carry of guns a couple of years ago, but exempted schools and hospitals until July 2017. As that date approaches in 18 months, there is little indication that the exemption will be extended, and there is great concern. A recent survey found that 70% of faculty and staff at the 6 state Regents universities oppose the law. Faculty are worried about telling students that they are failing them while they sit in their offices armed; doctors worry that if a crazy person pulls a gun in clinic, several others will draw down and make it more dangerous, police worry that they won’t even know who created the original threat. The data shows that there is a real risk of more homicide with more access and carriage of guns; “natural studies” of homicides showed a marked increase after Missouri eliminated its permit laws in 2007 and decrease after Connecticut tightened its laws after Sandy Hook.[1] [2] Moreover, 60% of gun deaths are suicides, and these are also dramatically decreased by making guns less easily accessible.[3]  Doctors and researchers need to speak out about the public health implications of easier access to guns. Luckily, many are; others are worried that perhaps the notoriously-vindictive Kansas legislature may respond by cutting funding for the university. These people will not become heroes, but they may keep their jobs and their funding.

Being a whistleblower is not easy. It is not a way to have a calm, peaceful life. Some folks have made a lot of money and retired far from those they blew the whistle on, but many more I know of are, like Roger Boisjoly, are shunned, forced out of their jobs, threatened, and may even suffer PTSD. It is not easy to take on the PTB. Better to work in their interests; for his great work as emergency manager in Flint, Darrell Earley has just been named emergency head of the Detroit Public Schools!

The full impact of the Flint lead-poisoning disaster is not yet known, because the full impact of these elevated lead levels on the brains and bones of Flint’s largely poor and African-American children will take years to take their toll. Even then, and even if, because they are treated the damage is limited, we will never know what kid who grew up seemingly ok and normal might otherwise have been brilliant.

She might have become a doctor, maybe even a heroic one like Dr. Hanna-Attisha.

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[1] Rudolph, KE et al., Association Between Connecticut’s Permit-to-Purchase Handgun Law and Homicides Am J Public Health. 2015;105:e49–e54. doi:10.2105/AJPH.2015.302703

[2]Webster D, et al., Effects of the Repeal of Missouri’s Handgun Purchaser Licensing Law on Homicides, Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 91, No. 2, doi:10.1007/s11524-014-9865-8

[3]  Crifasi CK et al., Effects of changes in permit-to-purchase handgun laws in Connecticut

and Missouri on suicide rates, Preventive Medicine 79 (2015) 43–49

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Medicaid expansion: Is there something the matter with Kansas?

One of the key parts of the Affordable Care Act’s (ACA) effort to cover most Americans was the expansion of Medicaid to cover everyone under 138% of the federal poverty level (FPL). The Supreme Court decision in 2012 (National Federation of Independent Business v. Sebelius) found in favor of the “individual mandate”, allowing the law to go forward, but found against the ability of the federal government to withhold all Medicaid funding from states that did not expand Medicaid. This decision did not prevent the federal government from creating an incentivefor states to expand Medicaid, which it did; for the first 4 years the federal share of cost of expansion would be 100%, dropping to 90% thereafter. This is quite a financial incentive, and as of December 15, 2015, 31 states have expanded Medicaid, 4 are considering it, and 16 are not, depicted on this map from the Kaiser Family Foundation (KFF).

Neither of the Kansas City area states, Kansas and Missouri, are in the expansion group, and thus a significant portion of their population remains uncovered. Like the other 14, control of their legislatures (and in Kansas, of the governor’s office) is in the hands of very conservative Republicans ideologically hostile to ACA. However, this is a problem not only for the poor people left without insurance and their advocates (like many of the healthcare foundations), but also the states’ hospitals, who continue to have to provide care for these people without reimbursement. To some degree it is also a problem for the state’s business community because more than half of the this group of people are employed, mainly in small businesses that cannot afford to buy private health insurance. It also decreases, in the opinion of many Chambers of Commerce, the state’s ability to attract new business and jobs.

On January 5, 2016, I attended a forum on expanding KanCare (Kansas’ privatized Medicaid program) sponsored by many of these business organizations (6 Chambers of Commerce), hospitals, physician provider organizations, and healthcare foundations (see list of sponsors on KC COC site). The event, held in Overland Park in the Kansas City area, followed a similar one held in Wichita in November, 2015.  It began with a presentation by Dave Kerr, a Republican former president of the Kansas State Senate, detailing how Medicaid expansion would bring in at least 10 times what the state would have to spend. After this were two panels, one consisting of 5 KS legislators (3 Republican, 2 Democratic; 3 senators, 2 representatives), and the other of 5 healthcare experts.

Prominently included in the second group was the president of the Indiana Hospital Association, Doug Leonard, who presented how his state had effectively expanded Medicaid. The presumption of the sponsors of the event was that this would resonate in Kansas, because Indiana is also a conservative state with a very conservative governor (Mike Pence) who had mandated the expansion based on certain principles of individual responsibility and fiscal neutrality. Indiana’s plan is one of 4 (those with asterisks on the map) that were developed with federal waivers. In its first year, it has enrolled 220,000 people into its Medicaid program, and, largely because it is paying providers at Medicare rates, increased by 1,000 those who accept Medicaid. It is paid for by a combination of increased cigarette taxes and levies on hospitals.

Unsurprisingly, this resonated well with most of the attendees and speakers, although support was not universal. Sen. Jim Denning (R., Overland Park), who is considered a health policy leader in the state senate (apparently he works for a group of private ophthalmologists), indicated that Indiana’s program would not pay for itself after the first year and would have to tap into the state general fund. The moderator asked Mr. Leonard, who drily indicated that perhaps Sen. Denning had information that Indiana did not have. When the moderator asked Sen. Denning the source of his information, he indicated “the Forbes article”. Mr. Leonard responded that, first of all, it was not an article but a blog post in Forbes, and second that the state had responded point-by-point to its incorrect assertions.  

Sen. Denning’s credibility as a source of facts was already questionable, as he had previously asserted that Medicaid expansion would affect only those between 100% and 138% of the FPL as those below 100% were already eligible for KanCare (not true; in Kansas, adults actually must be actual below about 33% of FPL, in addition to being a a special group like mothers of dependent children or disabled, to be eligible for KanCare) and that those between 100% and 138% of FPL could buy subsidized “silver” plan coverage on the exchanges for about $2.50 a month (not true; those below 138% of FPL are not eligible to buy coverage on the exchanges at all). I do not know if he misspoke or whether he believes those assertions to be true. If the latter, it is not clear whether whether those misconceptions in part inform his opposition to KanCare expansion (and thus could be changed by the facts) or if his ideological opposition informs his willingness to believe such incorrect information. However, he is a leader in the state senate, and so he is probably accurate when he asserts that the KS legislature will not expand KanCare. Other legislators on the panel, including the Republicans, indicated that such expansion would require leadership from KS Governor Sam Brownback, which the governor has not indicated will be forthcoming. One, Sen. Jeff King (R., Independence) is from the town whose hospital recently closed, at least in part because it could not count on KanCare expansion; he indicated that his father, who had had 2 heart attacks, was now 25 miles, not ¾ of a mile, from the closest hospital.

Beyond Sen. Denning, there were other concerns about the forum. Every panel member was white, and other than one state senator, Laura Kelly (D., Topeka), every one was man. Women gave the opening and closing remarks, but there were no people of color who spoke. This was obvious, but not the only important way in which the speakers (at least) and probably audience differed from the average person. One reason was that there were a lot of business leaders, because they have clout. They do, however, have a limited – and not always accurate – view of the rest of the people in this country. They seem to think that support for expansion of KanCare (and other social programs) is important until people get good jobs and get these benefits from their work (they referred a lot, disparagingly, to the “able bodied unemployed”). But where are the jobs? Job creation is supposed to be a high priority of the governor and legislature, and is the stated reason for the dramatic tax cuts of 2012 (indeed, rich people are now renamed “job creators”) but not only has job growth been slow, but it is mostly in lousy jobs – poorly paid and without benefits (eg., health insurance!). There was a great deal of talk about “retraining”, but there simply are not enough “good” jobs to employ everyone no matter how retrained they are. Their myopia may be because many well-to-do people have contact with others who are like them; in their neighborhoods, work, and country clubs. They have little insight into the real issues confronting those in the bottom 80%, not to mention 50% or 10%. I doubt they even know what the numbers are, but this article from CNN Money, with its neat interactive graph, should help; the median household (not individual) income in the US is $52,000.

I see lots of both poor and “regular” people as a doctor in the clinic and in the hospital. I live in a neighborhood that is mostly, well, working class. I see my neighbors, adults and children, on the streets when I walk my dogs. They’re trying, but it is not easy for them. Jobs are scarce, and many of those  that  they can get involve the sort of physical labor that takes its toll on their bodies and leaves them prematurely disabled. Lack of health insurance exacerbates their problems. A major recent NY Times/Kaiser Family Foundation study, reported by the NY Times, finds “Even Insured can face crushing medical debt”. Those business leaders who may think that $200K a year (for a household, most with two earners) is “middle class” should know it puts that household in the top 5% (and, for goodness sakes, in many parts of the country households making $200K are still struggling!). It would be good for them to meet with some regular folks and find out about their lives. I applaud the work that the various healthcare foundations in Kansas, many of whom co-sponsored this event, are doing. But our leaders, political, business, and otherwise, need a little reality check to leaven the ideology.

There are a lot of things that impact on whether a person is healthy besides access to health care (the social determinants of health: housing, warmth, food, education, safety, etc.). But access to health care helps. 

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