RFK on MLK and the actual struggle.

Graduate school has decided to be acutely painful in its final days. I’m couch-surfing through my last week. After that my friends I will resume responsibilities as mother, occasional blog writer, and amateur critic of everything that crosses my path.

Had to share this as I went down a rabbit hole on a health policy paper and ended up at this speech–recommended by my #1 policy prof via a note on an old assignment, “one of the most powerful political speeches of the modern era,” and what do you know all of a sudden I have time to look it up. RFK quotes Aeschylus. And the people of the Starbucks are used to my crying by now. You’ve seen it before? Are you watching the news? Watch this again.

Robert F. Kennedy delivered this impromptu speech announcing the death of Martin Luther King, Jr. to a largely African American audience in Indianapolis. His brother was dead 4 years, and he would be assassinated before the spring was out.

Have we become so cynical that our leaders are unable to move us? Or is it the patina of time that makes this sound genuine? Listen anyway.

Global public health development goals: Paul Farmer on who lives and who dies.

Global public health development goals: Paul Farmer on who lives and who dies..

Economics should never have sought to divorce itself from the other social sciences and can advance only in conjunction with them. -Thomas Picketty

A day late for World Health Day. I hope my prof won’t mind if I share an article from this week’s readings. It’s going to be a task to disentangle the social injustice from the ethics of access from the rageifying post-colonialist cut-and-run, then weave in a thread of third world problems here in the US, but hey I’ll do my best to analyze coherently.

I can’t tell if the article is unwieldy or if it’s just my feelings on the subject. Either way a worthwhile read.

FDA Proposes Easing Lifetime Ban On Blood Donations By Gay Men | Kaiser Health News

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FDA Proposes Easing Lifetime Ban On Blood Donations By Gay Men | Kaiser Health News.

Let’s look at some facts and data, shall we? Then I’ve got questions.

Statement from the FDA.
From Red Cross:

redcross blood safety

redcross blood safety 2

What it means: Blood is tested for antibodies to HIV 1&2 as part of the battery of tests performed to ensure donated blood is safe for use. However it may take several weeks to months after infection for HIV antibodies to present in the serum (if you contracted it last night, it may not be apparent until 3 months from now).

From CDC:
cdc hiv transmission rts

What it means: The population of concern are people who have been exposed to HIV but have not yet developed screen-able antibodies–new infections. So we look at the most recent transmission data from the CDC and note that men having sex with men are 2.5 times as likely to have a new infection as the second largest category, heterosexual contact.

My questions: How is the one year waiting period scientifically justified? One year would allow time for antibodies to appear, of course. But there is risk of undetectable infection in blood of people engaging in heterosexual contact, too. Even it it’s 2.5 times less than MSM is that risk not deserving of the one year abstinence period? And then where would be be in terms of blood supply? What is the risk benefit analysis here? I don’t yet get how this is a decision based in evidence on the part of the FDA. To me, it’s a little don’t-ask-don’t-tell-y. And by that I mean homophobic and embarrassing.

Also, I would like to know that data on the risk of transmission of HIV and the Heps when anitgen/antibody complexes are undetectable in the serum. And the number of people per year who contract HIV or Hep B or C from blood transfusions. Add that lit search to the pile.

From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages – ProPublica

Under federal law, nonprofit hospitals must offer care at a reduced cost to lower income patients, a service often called charity care. But crucial details—how poor patients need to be, how much bills are reduced, and how policies are publicized—are left to the hospital. The Affordable Care Act empowered the IRS to set new requirements for publicizing this information, but those have yet to be finalized.

If a patient can’t pay and Northwest obtains a judgment, it’s too late. Hospital policy says once the collection agency has “incurred legal fees” on a case, the patient is ineligible for charity care, regardless of earnings.

via From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages – ProPublica.

I’m breaking my break because this spectacular piece of investigative journalism is really all I wanted for Christmas. This is an issue that makes the individual mandate, as Salt-N-Pepa might say, very necessary.

Charity care/financial assistance is available at my academic health system. Patients qualify for financial assistance based on income and payments are calculated with a sliding scale. They may owe nothing, a percentage of the total, or be put on a payment plan. This article uncovers that the criteria for how a patient finds out about or applies for or qualifies for financial assistance is largely left up to the hospital. As a recent cancer patient with massive bills but good insurance and 2/3 of a graduate degree from the academic health system where I received treatment, I still messed up paying the hospital. Medical billing is incomprehensible and damn tricky. Adding the difficulty of applying for financial assistance on top of your stack of bills from many non-communicating entities is the real cherry on top of the garbage sundae. No, it’s an additional garbage sundae on top of the garbage sundae. No, it’s just a pile of garbage.

Bottom line: Access to aid is limited. Barriers to aid are significant. And, most shockingly to me, once you have been sued successfully by the hospital, you no longer qualify for aid. *MIND EXPLODES*

Where is my mind?

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I have really enjoyed dropping off the face of the earth for a few days. The academic schedule suits my glutton-for-punishment alternating with complete and total slacker personality. Of course I can be as maniacal at slacking as I am at work. Over the past week I read a 700 page novel in time to have a meeting of the introverts’ book club. You know–two people at a bar who read the same book. Reading a beautiful novel that has nothing to do with health care then going to a bar, an entirely selfish act for a wife and mother, is my best shot at spiritual renewal.

Early in graduate school our class was introduced to a mindfulness curriculum. It intends to create embodied, resilient, and compassionate providers. Man, I thought, this nonsense is going to burn off like so much morning fog. Then came the infamous mindfulness retreat. There was gentle yoga and meditation to the sounds of jungle rain. No wait that was just me crying uncontrollably. Mindfulness:1, Melissa: 0.

fetal-position-550x550

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I was not ready for mindfulness. It is powerful medicine. What was wrong with my foremothers’ ways of coping with life’s ups and downs? Beating carpets, aggressive scrubbing, tea.

Complementary and alternative medicine (CAM) is a booming area of research. What interests me is finding the best way to provide access to the modalities, germane to many folks aren’t hanging out on Maslow’s lowest 2 or 3 spots, to people who are unfamiliar with CAM and have a list as long as my arm of more immediate food-shelter-safety concerns. The people at Common Ground Healing Arts are making some impressive forays, working in public housing projects and a prison, and showing good results in terms of better controlled diabetes and lowered BPs. I came to them last winter with a note from the cancer center and they took care of my penniless self, too. I want to talk to them about their work. I kind of love them.

So to review, meditation/yoga/acupuncture, the whole package, is a significant thing. I buy it okay, I’m on board. I’m just not all the way ready. So practitioners please be aware that efforts to induce mindfulness may create a paradoxical reaction. Also, it’s okay if your way of clinging to mental health like hang in there kitty is reading a big book, drinking three fingers of whiskey, and talking to your friend about this beautiful line of prose, did you catch that leitmotif, and oh the point is that half of love is yearning.

Happy holidays all, do your thing to get restored.

Poetry Monday.

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Enlightenment

BY NATASHA TRETHEWEY

In the portrait of Jefferson that hangs
        at Monticello, he is rendered two-toned:
his forehead white with illumination —
a lit bulb — the rest of his face in shadow,
        darkened as if the artist meant to contrast
his bright knowledge, its dark subtext.
By 1805, when Jefferson sat for the portrait,
        he was already linked to an affair
with his slave. Against a backdrop, blue
and ethereal, a wash of paint that seems
        to hold him in relief, Jefferson gazes out
across the centuries, his lips fixed as if
he’s just uttered some final word.
        The first time I saw the painting, I listened
as my father explained the contradictions:
how Jefferson hated slavery, though — out
        of necessity, my father said — had to own
slaves; that his moral philosophy meant
he could not have fathered those children:
        would have been impossible, my father said.
For years we debated the distance between
word and deed. I’d follow my father from book
        to book, gathering citations, listening
as he named — like a field guide to Virginia —
each flower and tree and bird as if to prove
        a man’s pursuit of knowledge is greater
than his shortcomings, the limits of his vision.
I did not know then the subtext
        of our story, that my father could imagine
Jefferson’s words made flesh in my flesh —
the improvement of the blacks in body
        and mind, in the first instance of their mixture
with the whites — or that my father could believe
he’d made me better. When I think of this now,
        I see how the past holds us captive,
its beautiful ruin etched on the mind’s eye:
my young father, a rough outline of the old man
        he’s become, needing to show me
the better measure of his heart, an equation
writ large at Monticello. That was years ago.
        Now, we take in how much has changed:
talk of Sally Hemings, someone asking,
How white was she? — parsing the fractions
        as if to name what made her worthy
of Jefferson’s attentions: a near-white,
quadroon mistress, not a plain black slave.
        Imagine stepping back into the past, 
our guide tells us then — and I can’t resist
whispering to my father: This is where
        we split up. I’ll head around to the back. 
When he laughs, I know he’s grateful
I’ve made a joke of it, this history
        that links us — white father, black daughter —
even as it renders us other to each other.

Natasha Trethewey, “Enlightenment” from Thrall. Copyright © 2012 by Natasha Trethewey.

It’s World AIDS Day. Epi changes in HIV/AIDS.

CDC – Geographic Distribution – Statistics Overview – Statistics Center – HIV/AIDS.

Some highlights:

-> Largest percentage of newly diagnosed infections: The South

-> Largest percentage of people living with AIDS: Dixie

-> Largest percentage of deaths from AIDS: Former Confederate States of America

Racial disparity also observed (new diagnosis highest in African-American population, particularly African-American women).

What does it mean? The epidemiological profile of AIDS has changed quite a bit since the 1990s. HIV/AIDS needs to be on the radar for health care providers (and people having sex) everywhere: in the south, in rural areas, as well as major urban areas, the northeast, and the west coast. Screening should be taking place at every primary care visit and, since it is often used as a primary care, the Emergency Department. Normalizing HIV screening as one of those tests we do for everyone at every point of contact just makes sense. Broken leg? How about a side of HIV screen gratis b/c of Obamacare?

I’ve been HIV tested 3 or 4 times and I promise you it is fun and easy. Do it! Ask your doctor or nurse if they offer the test to everyone. If no, why not?

Now everyone feels bad about the pies.

(Image from CDC)

Happy day after Thanksgiving. Now that we’re all in regret mode, diabetes! This is a slow-motion public health train wreck, amiright? And it’s another marker of race disparity in health… but I’ll save that for another day.

Diagnostic for diabetesHemoglobin A1C>=6.5 OR 8 hour fasting plasma glucose of >= 126 mg/dl OR oral glucose tolerance test of >= 200 mg/dl OR random plasma glucose of >=200 mg/dl.

Super user-friendly.

So diabetes is a clear medical diagnosis to make, but telling someone with a fasting blood sugar of 120 that they do not have diabetes is the wrong message. You either have HIV or you don’t. Diabetes is a disease on a continuum. Even with moderately high sugars the vessels of the fingers and toes and heart are getting damaged. The delicate vasculature of kidneys and eyes is getting all junked up, and pancreas… oh poor pancreas you will never be the same.

So it would make sense to do some intensive nutrition education for people that fall into that pre-diabetic category, you know, maybe keep them from become full-blown diabetic? As it stands, Medicare does not reimburse (pay for) nutrition consults until you have the official diagnosis of diabetes. So we are giving nutrition education to people in the hospital after they have had their toes amputated, between debridements of wounds that won’t heal, and in dialysis while they wait for a kidney transplant. These are miserable, life-limiting procedures. All of which are way pricier than some front-end nutrition education. And the cost of diabetes has increased 41% over the past 5 years.

My mom falls into the pre-diabetes category. I write little lists and send texts and talk to her on the phone about how she is managing a blood sugar that is next door neighbors with diabetes. Based on my very limited knowledge of nutrition (nursing schools could really fortify this part of our education), here are some of tips I’ve given her: First, 5 a day, lots of fiber, and minimal processed foods. Look for added sugar in all all foods, especially processed. If a product is labeled low or non fat, you can assume that they replaced that fat with sugar. Check the label. Also, exercise helps your cells metabolize sugar, bringing down your blood sugar. Even if you don’t lose pounds. What else can I do? I’m genuinely asking.

Think globally, outrage locally.

One of the volunteers at our tiny county’s only food bank/emergency assistance provider/shelter is always wearing a t-shirt that says IF YOU AREN’T OUTRAGED YOU AREN’T PAYING ATTENTION. He’s one of the gentlest guys I know–a middle aged black man living in rural poverty who relies on the food bank and is its most faithful volunteer. I used to give his son a lot of (unsanctioned by my employer) rides back when I was working in our nearby town. Also soft-spoken and kind. And tall and broad and one of those kids whose stupid luck ends him up in the wrong place sometimes. I worry.

But that t-shirt, oh man it makes me like that guy.

So here’s something I wasn’t paying attention to before one of my nursing colleges (Michael Swanberg, a member of ACT UP, certified nurse midwife, and enchanting human being) brought it to light. This data is pulled from the Thomas Jefferson Health District’s community health assessment, 2012. Page 54. The image quality is terrible but the dark blue is TJHD black infant mortality, teal is TJHD white infant mortality.

infant mortality image

An examination of infant mortality stratified by race demonstrates the same phenomenon in Virginia and TJHD as in the nation — African-American babies die more frequently than white babies. In 2007-2011, the rolling average IMR in TJHD was 4.5 infant deaths per 1,000 live births among white infants, lower than the Virginia (5.4) and U.S. rates; it was 17.3 among African-American infants, which was higher than the Virginia (13.8) and the U.S. rates (Figure 109).

Check my math but that means that African-American neonates in our health district are nearly four times more likely to die than their white counterparts. Brand new no-jackass-on-earth-can-say-their-deaths-were-deserved babies. Are you feeling the outrage? The black neighborhoods in Charlottesville are literally in the shadow of the towers of an academic health center. Tell me how this can be.