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US Responses to Coronavirus Outbreak Expose Many Flaws in Our Medical System

Curator: Stephen J. Williams, Ph.D.

The  coronavirus pandemic has affected almost every country in every continent however, after months of the novel advent of novel COVID-19 cases, it has become apparent that the varied clinical responses in this epidemic (and outcomes) have laid bare some of the strong and weak aspects in, both our worldwide capabilities to respond to infectious outbreaks in a global coordinated response and in individual countries’ response to their localized epidemics.

 

Some nations, like Israel, have initiated a coordinated government-private-health system wide action plan and have shown success in limiting both new cases and COVID-19 related deaths.  After the initial Wuhan China outbreak, China closed borders and the government initiated health related procedures including the building of new hospitals. As of writing today, Wuhan has experienced no new cases of COVID-19 for two straight days.

 

However, the response in the US has been perplexing and has highlighted some glaring problems that have been augmented in this crisis, in the view of this writer.    In my view, which has been formulated after social discussion with members in the field ,these issues can be centered on three major areas of deficiencies in the United States that have hindered a rapid and successful response to this current crisis and potential future crises of this nature.

 

 

  1. The mistrust or misunderstanding of science in the United States
  2. Lack of communication and connection between patients and those involved in the healthcare industry
  3. Socio-geographical inequalities within the US healthcare system

 

1. The mistrust or misunderstanding of science in the United States

 

For the past decade, anyone involved in science, whether directly as active bench scientists, regulatory scientists, scientists involved in science and health policy, or environmental scientists can attest to the constant pressure to not only defend their profession but also to defend the entire scientific process and community from an onslaught of misinformation, mistrust and anxiety toward the field of science.  This can be seen in many of the editorials in scientific publications including the journal Science and Scientific American (as shown below)

 

Stepping Away from Microscopes, Thousands Protest War on Science

Boston rally coincides with annual American Association for the Advancement of Science (AAAS) conference and is a precursor to the March for Science in Washington, D.C.

byLauren McCauley, staff writer

Responding to the troubling suppression of science under the Trump administration, thousands of scientists, allies, and frontline communities are holding a rally in Boston’s Copley Square on Sunday.

#standupforscience Tweets

 

“Science serves the common good,” reads the call to action. “It protects the health of our communities, the safety of our families, the education of our children, the foundation of our economy and jobs, and the future we all want to live in and preserve for coming generations.”

It continues: 

But it’s under attack—both science itself, and the unalienable rights that scientists help uphold and protect. 

From the muzzling of scientists and government agencies, to the immigration ban, the deletion of scientific data, and the de-funding of public science, the erosion of our institutions of science is a dangerous direction for our country. Real people and communities bear the brunt of these actions.

The rally was planned to coincide with the annual American Association for the Advancement of Science (AAAS) conference, which draws thousands of science professionals, and is a precursor to the March for Science in Washington, D.C. and in cities around the world on April 22.

 

Source: https://www.commondreams.org/news/2017/02/19/stepping-away-microscopes-thousands-protest-war-science

https://images.app.goo.gl/UXizCsX4g5wZjVtz9

 

https://www.washingtonpost.com/video/c/embed/85438fbe-278d-11e7-928e-3624539060e8

 

 

The American Association for Cancer Research (AACR) also had marches for public awareness of science and meaningful science policy at their annual conference in Washington, D.C. in 2017 (see here for free recordings of some talks including Joe Biden’s announcement of the Cancer Moonshot program) and also sponsored events such as the Rally for Medical Research.  This patient advocacy effort is led by the cancer clinicians and scientific researchers to rally public support for cancer research for the benefit of those affected by the disease.

Source: https://leadingdiscoveries.aacr.org/cancer-patients-front-and-center/

 

 

     However, some feel that scientists are being too sensitive and that science policy and science-based decision making may not be under that much of a threat in this country. Yet even as some people think that there is no actual war on science and on scientists they realize that the public is not engaged in science and may not be sympathetic to the scientific process or trust scientists’ opinions. 

 

   

From Scientific American: Is There Really a War on Science? People who oppose vaccines, GMOs and climate change evidence may be more anxious than antagonistic

 

Certainly, opponents of genetically modified crops, vaccinations that are required for children and climate science have become louder and more organized in recent times. But opponents typically live in separate camps and protest single issues, not science as a whole, said science historian and philosopher Roberta Millstein of the University of California, Davis. She spoke at a standing-room only panel session at the American Association for the Advancement of Science’s annual meeting, held in Washington, D.C. All the speakers advocated for a scientifically informed citizenry and public policy, and most discouraged broadly applied battle-themed rhetoric.

 

Source: https://www.scientificamerican.com/article/is-there-really-a-war-on-science/

 

      In general, it appears to be a major misunderstanding by the public of the scientific process, and principles of scientific discovery, which may be the fault of miscommunication by scientists or agendas which have the goals of subverting or misdirecting public policy decisions from scientific discourse and investigation.

 

This can lead to an information vacuum, which, in this age of rapid social media communication,

can quickly perpetuate misinformation.

 

This perpetuation of misinformation was very evident in a Twitter feed discussion with Dr. Eric Topol, M.D. (cardiologist and Founder and Director of the Scripps Research Translational  Institute) on the US President’s tweet on the use of the antimalarial drug hydroxychloroquine based on President Trump referencing a single study in the International Journal of Antimicrobial Agents.  The Twitter thread became a sort of “scientific journal club” with input from international scientists discussing and critiquing the results in the paper.  

 

Please note that when we scientists CRITIQUE a paper it does not mean CRITICIZE it.  A critique is merely an in depth analysis of the results and conclusions with an open discussion on the paper.  This is part of the normal peer review process.

 

Below is the original Tweet by Dr. Eric Topol as well as the ensuing tweet thread

 

https://twitter.com/EricTopol/status/1241442247133900801?s=20

 

Within the tweet thread it was discussed some of the limitations or study design flaws of the referenced paper leading the scientists in this impromptu discussion that the study could not reasonably conclude that hydroxychloroquine was not a reliable therapeutic for this coronavirus strain.

 

The lesson: The public has to realize CRITIQUE does not mean CRITICISM.

 

Scientific discourse has to occur to allow for the proper critique of results.  When this is allowed science becomes better, more robust, and we protect ourselves from maybe heading down an incorrect path, which may have major impacts on a clinical outcome, in this case.

 

 

2.  Lack of communication and connection between patients and those involved in the healthcare industry

 

In normal times, it is imperative for the patient-physician relationship to be intact in order for the physician to be able to communicate proper information to their patient during and after therapy/care.  In these critical times, this relationship and good communication skills becomes even more important.

 

Recently, I have had multiple communications, either through Twitter, Facebook, and other social media outlets with cancer patients, cancer advocacy groups, and cancer survivorship forums concerning their risks of getting infected with the coronavirus and how they should handle various aspects of their therapy, whether they were currently undergoing therapy or just about to start chemotherapy.  This made me realize that there were a huge subset of patients who were not receiving all the information and support they needed; namely patients who are immunocompromised.

 

These are patients represent

  1. cancer patient undergoing/or about to start chemotherapy
  2. Patients taking immunosuppressive drugs: organ transplant recipients, patients with autoimmune diseases, multiple sclerosis patients
  3. Patients with immunodeficiency disorders

 

These concerns prompted me to write a posting curating the guidance from National Cancer Institute (NCI) designated cancer centers to cancer patients concerning their risk to COVID19 (which can be found here).

 

Surprisingly, there were only 14 of the 51 US NCI Cancer Centers which had posted guidance (either there own or from organizations like NCI or the National Cancer Coalition Network (NCCN).  Most of the guidance to patients had stemmed from a paper written by Dr. Markham of the Fred Hutchinson Cancer Center in Seattle Washington, the first major US city which was impacted by COVID19.

 

Also I was surprised at the reactions to this posting, with patients and oncologists enthusiastic to discuss concerns around the coronavirus problem.  This led to having additional contact with patients and oncologists who, as I was surprised, are not having these conversations with each other or are totally confused on courses of action during this pandemic.  There was a true need for each party, both patients/caregivers and physicians/oncologists to be able to communicate with each other and disseminate good information.

 

Last night there was a Tweet conversation on Twitter #OTChat sponsored by @OncologyTimes.  A few tweets are included below

https://twitter.com/OncologyTimes/status/1242611841613864960?s=20

https://twitter.com/OncologyTimes/status/1242616756658753538?s=20

https://twitter.com/OncologyTimes/status/1242615906846547978?s=20

 

The Lesson:  Rapid Communication of Vital Information in times of stress is crucial in maintaining a good patient/physician relationship and preventing Misinformation.

 

3.  Socio-geographical Inequalities in the US Healthcare System

It has become very clear that the US healthcare system is fractioned and multiple inequalities (based on race, sex, geography, socio-economic status, age) exist across the whole healthcare system.  These inequalities are exacerbated in times of stress, especially when access to care is limited.

 

An example:

 

On May 12, 2015, an Amtrak Northeast Regional train from Washington, D.C. bound for New York City derailed and wrecked on the Northeast Corridor in the Port Richmond neighborhood of Philadelphia, Pennsylvania. Of 238 passengers and 5 crew on board, 8 were killed and over 200 injured, 11 critically. The train was traveling at 102 mph (164 km/h) in a 50 mph (80 km/h) zone of curved tracks when it derailed.[3]

Some of the passengers had to be extricated from the wrecked cars. Many of the passengers and local residents helped first responders during the rescue operation. Five local hospitals treated the injured. The derailment disrupted train service for several days. 

(Source Wikipedia https://en.wikipedia.org/wiki/2015_Philadelphia_train_derailment)

What was not reported was the difficulties that first responders, namely paramedics had in finding an emergency room capable of taking on the massive load of patients.  In the years prior to this accident, several hospitals, due to monetary reasons, had to close their emergency rooms or reduce them in size. In addition only two in Philadelphia were capable of accepting gun shot victims (Temple University Hospital was the closest to the derailment but one of the emergency rooms which would accept gun shot victims. This was important as Temple University ER, being in North Philadelphia, is usually very busy on any given night.  The stress to the local health system revealed how one disaster could easily overburden many hospitals.

 

Over the past decade many hospitals, especially rural hospitals, have been shuttered or consolidated into bigger health systems.  The graphic below shows this

From Bloomberg: US Hospital Closings Leave Patients with Nowhere to go

 

 

https://images.app.goo.gl/JdZ6UtaG3Ra3EA3J8

 

Note the huge swath of hospital closures in the midwest, especially in rural areas.  This has become an ongoing problem as the health care system deals with rising costs.

 

Lesson:  Epidemic Stresses an already stressed out US healthcare system

 

Please see our Coronavirus Portal at

https://pharmaceuticalintelligence.com/coronavirus-portal/

 

for more up-to-date scientific, clinical information as well as persona stories, videos, interviews and economic impact analyses

and @pharma_BI

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Burden of Depressive Disorders

Reviewer and Curator: Larry H Bernstein, MD, FCAP

 

This article is an important contribution to the literature on depression, substantiation the cardiovascular burden of depression on cardiovascular disease.

Burden of Depressive Disorders by Country, Sex, Age, and Year:Findings from the Global Burden of Disease Study 2010

AJ Ferrar*,FJ Charlson,RE Norman,SB Patten, G Freedman, CJL.Murray,T Vos

1Universityof Queensland, School of Population Health,Herston, Queensland, Au
2Queensland Centre for Mental Health Research, Wacol, Queensland, Au
3University of Queensland, Queensland Children’s Medical Research Institute,Herston,Queensland, Au
4Universityof Calgary, Department of Community Health Sciences,Calgary, Alberta, Ca
5University of Washington,Institute for Health Metrics and Evaluation, Seattle, Wash

Abstract

Background

Depressive disorders were a leading cause of burden in the Global Burden of Disease (GBD) 1990 and 2000  studies. Here, we analyze the burden of depressive disorders in GBD 2010 and present severity proportions ,burden by country, region, age, sex, and year, as well as burden of depressive disorders as a risk factor fo rsuicide and ischemic heart disease.

Methods and Findings

Burden was calculated for major depressive disorder (MDD) and dysthymia. A systematic review of  epidemiological data was conducted. The data were pooled using a Bayesian meta-regression. Disability weights from population survey data

  • quantified the severity of health loss from depressive disorders.

These weights were used to calculate

  • years lived with disability (YLDs) and
  • disability adjusted life-years (DALYs).

Separate DALYs were estimated for

  • suicide and
  • ischemic heart disease

attributable to depressive disorders. Depressive disorders were the second leading cause of YLDs in 2010.

  • MDD accounted for 8.2% (5.9%–10.8%) of global YLDs and
  • dysthymia for 1.4% (0.9%–2.0%).

Depressive disorders were a leading cause of DALYs even though no mortality was attributed to them as the underlying cause.

  • MDD accounted for 2.5% (1.9%–3.2%) of global DALYs and
  • dysthymia for 0.5% (0.3%–0.6%).

There was more regional variation in burden for MDD than for dysthymia; with

  • higher estimates in females, and
  • adults of working age.

Whilst burden increased by 37.5% between 1990 and 2010, this was due to population growth and ageing. MDD explained

  • 16 million  suicide DALYs and
  • almost 4 million ischemic heart disease DALYs.

This attributable burden would increase the overall burden of depressive disorders from 3.0% (2.2%–3.8%) to 3.8% (3.0%–4.7%) of global DALYs.

Conclusions

GBD 2010 identified depressive disorders as a leading cause of burden. MDD was also a contributor of burden

  • allocated to suicide and ischemic heart disease.

These findings emphasize the importance of including depressive disorders as a public-health priority and

  • implementing cost-effective interventions to reduce its burden.

Please see later in the article for the Editors’ Summary.

Citation:Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G,etal.(2013) Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010. PLoS Med 10(11):e1001547. http://dx.doi.org/10.1371/journal.pmed.1001547

Abbreviations: CRA, comparative risk assessment; DALY, disability adjusted life years; DSM, Diagnostic and Statistical Manual of Mental Disorders; GBD, global burden of disease; ICD, International Classification of Diseases; MDD, major depressive disorder; MEPS, US Medical Expenditure Panel Survey; NESARC, US National Epidemiological Survey on Alcohol and Related Conditions 2000–2001 and 2004–2005; NSMHWB, Australian National Survey of Mental Health and Well being of Adults 1997; RR, relative risk; YLD, years lived with disability;YLL,years of life lost.

Figure1.YLDs by age and sex for MDD and dysthymia in 1990 and 2010.  http://dx.doi.org/10.1371/journal.pmed.1001547.g001

Figure1.YLDsbyageandsexforMDDanddysthymiain1990and2010.

Figure2.YLD rates (per100,000) by region for MDD and dysthymia in 1990 and 2010. 95%UI, 95% uncertainty interval; AP-HI, Asia Pacific, high income; As-C, Asia Central; AS-E, Asia East; AS-S, Asia South;A-SE, Asia Southeast; Aus, Australasia; Caribb, Caribbean; Eur-C, Europe Central; Eur-E, Europe Eastern; Eur-W, Europe Western; LA-An, LatinAmerica, Andean; LA-C, Latin America, Central; LA-Sth, LatinAmerica, Southern; LA-Trop, Latin America, Tropical; Nafr-ME, NorthAfrica/MiddleEast; Nam-HI, North America, high income; Oc, Oceania; SSA-C, Sub-Saharan Africa, Central; SSA-E, Sub-Saharan Africa, East; SSA-S, Sub-Saharan Africa Southern; SSA-W, Sub-Saharan Africa,West.  http://dx.doi.org/10.1371/journal.pmed.1001547.g002

Figure2. YLD rates (per100,000) by region for MDD and dysthymia in 1990 and 2010

Plot 1  age dtandardized YLD rates

Editors’ Summary

Background.

Depressive disorders are common mental disorders that occur in people of all ages across all world regions. Depression—an overwhelming feeling of sadness and hopelessness that can last for months or years—can make people feel that life is no longer worth living. People affected by depression lose interest in the activities they used to enjoy and can also be affected by physical symptoms such as disturbed sleep. Major depressive disorder (MDD, also known as clinical depression) is

  • an episodic disorder with a chronic (long-term) outcome and increased risk of death.

It involves at least one major depressive episode in which the affected individual experiences

  • a depressed mood almost all day, every day for at least 2 weeks.

Dysthymia is a milder, chronic form of depression that lasts for at least 2 years. People with dysthymia are often described as constantly unhappy. Both these subtypes of depression (and others such as that experienced in bipolar disorder) can be treated with antidepressant drugs and with talking therapies.

Why Was This Study Done? Depressive disorders were a  leading cause of disease burden in the 1990 and 2000 Global Burden of Disease (GBD) studies, collaborative scientific efforts that quantify the health loss attributable to

  • diseases and injuries in terms of disability adjusted life years (DALYs; one DALY represents the loss of a healthy year of life).

DALYs are calculated by adding together the years of life lived with a disability (YLD, a measure that includes a disability weight factor reflecting disease severity) and the years of life lost because of disorder-specific premature death. The GBD initiative aims

  • to provide data that can be used to improve public-health policy.

Thus, knowing that depressive disorders are a leading cause of disease burden worldwide has helped to prioritize depressive disorders in global public-health agendas. Here, the researchers analyze the burden of MDD and dysthymia in GBD 2010 by country, region, age, and sex, and

  • calculate the burden of suicide and ischemic heart disease attributable to depressive disorders (depression is a risk factor for suicide and ischemic heart disease).

GBD 2010 is broader in scope than previous GBD studies and quantifies the direct burden of 291 diseases and injuries and the  burden attributable to 67 risk factors across 187 countries.

What Did the Researchers Do and Find? The researchers collected data on

  • the prevalence, incidence, remission rates, and duration of MDD and dysthymia and on deaths caused by these disorders from published articles.

They pooled these data using a statistical method called Bayesian meta-regression and calculated YLDs for MDD  and dysthymia using disability weights collected in population surveys. MDD accounted for 8.2% of global YLDs in 2010, making it the second leading cause of YLDs. Dysthymia accounted for 1.4% of global YLDs. MDD and dysthymia were also leading causes of DALYs, accounting for 2.5% and 0.5% of global DALYs, respectively. The regional variation in the burden was greater for MDD than for dysthymia, the  burden of depressive disorders was higher in women than men, the largest proportion of YLDs from depressive  disorders occurred among adults of working age, and the  global burden of depressive disorders increased by 37.5%  between 1990 and 2010 because of population growth and ageing. Finally, MDD explained an additional 16 million  DALYs and 4 million DALYs when it was considered as a risk factor for suicide and ischemic heart disease, respectively.  This ‘‘attributable’’ burden increased the overall burden of depressive disorders to 3.8% of global DALYs.

What Do These Findings Mean? These findings update and extend the information available from GBD 1990 and  2000 on the global burden of depressive disorders. They confirm that

  • depressive disorders are a leading direct cause of the global disease burden and show that
  • MDD also contributes to the burden allocated to suicide and ischemic heart disease.

The estimates of the global burden of depressive disorders reported in GBD 2010 are likely to be more accurate than those in previous GBD studies but are  limited by factors such as the sparseness of data on depressive disorders from developing countries and, consequently,

  • the validity of the disability weights used to calculate YLDs.

Even so, these findings reinforce the importance of treating  depressive disorders as a public-health priority and

  • of implementing cost-effective interventions to reduce their  ubiquitous burden.

Additional Information. Please access these websites via  the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001547.

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