A Twitter battle over the size of each “nuclear button” possessed by President Trump and North Korea’s Kim Jong Un has triggered a surge in sales of a drug that protects against radiation poisoning.

Troy Jones, who runs the website www.nukepills.com, said demand for potassium iodide soared last week, after Trump tweeted that he had a “much bigger & more powerful” button than Kim – a statement that raised new fears about an escalating threat of nuclear war.

“On Jan. 2, I basically got in a month’s supply of potassium iodide and I sold out in 48 hours,” said Jones, 53, who is a top distributor of the drug in the United States. His Mooresville, N.C., company sells all three types of the over-the-counter product approved by the Food and Drug Administration. No prescription is required.

In that two-day period, Jones said, he shipped about 140,000 doses of potassium iodide, also known as KI, which blocks the thyroid from absorbing radioactive iodine and protects against the risk of cancer. Without the tweet, he typically would have sent out about 8,400 doses to private individuals, he said.

Jones also sells to government agencies, hospitals and universities, which aren’t included in that count.

Alan Morris, president of the Williamsburg, Va.-based pharmaceutical company Anbex Inc., which distributes potassium iodide, said he has seen a bump in demand, too.

“We are a wonderful barometer of the level of anxiety in the country,” Morris said.

A spokeswoman for a third company, Recipharm AB, which sells low-dose KI tablets, declined to comment on recent sales.

Jones said this isn’t the first time in recent months that jitters over growing nuclear tensions have boosted sales of the drug, which comes in tablet and liquid form and should be taken within hours of exposure to radiation.

It’s the same substance often added to table salt to provide trace amounts of iodine that ensure proper thyroid function. Jones sells his tablets for about 65 cents each, though they’re cheaper in bulk. Morris said he sells the pills to the federal government for about a penny apiece.

Yet, neither the FDA nor the Centers for Disease Control and Prevention recommends that families stockpile potassium iodide as an antidote against nuclear emergency.

“KI (potassium iodide) cannot protect the body from radioactive elements other than radioactive iodine — if radioactive iodine is not present, taking KI is not protective and could cause harm,” the CDC’s website states.

The drug, which has a shelf life of up to seven years, protects against absorption of radioactive iodine into the thyroid. But that means that it protects only the thyroid, not other organs or body systems, said Dr. Anupam Kotwal, an endocrinologist speaking for the Endocrine Society.

“This is kind of mostly to protect children, people ages less than 18 and pregnant women,” Kotwal said.

States with nuclear reactors and populations within a 10-mile radius of the reactors stockpile potassium iodide to distribute in case of an emergency, according to the Nuclear Regulatory Commission. An accident involving one of those reactors is far more likely than any nuclear threat from Kim Jong Un, Anbex’s Morris said.

Still, the escalating war of words between the U.S. and North Korea has unsettled many people, Jones said. Although some of his buyers may hold what could be regarded as fringe views, many others do not.

“It’s moms and dads,” he said. “They’re worried and they find that these products exist.”

Such concern was underscored last week, when the CDC announced a briefing on the “Public Health Response to a Nuclear Detonation.” One of the planned sessions is titled “Preparing for the Unthinkable.”

Hundreds of people shared the announcement on social media, with varying degrees of alarm that it could have been inspired by the presidential tweet.

A CDC spokeswoman, however, said the briefing had been “in the works” since last spring. The agency held a similar session on nuclear disaster preparedness in 2010.

“CDC has been active in this area for several years, including back in 2011, when the Fukushima nuclear power plant was damaged during a major earthquake,” the agency’s Kathy Harben said in an email.

Indeed, Jones saw big spikes in potassium iodide sales after the Fukushima Daichii disaster, after North Korea started launching missiles — and after Trump was elected.

“I now follow his Twitter feed just to gauge the day’s sales and determine how much to stock and how many radiation emergency kits to prep for the coming week,” Jones said, adding later: “I don’t think he intended to have this kind of effect.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundationthat is not affiliated with Kaiser Permanente. Follow JoNel Aleccia on Twitter: @JoNel_Aleccia.

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Doctors at some of the country’s largest hospital chains admit they went overboard with opioids to make people as pain-free as possible.

Now the doctors shoulder part of the blame for the country’s opioid crisis. In an effort to be part of the cure, they’ve begun to issue an uncomfortable warning to patients: You’re going to feel some pain.

Even for those who’ve never struggled with drug use, studies are finding that patients are at risk of addiction anytime they go under the knife.

“I had the C-section, had the kiddo,” says Michelle Leavy. “And then they tell me, ‘It’s OK, you can keep taking the pain medications, it’s fine.’ “

Leavy, 30, is from Las Vegas. A mother of three and a paramedic, she has dealt with many people with addiction problems. She welcomed the high-dose intravenous narcotics while she was in the hospital and as she went home. She gladly followed doctors’ orders and kept ahead of the pain with her Percocet pills.

But then she needed stronger doses. And pretty soon, she realized she was no longer treating pain. “Before I went to work I took them, and to get the kids after school I had to take them,” she says. “Then I was taking them just to go to bed. I didn’t really realize I had a problem until the problem was something more than I could have taken care of myself.”

She said she was becoming like the patients with addiction problems that she transported by ambulance, lying to emergency room doctors to con a few extra doses.

She lost her job and her fiancé, before going to rehab through American Addiction Centers and stitching her life back together.

An About-Face On Opioids

Opioid addiction is a reality that has been completely disconnected from where it often starts — in a hospital.

Anesthesiologist David Alfery says he was rarely stingy with opioids. “If I could awaken them without any pain whatsoever, I was the slickest guy on the block and it was a matter of enormous pride,” he says.

Alfery is part of a working group at the Nashville-based consulting firm Health Trust. It’s helping hospitals to set aside some of their competitive interests to swap ideas about a top priority — reducing opioid use.

“It starts with patient expectations, and I think over the years, patients have come to expect more and more in terms of, ‘I don’t want any pain after surgery,’ and it’s an unrealistic expectation,” Alfery says.

The expectation exists in part because pain treatment became an institutional priority. Hospitals are graded on how well they keep someone’s pain at bay. And doctors can feel pressure from the institution, and on a personal level, to minimize pain.

“I just wanted my patient not to be in pain, thinking I was doing the right thing for them and certainly not [being] an outlier among my colleagues,” says Dr. Mike Schlosser, chief medical officer for a division of HCA, the nation’s largest for-profit hospital chain.

Schlosser spent a decade as a spinal surgeon putting his patients at HCA’s flagship facility, Centennial Medical Center in Nashville, through some of the most painful procedures in medicine, like correcting back curvature. He says he genuinely just wanted to soothe the hurt he caused.

“But now looking back on it, I was putting them at significant risk for developing an addiction to those medications,” he says.

Using HCA’s vast trove of data, he’s found that for orthopedic and back surgeries, the greatest risk isn’t infection or some other complication — it’s addiction.

So the nation’s largest private hospital chain is rolling out a new protocol prior to surgery. It includes a conversation Schlosser basically never had when he was practicing medicine.

“We will treat the pain, but you should expect that you’re going to have some pain. And you should also understand that taking a narcotic so that you have no pain really puts you at risk of becoming addicted to that narcotic,” Schlosser tells patients.

Besides issuing the uncomfortable warning, sparing use of opioids also takes more work on the hospital’s part — trying nerve blocks and finding the most effective blend of non-narcotics. Then after surgery, the nursing staff has to stick to it. If someone can get up and walk and cough without doubling over, maybe they don’t need potentially addictive drugs, or at least not high doses of them.

There are potential benefits aside from avoiding addiction.

“I’ve had people tell me that the constipation was way worse than the kidney stone,” says Dr. Valerie Norton, medical director at the Scripps Health System in San Diego, which is also working with Health Trust.

“There are lots of other complications from opioids — severe constipation, nausea, itching, hallucinations, sleepiness. We really need to treat these drugs with respect and give people informed consent and let people know these are not benign drugs.”

Managing The Optics

Of course, from a business point of view, no one wants to run the hospital where it hurts more to be a patient.

You don’t want people to think that they’re being treated inappropriately, says John Young, national medical director of cardiovascular services for LifePoint Hospitals. But the Nashville-based hospital chain is putting special emphasis on how it handles people coming into the ER looking for pain medicine.

Young says tightening up on opioids becomes a delicate matter, but it’s the right thing to do.

“We really do have a lot of responsibility and culpability and this burden, and so we have to make sure we do whatever we can to stem this tide and turn the ship in the other direction,” he says.

While hospitals get their ship in order, some patients are taking personal responsibility.

Now that she’s in recovery, Michelle Leavy won’t touch opioids. That meant she had emergency gallbladder surgery in 2017 without any narcotics. She says it can be done.

“I mean, it hurt,” she says. “But I lived.”

Leavy says she was nervous about telling her doctors, but they were happy to find opioid alternatives.

This story is part of a reporting partnership with NPR, Nashville Public Radio and Kaiser Health News.

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The expansion of Medicaid helps rural hospitals stay afloat in states like Colorado, which added 400,000 people to the health insurance program under the Affordable Care Act.

Hospitals in states that expanded Medicaid were about 6 times less likely to close than hospitals in non-expansion states, according to a study by researchers at the University of Colorado Anschutz Medical Campus.

The study was published Monday in the January edition of the journal Health Affairs.

Colorado was one of 32 states to expand Medicaid under the Affordable Care Act. That cut the state’s uninsured rate in half. The biggest group that got coverage was childless adults.

Richard Lindrooth, a professor at the Colorado School of Public Health and lead author of the study, says hospitals saw more people showing up to hospitals with that insurance — so Medicaid payments increased. That helped the hospitals’ bottom line.

“It’s not as though Medicaid is an extremely profitable form of reimbursement, but it is something,” says Lindrooth, a professor the University of Colorado’s School of Public Health. “On the margins, it certainly helps the hospitals’ cash flow.”

Lindrooth says he and his colleagues hypothesized that hospitals in expansion states stood a better chance of remaining financially viable. So they examined national hospital data and local market conditions.

They compared four years before the Affordable Care Act went into effect (2008-2012) with years right after the launch of the ACA (2015-2016). Lindrooth says the results were noteworthy, especially for rural hospitals, which often struggle to stay open.

“Rural hospitals tend to be in more of a financially tenuous position, even prior to the Medicaid expansions,” Lindrooth says. “We found that really about half of the closures that did occur in non-expansion states could have been averted through the expansion.”

With more insured people in expansion states, hospitals made more money and provided less free care. “So overall their margins improved,” he says. Rural hospitals in non-expansion states didn’t have that advantage.

Rural health leaders said the study confirmed what they’ve seen on the ground.

Jason Cleckler, CEO of Delta Memorial Hospital in Delta, Colo., in the rural western part of the state, said the Medicaid expansion helped his hospital’s finances. He compared the numbers in 2011 with 2016, after expansion. The hospital’s Medicaid population grew from 10 percent to 20 percent, and the hospital was left with less uncompensated care. It saved the hospital more than $3 million.

“I think that really speaks to what the researchers found. So Medicaid doubled, our bad debt decreased significantly, and the uninsured rate decreased significantly,” Cleckler says. “It’s pretty remarkable, and I would venture to say that most hospitals, even ones with a lower percentage of Medicaid, have experienced a similar story.”

Cleckler did describe Medicaid coverage as a “mixed bag” for rural providers. Reimbursement rates can be paltry, he says. A hospital that pays $100 for a lab test may only be reimbursed $20. Another problem, he said, is many doctors and providers either won’t accept or limit the number of Medicaid patients due to low reimbursement rates.

An average of 30 percent to 50 percent of rural patients are covered by Medicaid, noted Michelle Mills, CEO of Colorado Rural Health Center, which offers rural health providers education and training. Mills says the population in rural areas is generally “older, sicker and poorer” than in urban communities.

She says the expansion plus a bump in Medicaid reimbursement rates “has helped rural Colorado hospitals from closing.” The jobs generated by those hospitals are key to rural economies, with health care one of the top three rural employers in Colorado.

“The importance of Medicaid expansion in our state cannot be understated,” says Cara Welch, director of communications with the Colorado Hospital Association.

Welch says other factors also provided a boost, including the state’s strong economy and its hospital provider fee. That fee helps reimburse hospitals for uncompensated care from the indigent population and those paying with Medicaid.

Brock Slabach, senior vice president of the National Rural Health Association, says the study correlates with data the group has reviewed. “If state legislatures and Congress want to cure the rural hospital closure problem, expanding Medicaid and not block-granting this important program would be the answer,” he says.

Members of the Republican majority in Congress have suggested changing Medicaid to a block grant. That means that instead of the federal and state governments sharing payment for every enrollee who qualifies, the federal government would provide each state a set amount of money, capping total Medicaid spending. It would let states decide how to spend the money. But health care and hospital advocates worry that the change would likely lead to cuts over time.

This story is part of a reporting partnership with NPR, Colorado Public Radio and Kaiser Health News.

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Some states are facing a mid-January loss of funding for their Children’s Health Insurance Program despite spending approved by Congress in late December that was expected to keep the program running for three months, federal health officials said Friday.

The $2.85 billion was supposed to fund states’ CHIP programs through March 31. But some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. CMS did not say which states are likely to be affected first.

The latest estimates for when federal funding runs out could cause states to soon freeze enrollment and alert parents that the program could soon shut down.

The CHIP program provides health coverage to 9 million children from lower-income households that make too much money to qualify for Medicaid. Its federal authorization ended Oct. 1, and states were then forced to use unspent funds to carry them over, while the House and Senate try to agree on a way to continue funding.

Congress extended funding on Dec. 21 — and said the temporary patch would give states enough money to continue the program while Congress works on a long-term funding solution. But a CMS official says it can only guarantee that appropriation will be enough to fund all states through Jan. 19.

CMS says the agency is in discussions with states to help deal with the funding shortfall.

“The funding … should carry all the states through January 19,based upon best estimates of state expenditures to date,” says CMS spokesman Johnathan Monroe. “However, due to a number of variables relating to state expenditure rates and reporting, we are unable to say with certainty whether there is enough funding for every state to continue its CHIPprogram through March 31, 2018.”

“States need to know whether they will need to find additional funding for children covered under the Medicaid CHIP program at a much lower federal matching rate; send letters to families and reprogram their eligibility systems,” says Lisa Dubay, a senior fellow at the Urban Institute. “Of course, the implications for families with CHIP-eligible children cannot be understated: Parents are worried that their children will lose coverage. And they should be.”

Although the program enjoys bipartisan support on Capitol Hill, the Republican-controlled House and Senate have for months been unable to agree on how to continue funding CHIP, which began in 1997.

The House plan includes a controversial funding provision — opposed by Democrats — that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for five years but did not unite around a plan on funding.

Before the CHIP funding extension on Dec. 21, Alabama said it would freeze enrollment Jan. 1 and shut down the program Jan. 31. Colorado, Connecticut and Virginia sent letters to CHIP families warning that the program could soon end.

After the funding extension, Alabama put a hold on shutting down CHIP.

“Some states will begin exhausting all available funding earlier than others,” a CMS official says. “But the exact timing of when states will exhaust their funding is a moving target.”

Bruce Lesley, president of First Focus, a child advocacy group, says Congress should have known its short-term funding plan was not enough.

“The math never worked on the patch, as it only bought a few weeks,” he says. “Congress must get this finalized before Jan. 19.”

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Phil Galewitz is a senior correspondent for KHN.

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The searing abdominal pain came on suddenly while Dr. Rana Awdish was having dinner with a friend. Soon she was lying in the back seat of the car racing to Henry Ford Hospital in Detroit, where Awdish was completing a fellowship in critical care.

On that night nearly a decade ago, a benign tumor in Awdish’s liver burst, causing a cascade of medical catastrophes that almost killed her. She nearly bled to death. She was seven months pregnant at the time, and the baby did not survive. She had a stroke and, over the days and weeks to come, suffered multiple organ failures. She required several surgeries and months of rehabilitation to learn to walk and speak again.

Helpless, lying on a gurney in the hospital’s labor and delivery area that first night, Awdish willed the medical staff to see her as a person rather than an interesting case of what she termed “Abdominal Pain and Fetal Demise.” But their medical training to remain clinically detached worked against her. Later, in the intensive care unit, she overheard her case being discussed by the surgical resident during morning rounds.

“She’s been trying to die on us,” he said. It made her angry, she says, because she was trying desperately not to die. “I felt he was positing me as an adversary. If my care team didn’t believe in me, what possible hope did I have?”

Awdish survived and returned to her work at Henry Ford Hospital, but her perspective was indelibly altered. In her recently published book, In Shock, she describes her through-the-looking-glass experience as a critically ill patient. The ordeal opened her eyes to communication lapses, uncoordinated care and at times a total lack of empathy at an institution that says on its home page that health care there “should be built around just one person: you.”

The health system has embraced many of her suggestions for change.

Today, she splits her time working as a critical care physician and as the medical director of care experience for the Henry Ford Health System. In the past five years, she and three colleagues have developed a program called Clear Conversations to improve empathy and communication with patients. At retreats that typically last two days, Henry Ford Hospital staff practice having difficult conversations with improvisational actors who play their patients. The program also trains providers in fundamental patient communications skills and offers real-time physician “shadowing” to provide feedback.

Awdish regularly speaks about her work around the country at conferences and medical schools, “trying to capture the students a bit upstream,” she says.

“To listen to our patients with a generous ear does require a willingness to relinquish control of the narrative,” she says in her book. “Our questions allow for the possibility that we do not already know the answers. By not dominating the flow of information, we allow the actual history to emerge.”

Awdish spoke with me recently about her book. The following interview has been edited for length and clarity.

Interview Highlights

What about being a patient surprised you?

What surprised me the most about being a critically ill patient was how much what I needed as a patient was different than what as a physician I would have thought I needed. As a physician, I was truly focused on trying to provide the best medical care possible. I thought that meant trying to treat people and bring them back to health as fast as possible, not staying in emotional spaces.

As a patient, I realized that someone could treat me but if I didn’t feel they really saw me, that somehow I didn’t feel healed. That emotional space is really where healing occurs.

Through the Clear Conversations program, you’re trying to address the lack of effective communication and empathy you experienced as a patient. Did it help or hinder you that you were bringing this idea to your own hospital?

What helped me in my patient experience was that as much as I saw what was missing, I also saw myself in every failure. And it was very clear that as a physician I was a product of my training. We all are. That removed much of the shame. That very much helped.

Though I believed we were doing this for the patients, what was shocking for me was how valuable the physicians found the training. As physician and author Atul Gawande said, “We all need a coach.” Once we go into practice, where do you go for guidance?

Do the changes really “take” after a two-day workshop?

By immersing departments, by training not only senior staff physicians in how to have these conversations with patients but also their fellows and residents, we gain traction. Because if residents don’t see the communication tools valued by their mentors, they won’t value it. And everyone holds each other accountable. Everyone’s ears are attuned to the same thing. It does start to create change in the sense that expectations have changed for everybody.

How is insurance a barrier to change?

The system is not set up to facilitate conversation, to facilitate time spent with patients. It doesn’t facilitate things that are of value. The need to see patients so often to keep up productivity, and the limitations on time because we’re so caught up in electronic medical record charting — all those things pull you away from patients. It’s up to physicians to keep that space sacred against the competing priorities.

Is there anything that patients can do to help connect with a physician?

What I most wish people knew is that while the system is broken, the people are good. The system actually obstructs things like communication and access. So it’s up to us to figure out the best way to communicate on a one-on-one basis and create that sacred space between ourselves.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Michelle Andrews is on Twitter @mandrews110.

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When a hepatitis C treatment called Harvoni was released in 2014, Dr. Ronald Cirillo knew it was big.

“It’s the reason that dragged me out of retirement!” he says.

Cirillo specialized in treating hepatitis C for more than 30 years in Stamford, Conn., before retiring to Bradenton, Fla. During his time in Connecticut, the only available treatment for hepatitis C had terrible side effects and it didn’t work very well. It cured the viral infection less than half the time. But the newer drugs Harvoni and Solvaldi cure almost everybody, with few adverse reactions.

“In my lifetime I’ve seen it change from a horrible treatment to a manageable treatment,” Cirillo says.

His mission is finding the patients.

“The disease is out there,” he says. “My job is to get the disease in here so we can follow them and treat them.”

Cirillo joined the Turning Points free clinic last year. It’s in Bradenton, about an hour south of Tampa. The clinic primarily serves uninsured Floridians who fall into what many refer to as a coverage gap in states like Florida that chose not to expand Medicaid. Falling into this gap are people who make too much money to qualify for Medicaid in the non-expansion state, but can’t get subsidies to buy insurance on the Affordable Care Act exchanges; subsidies kick in when people make 100 percent of the poverty level — about $12,000.

Cirillo is trying to test every high-risk patient he encounters. Today, his assistant pricks a patient’s finger, and squeezes blood onto the end of a small plastic tube.

“And this little measuring tool goes into the blood and solution mix there,” Cirillo says. “We are going to time it — 20 minutes and that’s it. That’s the test.”

Nearly 30,000 people in Florida were found to have hepatitis C in 2016. It’s likely that many more are infected, because the virus can lie dormant for decades.

Cirillo spearheaded a partnership with Harvoni’s maker, Gilead Sciences, and that partnership has provided treatment to about 100 patients.

“We treat people without any insurance, that have no hope,” Cirillo says.”If you qualify to be a patient here, you’ll get tested.”

A 57-year-old patient named Patricia discovered she had hepatitis C a few months ago during a trip to the clinic. NPR is not using her last name because the virus is sometimes associated with illegal IV drug use. It can also spread via sex. Patricia says she’s not sure how she got it.

“So, just because of my age, I guess, they went ahead and tested me for it and it blew my mind that I actually had hep C,” she says. “And the levels ended up being really high.”

The virus had started to scar and inflame her liver. But she lacked insurance and a job; the $94,000 Harvoni treatment would have been out of reach if she hadn’t had financial help.

“I would never been able to afford that treatment,” she says. “Never.”

Staff at the clinic help patients fill out the complicated application from Gilead. Only patients who don’t have insurance, have been drug-free for at least six months, and who meet income requirements are eligible.

Patricia was able to get the treatment — one pill a day for 12 weeks — and will be tested again in three months to determine whether she is free from hepatitis C.

“Had they not discovered it, really, and gotten me onto the program — who knows?” she says.

The Bradenton clinic is just one of many free clinics across Florida. But it stands out in its success in treating people who have hepatitis C.

This story was produced with the USC Center For Health Journalism’s National FellowshipandKaiser Health News.

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Federal taxpayers are pouring hundreds of millions of dollars into a quest for blood samples, medical information and fitness readouts from a million Americans. It’s called the All of Us precision medicine initiative, and it’s the biggest push ever mounted to create a huge public pool of data that scientists — and anybody else who is interested — can mine for clues about health and disease.

Proponents say this big data approach to medicine will be revolutionary. Critics aren’t so sure.

The plan is to recruit a million Americans to sign up for a program that will not only gather all sorts of medical data about them but will also follow them for at least a decade, possibly much longer. Their electronic medical records could end up in huge databases. The physical samples of blood and urine will end up in an industrial park in Rochester, Minn.

Mine Cicek, an assistant professor of laboratory medicine and pathology at the Mayo Clinic, leads me into a vast building with more than an acre and a half of floor space. “This used to be an old warehouse, but when we moved in three to four years ago, we really built a laboratory, and it’s in the space,” she says.

Power cords drop down from the ceiling to lab benches and robotic instruments, lined up row after row. These machines will help take the grunt work out of sorting through what will eventually be 34 million samples, gathered from all across America.

At the moment, the project is limited to pilot studies, with fewer than 100 samples a day coming off the UPS and FedEx trucks to be sorted, centrifuged and ultimately plunged in the deep freeze. But when the operation is fully up to speed, the lab may receive specimens from a thousand participants a day.

Cicek takes me into another cavernous part of the warehouse, filled not only with ordinary looking freezers but also with one behemoth — 74 feet long and more than 15 feet wide. It’s bigger than a railroad boxcar.

We loop around to the front, which has a glowing green slit, delineating the narrow freezer door.

Inside, robots pick up the samples, read bar codes stamped on them and store them in individual freezers hidden inside. The robot works in a freezer set to minus 20 degrees Celsius, sorting samples into smaller freezers kept at minus 80 C (or minus 112 degrees Fahrenheit). People only enter the freezer if there is a problem inside.

When everything is up and running, Cicek says, the incoming tubes of blood will be processed by a fully automated system. All she’ll have to do is pick up boxes of samples and feed them into this freezer.

And the scientific output for this enterprise? That is less tangible at the moment.

“It’s really a research resource that we’re building for the whole country, if not for the whole world,” says Eric Dishman, who runs the National Institutes of Health’s All of Us initiative from another anonymous building, in Rockville, Md., a suburb of Washington, D.C.

His job is to build it and then make the data widely available — to top biomedical researchers as well as to community colleges and even high schools, so all sorts of people can dive into the data and try to extract meaning from it.

Echoes of the human genome project

In some ways, this project is akin to the original effort to sequence the human genome more than a decade ago. It’s not an end in itself; it’s a tool. The idea is to bring the big data revolution that has reshaped online commerce and social media to science. Ultimately, the information could help make medicine more personal and precise.

Scientists don’t yet have a concrete plan, but Dishman sketches out the goals. “We keep looking at diseases in isolation,” he says. But by looking at entire genomes, he hopes scientists will get a better idea about how diseases are interconnected.

“The All of Us research program is really trying to bring a diversity of people, of health conditions, and a diversity of data sets to try to understand us more in our complexity,” he says.

Scientists might scour this pile of data for unexpected patterns or dive into it looking for answers to specific questions.

Dishman, who has lived through a 23-year odyssey with kidney disease and kidney cancer, uses his experience as an example. “I had $6 million of care. Now looking back at it, scientists tell me that 90 percent of everything we ever did to me was destined to be wrong.”

Medicine is often a matter of trial and error, so that is not so unusual. But Dishman also had the DNA in his tumor deciphered. That gave doctorsyet one more clue about what to do, and it led to an effective treatment.

“I’m nervous about sharing this story because it is hopeful,” Dishman says. “I also know there’s a lot of science, but also a lot of luck this worked for me.”

Still, he regards his story as a lesson about what the future could bring, in a world where genetic data are merged with information from medical records, exercise monitoring gear and whatever else can be put into a giant database for analysis. The hoped-for output of this will be “precision medicine.”

“We are in the early days of precision medicine and this is exactly why we need to accelerate the science and the discovery so there’s an evidence base for the decisions and choices we’re making for you as an individual, as well as the general population.”

Millions invested, future benefits unknown

Among those skeptical about the big talk — and big investment — behind precision medicine is Kenneth Weiss, who recently retired from his post as a genetics professor at Penn State, and has written about this issue.

“I think there will be some progress, but I also think this is also as much a slogan to get funding as it is a serious promise,” he says. The All of Us programreceived $360 million for its first two years of funding and hopes to run for many decades.

Gathering huge data sets may be useful for merchants trying to suss out consumer spending patterns, but he cautions that in biology, it may lead to more confusion than clarity. That is because many health conditions involve hundreds of genes, and the pattern is different in every individual. As it is, the more scientists look the more variants they find. So, he says, think about what that will look like when they have gathered a million samples.

“Bigger and bigger samples will just in a way identify more and more very rare or very weak effects, and the upshot will be each person will become even more different in terms of the identifiable genetic effects,” Weiss predicts.

When the human genome was sequenced, many scientists hoped they would quickly be able to identify the common genes that are responsible for common diseases, like diabetes, heart disease, high blood pressure and so on. That simply didn’t pan out. Common diseases don’t have common genetics. Weiss says it’s time to cut our losses pursuing that concept.

“I think we’re already at the diminishing returns point for many of the complex traits that important to our society in terms of health.”

The solutions to these common conditions lie largely in changing diets, exercise habits and tobacco addiction. Focusing genetic resources on diseases that do have strong genetic components makes a lot of sense, he says.

“But pouring more and more investment into these huge studies based on the idea that if you search enough computer data you will get an answer, I think is a false promise,” he says.

He would rather take the money being spent on All of Us and use it to work on gene therapies for diseases that have a clear genetic cause, such as muscular dystrophy or Huntington’s disease. “And once those [therapies] are developed — which I think they will be because I think humans are really good at engineering — then we can extend to the less clear-cut genetic traits.”

Meanwhile, if the goal is to improve the health of our population, he says, “let’s spend money on dietary exposures, exercise exposures, all the things that we know about to reduce the frequency of the kinds of diseases that we’re spending so much money to try to treat is if they were genetic.”

Given all the momentum built up behind the precision medicine initiative, Weiss is not voicing a popular point of view. But the retired geneticist says he has no ax to grind — and no brilliant insights about what would actually lead to medical breakthroughs. His concern is that biomedical research is committed to this idea because they have a tool they are eager to use — not because they have a clear path ahead.

You can contact Richard Harris via email.

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Unlike many things from the 1967 “Summer of Love,” the Haight Ashbury Free Clinic survived.

The clinic, now part of a larger network, still operates out of a second-floor office overlooking Haight Street in San Francisco. A steep wooden staircase leads to a warren of small but airy rooms.

One exam room still has a wall covered by a faded psychedelic mural, featuring a collage of famous rock stars, naked bodies and peace signs.

The decor used to be even more colorful, according to lab manager Pam Olton. She has worked at the Free Clinic for more than 40 years.

“Pink, aqua, Day-Glo orange … all of these exam rooms were painted in those Day-Glo colors,” she says.

The colors helped the young patients feel welcome, Olton explains, easing their drug-induced paranoia or just reassuring them that the clinic was a safe and sympathetic space. In the summer of 1967, and for years after, the Free Clinic treated the countercultural denizens of the Haight-Ashbury neighborhood. They were often the patients that nobody else wanted.

“You had a big flash mob of kids coming to this neighborhood from all over — from everywhere in America,” Olton says. Most had no health insurance, and some were living in parks, on the street or sharing crowded apartments.

“They’re kids, they’re dirty, they’re a mess and they’re addicted,” Olton says. “But we have to take care of their medical needs first. And we have to be nonjudgmental. They’re human beings — they’re somebody’s kid and we need to take care of them.”

Dr. David Smith was a young faculty member at the University of California, San Francisco when he started the free clinic 50 years ago. He’s now 78 and still works in addiction medicine.

“We were kind of the caregivers to the love generation,” Smith says. At the beginning of 1967, he had one foot in the world of academic medicine and one foot in the burgeoning counterculture. He lived in the Haight and had experimented with drugs.

“I had an LSD spiritual experience, and a vision that denial of health care to one segment of the population is a denial to all,” Smith recalls. “So there was a transformation of me in that period, in ’67, like what happened to so many young people. I just happened to have a medical skill when that transformation occurred.”

‘Health care is a right, not a privilege’

Smith knew that thousands of young adults would flood into San Francisco that summer, and he was worried about who would treat them and how these young people would be treated by people in mainstream medicine.

“Some of us went to the city [health officials] and said, there’s going to be a huge problem this summer, and we need what we called then ‘a hippie clinic,’ ” Smith recalls. “And it was soundly rejected by the health department. They had no interest in this. They said, ‘We don’t want to take care of them. We want them to go away.’ “

Smith and some colleagues, along with residents of the Haight, started getting ready anyway. It was during one of their planning meetings that Smith stood up and declared: ” ‘Health care is a right, not a privilege.’

“It became the founding slogan of our Haight Ashbury Free Clinic,” he says.

The clinic opened on June 7, 1967, to a line of people stretching down the block. The team worked through the night and treated 250 people, Smith says. The next day, the staff treated 350 more.

At that time, the staff was entirely volunteer — a mix of sympathetic doctors, nurses and students from the local medical and pharmacy schools.

Keeping the clinic going was a struggle. Money for rent and supplies was in short supply. Police officers would frequently show up and search the rooms, looking for illicit drugs and underage runaways.

But Smith was determined to keep the clinic open. If hippies hurt themselves, many mainstream doctors thought they got what they deserved. Sometimes hospitals turned them away. And when they got sick from taking illegal drugs, or overdosed, or became psychotic, they were often shamed, restrained or thrown in jail. The Free Clinic offered a safe space.

“If you were taken to the Haight Ashbury Free Clinic, you would be put into a room … with a talk-down guide and a lava lamp,” he says. “You’d be examined by a physician to see if you needed medication to help you come down.”

After 1967, the clinic continued as a medical refuge and its compassionate approach endured through the harder drugs of the 1970s, and the AIDS epidemic of the 1980s.

Eric Smith (no relation to the clinic’s founder) remembers visiting the Free Clinic about 15 years ago. He was living on the streets of San Francisco and using heroin. He can’t remember why he went there for care, but he does remember what it felt like to be there.

“I went in there — there was a whole bunch of people hanging out. It was cool,” Eric says. He remembers the staff and others asking, ” ‘How can we help you out?’ “

“People were eating,” he recalls. “Some girl asked if I was hungry. She brought me a vegetarian burrito. It was very welcoming, and I didn’t feel nervous or ashamed being in there. You know? I felt like these are my people, they’ll help me out. I can be honest with them. I think that carries on right now.”

Meeting modern challenges

Eric Smith eventually got off drugs, and for the last two years has worked for the clinic as a patient coordinator.

When patients come to the clinic, Smith makes sure they are connected to the services they need — whether that’s medical or dental care, therapy, detox or a drug recovery program.

And he walks the neighborhoods of San Francisco, doing outreach.

He brings naloxone for opioid overdoses and a CPR mask. He has a big backpack full of snacks to hand out, along with gloves, socks, condoms and toothbrushes.

On the day I join him for his rounds, Eric stops by a row of tents on Folsom Street. Men gather around as he passes out supplies.

“You guys know who I work with, right?” he asks as he hands out socks and granola bars. “So, you guys need any services at all? Is there anything you need?”

On this particular day, none of the men are interested in visiting the clinic.

Eric just smiles and moves on. No encounter is ever wasted, he tells me.

“I have to build a trust and rapport with the individual, so they know — no matter what they tell me — that it’s safe,” he says.

“You want the best for everybody, but you can’t really push yourself too hard on them,” he added. “You’ve got to meet them where they’re at, and in their time they’ll come around eventually, you hope.”

Erie Street is just one block from the Haight Ashbury Free Clinic’s location in the Mission district. It’s a long alleyway of sharp shadows and slants of sunlight. On the day we walk past, there is a tent at the far end, and a guy on a stepladder, spray-painting a mural on a large blank wall.

“It’s heartbreaking — I used to get high in this alley, too,” Eric says. “I feel for these individuals.”

He spots some new faces.

“Hey, guys,” he booms, smiling and striding over. “You need any socks?”

A man and a woman are cuddled together with just thin sleeping bags against the hard sidewalk.

Nearby is a shopping cart stuffed with belongings and a cooler. A pit bull puppy flops across their legs. They sit up and happily accept everything Eric offers.

“Hey, so you guys, you guys need any medical attention at all?” Eric asks. “Do you got Medi-Cal?” he asks, referring to the Medicaid program in California — the health insurance for low-income people.

The young couple — Sean and Kat — are from Mendocino County, they tell us, and have been in San Francisco for only a month. They are trying to a quit a drug habit, and NPR agreed not to use their last names. They need advice, and Eric has plenty: They talk about places to get day-old pastries; charities that offer free breakfast or lunch; and places to shower. Eric points out the nearby clinic. They discuss getting the puppy fixed at the SPCA, which is also in the neighborhood.

“You guys use?” Eric asks. “I mean I’m an old junkie, all right?”

“We’re working on quitting,” Kat says.

“Oh what, heroin?”

“No,” says Sean.

“Meth?”

“Yeah.”

“Slamming it?”

“No.”

“Smoking?”

“Yeah, we smoke.”

Kat tells Eric she used to slam, meaning she used to inject the drug. But after meeting Sean, she was able to stop that. He helped her “get off the needle.”

Eric jumps on this point: “Really? So you guys are together. And you’re supporting one another, all right?”

Giving up the needle is a small step, but a positive one. It’s a little less harmful. Eric wants them to know he gets it: They’re trying.

“So, you guys, come and talk to me, OK?” he tells them. “Seriously, if you want help at all. I don’t care if you don’t want recovery or not, but just to know that there’s someone out there. I used to get high right here in this alley, dude — back in the day.”

Survival in consolidation

Today, the Haight Ashbury Free Clinics are part of an umbrella organization called HealthRIGHT 360. It’s a large network of social service agencies tackling a variety of issues besides health care: domestic abuse; rehabilitation for ex-inmates; gay, lesbian and transgender health issues, and addiction.

Consolidating with other agencies helped the Haight Ashbury Free Clinic survive.

Seven years ago, in 2010, it was struggling financially. Some staffers had been caught embezzling, and the clinic couldn’t afford the transition to electronic medical records — a requirement of the Affordable Care Act.

In 2011, the Free Clinic joined forces with Walden House, a nearby addiction recovery center. Other nonprofits soon joined as well, and HealthRIGHT 360 became the umbrella brand, allowing the smaller agencies to pool resources for administration, electronic records and fundraising.

Dr. David Smith, who started it all, applauds the decision to consolidate with other nonprofits. But he does miss the intimacy of those early days, he says, when volunteers from the neighborhood worked at the clinic.

When money got tight back then, they held benefit concerts, featuring local bands — like Big Brother and the Holding Company, during the time Janis Joplin was the lead singer.

After 1967, free clinics opened in Seattle, Los Angeles and Berkeley. By the end of the 1960s, the U.S. had dozens of free clinics — a third of them in California.

This story is part of a NPR’s reporting partnership with KQED and Kaiser Health News.

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On a Monday afternoon in October, a panel of Iowa state legislators gathered in the statehouse to discuss the opioid epidemic.

Doctors, law enforcement officials and health insurers all took turns at the lectern.

One of the witnesses was Deborah Thompson.

She’s testified in front of state legislators plenty of times. As the legislative liaison for the Iowa Department of Public Health, she’s often asked to provide legislators a window into what the epidemic looks like in Iowa. The information can be wonky at times, like how many morphine equivalent milligrams are prescribed each year, or cold facts, like that year’s death toll.

Last year in Iowa, there were 80 opioid-related deaths. In 2017, there are projected to be 201.

This time, there was something else she wanted to share.

“Today would have been my seventh wedding anniversary,” she told the panel. “My husband, Joe Thompson, passed away from an accidental heroin overdose last September. He left me and his 1-year-old son, Lincoln.”

For years, Thompson had worked on policy related to the opioid crisis in Iowa while keeping her own family’s struggle with addiction in the background. She’d told a couple of state legislators she had close relationships with, but sharing her story in public was a big moment.

Thompson went back and forth about whether she could keep this to herself. She saw her role as the policy expert working in the background, not a face of a national problem.

“I wasn’t really sure I was going to, and I just couldn’t shake the fact that it was our wedding anniversary, and that had to mean something,” she tells NPR’s Robert Siegel. “The coincidence was too great. Joe had always gravitated toward the helping professions, he wanted to be a nurse or a counselor or something like that, and it would be quite an anniversary gift to give him, to be able to, maybe grant that wish through me, if it helped a lot of people. It was probably one of the better gifts I gave him. I was never very good at our anniversary gifts.”

Joe Thompson’s struggle with opioids started back in 2004. After he was in a serious car accident, Thompson says her husband was likely over-prescribed medication to treat the pain. He started going from doctor to doctor, a practice called doctor shopping, to get new prescriptions or refills. At his job as a package handler for UPS, he started swiping prescription drugs being shipped through the mail.

Joe tried to get help. He enrolled in an outpatient facility. Several times he got sober, sometimes for several years at a time. He even went back to school and got his nursing degree. But then he would relapse again.

“I think it’s hard to understand that,” Deborah Thompson says. “I think logically your mind can get there, but your heart hurts … the way the disease manifests itself, it’s selfish, things are done to you, money was stolen from me, lies were told to me, and it’s hard to wrap your mind around the idea that it’s a disease causing this behavior while you’re in it.”

It took Thompson a while to really grasp that her husband was sick — that his addiction was not just a bad habit he couldn’t kick, but a disease that was really hard to climb out from.

“I just kind of equate it to, when my mother had brain cancer, we could see the tumor on the X-ray scans, we knew that something was growing and taking over her brain,” she says. “I wish I’d known more about the science when we were in it. … I felt like I was finally ready to deal with Joe’s addiction, and then time ran out.”

Joe Thompson died in September 2016 from a heroin overdose. He was 35.

Joe may not have beat his addiction, but Thompson is confident Iowa can.

She says new funding has helped, as well as changes in the law that have given states additional flexibility to respond to the crisis. One policy change that she says could help save lives right now is requiring doctors in every state to check prescription monitoring databases — information that would prevent doctors from prescribing or refilling opioids to people who don’t actually need it or are dealing with an addiction. She says waiting for doctors to voluntarily adopt best practices simply isn’t enough.

Deborah Thompson is also hoping her unique position at the crossroads of policy and personal experience can help move her state just a little bit closer to curbing the epidemic.

“Just looking at how many community partners that are involved, that run the gamut of law enforcement, the healthcare community, public health professionals, community agencies, coming together in Iowa to fight this, I can’t imagine we’ll lose,” she says.

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