Nurse Love from the NYT.

The New York Times is all about nurses today!

In this “Fixes” piece on “The Power of Nursing,” David Bornstein talks about the Nurse Family Partnership (where nurses make home visits to families beginning early in a mother’s pregnancy and continuing until the child is 2) and its great successes in improving health and preventing all kinds of troubles — including criminality later in life for the kiddos. Perhaps the most interesting thing he notes? It doesn’t work if someone who isn’t a nurse makes the same kind of visits.

Lawyer’s favorite part:

What’s special about nurses? For one thing, trust. In public opinion polls, nurses are consistently rated as the most honest and ethical professionals by a large margin.


That’s definitely not, er, something people say about lawyers. 


On the bedside table:

I recently picked up Mark Pendergrast’s Inside the Outbreaks about the history of the Epidemic Intelligence Service. The what? No kidding! It’s a CDC program founded in 1951 that takes young health professionals (mostly physicians) and sends them to investigate epidemics and outbreaks world-wide. It was named provocatively on purpose to stress the importance of public health as part of security, just like intelligence. . . and the book is chock-full of interesting tidbits about eradication efforts (think smallpox and polio), the ethics of using disadvantaged populations for studies, the government’s role in regulation, bioterrorism. . .  the list goes on! If you’re like me and enjoy geeking  out over medical mysteries, check it out!

Coincidences happen. Even when you get a flu shot.

The New York Times has an article about the CDC’s concern that people who get flu shots this year will blame anything that goes wrong with their health on shots. (i.e. Someone gets a flu shot, two days later he has a heart attack, so obviously flu shots cause heart attacks. RIGHT?)

So, those of us who remember our stats or are science-trained sometimes utter the phrase “correlation does not prove causation” in our sleep. But much of the rest of the country world isn’t so quick to remember this fact. The CDC is especially worried that the news media will seize on individuals’ claims that the vaccine made them sick, and publicize them, which will spread that misinformation to the general public who believe anything they hear on TV or read in USA Today.

Why do we care? If people want to make themselves crazy freaking out, why would nurse and lawyer want to get in the middle of that?

One big reason: we don’t want people who really need the protection to be afraid of getting it. Pregnant women are one such class — need the protection, but wanting to be extra careful. Senior citizens are another group who need the protection and may be more susceptible to scare tactics. It could really interfere with our public health goals of preventing this from becoming a pandemic if people are afraid to get the shot. Right, nurse?

So what can we do? We obviously can’t forbid “news” organizations from reporting these kinds of stories. (Hello, First Amendment.) What about some kind of voluntary agreement, where news organizations are made aware of the problem and its potential consequences, and agree not to report these kinds of stories without appropriate context describing the nature of the correlation? What if we set a threshold for how many incidents of the same sort must be observed before it becomes a “trend” that they could report? Admittedly this is more a question of journalistic ethics than of law, but… I want to be able to do something about it!

Other ideas? Anyone?

Don’t shoot yourself in the foot!

Lawyer:  Here is part three of my series on public health emergency law.

There are a number of measures written into various laws that allow government agencies more flexibility during public health emergencies. We have a lot of regulations surrounding health care, including privacy rules, procedures for various state-fudned health care programs, and regulations about the use of drugs and medical equipment, and when we need to act fast, these rules, which are important protections most of the time, can really get in the way of a quick and coordinated response. Here are a few interesting possibilities:

Emergency Use Authorizations: The Health and Human Services Secretary can ask the FDA commissioner to issue an authorization to use a drug or device that has not yet been approved if there is reason to believe that its risks are minimal and it will help with the health emergency. Likewise, they can authorize the use of an approved drug in a new population or for a new use. These have been used in the past, and there is one in place now allowing the use of flu drugs in children.

Certain laws relating to Medicare/Medicaid — specifally, some of the requirements of health care professionals (i.e. specific timetables for certain kinds of paperwork, requirement that the license be in the specific state where they are providiing services, etc.)

These kinds of built-in flexibilities are important to a functioning system! We wouldn’t want to operate this way all the time, but we also wouldn’t want to be bound by regulations that don’t make sense in a context that requires rapid action. The potential concern — that flexibility opens up the possibility for abuse — is mild in this context, and the alternative is far worse. (As I write this, Arizona has moved up in the list of states with the most cases, but the flu also continues to look mild, and the hot weather may slow its spread — here’s hoping!

(xposted on Ready or Not.)

Helping at the health department

So, nurse, after hearing lawyer discuss some of her duties as a volunteer coordinator, signed up to work in the Pima County public health department’s call center handling calls about the swine flu.kirk-telephone-lgjpg

Ever wonder who you’re talking to when you call a number like that for information? Well, it’s me! And other nurses and doctors who are either volunteers or employees.  What did we do? Logged calls, sorted them into either informational, medical triage, or epidemiology. People who wanted to know if there were cases reported in the area, or what the symptoms were, or when they should close the school. . . etc., were informational calls. We just answered their factual questions– and told them to wash their hands a lot and call back if they were concerned. (no confirmed cases in the county, regular flu symptoms, we will reevaluate if there are local cases confirmed and issue recommendations at that time). Triage questions were people saying, “my kid has a fever, I have a cough, I just threw up. .. ” and they want to know what to do (mild symptoms: stay home until you’ve had no symptoms for two-three days, severe symptoms: to go your MD, urgent care, or ER, respiratory distress: call 911). This category of calls is really why they have nurses on the line– we can make recommendations based on these reports. Finally, questions from medical offices, hospitals, and other health departments mostly went to the epidemiologists. Pretty neat, huh? We got a lot of all kinds of calls, and I think it’s a great way to spread factual information and quell panic.

Public Health Emergency Law

Lawyer: This morning I participated in a conference call with several lawers from FEMA and HHS. They gave a broad overview of federal law as it applies to public health emergencies. It was interesting to me, but then, I’m a nerd, so I’ve tried to distill a few broad ideas from it to share.

First, there are two ways an emergency can be declared. Either the president can declare an emergency or a major disaster, or the HHS Secretary can declare a public health emergency (which he has just done.) The main reason for these declarations is to gain access to additional funds, supplies, or powers that may help control the emergency or, in this case, the potential emergency. The legal issues surrounding pandemic response can be grouped into several categories.

1. Liability. A lot of the laws surrounding disasters and emergencies deal with protecting emergency workers from being sued, altering licenscing regulations so that workers can more easily respond without sacrificing quality of care, and protecting volunteers. Federal laws generally apply only to federal employees. State laws vary widely.

2. Many of the laws are designed to give government agencies and hospitals more flexibility in emergency situations. Some temporarily relax requiremetns surrunding medicare and medicaid, and there is a program that allows for the emergency use of drugs or other treatments that have shown themselves to be helpful but have not yet been approved by the FDA.

3. Some laws make provision for the availability of resources - -not money as much as medical personnel (HHS commissioned corps, for example) and the Strategic National Stockpile, a large collection of medications, medical devices, supplies, and equipment that would help the US to respond to a public health emergency. The public health emergency declaration isused early this week gives the federal government the authority to deploy these resourcesnot just domestically, but overseas, if there is evidence that such an action would protect our own national security.

4. Perhaps the most fascinating legal questions concern safety vs. civil liberties. In particular, this applies to quarantine laws, which are actually in the process of being rewritten for a world in which people don’t generally travel by ship. The new laws, which are due to be passed mid-June (we’ll see) include a procedure for appeals to take care of the 5th ammendment concerns that often acompany quarantine and isolation ideas.

Lots of issues to explore here. Unless breaking news demands my blogging attention, I might take the next few entries to look at each of these areas in more detail. Stay tuned!


Thoughts on Swine Flu from lawyer, wearing her disaster preparedness hat

Seen the stories recently about the swine flu that’s killed up to 61 people in Mexico? And has also been found in California and Texas? Especially scary because its victims are not the very old and very young, who are typical flu victims — it’s killing young, healthy adults. The article linked above gives details.

Mexico City has closed schools and museums to work on containing it, and though we don’t have a serious outbreak here, it remains possible. It raises some really tough questions. One topic is non-pharmaceutical interventions (NPI) — the most common of which are social distancing measures. (Maybe we’ll talk about drugs and vaccines and who should get them in another post.)

At what point does it become necessary or wise to close schools? Museums and movie theaters? Workplaces? My take is that closing museums and movie theaters and the like can help prevent the spread of disease and kind of sucks, but doesn’t create any huge social problems. Closing schools leaves many families up a creek — but is one of the most effective ways to prevent the spread of illness among  children. I’m in favor of it — and also in favor of requiring employers to allow employees to take leave if a school closure is enacted. It’s still a tough situation for a lot of people, but better a tough situation than dying of swine flu. And that’s really the bottom line here.

What about imposing requirements that people wear masks in public? What about curfews and quarantines?  It’s tricky — we don’t want to make overly restrictive laws (and even if we do, people may not obey them) but we do want to keep the public safe, and there will always be those who act irresponsibly. Even with the force of law, there’s not a lot that can be done to keep a few irresponsible people from spreading infection and posing a great risk to public health. When greatly restrictive laws have been imposed to combat previous outbreaks, governments have been unable to enforce them. Distribute masks with instructions on how to use them and why it’s important. Give people the tools to protect themselves. Success through education, not force.

Recently, we discussed what health care workers should be required to do in a public health emergency.  This discussion could become a lot less abstract in the coming months. If you work in healthcare, check into your institution’s policies.

Containment doesn’t seem to be an option here — it isn’t confined to a small geographical area — but in other pandemic situations, that’s another tough choice we’d face.

Here is my hope: that if US city and state governments end up facing this choice, they are as transparent as possible. Communicate clearly with the citizens. Let us know what’s going on. Make recommendations. Give us options. Help us understand why you’re asking us to do certain things rather than just telling us we have to.

Stay tuned for more thoughts as the situation unfolds!

Soda Tax

New York’s health commisioner is proposing an 18% tax on non-diet soda. (nurse sheepishly puts down her diet coke and breathes a sigh of relief).

Nurse: The proposed soda tax, as discussed in the New England Journal of Medicine, is suggested to have the power to not only raise revenue but also to affect behavior. Bloomberg shot it down, saying that there would be a huge public outcry. Nurse’s take? BOO HOO! That’s not a good reason. There might be a good reason out there, but that’s not it!

Lawyer: You tell ‘em, nurse! Solutions like this really interest me, because they go where the law cannot – you can’t make soda illegal, but you can make it less attractive. And to people who say, why should we have to pay extra for something, just because you say it’s bad for me, I say this: Why should we have to pay for treating your diabetes, heart disease, etc, that you were at much greater risk for due to your obesity caused in part by soda consumption?

Nurse: The easiest analogy here is to a tobacco tax, which overall has been enormously effective, and works to combat arguments such as “but, big corporations will kill us!” and “it won’t effectively raise money!” Of course there are some major differences too; I would imagine that more people drink soda than smoke cigarettes, the direct link between soda and disease is not there as it is with cigarettes. Now, people still smoke, but a combination of education and the tax has changed the picture.
Of course, the major underlying public health issue here is obesity, and more specifically, childhood obesity. The CDC puts out some quite alarming statistics which we’ve probably all seen before.
The NJMA article points out that education alone won’t be able to make significant behavior changes (it hasn’t, and neither have various other tactics). That’s a good point—but education has to be part of the package. A soda tax might help drive down consumption of sugary soda a bit, but replacing it with diet soda or even fruit juice will have other negative affects on health (artificial sweeteners are controversial, juice is high in calories). A tax would certainly be a way to reach out and put more punch behind a public health effort. (Now I’m picturing cigarette-style warning labels on soda cans. It’s funny. . . or is it?)
An example: A big gulp can have 64 oz, which could be nearly 800 calories—some people don’t know that, some people don’t care, and some people wouldn’t buy it with an 18% tax. I think that we need to make the first people aware, the second people scared, and the third people the target of things like this!

Lawyer: One more thought to toss in there… another effort to reduce soda consumption has been through eliminating the sales of soda in schools.