By Richard Knox
The United States has entered a new phase in its response to Ebola. Call it “officially sanctioned panic.”
Governors of both parties declared over the weekend that even symptom-free health care volunteers coming home from Ebola duty in West Africa will be considered infected (and infectious) until they prove otherwise — by not falling ill for three weeks after their return.
But experts say mandatory quarantine of health workers and travel bans are unnecessary and could cripple the global fight against Ebola.
Against this backdrop, I had a long conversation this past weekend with Prof. Alessandro Vespignani. He’s a Northeastern University expert on how humans behave in the face of disease threats. The main takeaways: The key to defeating the outbreak is to get health care workers to West Africa and back, so to the extent a travel ban or quarantines impede that flow, they will be dangerously counter-productive. And travel is so hard to control fully that bans do little to stem the spread of disease anyway.
Vespignani is spending a lot of time these days consulting with the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention and the World Health Organization on how the Ebola situation could evolve over the coming months.
He’s thinking some ominous thoughts, which he says reflect the views of U.S. and international health officials that he talks to. But the scenarios they worry about are very different from those that preoccupy many politicians and voters. Politicians worry more about the small, containable immediate threat to Americans of occasional imported cases than the longer-term and potentially catastrophic Ebola scenario that could affect the whole world — in other words, an Ebola pandemic.
Here’s an edited version of our conversation:
RK: Your group published a paper the other day in the journal Eurosurveillance that would seem counter-intuitive to many Americans. You say that imposing a ban on travelers from Ebola-affected countries won’t do much to prevent importation of the virus to the United States. Why is that?
Vespignani: People think if you have a travel ban everybody from those countries will be kept out. It’s not like that.
It’s important to know that we don’t have direct flights from West Africa. So a travel ban has to be coordinated internationally. There are a lot of people with two passports (whose country of origin can’t be easily tracked). People would try to circumvent the travel ban, and they wouldn’t be trackable — that’s one of the most dangerous things.
You can stop 95 percent of travelers from a country, but it’s very difficult to do 100 percent. And even a 90 or 95 percent travel ban is going to delay the arrival of Ebola (in the U.S.) by only about two months. It’s only buying time.
Already there is almost an 80 percent reduction in travel to the U.S. from that region, so we have already bought some time — about four to five weeks.
So what’s the practical effect of that delay? How much would a travel ban reduce Americans’ risk?
AV: The problem for the United States is not in the next couple of months. We will see at most one or two cases [per month] in that period. The problem is down the road.
The number of cases we will see here increases the more cases there are in West Africa and other countries. By December or January, we can get to hundreds of thousands of cases in Africa. You can have outbreaks in Mali [where a case has just been reported, in a little girl who came by bus from Guinea], in Ivory Coast, and in Nigeria. Nigeria was able to contain one outbreak, but you cannot be confident they will be able to do that over and over again.
If the outbreak continues to grow exponentially, we will see more imports of Ebola in the United States. Instead of two or three cases per month, we will likely have three or four, then five to 10. These are all things we should be prepared for and should not panic over.
On the other hand, the fact is, as long as we have the outbreak in West Africa, nobody can be safe. So the only way to buy an insurance policy is to defeat the disease in West Africa. That’s what we have to do.
What is your worst fear?
If we don’t stop the West African outbreak, we can start to see Ebola cases in South Africa, Kenya — countries with much more [global] trade and travel. People can travel by bus or cross borders in many different ways. With hundreds of thousands of cases, there will be spillover to other countries. It’s a domino effect. The whole world could see cases.
We could see cases of Ebola going to countries in Asia — China or India — where one-third or more of the human population live. In some [Asian] cities, they have health care systems as good as we have [so could control Ebola]. But in other places, they do not. So you never know what could happen there.
In our global world, to seal off a country is a huge task. If the epidemic continues to grow and affects other countries, the task becomes more difficult still. You might eventually have to do a travel ban for more and more countries — for China, for India.
This brings us back to the question of the moment: What should the United States be doing?
To win the battle, we have to have health care workers, doctors, NGOs and the military go there [to Ebola-affected areas]. And they have to be able to come back. You could really make it so complicated for them that they are not going to go there. If you talk to the World Health Organization, they will tell you, “Look, travel bans are just going to make efforts to contain the disease in West Africa more complicated.”
Do you worry about the effect of putting returning health care workers in quarantine?
I do worry about it. These people are heroes. They are going to fight a battle in which they are risking their lives. They are not just helping African people. They are defending us. We need to stop the outbreak there to be sure we won’t have Ebola in our country. The more we hamper their effort, the more it could backfire on us. We have to be very careful about that, and also very rational.
It’s nearly half the state budget, almost 20 percent of the state’s economy and a perennial top concern for voters. The issue is health care, and so far, neither Democrat Martha Coakley nor Republican Charlie Baker has taken the lead on this topic with voters in the gubernatorial race.
“Coakley has perhaps a slight edge on the general health care issue, as well as the affordability issue, but neither campaign has really broken away” on health care, said Steve Koczela, president of the MassINC Polling Group. “It’s not like taxes, which go big for Baker. It’s not like education, which tends to go a bit bigger Coakley. It’s an issue that is still very closely fought.”
So where do the gubernatorial candidates stand on some of the key concerns in health care? Below is a summary of the candidates’ proposals for how to treat the health of the state.
On Making Health Care More Affordable:
BAKER: He argues that giving patients information about how much tests and procedures cost, in advance, will help us become informed consumers of care. We’ll spend less money, because we’ll choose to have a baby, for example, at the hospital with the lowest cost and best quality scores. As of Oct. 1, health plans in Massachusetts are required to post what they pay each hospital and doctor.
Baker would take a next step. “I’d like to get to the point where hospitals just post prices and people can see them plain as day,” Baker said. “As governor, I’m going to lean really hard on this.”
Some health care analysts say Baker’s strategy for reducing health care costs could backfire. Patients may assume that the most expensive hospital is the best even though that’s generally not true. And letting Brockton Hospital, for example, know that it is paid about half of what Massachusetts General Hospital receives for a C-section may mean Brockton Hospital demands more money, instead of MGH saying, “OK, I’m going to lower my prices to compete.” In addition, some of the expensive hospitals say their higher prices subsidize teaching and research.
COAKLEY: She argues she is uniquely positioned to tackle health care spending. She created a health care division in the attorney general’s office, issued the first detailed reports on health care costs and used her leverage to negotiate a deal that would limit the price increases Partners HealthCare could demand in the near future.
“The agreement that we have reached, to be approved by the court, caps costs and lowers costs as opposed to maintaining the status quo, which we all agree is too expensive,” Coakley said during a campaign debate on WBZ-TV.
But Coakley’s deal has been widely criticized, because it lets Partners add doctors and hospitals and expand the market power Coakley’s reports say have driven up costs.
Coakley suggests the state’s attorney general needs more power to effectively block harmful health care mergers. She would file legislation giving the attorney general authority to file suit based on a recommendation from the state’s Health Policy Commission.
“It would allow us to work more quickly and with a different and lower threshold [than the anti-trust statute] to address cost containment in mergers, acquisitions, other transactions in the health care field, that we think negatively would affect cost containment,” she said.
And Coakley would consider setting price limits for tests and procedures if the state does not meet its health care spending goal.
“We’ve always said if the market can’t correct, there’s always the opportunity to look at price convergence and have the state more involved,” she said.
Independent Candidates In 2014 Governor’s Race Health Care Goals In Summary:
EVAN FALCHUK: He would try to break hospital monopolies whose prices “lead to skyrocketing premiums for consumers.” And Falchuk would “create a fee schedule that will apply equally to all hospitals.”
JEFFREY MCCORMICK: His approach includes a focus on primary care, especially community-based and home care options.
SCOTT LIVELY: He says the state can lower health care spending by creating “nonprofit risk pools that are much less costly, where people are not restricted to the doctors and hospitals they can go to and where the members are stakeholders in the billing process which has a substantial downward pressure on costs.”
On Improving Health Care:
COAKLEY: She says the state has to build up mental health services and merge care for the body and mind.
“We haven’t been able to coordinate care, and it’s put costs way up on the physical health side,” Coakley said.
This is personal for Coakley, who has told the story of her brother Edward’s suicide throughout the campaign to explain her commitment to mental health care. She’d push for more screening to catch problems early on and expand access to programs and therapists.
Coakley would keep Taunton State Hospital open. She would require that mental health evaluations be done in a civil facility, not at Bridgewater State Hospital, and be conducted by staff from the Department of Mental Health, not Corrections.
BAKER: He would boost primary care as a whole, beginning with a Medicaid waiver that would increase pay for primary care doctors.
“If we simply invested in primary care,” Baker said, “we would spend less on health care overall, and we’d have healthier happier people. I really believe that.”
On The Move From Fee For Service And Toward Global Budgets Or Payments:
How you get paid doesn’t really seem to relate all that much to how expensive you are or how high quality you are. What seems to drive that more than anything is the culture of your group, and my view has been for a while that if a group wants to be compensated under a global budget and is willing to do the work that’s associated with being compensated that way…then I’m like, ‘Sure, go for it!’ But I think we need to be careful about pushing people into that type of arrangement, because I don’t think they’ll be very effective participants. There’s evidence out there that as long as you have the right incentives and the right culture in place, you can make a fee for service model work too.
As we move away from fee for service and try to get into our communities more affordable and integrated health care, it is the one way where you’re going to be able to address mental health care and behavioral health care.
On The Affordable Care Act And The Connector:
One big unknown for the next governor is whether the Connector website will be working, and if enrolling the roughly 450,000 residents who’ve been in limbo this year will be going smoothly when the new governor takes office.
COAKLEY: “The roll out of the Connector website was unacceptable,” she said. “I’ve also said that it’s very important that Massachusetts maintain control over what we are doing here. I’m glad that we are not going down the federal path [merging with the federal site, Healthcare.gov]. I have advocated with my colleagues around the country to say, we need a ‘not one size fits all program.’ We’ve done well here in Massachusetts, we need to keep moving forward on that.”
BAKER: He says “job number one has to be to get the website to work.”
There is some confusion about what Baker means when he says he would ask for a waiver or waivers from the Affordable Care Act.
“I’d like to be in a situation where the commonwealth can actually advocate for its own interests and if there are things we think we can do and make the case to the federal government that they’re the right things to do for the people of Massachusetts and fit within some framework that relates to the goals and objectives of the Affordable Care Act (ACA),” he explained. “I think we should be able to do that. That’s what I mean when I talk about a waiver.”
Baker has not outlined items in the ACA for which he would seek a Massachusetts waiver.
On Opening Medical Marijuana Dispensaries, Would The Candidates Continue The Current Process Or Stop And Start Over?
I’d want to take a look at where we are. No licenses have been issued yet. I think that the vetting that is supposed to take place is taking place. If it isn’t where it should be, I’m happy to start over. I’m not saying we need to do that. I want to make sure that we move as quickly as possible, but we have the regulatory piece in place.
We have huge process credibility issues here; we have pending lawsuits. I think it might be best to just redo this. I mean, compress the time frame, but get some real experts involved in it and do something that I think would have more integrity. I also worry about the fact that as far as I can tell we’re going to come nowhere near meeting the requirement that these dispensaries be available to the people within a certain geography. If you look at a map of Massachusetts and you point these things on that map, there are huge gaps in access and coverage.
On Legalizing Marijuana (An Issue Likely To Come Up During First Four Years):
BAKER: “I am against legalization. I’ve talked to too many people in the addiction community and too many people in law enforcement community. The addiction community, their stories and their concerns are particularly telling.”
COAKLEY: “We would like to see where Washington and Colorado go — states that are ahead of us on medical marijuana dispensaries and have legalized it.”
On Opiate Abuse:
BAKER: “I’ve had some friends who’ve either lost or come very close to losing children over the heroin problem. We need to have a real heart-to-heart about the way the health care community prescribes opiates.”
Baker would require all doctors to consult the state’s Prescription Monitoring Program before writing or renewing a patient’s prescription for pain medication.
COAKLEY: “One out of the three people is at risk for becoming addicted to something like Oxycontin. We have seen too many drugs prescribed, not monitored by doctors and pharmacists. We also need to find better ways for people who are addicted to get them off that and provide for rehabilitation. It is a burning issue for me. Sixty to 80 percent of people sitting in a house of correction have some kind of a mental health or substance abuse issue.”
Coakley has not released a plan to address opiate abuse.
Election Day is Tuesday, Nov. 4.
The bleeding started suddenly and lasted 15 minutes, soaking through the sheets and pooling on the floor. Turning pale, Armando Reagan cried out to the nursing home staff.
“Help! Help! I do not want to die!”
By the time paramedics got Reagan to a Glendale emergency room, he was incoherent, with his heart beating rapidly and his breathing labored, documents show. Within an hour, he was dead.
The Los Angeles County coroner determined that Reagan, a 30-year-old paraplegic and former gang member, died that day in July 2010 from hemorrhagic shock due to chronic infections stemming from an old gunshot wound and “neglect by provider.”
The county Department of Public Health later found that the Montrose nursing home failed to closely monitor Reagan for the effects of blood thinners he was prescribed. An inspector told facility officials that they should expect the most severe citation possible: an AA penalty that can bring a fine of up to $100,000, according to the county’s long-term care ombudsman, Molly Davies, whose staff was involved in the case.
Yet the final citation, released in 2012, was reduced to a lower-level violation and Verdugo Valley Skilled Nursing and Wellness Centre was assessed just $20,000, documents show. No written explanation was given for the change.
A county auditors’ report in August found that supervisors in the public health department have regularly downgraded draft citations without documenting their justification or discussing their findings with inspectors.
But Reagan’s case and two others reviewed by Kaiser Health News appear to provide new details on how that practice played out when nursing homes were faulted in patient deaths.
The audit did not identify patients in the downgraded cases. Though it said some involved children as young as 3 years old, it is not clear who those children were.
However, two knowledgeable sources who were not authorized to speak on the record cited the deaths of two toddlers at a Sun Valley nursing home in 2012. In both cases, they said, inspectors’ recommendations for AA citations were lowered to level A’s.
Documents show the children died at Totally Kids Specialty Healthcare just seven months apart. Both had histories of trying to pull out their breathing tubes and eventually did so, the documents show. County public health inspectors found that the facility failed to have a plan to prevent the children from pulling out the tubes and to watch them closely, records show.
The A-level fine was $20,000 for the first child’s death, and because a similar violation occurred within the same year, the fine was tripled to $60,000 for the second death. (A-level citations are issued when a violation presents an imminent danger of death or serious harm to patients, while AA citations arise when a violation directly causes a patient death.)
Totally Kids believes that the allegations against the home are not correct and is contesting both citations, said Doug Padgett, CEO of Mountain View Child Care Inc., which runs Totally Kids.
“We know that we provided the best care possible to those patients,” Padgett said in an interview. “We believe we fully complied with the regulations.”
The Verdugo Valley facility, where Reagan died, also defended its care. A lawyer for the facility, Mark A. Johnson, said in a statement that it accepts “extremely compromised and challenging patients” that most facilities won’t take and is committed to providing them with the highest possible level of care.
The county Department of Public Health, responsible for overseeing nursing homes on behalf of the state and the federal government, described the A-level citations as appropriate in all three deaths described in this story.
“In some instances, violations found by our Health Facilities Inspection Division (HFID) surveyors require substantive review by both County and State physicians,” the department said in a statement. “After this review some citation levels may change based upon the medical consultations.”
Asked about its lack of documentation for downgrading inspectors’ recommended citations, officials noted that earlier this year, they began using a form developed with the state public health department to explain its approval or changes to such recommendations. The completed form is for internal use and not publicly available.
‘He was nothing’
A gang member with two drug-related criminal convictions, Reagan was wounded at 19 during a drive-by shooting outside a North Hills apartment complex.
He cycled in and out of nursing homes for years, arriving at Verdugo Valley in March 2010 with several pressure ulcers, kidney failure and a blood clot, documents show. He was briefly hospitalized in April for treatment of infections.
Three months later, in July, Reagan started bleeding from his groin. Nursing home staff applied pressure to the wound but didn’t lower his head as needed to help blood flow to his heart, according to an account by the ombudsman’s office.
In her citation, the inspector, Magnolia Frausto, wrote that staffers failed to follow the physician’s orders for lab tests to ensure blood thinners were given safely and that bleeding was not excessive. “Both the effect of the drugs on the resident’s ulcers and on the integrity of the blood vessels surrounding the ulcers were not monitored to detect early warning signs and symptoms for bleeding from the ulcers,” she wrote.
The public health department would not make Frausto available for comment and said in a statement that there was no documentation on “how, or if, any changes were communicated” to her.
But Rachel Tate, the regional manager of the county ombudsman’s office, was aware that the recommended citation had been downgraded because she was present when the inspector delivered her initial findings, said her boss, Davies.
Tate asked Yolanda Moore, a supervisor within the county public health department, for an explanation. “I am not at liberty to disclose this information,” Moore responded, according to an email reviewed by a reporter.
Davies officially appealed the citation. In a July 2013 letter, she wrote, “The facility made no attempt to ensure that a resident at risk for severe bleeding did not actually experience severe bleeding.”
Both county and state officials denied the appeal – in part by blaming the patient for poor cooperation in the past. The state public health department said in a November 2013 letter to Davies that Reagan had turned away treatment on several occasions, including refusing to take antibiotics and blood thinners and declining wound care.
“The resident’s refusal of treatments and care offered by the skilled nursing facility in question also makes him culpable for the risk of experiencing either imminent danger or serious harm to his health and safety,” wrote Debby Rogers, former deputy director of the state health department’s Center for Health Care Quality.This KHN story also ran in The Los Angeles Daily News. It can be republished for free (details).
Reagan’s cousin, Marleen Aparicio, remains angry at the department and the nursing home for his death. “They just got a slap on the wrist,” she said of Verdugo Valley.
Despite Reagan’s troubled past, “he was somebody’s son, he was somebody’s nephew, he was somebody’s cousin,” she said.
To the nursing home and the health department, Aparicio said, “He was nothing.”
The downgrading of an AA citation can be more than a matter of money.
When a facility receives two AA citations within two years, officials are required by law to initiate the suspension or revocation of its license. Verdugo Valley had already received a AA citation after a developmentally disabled and mentally ill man, Charles Morrill, killed himself in 2009 by discharging a fire extinguisher in his mouth. Two weeks before his death, Morrill had attempted suicide in the same way.
According to that citation, the facility didn’t make a plan to protect Morrill once he returned from the psychiatric unit of an acute care hospital. The nursing home, owned in part by Brius LLC, one of the largest chains statewide, also was indicted on charges of abuse and neglect in 2011 because of the suicide. The California attorney general’s office agreed to drop the charges in 2012 in exchange for placing the facility under a three-year court injunction requiring ongoing monitoring.
“It should go without saying that the facility deeply regrets these tragic incidents, both of which occurred years ago and not long after the current owners acquired the facility,” Johnson, who also represents Brius, said in his statement. “It has been more than four years since the most recent of these incidents, and the facility has not had a citation for any serious incident since.”
Will Evans of The Center for Investigative Reporting contributed.
This article was produced by Kaiser Health News with support from The SCAN Foundation.
standing orders and one administrative directive.
Standing Order No. 1-80 (Notices of Appeal/Notification to Justices)
is unnecessary due to the advent of electronic dockets.
Standing Order No. 5-80 (Trial Session Hours) is inconsistent with
Standing Order No. 6-80 (Complaints for Judicial Review of Surcharge
Matters Under G.L. c. 175, §113P; Notice to the Department of the
Attorney General; Form Complaints) has been superseded by Superior
Court Standing Order No. 1-96.
Standing Order No. 1-86 (Transfer Procedure Under G.L. c. 231, §102C
and Superior Court Rule 29) is outdated in the current civil one-trial
Administrative Directive No. 90-2 (Non-Filing of Discovery Materials)
is unnecessary due to a 2002 amendment to Mass. R. Civ. P. 5(d)(2).
A list of current standing orders can be found at Massachusetts Superior Court Standing Orders and directives can accessed at Superior Court Administrative Directives.
Massachusetts has no plans to follow New York and New Jersey in requiring a 3-week quarantine for health care workers and others who have had contact with Ebola-stricken patients.
“It’s probably a step further than we need here in the Commonwealth,” Governor Deval Patrick said in comments provided by his press office, “but we’re prepared. It’s certainly a step further than what the CDC has recommended.”
Patrick said his counterparts, Andrew Cuomo in New York and Chris Christie in New Jersey, may have more reason to be concerned about Ebola.
“I understand why they are going to the extent they are going to, because two of the five receiving airports are in New York and New Jersey,” Patrick said.
Illinois Governor Pat Quinn joined Cuomo and Christie Friday in imposing a quarantine on travelers who could be infected with Ebola.
A nurse placed under quarantine in New Jersey Friday described a chaotic scene at Newark Airport.
In Massachusetts, Patrick and Boston Mayor Marty Walsh have focused on calming public fear about Ebola.
“I understand that folks are anxious,” Patrick said again on Saturday. “We have worked very hard to make sure that our medical professionals have all of the guidance that we have, and that training is happening where and as it should, that public safety officials are fully briefed and prepared. From all accounts from the professionals, the risk is very, very low in Massachusetts.”
That assessment is based on the expectation that there is not much travel between Boston and West Africa right now, that Ebola does not easily spread, and that hospitals are prepared to handle any cases that may arise.
“It is obviously dangerous,” Patrick said, but “you have to be directly exposed to the bodily fluids of someone who is showing symptoms of Ebola, not someone who has been near somebody with Ebola. If people are showing any of those symptoms — nausea, high fever — they should get themselves to an emergency room quickly, and there are protocols for testing.”
Here’s the press release – more to come…Partners In Health Names Gary Gottlieb Chief Executive Officer Ophelia Dahl Remains Chair of the Board
BOSTON (Oct. 24, 2014)—Partners In Health announced today that it will name Dr. Gary Gottlieb as the organization’s next CEO, effective July 1, 2015. Gottlieb, currently the president and CEO of Partners HealthCare, was recruited by Partners In Health to assume the role long held by Ophelia Dahl. Last May, Dahl announced she would step down as executive director but would remain deeply involved in the organization’s work and serve as chair of the board.
Dahl has led Partners In Health since 2000, an organization she co-founded in 1987 with Dr. Paul Farmer, World Bank President Dr. Jim Yong Kim, Todd McCormack, and Tom White. Over the past three decades, Partners In Health has grown from a rural clinic in Cange, Haiti, to a leading global health organization delivering high-quality health care on four continents.
“I cannot imagine anything more fulfilling than being involved in a mission that links social justice and health care,” said Dahl. “Together we have taken significant steps to improve access to health care in poor communities around the world. But there is more work to do to leverage service with research and teaching, and that is why I am thrilled Gary Gottlieb will take the helm of the organization. Gary brings a passion for social justice and vast experience in the health care field. I look forward to working closely with Gary toward advancing our mission and amplifying our impact across all the places we work.”
Gary Gottlieb has served as president and CEO of Partners HealthCare since 2010. Throughout his career, Gottlieb has focused on disparities in health care and been an active member on Partners In Health’s Board of Governors for nearly a decade. By joining Partners In Health as CEO, Gottlieb will have the opportunity to continue this work as a champion for social justice and access to health care in a full-time capacity.
“Expanding and improving access to health care has been the most challenging and important work of my life,” said Gottlieb. “I’m eager to take on this inspiring role to tackle global health issues with Partners In Health. There is still much work to do to bring high-quality health care to poor and marginalized communities across the globe. I’m honored to join this top-notch team, and humbled by the challenge.”
“Ophelia has been our guide for the better part of two decades, and one of the reasons PIH has continued to grow over the years, the other being an immense and still unmet need, as Ebola reminds us,” said Dr. Paul Farmer, co-founder and chief strategist of Partners In Health.
“The mission of PIH—to link the delivery of health care for the poor to the tasks of training ‘local’ partners to do so and to generate new knowledge—comes from the model of academic medicine,” Farmer said. “So those of us who founded PIH almost three decades ago, including Ophelia, were hoping and praying for a leader from academic medicine, someone with a commitment to social justice and to improving the management of health systems, some of the most complex institutions in the world, even in settings of great privation.”
“Gary is a dream come true. He weds deep affection for PIH—through many trips to Haiti and Rwanda, but also as a board member and the former or current boss of scores of our volunteers from Harvard’s teaching hospitals—with the sort of management and clinical skills needed to bring PIH to the next level,” said Farmer. “There’s no place from which to see this more clearly than West Africa right now.”
About Partners In Health: Partners In Health is a global health organization relentlessly committed to improving the health of the poor and marginalized. We build local capacity and work closely with impoverished communities to deliver high-quality health care, address the root causes of illness, train providers, advance research, and advocate for global policy change. For more information please visit www.pih.org.
About Gary Gottlieb, MD: Dr. Gary Gottlieb has served as president and CEO of Partners HealthCare since 2010. Dr. Gottlieb is a professor of psychiatry at Harvard Medical School and is a member of the Institute of Medicine of the National Academies. He served as president of Brigham and Women’s Hospital, as president of North Shore Medical Center, and as chairman of Partners Psychiatry. Dr. Gottlieb has also served as executive vice-chair of psychiatry and associate dean for managed care at the University of Pennsylvania Medical Center, and as director and CEO of Friends Hospital in Philadelphia. Throughout his career, Gottlieb has focused on disparities in health care and been an active member on Partners In Health’s Board of Governors for the past eight years. By joining Partners In Health as CEO, Gottlieb will have the opportunity to continue this work as a champion for social justice and access to health care in a full-time capacity.
Confession: I eat chia seeds everyday. I feed them to my children. They make me feel full and satisfied and, yes, I’m a sucker for foods touted as “super” even though I know deep down it’s just marketing.
I may be crazy, but I’m also trendy: chia seeds are everywhere, in energy bars and smoothies, atop yogurt parfaits and at the core of crunchy kid snacks. Good Morning America called chia seeds the “it” food of 2013.
And they really are good for you: “a rich source of fiber, protein and heart-healthy omega-3 fatty acids,” according to an NIH publication.
But this week, my chia euphoria took a hit. “Despite potential health benefits, chia seeds may pose a risk if they are not consumed properly, according to new research,” said the Medline headline.
A case report presented by a North Carolina GI doctor describes a scary case of chia seeds gone bad: a 39-year-old man spent several hours in the emergency room under anesthesia after eating no more than a teaspoon of dry chia seeds followed by a glass of water.
The seeds, which can absorb up to 27 times their weight in water, apparently expanded post-ingestion and completely blocked the man’s esophagus, according to the doctor who handled the case, Rebecca Rawl, MD, MPH, a gastroenterology fellow at Carolinas Medical Center in Charlotte, North Carolina.
I spoke to Rawl, and she told me the story of the chia seed blockage — believed to be the first report of its kind. She presented the case earlier this week at the American College of Gastroenterology’s annual meeting in Philadelphia. It began innocently enough, she said:
The man arrived at the hospital and said he had this feeling of pain at the top of his stomach and couldn’t swallow anything — “not even his own saliva.” Hospital staff took him in for an upper endoscopy and the imaging clearly showed the culprit: puffed up chia seeds.
What did it look like?
It was a gel of these seeds, the consistency was similar to Playdoh — not solid, but not a liquid.
That’s what made it very difficult to remove the obstruction — we initially tried using an adult endoscope…We tried to push the mass or gel of chia seeds through to the stomach. But because of the consistency, the seeds would just go around the scope.
After trying unsuccessfully with a variety of other medical implements to move the sloshing mass of seeds, Rawl said she switched to a neonatal or baby endoscope with a smaller diameter: “And we were able to get past the obstruction to see what was ahead and we used the tip of instrument to push a few seeds at a time into the stomach,” she said.
Little by little, then, over several hours, doctors were able to clear the man’s esophagus. “Afterwards, she said, “he was fine.”
The Michael Pollan-y moral here would go something like this:
Eat Them Wet
Chew A Lot.
A more nuanced moral, from Rawl, also urges caution:
“Nobody should be eating these seeds dry,” said Rawl, who has never personally eaten a single one of the tiny, oval-shaped seeds. “I don’t think it’s a good idea. Let them expand fully in some kind of liquid first — especially for people who have this sensation of food getting stuck. Chia seeds are tiny, so people would not necessarily think there are problems, but some people do have underlying “strictures” or narrowing of the esophagus.”
And of course, added Rawl, whose primary research focuses on irritable bowel disease, anyone who has recurring swallowing problems — whether from hot dogs or chicken or chia — should see a doctor.
But chia seeds — “which come from a species of flowering plant in the mint family native to central and southern Mexico and Guatemala” — are already so pervasive in the foodosphere, it may be hard to get that “proceed with caution” message across.
Nina Manolson, one of my go-to health coaches here in the Boston area told me she loves, loves, loves chia seeds. Here’s her response to the quasi-ominous medical report:
Chia seeds live up to their superfood name. They are high in Omega 3’s (healthy fat that is an anti-inflammatory), they are an antioxidant, contain important micro-nutrients like magnesium, calcium and manganese and they are also loaded with protein. But possibly Chia’s biggest claim to fame is its fiber content. In 1 oz of chia seeds there are 11 grams of fibre – including both soluble and insoluble fiber.
Insoluble fiber is the kind of fiber that acts like a scrub brush in your colon. Soluble fibre absorbs water so it creates bulk and it makes us feel full.
The interesting thing about Chia seeds is that it can absorb A LOT of water – claims vary from 8-27X their weight in water, which makes it a great food to add to your diet if you’re looking to feel satisfied for a long time without needing to eat a lot – as in trying to lose weight.
Chia seeds are also great at keeping dehydration at bay because it holds so much liquid. However, if you eat dry chia seeds, without giving them any liquid to absorb before ingesting them, they’ll absorb the water within your system and potentially cause a blockage. I can imagine, although I’ve never seen it happen, if you ate a lot of chia seeds without any liquid and they got stuck in your throat or windpipe, it could cause a blockage. But so could flax seeds, which also absorbs water and become gelatinous.
But the fact that you could choke on chia seeds – really, you could choke on any food – should definitely NOT be a reason to avoid them.
Chia seeds (and flax seeds) have huge nutritional benefits, and should definitely be included in a healthy diet. But, they should be eaten accompanied by a liquid, either while eating them or allowing them to soak in advance.
My favorite recipe: Raspberry chia seed pudding
I must say, after reading about the medical case, I’ve taken a bit of a chia seed hiatus. And at $19.99 for a 15-ounce package at my neighborhood Whole Foods, maybe I’ll go seedless for a little while longer.
Family medicine doctors are joining forces to win a bigger role in health care – and be paid for it.
Eight family-physician-related groups, including the American Academy of Family Physicians, have formed Family Medicine for America’s Health, a coalition to sweeten the public perception of what they do and advance their interests through state and federal policies.
The launch of their five-year, $20 million campaign Thursday comes at a critical time for primary-care doctors. Thanks to the health law, millions more people can seek care with newly gained insurance. But there’s growing debate about whether nurse practitioners and physician assistants should provide a lot more basic care, either on their own or as part of clinics sponsored by pharmacies or other businesses. Some major doctor groups have challenged the ability of lesser-trained medical professionals to independently treat patients.
Glen Stream, chairman of the new coalition, said that it plans to focus on:
– Paying primary-care doctors for more than just office visits, including the time they spend making referrals to specialists, checking in with patients about treatment regimens, being available 24/7 and calling and emailing patients. Specialty doctors generally are paid more for their time and for procedures they do.
– Creating additional incentives for medical school students to go into primary care and tying medical schools’ federal funding to the primary care training they provide.
– Making electronic health records less burdensome, freeing more time for conversation with patients.
– Getting doctors to switch to a team-based, patient-centered “medical home” format, with a payment structure that reflects the work that goes into coordinating care for a patient.
– Persuading private and public employers with health plans to lean on insurers to increase compensation for primary care services.
“If we don’t spend enough on primary care, outcomes in the future will suffer because much of the chronic diseases that drive spending are preventable,” said Stream, a family physician and former president of the American Academy of Family Physicians. He added that larger employers could negotiate higher payment rates for primary care when picking an insurance company.
While the campaign is touted as helping patients, it’s also about asserting that family doctors are important.This KHN story can be republished for free (details).
“It’s always a question of what motivates groups to do these kind of campaigns — is it looking out for patients or your own interests, and generally it’s a combination of both,” said Atul Grover, chief public policy officer at the Association of American Medical Colleges.
In September, the American Academy of Family Physicians announced recommendations on medical school funding, saying teaching hospitals should provide more primary care training as a condition of continuing federal funding at the same level. But Grover said the kind of training medical students receive doesn’t drive what type of doctor they become. The reimbursement system – which typically pays specialists at higher rates – is more important.
Grover also said that while primary care is important, taking funding away from specialty training isn’t necessarily a solution because an aging population will need more specialty care.
Other groups in the coalition are the American Academy of Family Physicians Foundation, American Board of Family Medicine, American College of Osteopathic Family Physicians, Association of Departments of Family Medicine, Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine.
I have to admit that, at the end of September, it was difficult for me to think about anything besides baseball. The Nationals were first in their Division (no comments from Giants fans, please) and, at the last game of the season, I saw my first no-hitter.
Being thus preoccupied I, figured I had to find a way to turn my baseball thoughts into working thoughts.
But what else connects baseball and law?
I began to search the Library’s catalog for law titles pertaining strictly to baseball. Because, really, what true baseball fan can think of other sports come October? But was there even a subject heading for baseball in the K class schedule? Well, no. In fact, the only specific sports I found mentioned were Prizefighting, Horse Racing and Lotteries/Gambling.
So I limited my search to items in the Law Library’s collection using ‘baseball’ as a term appearing anywhere in the bibliographic record. Not the most brilliant search ever, but I did get 53 hits (which was more than what I thought would come up).
I diligently pulled all the volumes from the stacks and took them to my office for research.
And then – tragedy struck!
Not only did my beloved Washington Nationals not make it through the first round of the playoffs, but the Baltimore Orioles likewise fell short of their World Series goal (no comments from Royals fans either, thank you). My thoughts turned dark, and I began to wonder what was the point of writing a blog post now?
The books stayed in my office, taunting me, and eventually, with a deadline looming, I had to face up to my own personal nightmare. So I began to peruse the books – still somewhat bitter.
A dozen Congressional hearings – all about antitrust laws. No, not today.
Twenty-five or so treatises dealing with antitrust, one titled Courting the Yankees. Um, no thank you.
Another 10 volumes on case law. Yawn.
A biography of Justice Sonia Sotomayor? Interesting.
I flipped to the Table of Contents and there it was – “Chapter 4 Federal Judgeship: the Savior of Baseball“. How could I not be drawn in? I read that chapter and went on to the next. Pretty soon I’d read to the end and then went back to the start to see what I’d missed in the first three chapters.
When I finished the entire book, I looked at the remaining titles on the truck and knew I had my answer.
Not to my blog post quandary but to the age-old question about what to do during the off-season.
The answer? Return all those other books to the shelves and read through the Law Library’s collection of biographies on Justice Sotomayor.