Medicae and hospitals are integrated “The Power to Heal: Civil Rights, Medicare, and the Struggle to transform America’s Health Care System” by David Barton Smith, Vanderbilt University Press, 2016
An American Sickness by Elizabeth Rosenthal. Penguin Press. 2017.
https://www.managedcaremag.com/archives/1996/6/what-profit-trend-health-care-really-means ——Managed Care Magazine June 1996: “In June 1994, a little-known event occurred behind closed doors in Washington, D.C., that opened the path for any of the 63 Blues plans to switch. The Blue Cross and Blue Shield Association’s board of directors gathered to discuss, among other things, changing the association’s bylaws to allow its affiliates to operate as for-profit companies. It wasn’t the first time the board discussed the hotly-debated issue, but this time the measure had enough supporters to enact the proposed reform by a narrow margin. Until then, the board only allowed its plans to operate for-profit subsidiaries, while the parent company using the Blue Cross and Blue Shield name had to remain nonprofit.”…”Whatever its implications for that “social value,” the market — employers, government and patients themselves — is clearly calling the shots in health care today. In most places, it seems to be saying that for-profit plans are the wave of the future.”
The Hillary Clinton Health care proposal (abridged.) The health plans they proposed had to cover: hospital services; health professionals; emergency and ambulatory medical and surgical services; clinical preventive services; mental illness and substance abuse services; family planning and services for pregnant women; hospice and home health care. extended care and ambulance services outpatient laboratory, radiology, and diagnostic services; outpatient prescription drugs and biological; outpatient rehabilitation services durable medical equipment; prosthetic and orthotic devices; vision care; dental care; health education classes; investigational treatments;
The items and services provided could not be subject to any duration, scope limitation, deductible, copayment, or coinsurance.
The legislative proposal included a “low” cost sharing schedule: no deductibles; An annual individual out-of-pocket limit on cost sharing of $1500; and (B) an annual family out-of-pocket limit on cost sharing of $3000;
High cost packages which (with a few exceptions) had an annual individual general deductible of $200 and an annual family general deductible of $400.
Individuals had to pay for the first day of care for each episode of inpatient and residential mental illness and substance abuse, and for each episode of intensive nonresidential mental illness and substance abuse treatment. And patients were responsible for the first $250 for outpatient prescription drugs and biological. Then the plan provided benefits.
To keep costs from going through the roof there was a regional target. If the projected cost of care was exceeded there were: automatic, mandatory, nondiscretionary reductions in payments to health care providers.
For out of network emergency and urgent care, individuals had to pay “a percentage of fee set by the alliance.
The items and services provided could not be subject to any duration, scope limitation, deductible, copayment, or coinsurance.
The legislative proposal included a “low” cost sharing schedule: no deductibles; An annual individual out-of-pocket limit on cost sharing of $1500; and (B) an annual family out-of-pocket limit on cost sharing of $3000;
Balanced billing was prohibited: A provider was not allowed to charge or collect money in excess of the fee schedule. And they couldn’t directly bill the patient.
They also recommended caps on health insurance premiums. Companies who wanted to charge more would now have to come before a commission and explain where the money was going and why it was needed.
Chapter Thirty-Three: Obamacare—the Affordable Care Act
In 2014, as part of the Affordable Care Act, members of congress and their staff members lost the ability to purchase insurance through the FEHB. So they established a new way to buy highly subsidized care. They are using the DC health care exchange, and the government still
In the early 1980s, Mario Capecchi discovered that sections of DNA that had been inserted into the cell nuclei of mammals could be incorporated into the cell’s genome.
Out-of-Network Emergency-Physician Bills — An Unwelcome Surprise. Zack Cooper, Ph.D., and Fiona Scott Morton, Ph.D. November 17, 2016 N Engl J Med 2016; 375:1915-1918
In 1995 around half of private hospitals were solo. Then, over the decades for profit and non-profit hospitals have increasingly merged and/or joined systems with at least one other hospital partner in the same metropolitan statistical area (MSA). https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.6.77
What insurance companies pay for services by zip code
As Elisabeth Rosenthal of Kaiser Health News put it: “there’s money to be made by billing for everything and anything.” And hospitals currently intentionally submit amplified bills for their services.
Each hospital has an all inclusive list of “items billable to a person or a health insurance provider.” Called “charge masters” they have long been secret in most states; but starting in 2019 they will be posted on line. They do not include physician charges, and they are intentionally inflated–or in the “speak” of the University of California San Francisco Hospital: “they are not the amount that either you or your insurer will actually pay. Out-of-pocket costs will be impacted by insurance plan coverage, co-pays and deductibles, if any, (etc.) – so our list should not be used to estimate the actual final cost you will incur.”
Insurance companies like to flaunt them to demonstrate how much money they are saving their patrons. And hospitals can claim that overstated prices are useful when they negotiate contracts with insurance companies. The “fair” cost, the amount insurance companies (on average) really pay for most emergency and hospital visits, is accessible to anyone who has a smart phone. They merely have to open Healthcarebluebook.com or some similar service, and type in their zip code.
Medicare strictly regulates the amount the government shells out to hospitals. The agency is constantly updating what it pays for an illness or operation; 98% of American hospitals accept what the Feds dole out as payment in full.
Exaggerated bills punish the ill and wounded who are cared for in a hospital that does not have a contract. They hassle the person who is seen in an “out- of-network” facility or who was cared for by a doctor who was not covered by an agreement. And they are especially harmful to people who don’t have health insurance.
Paradoxically the people who try to collect the most exorbitant amounts of money commonly tend to blame the injured party.
I believe that once hospitals start charging people without insurance fairly, a form of BACK STOP INSURANCE makes sense. As detailed in the “alternative approach” chapter, when corporations have a big stock offering, they obtain insurance. If some of the stocks and bonds are not sold on the open market, the investment firm that is handling the transaction has to buy them.
We need to take a similar approach to people who can afford insurance but don’t have a policy. Health insurance is rarely used by some because they have a healthy life style, they’re young, and they are lucky. And because bodies have an innate ability to fight off invaders and heal wounds.
If one of these people is in a “higher income” category, and they haven’t purchased medical insurance, and they get sick or are injured, they would be best served if the system has “automatically enrolled them in a “backstop” insurance plan.” If they are seen in an emergency room or are hospitalized the facility should be able to submit a claim and it should be paid by the government. At tax time the IRS can then decide how much the person owes for a year’s worth of “backstop insurance.” (As conceived by Matthew Fielder, NEJM: May 2, 2019.)3
II. HEALTH INSURANCE: Some employer policies are unusable because the co-pays are so high. In addition to taking care of the people with pre-existing conditions, we need a law or regulations that make health insurance affordably-useable. There should be caps on premiums and co-pays; out of pocket payments should be based on income—should mirror earnings
Several of the Democratic candidates for president believe in Medicare for All. Like all “rights” this form of care must be paid for. That usually means taxes, and people who promise more taxes aren’t usually elected. In addition to something like the current payroll tax– the government would have to collect the money employers contribute to a person’s insurance and the excess insurance company profits.
As an old retired M.D. and a socialist at heart I favor Medicare for all. But as a realist I’m worried.
In the 60s and 70s affordable health care was available to those who wanted it via Blue Cross and programs like Kaiser (my people.) Then insurance companies entered the market and did what insurance companies do. They risk adjusted. People who live in the low lands near the Mississippi River pay more for flood insurance, and we in California pay more for earthquake insurance. Private insurers didn’t sell affordable policies to people with pre existing conditions. Premiums for the young and healthy were relatively cheap.
Over the subsequent decades the young, healthy and employed started choosing private insurers; people with problems joined Blue Cross and Kaiser. Year by year medical care improved and it also became increasingly costly: CAT scans; MRI’s; organ transplants; angioplasties; artificial joints; and ICU’s aren’t cheap.
As their population increasingly had fewer healthy clients and more people with costly problems, Blue Cross and Kaiser started “hemorrhaging money.” Ultimately they were on the verge. After Hilary’s very reasonable Health Care adjustments were rejected, many Blue Cross companies and Kaiser said “uncle”. They adopted a risk adjusted approach.
Over the subsequent decades people forgot that affordable health care, like the roads or schools, was once widely available. The young, healthy, and employed grew up assuming they would be able to buy insurance that was good and affordable. It was their “right.” Understandably, they don’t want to give it up. And we need their votes.
My approach: lower the Medicare age, and keep dropping it. Make affordable Medicare purchasable for those who want it. At the same time, over a few years–SUBSTANTIALLY LOWER THE MEDICAL LOSS RATIO. Under the Affordable Care act companies get to keep 15 to 20 % of premiums for expenses, bonuses and stock holders. The overhead of Medicare allegedly is 3%. If insurance companies could keep 8% of the premiums, they should still be profitable. If a yield of 5% isn’t enough, a company can leave the market. And some will. Over time healthy people will increasingly migrate to Medicare. We may never get to Medicare for All but we’ll get close.
As a result of the current medical loss ratio, the heads of the health insurance companies are doing quite well. In 2018 as a result of exercised stock options and stock awards, the one year compensation of the head of 49.5 million member UnitedHealth insurance, the nation’s largest, was over $18 million. The leader of Anthem, the 40.2 million policy, second largest was $14.2 million.4
III. We should also extend some of the benefits of the Affordable Care Act (ACA) to traditional Medicare. The ACA (Obamacare) created an annual lid on the amount people are forced to pay for their care. In 2018 it was $7350. By contrast, traditional Medicare, has no cap, no maximum amount a person can be charged. When people see a doctor or are hospitalized, they are responsible for “copayments, coinsurance, and other gaps in coverage.” If someone has a very serious illness and is hospitalized for months, the government stops paying the bill “after the 150th day in the hospital.
People can buy an insurance policy that pays the bills that are not covered by Medicare. There are 10 levels of “Medigap” plans. If a person doesn’t buy one of them when they enroll in Medicare, the policies are subsequently only available (most of the year) to people who pass an insurance physical.
Medicare Advantage plugs a number of the holes in traditional Medicare. Currently (according to AARP) 44 million Americans are insured by Medicare. The number opting for Medicare Advantage rose to 20 million in 2018 and it’s going up. Advantage plans are capitated. The government gives the insurer a dollar amount per person per year, and “everything” is covered. Plans may include limited dental care and gym memberships. Out-of-pocket costs were capped at $5,215 per year in 2018. (November 14, 2018, NEJM.org.)
According to Wiki “You cannot have both a Medicare supplement (Medigap plan) and a Medicare Advantage plan at the same time.” It’s time to identify and close the Medicare gaps.
IV: Extra money for health care was supposed to come from a few additional sources. Congress recently abolished the Medical Device tax, the health insurance tax , and the tax on Cadillac plans.
I suggest re-opening the question of what happens when university and nonprofit hospitals make hundreds of millions of dollars. Should they be taxed? Should they return some of the tax funds they received from the government for use elsewhere in the health care system? Or perhaps charitable and university hospitals should (like the for-profits) generate a bill for the service rendered. The amount charged would be similar to the sum Medicare or insurance companies would actually pay. (Inflated excessive charges should be treated as potential tax fraud.) The institution’s outlay could then be deducted from the hospital’s gross income. If an institution performs a lot of charity work and has no net income they would owe no taxes. If they generate a large profit, they, like for-profit corporations, could pay a tax.
Summary: if our goal is to make quality health care affordable and available :
We need to fix the drug price problem.
Pevent hospitals from generating outrageous inflated bills for their services.
Eliminate out of network charges.
Eliminate balanced billing.
Allow the medical loss ratio (MLR) to whither.
Put a cap, an upper limit, on the out of pocket Medicare bills that unsuspecting seniors are sometimes forced to pay.
And we should allow people to buy into Medicare.
And perhaps tax the excess profits of University and Charitable hospitals.
Chapter Twenty-Four: Generic Drugs
HATCH WAXMAN
Overview of the Hatch-Waxman Act and Its Impact on the Drug Development Process
Prior to the creation of the World Trade Organization in 1995, individual countries were free to determine their own patent laws. This position has now changed. All members of the WTO are required to adopt patent laws that comply with the Agreement on Trade-related Aspects of Intellectual Property Rights,1 including the implementation of patent protection for pharmaceuticals. The developed members of the WTO negotiated mandatory protection for pharmaceutical products and processes in the TRIPS Agreement on the basis that such mandatory protection will provide the necessary incentives for continued pharmaceutical innovation. In contrast, the developing countries and the Least Developed Countries argued that enacting patent laws that comply with TRIPS may restrict production and supply of low-cost generic medicines by their local pharmaceutical industries or by the pharmaceutical industries in other developing countries, and hence could increase the price of pharmaceuticals to the point that pharmaceuticals become inaccessible to their populations.
In much of Europe biosimilars can be marketed as soon as they have been shown to perform as well as the original drug, but they are usually not thought of as interchangeable or a generic version of an existing medication. They are instead treated like a competitor or a therapeutic alternative, and outside of a small number of Eastern European countries pharmacists can’t substitute a biosimilar for a designated medication without permission from the prescribing physician. When the biosimilars begin to significantly price compete attitudes will probably change, but for now in France and Italy, at least, “biosimilar adoption rates have been low.”
Used in place of the some european hospitals In the hospital setting, however, there are also coordinated efforts to switch patients, with reports of U.K. hospitals switching >95 percent of their rituximab patients in just six weeks since the biosimilar for rituximab was introduced. All stakeholders in the hospital (including patients) realize how, by switching, they are able to generate savings ion, and
(e.g., Estonia, Latvia, Poland), while France recently introduced legislation allowing substitution in treatment-naive patients under specific conditions (although in practice, this is still uncommon). But in most other European markets, biosimilars have been treated as competitors of the originator products in much the same way blood products such as factor agents, immunoglobulins, and other high-cost treatments are handled.1 This is evidenced by the widespread use of tenders to drive procurement decisions across Europe, although these can take many guises ranging from exclusive to nonexclusive contracts.
In 2019, according to the NIH, the most common causes of blindness are: Cataracts (51%); Glaucoma (8%); Age-related macular degeneration (5%);Corneal opacification (4%); Childhood blindness (4%; Refractive errors (3%); Trachoma (3%); Diabetic retinopathy (1%)
In all he wrote six books, over 100 publications in scientific journals and held over 150 patents. He received a great many awards during and after his life. In 1993, Asteroid 3899 was named Wichterle and a statue was erected outside the IMC in 2005.
Li HT, et al. Geographic Variations and Temporal Trends in Cesarean Delivery Rates in China, 2008-2014. JAMA. 2017;317:69–76. doi: 10.1001/jama.2016.18663.
Heavy Menstrual Bleeding in Women with Uterine Fibroids. William D. Schlaff, M.D., et al NEJM January 23, 2020
https://www.nejm.org/doi/full/10.1056/NEJMoa1904351?query=featured_home “Half of women with Uterine fibroids (leiomyomas have symptoms: heavy menstrual bleeding, which can lead to anemia, pelvic pain and pressure, urinary and gastrointestinal symptoms, infertility, and complications of pregnancy.” They sometimes affect a woman’s physical, psychological, and social well-being.”
In 1976 the U.S. Supreme court created a right for medical care to one group of Americans: People in Jail. Eight of nine justices “acknowledged that the eight and fourteenth amendments required the Texas government to provide medical care for prisoners.” Estelle vs. Gamble.
In 2006, in response to a law suit, a federal judge learned that prison conditions were “disgraceful”, declared the health care the institutions provided was unconstitutional,” and put the California State facilities into receivership.
Washington University 2010 therapeutic manual for doctors listed drugs that block the virus at several transitional sites. We had more than 10 reverse transcriptase inhibitors, 9 protease inhibitors, 2 entry inhibitors and an integrase inhibitor. All drugs had side effects. People who couldn’t tolerate one reverse transcriptase inhibitor often had no problem taking a different one. When a combination of medications was used, the viral biochemical assembly line was blocked in more than one location, and viral resistance was uncommon. Refractory HIV however, commonly developed when a person stopped and started the medications. That happens when people can’t afford their co-pay, when they live in a remote part of the world and don’t have access, or if they merely decide to take a “drug holiday”.
Milestones Pioneered by Interventional Radiologists
1964 Angioplasty
1966 Embolization therapy to treat tumors and spinal cord vascular malformations by blocking the blood flow
1967 The Judkins technique of coronary angiography, the technique still most widely used around the world today
1967 Closure of the patent ductus arteriosis, a heart defect in newborns of a vascular opening between the pulmonary artery and the aorta
1967 Selective vasoconstriction infusions for hemorrhage, now commonly used for bleeding ulcers, GI bleeding and arterial bleeding
1969 The catheter-delivered stenting technique and prototype stent
1960-74 Tools for interventions such as heparinized guidewires, contrast injector, disposable catheter needles and see-through film changer
1970’s Percutaneous removal of common bile duct stones
1970’s Occlusive coils
1972 Selective arterial embolization for GI bleeding, which was adapted to treat massive bleeding in other arteries in the body and to block blood supply to tumors
1973 Embolization for pelvic trauma
1974 Selective arterial thrombolysis for arterial occlusions, now used to treat blood clots, stroke, DVT, etc.
1974 Transhepatic embolization for variceal bleeding
1977-78 Embolization technique for pulmonary arteriovenous malformations and varicoceles
1977-83 Bland- and chemo-embolization for treatment of hepatocellular cancer and disseminated liver metastases
1980 Cryoablation to freeze liver tumors
1980 Development of special tools and devices for biliary manipulation
1980’s Biliary stents to allow bile to flow from the liver saving patients from biliary bypass surgery
1981 Embolization technique for spleen trauma
1982 TIPS (transjugular intrahepatic portosystemic shunt) to improve blood flow in damaged livers from conditions such as cirrhosis and hepatitis C
1982 Dilators for interventional urology, percutaneous removal of kidney stones
1983 The balloon-expandable stent (peripheral) used today
1985 Self-expandable stents
1990 Percutaneous extraction of gallbladder stones
1990 Radiofrequency ablation (RFA) technique for liver tumors
1990’s Treatment of bone and kidney tumors by embolization
1990’s RFA for soft tissue tumors, i.e., bone, breast, kidney, lung and liver cancer
1991 Abdominal aortic stent grafts
1994 The balloon-expandable coronary stent used today
1997 Intra-arterial delivery of tumor-killing viruses and gene therapy vectors to the liver
1999 Percutaneous delivery of pancreatic islet cells to the liver for transplantation to treat diabetes
1999 Developed the endovenous laser ablation procedure to treat varicose veins and venous disease
In 2015 Medtronic bought a Tyco spinoff (Covidien) that was headquartered in Dublin for 42.9 billion and moved their home base to Ireland. They made most of their money in the U.S. and avoided paying tax on $14 billion. They called the maneuver a “tax inversion” and it was legal. Between 1982 and the present 82 companies have shifted their headquarters to a foreign destination, usually Ireland or Bermuda “without changing the majority ownership”
Epipen –House of Representatives: Cummings on Bresh http://www.digitaljournal.com/news/politics/epipen-ceo-raked-over-the-coals-during-hearing-on-price-gouging/article/475477#ixzz6bLqV6Hdh
Then, in 1981, Jacques Dubochet and Alasdair McDowall made a breakthrough in imaging macromolecular complexes with EM — introducing the rapid cryo-cooling of individual molecules in a thin layer of vitrified water –
Ruska electron microscope Ruska electron microscope
A Better Treatment for Hepatitis C (edited) Dec 9, 2013 New Yorker By Celine Goundera physician, public-health specialist, and medical journalist
There are six genotypes of hepatitis C. Using interferon some were more responsive to treatment than others. “Sofosbuvir changed everything. One-pill-a-day therapy, very high cure rates, shorter treatment duration, and fewer side effects.” Sofosbuvir was invented by, and named after, Michael Sofia, the kind of person who daydreams about enzymes metabolizing drugs. Sofia was raised in a row house on the northeastern side of Baltimore. His parents, a barber and a payroll clerk, were both children of Italian immigrants, and born within a block of each other in Baltimore’s Little Italy. Although they instilled an immigrant’s appreciation for education in their three children, who would all go on to work in science, Sofia’s reading skills were so poor as a child that in the fourth grade he was put in a remedial reading class. Sofia credits the nun who taught him with transforming into a “completely different student.” Sofia eventually enrolled at Cornell and went on to earn his Ph.D. from the University of Illinois.
When he arrived at Pharmasset, the company had already started moving away from the H.I.V.-drug development that it was initially known for, since the market had become saturated with “nucleoside” drugs that worked reliably with manageable side effects. Nucleosides are the building blocks of D.N.A. and R.N.A.; they can be chemically altered to terminate chains of genetic code early, producing something like a defective Lego that can’t be build onto, stopping the growth of the virus. Though this chemistry had been used successfully to treat H.I.V., only a few labs were trying this approach with hepatitis C. Sofia noted that one of the company’s test drugs, PSI-6130, showed activity against hepatitis C. He realized that any effective hepatitis-C drug not only needed to get into the liver, where the virus was replicating, but stay there, to avoid unintended side effects elsewhere in the body. In their active form, nucleoside drugs don’t enter liver cells. Sofia hypothesized that if he could shroud a nucleoside with an “invisibility cloak” to get it into liver cells he could then count on the liver’s enzymes to break down the cloak and activate the drug. Once the cloak has been shed, the nucleoside would be trapped inside, protecting the rest of the body from exposure. “ He explicitly engineered sofosbuvir with this and a number of other goals in mind—that the drug would be taken orally, ten times more potent than PSI-6130, and effective against all six genotypes of hepatitis C. Beginning with a modified version PSI-6130, after three years of development, Sofia and his colleagues arrived at sofosbuvir in 2007. What’s remarkable, according to Sofia, is that it was not in fact a happy accident, but a product of explicit engineering. Following the Pharmasset acquisition in 2011, Sofia worked with Gilead for about a year to manage the transition process.
A little over a century ago, my six-year-old dad and his family lived in a small, wooden, dirt-floored cottage in a shtetl that straddled one of the main Ukrainian-Russian east-west highways. In 1914, the First World War started. The Russian army attacked Germany and fell into a trap. The Russian Second Army was virtually destroyed at the Battle of Tannenberg, and thousands of the surviving soldiers retreated. When they came through my father’s town, the fleeing Cossacks burned the family home to the ground. During the subsequent war years, the family crowded into one of the remaining cabins on the edge of the village. It was owned by an elderly Ukrainian who hadn’t left for mother Russia with his family.
During the war, no one bathed or boiled their clothes. Everyone’s garments and bedding contained body lice. One winter there was a typhus outbreak. The infectious disease is caused by a tiny bacterium (ricketsia) that lives in the lice. When the creatures defecate, their droppings itch. People scratch, tear their skin, and bacteria enter their bodies. One to two weeks later, the aching starts. Many become quite ill. They have chills, high fevers, an unremitting headache, and exhaustion. When my grandmother became feverish, she was also confused. A Russian army nurse who was making the rounds came by. The family was unable to hide the sick woman and the nurse summoned a wagon. It took my grandmother to the schoolhouse, the large hall full of beds where most died. My grandfather watched and cried as they carted her away.
“During the eight years between 1917 and 1925, more than 25 million people living in Russia developed epidemic typhus, and three million died.” Some claim epidemic typhus has caused more deaths than all the wars in history. My father always remembered his boyhood, and when I chose to go to medical school, he shrugged. Based on what he witnessed, he believed doctors know how to recognize and diagnose illness, but that’s all they can do. (In the 21stcentury, typhus is easily cured and prevented with the antibiotic Doxycycline.)
The human body knows how to mend itself and fight off infections, and there have always been healers and helpers. The first sign of civilization, according to anthropologist Margaret Mead, was a femur (thighbone) that had been fractured and healed. Repair and restoration takes time. Without help creatures with broken legs can’t escape danger and don’t survive.
Prior to the 1900s, mankind didn’t have the ability and tools needed to cure the lame and blind, turn around a lethal infection, remove a cancer, or give someone a new heart or kidney. The needed drugs, devices, and skills—“health care”—were created (or transformed) during the last 120 years. It’s a gift we received because we were born in the 20th and 21st centuries. It may be as common as the iPhone, the airplane, or the internet. We may take it for granted and feel like it has always been and always will be available when we need it.
But it has become expensive. In the last 50 years, some of us have had to deal with costly insurance, obscenely priced medications, and outrageous hospital bills. Many of the people in charge don’t believe health care is or should be a shared responsibility.
—————————–
The authors of the Declaration of Independence didn’t think health care was an “unalienable right that was endowed by our creator” and health care wasn’t one of the many rights that were added to the nation’s Constitution in 1791.
Back then, nursing care supported the ill and sped their recovery. Amputations prevented some deaths. But most of the treatments doctors employed were pretty awful. Consider—the December morning in 1799 when 67-year-old George Washington awoke desperately ill. He was retired and lived at Mt. Vernon. The previous day, Washington felt well and went out in the snow to “mark trees that were to be cut down.” Upon awakening on the day in question, he couldn’t talk and had trouble breathing. His wife, Martha, sent for one doctor, then another. She and her husband were two of the country’s richest people and obviously didn’t need subsidized care.
During the day, three prominent physicians came to their home and plied their trade. The doctors were among the country’s best and they worked hard. On four occasions, they bled the sick man and removed a lot of blood. His throat was swabbed, he gargled, his feet were covered with wheat bran, and he was given an emetic to induce vomiting. Nothing worked. When Washington’s breathing got worse, he dressed, thanked his three doctors, and made arrangements for his burial. That night, he died. (As related by his secretary Tobias Lear)
Before 1800, the educated elites relied on the teachings of the ancients, like the Greek physician Hippocrates, who believed that illness was “due to an imbalance of blood, phlegm, black bile, and yellow bile,” and the Roman Galen who dissected monkeys and wrote about their anatomy.
Mankind was not aware of the microscopic creatures who lived in, around, and on us until the late 1700s.
During the 1800s we gradually learned about their existence. We started believing and understanding that they were the source of many of our maladies, and we began to take precautions.
In the 1900s our abilities exploded: We learned how to safely transfuse blood. Hormones were isolated. Antibiotics and drugs that fought viruses and parasites were developed. Experts learned and taught others how to replace eye lenses that were opaque. Vaccines were crafted. Thousands of medical gadgets were devised. Surgeons were taught how to proceed after they cut a person open, and a large number of effective drugs became available.
In 1965, over 100 million Americans were introduced to socialized medicine—Medicare and Medicaid. Most loved it.
In 2003, the entire human genome was “sequenced.” Scientists determined the exact order, the way the 3 billion pairs of human DNA nucleotides (building blocks) lined up, and our ability to attack and “cure” genetic conditions got a big boost. The push and pull between medical care as a shared endeavor or a wealth-producing commodity started in the 1900s. It intensified over time. In the last half of the 20th century, “health care” increasingly became a major part of the U.S. economy and obstacles and inequalities were created. This book seeks to make sense of the wonders that were developed and the challenges we face.
In the pages that follow, I’d like you to accompany me up the miraculous, tortuous road medicine has traveled during the last 200 years, and get a more detailed understanding of what I’m talking about.
The typhus epidemic in a shtetl during the First World War.
According to Abbe’s calculations the wavelength of light determines the light microscope’s ability to see tiny objects and the magnification factor can’t be much more than 1,000. A number of parasites that had not, previously, been visible were identified. After Zeiss died in 1888, Abbe became the head of the company and, ahead of his time, he introduced an 8 hour work day, pensions and holiday and sick pay.
Ruska developed the electorn microscope and one the nobel prize in 1986
Dzintars GothamFaculty of Medicine, Imperial College London, London, UK; et al. Estimated generic prices for novel treatments for drug-resistant tuberculosis Journal of Antimicrobial Chemotherapy, Volume 72, Issue 4, April 2017, Pages 1243–1252
The son of a York farmer, Snow had moved to Newcastle, a northern English city located on the Tyne River when he was 14 and was an apprentice to an Apothecary- surgeon for 9 years. He then moved to London where he studied medicine. He became a member of the Royal College of Surgeons ten years before “the first case of Asiatic cholera” came to “the great city.” The illness arrived in the body of a seaman who died a few hours after the illness “seized” him. The sailor had been working on a steamer where “the disease was prevailing.” Shortly after the man’s death his body was removed from the room he had been renting and another man moved in. Eight days later the newcomer developed severe diarrhea and fever—cholera. Snow discussed their illness in a medical paper and argued cholera was not airborne. “He also wrote about the neighborhood keeper of a coffee shop who served glasses of water from the Broad Street pump along with meals. She knew of nine of her customers who had contracted cholera.”
Mostly a vegetarian Snow “occasionally” drank wine when he was older, but he continued to have “faith in the temperance cause.” He dressed plainly, never married, “and found every amusement in scientific books, and simple exercise.” He was “full of humorous anecdotes” and told them in an irresistibly droll style. His husky voice “rendered first hearings from him painful,” but when he guffawed “his good natured face laughed in every feature.”
“Lien Jih-ching (連日清) is a specialist in mosquito-borne diseases and helped eradicate malaria in Taiwan by reducing the number of endemic cases from more than 1 million to zero within a decade,” Chen said, adding that Lien helped Taiwan become the first nation in the world to be declared “malaria-free” by the WHO in 1965.
“People call me the ‘mosquito man,’” said Lien, who is nearly 90 years old.
Lien also helped to significantly reduce the prevalence of malaria in Sao Tome and Principe — an island nation in western Africa — as depicted in the second part of the documentary.
“The prevalence of malaria was about 40 percent in 2000 … after we applied mosquito prevention measures, the numbers of patients hospitalized for malaria in Sao Tome and Principe dropped to zero in 2003,” Lien said in the documentary.
The use of an insecticide called dichlorodiphenyltrichloroethane is credited with the eradication of malaria in Taiwan, but it was not as effective in Sao Tome and Principe, Lien said, adding that he instead used alpha-cypermethrin, which had proven effective in southern Taiwan against dengue fever.
The story of Lice and ticks is on the web site but not in the book.
LICE
In the 1800s some claimed the river flowing past Rouen smelled bad when too many in Paris flushed at the same time. Rouen borders the Seine River and is 80 miles closer to the ocean than the city of lights. It is the capital of Normandy, is known for the Monet paintings of its Gothic cathedral, and is the home of the ancient marketplace where Joan of Arc was burned at the stake.
It’s also the town where Jules Noelle was born in 1866. At age 29, after he studied in Paris and became a doctor. Then he moved back home and married 21 year old Alice Louise Avice. He got a job at the local medical school, but his position was not tenured, his colleagues were reluctant to accept his “wonky” Parisian belief that germs caused disease, and he was unable to hear well enough to use a stethoscope. His career was going nowhere when the French government came looking for doctors for Tunisia, their recently conquered colony. Jules’ brother was offered a job in north Africa and he declined, but 36 year old Jules applied for the position and was hired.
In Tunisia an illness called Typhus was a problem each winter. (The name comes from the Greek word tuphos or stupor.) People in the “overcrowded prisons, asylums, and tent villages” ran fevers, became confused, and sometimes died. When Jules arrived an outbreak “was raging in a native prison 80 kilometers south of Tunis/” The doctor in charge of health care was planning to visit the area and Jules asked if he could accompany him.” The night before the trip Nicolle coughed up blood and he decided to stay behind. The chief doctor and his servant, visited the prison, spent the night, contracted typhus and both died.
As one of the now senior physicians, Nicolle decided to learn more about the illness. He visited a hospital, and recalled stepping over the bodies of typhus patients who were awaiting admission to the hospital and had fallen exhausted at the door.” He noticed that sick people “spread the contagion “to others in the hospital waiting room but stopped contaminating others as soon as they bathed and dressed in a hospital uniform.” Nicole figured the clothes—more specifically the lice that lived in the clothes, had to be the vector that spread the disease.
He injected a chimpanzee with blood from an ill patient and a day later the chimpanzee was running a fever and was prostrate. “Nicolle then injected a toque macaque (Macaca sinica) with blood from the ill chimpanzee and two weeks later the macaque got sick. He transferred the lice that were feeding on sick macaques to other macaques and they got sick. Nicolle was unable to culture the offending organism in agar or broth, but he published his findings in 2009 and remained in Tunis where he became an important bacteriologist. As he aged Nicolle became philosophical and a nature lover. His deafness got worse, it was hard to be social, and he spent much of his non research time writing and publishing three novels: The Two Thieves, The Pleasures of Boredom, and Marmouse and his Guests. He was “Captivated by the town of Carthage” built near the ruins of a once influential and affluent city. Noelle was known to hold court and sip mint tea in the village of Sidi Bou at a café that overlooked the town. Carthage had once been the home of Hannibal the general who marched his troops and elephants across the Alps and almost reached Rome. Between 264 and 146 BC the ancient city-state fought three bloody wars with Rome. During the third war the Carthaginian troops were defeated and the town was thoroughly destroyed. At age 62 Noelle was awarded a Nobel Prize.
The germ that causes typhus belongs to a “type” of bacteria that replicates inside other cells but doesn’t grow on agar. Called Rickettsia, this type of bacillus enters the body through a skin scratch, gets into the blood stream, and infects the cells that line the arterial walls. The first illness proved to be caused by this type of bacteria was Rocky Mountain spotted fever. Infected people have headaches, fever, and a rash. Some become quite ill, and a few die. The name—Rocky Mountain fever–is a bit misleading because the disease affects people in many parts of the U.S. The groups of bacteria that only replicates inside cells are called Rickettsia after Thomas Rickets, a small town Illinois boy who showed how Rocky Mountain spotted fever is spread. As a young researcher Rickets spent four years working mostly alone and separated from his young family. He pitched a 10 by 10 foot tent in a hospital yard in the Bitter Root Valley of Montana, in a location where the population of ticks increased when the snow melted in spring. Rickets spent much of the research years catching and studying the vector that he thought probably spread the disease. One of the human families Rickets studied lived on a farm where large number of ticks thrived around the house, on trees, and on the ground. At one point, Rickets stained a sample of blood from a sick boy who had been bitten multiple times. Examining the slide Rickets saw the gram-negative bacillus that caused the illness. He was the first to identify the organism, and in 1910 he wrote a medical paper describing his findings. His discovery made him famous and later that year he went to Mexico to look for the organism that caused typhus. In the process of his research he developed typhus–and he died.
In 1930, the year after Nicolle won the Nobel Prize, Paul Müller, a Swiss biochemist working for the pharmaceutical company Geigy, discovered that dichlorodiphenyltrichloroethane (DDT) was highly effective for killing lice and other insects and seemed to be safe for man. Muller had become interested in chemistry when he was a high school student. As a teenager he “was often mocked by his peers and called, “The Ghost,” due to his thin and pale appearance” In later life he owned “a home in the alps, tended a small fruit farm, and took the children on early morning nature walks. In 1948 Muller was awarded a Nobel Prize. After it was discovered DDT was widely used in Europe and elsewhere and Typhus stopped being a major problem. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819868/
