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Health June 29, 2016

Heat On White House To Scrap Redo Of Human Research Rules

HeLa cells, commonly used in research, were derived from cervical cancer cells taken in 1951 from Henrietta Lacks without her permission.

HeLa cells, commonly used in research, were derived from cervical cancer cells taken in 1951 from Henrietta Lacks without her permission. Science Source hide caption

toggle caption Science Source

An influential federal panel has taken the unusual step of telling the Obama administration to withdraw a controversial proposal to revise regulations that protect people who volunteer for medical research.

The proposal is “marred by omissions, the absence of essential elements, and a lack of clarity,” according to the National Academies of Sciences, Engineering and Medicine. The conclusions are part of a 283-page report released Wednesday.

The regulations are known collectively as the Common Rule. They were put in place decades ago to make sure medical experiments are conducted ethically.

But the rules haven’t been updated in nearly a quarter century. So last year the Department of Health and Human Services proposed a major revision.

But the proposal prompted a wide range of criticism. Some argued the revisions were too vague, complex and confusing. Others attacked specific changes.

One especially contentious requirement would oblige scientists to obtain explicit consent from patients before using their blood or tissue for research.

The requirement aims to prevent a repeat of what happened to Henrietta Lacks. She was an African-American woman who died of cervical cancer in 1951. Tumor cells taken from her were used without her consent to produce a research cell line that has been kept alive in labs around the world ever since.

But many researchers feared the new requirement would create unnecessary red tape and significantly hinder important research.

The academies report appears to agree. It concludes that “much of this research does not involve physical risk to participants; rather, risks are limited to the more remote possibility of informational harm resulting from the inadvertent release of confidential information.”

The report recommends that the proposal be withdrawn. Instead, it says the president should appoint an independent national commission modeled on the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical And Behavioral Research to essentially start from scratch in revising the regulations.

HHS says it is reviewing the report, along with more than 2,100 public comments on the proposed revision.

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Health June 28, 2016

States Offer Privacy Protection For Young Adults On Parents' Health Plan

How do you stay on the family health plan without your parents finding out about your health issues?

How do you stay on the family health plan without your parents finding out about your health issues? Alex Williamson/Ikon Images/Getty Images hide caption

toggle caption Alex Williamson/Ikon Images/Getty Images

The Affordable Care Act opened the door for millions of young adults to stay on their parents’ health insurance until they turn 26.

But there’s a downside to remaining on the family plan.

Chances are that Mom or Dad, as policyholder, will get a notice from the insurer every time the grown-up kid gets medical care, a breach of privacy that many young people may find unwelcome.

With this in mind, in recent years a handful of states have adopted laws or regulations that make it easier for dependents to keep medical communications confidential.

The privacy issue has long been recognized as important, particularly in the case of a woman who might fear reprisal if, for example, her husband learned she was using birth control against his wishes. But now the needs of adult children are also getting attention.

“There’s a longstanding awareness that disclosures by insurers could create dangers for individuals,” said Abigail English, director of the advocacy group Center for Adolescent Health and the Law, who has examined these laws. “But there was an added impetus to concerns about the confidentiality of insurance information with the dramatic increase in the number of young adults staying on their parents’ plan until age 26” under the health law.

Federal law does offer some protections, but they are incomplete, privacy advocates say. The Health Insurance Portability and Accountability Act of 1996 is a key federal privacy law that established rules for when insurers, doctors, hospitals and others may disclose individuals’ personal health information. HIPAA contains a privacy rule that allows people to request that their providers or health plan restrict the disclosure of information about their health or treatment. People can ask that their insurer not send to their parents the ubiquitous “explanation of benefits” form describing care received or denied, for example. But an insurer isn’t obligated to honor that request.

In addition, HIPAA’s privacy rule says that people can ask that their health plan communicate with them at an alternate location or by using a method other than the one it usually employs. Someone might ask that EOBs be sent by email rather than by mail, for example, or to a different address than that of the policyholder. The insurer has to accommodate those requests if the person says that disclosing the information would endanger them.

A number of states, including California, Colorado, Washington, Oregon and Maryland, have taken steps to clarify and strengthen the health insurance confidentiality protections in HIPAA or ensure their implementation.

In California, for example, all insurers have to honor a request by members that their information not be shared with a policyholder if they are receiving sensitive services such as reproductive health or drug treatment or if the patient believes that sharing the health information could lead to harm or harassment.

“There was concern that the lack of detail in HIPAA inhibited its use,” said Rebecca Gudeman, senior attorney at the National Center for Youth Law, a California nonprofit group that helps provide resources to attorneys and groups representing the legal interests of poor children. She noted that HIPAA doesn’t define endangerment, for example, and doesn’t include details about how to implement confidentiality requests.

Concerns by young people that their parents may find out about their medical care leads some to forgo the care altogether, while others go to free or low-cost clinics for reproductive and sexual health services, for example, and skip using their insurance. In 2014, 14 percent of people who received family planning services funded under the federal government’s Title X program for low-income individuals had private health insurance coverage, according to the National Family Planning and Reproductive Health Association.

Even though most states don’t require it, some insurers may accommodate confidentiality requests, said Dania Palanker, senior counsel for health and reproductive rights at the National Women’s Law Center, a research and advocacy group.

“Inquire whether there will be information sent and whether there’s a way to have it sent elsewhere,” Palanker said. “It may be possible that the insurer has a process even if the state doesn’t have a law.”

Insurers’ perspective on these types of rules vary. In California, after some initial concerns about how the law would be administered, insurers in the state worked with advocates on the bill, Gudeman said. “I give them a lot of credit,” she said.

Restricting access to EOBs can be challenging to administer, said Clare Krusing, a spokesperson for America’s Health Insurance Plans, a trade group. A health plan may mask or filter out a diagnosis or service code on the EOB, but provider credentials or pharmacy information may still hint at the services provided.

There’s also good reason in many instances for insurers and policyholders to know the details about when a policy is used, experts say. Policyholders also may have difficulty tracking cost-sharing details such as how much remains on the deductible for their plan.

In addition, “if a consumer receives a filtered or masked EOB, he or she has no way of knowing whether their account has been compromised or used as part of fraudulent activity,” Krusing said.

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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Health June 27, 2016

Texans React To Supreme Court's Ruling On State Abortion Law

People in Texas react to the Supreme Court’s decision Monday overturning a state law cutting the number of health clinics that perform abortions.

Transcript

ROBERT SIEGEL, HOST:

Since Texas passed the law at the center of the Supreme Court case, more than half of the clinics in the state that perform abortions have closed. That means that today’s ruling was an emotional one for people on both sides of the debate there. NPR’s Wade Goodwyn has their reaction.

WADE GOODWYN, BYLINE: In women’s clinics across the state, abortion rights advocates gathered this morning and waited to hear the Supreme Court’s ruling. At the Houston Women’s Clinic, they sat together hopefully, anxiously, fearfully, their eyes glued to their cell phones, waiting for the website SCOTUSblog to report the news. Houston Public Media was there, too. Women’s Clinic counselor Jessica Rossi saw it first.

JESSICA ROSSI: Yes. The decision of the 5th Circuit is reversed. Yes, the vote is 5-3.

(CROSSTALK, CHEERING)

ROSSI: Five-three, 5-3. It’s 5-3.

GOODWYN: In Austin, they gathered at the now-closed Whole Women’s Health Clinic. Whole Women’s Health was the lead plaintiff in the case. Heather Busby was there. She’s the executive director of NARAL Pro-Choice Texas. Busby says that while today’s decision was a major win, over the last five years, the state has wrecked its women’s health care infrastructure.

HEATHER BUSBY: Since 2011, we’ve lost more than 80 – that’s eight-zero – family planning clinics around this state. And now we’ve lost abortion care clinics which also provided family planning and well women exams and STI screening and treatment. So we have a broken reproductive health care system in this state. Rebuilding it will not happen overnight. The fight continues. It continues to go on because Texas is still very hostile to reproductive health care.

JOE POJMAN: We are very disappointed that the Supreme Court ruled the way it did today.

GOODWYN: Joe Pojman is the executive director of Texas Alliance for Life.

POJMAN: We think it’s a big setback – no question about it. It means that the state of Texas is not going to be able to enforce what we believe are very reasonable safety standards. And that’s a very big disappointment to us.

GOODWYN: The movement and its allies in the Republican-dominated Texas Legislature say that while they may be wounded, they’re ready with another strategy. John Seago is the legislative director of Texas Right to Life. Seago says they will shift focus from protecting the health of the woman to protecting the fetus from pain. They’ll urge the Texas Legislature to pass new laws that prohibit certain types of abortion procedures.

JOHN SEAGO: So in Texas, we’re recommending passing the dismemberment abortion ban, a law that would prohibit dismemberment abortion, the method – specific method of abortion that takes the life of the preborn child by taking its limbs apart.

GOODWYN: As for Planned Parenthood, instead of fighting a rear guard defensive action as it has the last three years, it will use the Supreme Court’s decision to go on the offensive and remove state restrictions on abortion rights. Dawn Laguens is the executive vice president of Planned Parenthood.

DAWN LAGUENS: States like Texas, Ohio, Arizona, Louisiana, Pennsylvania, Wisconsin – all should have regulations that should fall as a result of this.

GOODWYN: And so the passionate fight over abortion moves to its next front, each side every bit as determined as before. Wade Goodwyn, NPR News, Dallas.

Copyright © 2016 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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Health June 24, 2016

Minnesota's Largest Health Insurer Will Drop Individual Plans

At Blue Cross and Blue Shield headquarters in Eagan, Minn., the losses on the sale of insurance plans to individuals led to a change in course.

At Blue Cross and Blue Shield headquarters in Eagan, Minn., the losses on the sale of insurance plans to individuals led to a change in course. Jim Mone/AP hide caption

toggle caption Jim Mone/AP

Blue Cross and Blue Shield of Minnesota will retreat from the sale of health plans to individuals and families in the state starting next year. The insurer, Minnesota’s largest, said extraordinary financial losses drove the decision.

“Based on current medical claim trends, Blue Cross is projecting a total loss of more than $500 million in the individual [health plan] segment over three years,” the insurer said in an emailed statement.

The Blues reported a loss of $265 million on insurance operations from individual market plans in 2015. The insurer said claims for medical care far exceeded premium revenue for those plans.

“The individual market remains in transition and we look forward to working toward a more stable path with policy leaders here in Minnesota and at the national level,” the company stated. “Shifts and changes in health plan participation and market segments have contributed to a volatile individual market, where costs and prices have been escalating at unprecedented levels.”

The decision will have far-reaching implications.

Blue Cross Blue Shield says the change will affect about “103,000 Minnesotans [who] have purchased Blue Cross coverage on their own, through an agent or broker, or on MNsure,” the state’s insurance exchange.

“We understand and regret the difficulty we know this causes for some of our members,” the insurer wrote. “We will be notifying all of our members individually and work with them to assess and transition to alternative coverage options in 2017.”

Cynthia Cox of the Kaiser Family Foundation, who analyzes individual health insurance markets around the country, says what the Blues are doing in Minnesota is similar to a walk back by UnitedHealth Group, the nation’s largest health insurance company.

“Right now what it seems like is that insurance companies are really trying to reset their strategy,” Cox said. “So they may be pulling out selectively in certain markets to re-evaluate their strategy and participation in the exchanges.”

She said the individual markets just aren’t turning out as expected. “The hope was that these markets would encourage exchange competition and [get] more insurers to come in. … I don’t know if we’re at a point where it’s completely worrisome, but I think it does raise some red flags in pointing out that insurance companies need to be able to make a profit or at least cover their costs.”

In response to the development in Minnesota, Gov. Mark Dayton, a Democrat, highlighted gains in enrolling more Minnesotans in health insurance plans since the implementation of the Affordable Care Act. But he also acknowledged the insurer’s departure reflects the instability in the market for individual and family coverage.

“This creates a serious and unintended challenge for the individual market: the Minnesotans who seek coverage there tend to have greater, more expensive health care needs than the general population,” said Dayton. “Blue Cross Blue Shield’s decision to leave the individual market is symptomatic of conditions in the national health insurance marketplace.

University of Minnesota health economist Roger Feldman called the Blues’ departure a major blow to Minnesota’s already troubled individual market.
“What this says about the individual market is that it is very unstable and it has been disrupted by a number of events, and we still don’t know whether it will recover or not from those disruptions,” he said.

Feldman said lawmakers would be wise to pay attention to the unstable individual markets and to shore them up with a carrot and stick approach.

“To get people to sign up in the exchange we need one or both of those,” he said. “The stick could be to raise the penalties on people who don’t buy insurance, and the carrot could be to increase the subsidies for people that do. I think that’s the only way that we’re going to get a decent mix of risks to buy into that exchange.”

Although the main Blue Cross Blue Shield unit is leaving Minnesota’s individual market, its much smaller subsidiary, Blue Plus, will continue to offer plans on the individual market, according to the company statement. Blue Plus has only about 13,000 members, according to his message.

Kaiser’s Cox says that’s typical and leaves insurers a re-entrance option.

MNsure spokesman Shane Delaney said about 20,000 Minnesotans purchased Blue Cross and Blue Shield of Minnesota plans through MNsure. He said the vast majority of them qualified for tax credits to help pay premiums. Delaney said all of the Blue Cross and Blue Shield customers losing their coverage next year should look for other options on MNsure, the only place eligible applicants can secure federal tax credits.

This story is part of a reporting partnership with NPR, Minnesota Public Radio and Kaiser Health News. You can follow Mark Zdechlik on Twitter: @MarkZdechlik.

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Health June 23, 2016

The Challenge Of Taking Health Apps Beyond The Well-Heeled

The Text4Baby app sends free, periodic text messages in Spanish or English to pregnant women and new moms about prenatal care, labor and delivery, breastfeeding, developmental milestones and immunizations.

The Text4Baby app sends free, periodic text messages in Spanish or English to pregnant women and new moms about prenatal care, labor and delivery, breastfeeding, developmental milestones and immunizations. Kristin Adair/NPR hide caption

toggle caption Kristin Adair/NPR

When you hear the phrase “digital health,” you might think about a Fitbit, the healthy eating app on your smartphone, or maybe a new way to email the doctor.

But Fitbits aren’t particularly useful if you’re homeless, and the nutrition app won’t mean much to someone who struggles to pay for groceries. Same for emailing your doctor if you don’t have a doctor or reliable Internet access.

“There is a disconnect between the problems of those who need the most help and the tech solutions they are being offered,” said Veenu Aulakh, executive director of the Center for Care Innovations, an Oakland, Calif.-based nonprofit that works to improve health care for underserved patients.

At most digital health “pitchfests,” it’s pretty much white millennials hawking their technology to potential investors. “It’s about the shiny new object that really is targeted at solving problems for wealthy individuals, the ‘quantified-self’ people who already track their health,” Aulakh said. “Yet ….What if we could harness the energy of the larger innovation sector for some of these really critical issues facing vulnerable populations in this country?”

A small but growing effort is underway to do just that. It’s aimed at using digital technologies – particularly cellphones – to improve the health of Americans who live on the margins. They may be poor, homeless or have trouble getting or paying for medical care even when they have insurance.

The initiatives are gaining traction partly because of the growing use of mobile phones, particularly by lower-income people who may have little other access to the Internet.

The Affordable Care Act and the expansion of Medicaid have added millions of previously uninsured people to the nation’s health care system, including community health clinics that serve poor and largely minority populations, according to a California Health Care Foundation report. (California Healthline is an editorially independent publication of the California Health Care Foundation.)

In California alone, the number of people on Medi-Cal, the state’s version of the Medicaid program for the poor, rose from 7.5 million in 2010 to 12.4 million by early 2015. Many Americans remain uninsured, however, because they live in states that have declined to expand Medicaid eligibility.

Health advocates say it’s important to tailor digital health technologies to lower-income people not only to be fair, but because they’re more likely to have chronic illnesses, like diabetes, that are expensive to treat.

Health-care providers have incentives as well. They are being rewarded financially under the Affordable Care Act, Medicare and Medicaid for keeping patients healthy, and this goes beyond simply performing medical procedures and prescribing drugs.

For now, experiments targeting low-income people are a tiny part of the digital health industry, which racked up an estimated $4.5 billion in venture funding in 2015 alone. Entrepreneurs are still trying to figure out how they’re going to get paid by serving this population, and government health programs like Medicaid and Medicare are taking a while to figure out how they’re going to pay providers for approaches that don’t involve a doctors’ visit.

But Jane Sarasohn-Kahn, author of the California Health Care Foundation report, says investors are getting more interested in digital health initiatives for low-income patients simply because there are so many of them.

Investors are eyeing the “fortune at the bottom of the pyramid,” she said, much as Walmart profits from selling low-priced items to millions.

“It’s now sexy to scale,” she says. “If you can have impact [on many people], inexpensively, you can make a lot of money. If we get it right, we can do well and do good.”

Some initiatives are simple and cheap, like Text4Baby. The free text-messaging service for pregnant women and new moms offers information in English and Spanish about prenatal care, labor and delivery, breastfeeding, developmental milestones, and immunizations. The specific texts are timed to the baby’s due date.

Operated by the nonprofit ZERO TO THREE and the mobile health company Voxiva, Inc., Text4Baby has reached nearly 1 million women since starting in 2010. In one survey, more than half of them reported yearly incomes of less than $16,000.

Other experiments are far more elaborate. In California and Washington state, San Francisco-based Omada Health is testing a version of Prevent, a diabetes and heart disease prevention program that’s been modified for “underserved” populations – basically people on Medicaid or who are uninsured. The free program offers patients a digital scale as well as behavior counseling and education, access to a personal health coach and an online peer network.

To adapt the program, the company made it available in Spanish and English and lowered its reading level from ninth grade to fifth grade. Bilingual health coaches were hired, and the educational materials now acknowledge potential food access, neighborhood safety and economic issues that participants may face, said Eliza Gibson, Omada’s director of Medicaid and safety-net commercial development.

The scale doesn’t require a wireless connection, and the patient just needs to be able to access the Internet for one hour each week, Gibson said.

Omada is enrolling 300 community clinic patients in Southern California and rural Washington in a year-long clinical trial of Prevent, in hopes that the program can demonstrably slow the progress of diabetes.

Patients at other community clinics in California will try out the program but won’t be included in the clinical trial, Gibson said. Omada Health is also offering a version called Prevent for Underserved Populations that specifically targets low-income community clinic patients.

Among the people trying out the program is Susy Navarro, an elementary school substitute teacher who lives in the Spring Valley community east of San Diego. After being diagnosed with prediabetes, Navarro, 28, set an ambitious goal to lose 100 pounds. In the meantime, she is taking medication to stave off Type 2 diabetes.

“You name it, I’ve probably tried it – Weight Watchers, low-fat, low carb, pills, injections, acupuncture,” Navarro said. “The first time I try things it goes very well, I feel like I’m very successful, then I wean off and I’m not successful. This program focuses more on life choices that are going to help us out long-term, not just for a little bit.”

Navarro described the scale she was given as “sophisticated looking – all black, flat, digital.” It has been programmed to her weight profile (she is considered obese), and transmits her weight every morning to the program’s counselors.

The program, with its daily weigh-ins, helps her pay attention to what she eats, and her blood sugar levels are declining, Navarro said. She also appreciates the ability to connect online with fellow patients on her “team.” “It’s very awesome – you get to know the other members and feel like it’s a team effort.”

As they continue to explore digital health possibilities for underserved patients, developers are learning more about what works and what doesn’t, says Sarasohn-Kahn. For example, apps chew up a lot of cellphone data, so many community clinic patients prefer lower-cost text messaging.

At the Petaluma Health Center, a network of community clinics in Sonoma County, Calif., staffers offered free, simplified “loaner” digital devices to patients after a hospital stay to help them avoid complications that could land them back in the hospital.

They first offered an Android tablet to allow for a video visit with a health professional, but patients were reluctant to take it, saying it was hard to hide and could be stolen, said Dr. Danielle Oryn, the network’s chief medical information officer.

Then they tried iPhones, in which everything was locked down except the ability to call 911 and a single button triggering the video visit. Those were more acceptable. Still, there were challenges. Would patients, some recuperating at homeless shelters, have access to electricity to charge their phones? Oryn said they had to learn by trial and error. She was surprised and pleased to see seniors accepting the technology. Every loaner iPhone was returned to the clinic.

Oryn’s advice to the captains of the digital health industry?

They should “not necessarily come in with too many assumptions. They should come with an open mind and a willingness to listen,” Oryn said. “Safety-net people are very excited to have these companies interested in them and to share their experiences.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation. Follow Barbara Feder Ostrov on Twitter: @barbfederostrov.

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Health June 22, 2016

House Speaker Paul Ryan Reveals GOP Health Care Plan

House Speaker Paul Ryan unveiled the health care component of congressional Republicans’ policy agenda Wednesday, a long-awaited alternative to the Affordable Care Act.

Transcript

AUDIE CORNISH, HOST:

Today House Republicans offered up an outline of what America’s health care system might look like under a future Republican president. Their plan calls for more options for health insurance policies and the possibility of lower cost. It also includes fewer safeguards for people who get sick. NPR’s Scott Horsley reports.

SCOTT HORSLEY, BYLINE: Ever since Democrats in Congress passed Obamacare more than six years ago, Republicans have been vowing to repeal it. But for the most part, they have not said what they want to replace it with until now.

(SOUNDBITE OF ARCHIVED RECORDING)

PAUL RYAN: Here it is, a real plan in black and white right here.

HORSLEY: House Speaker Paul Ryan unveiled the Republican health care plan this afternoon at a conservative think tank here in Washington. He says it represents not just a change in policy from Obamacare, but a whole different philosophy.

(SOUNDBITE OF ARCHIVED RECORDING)

RYAN: Either we have the government forcing us and telling us what we have to do, where we have to do it and how much we have to pay for it or we put ourselves in charge – we as consumers, as patients.

HORSLEY: The GOP plan would do away with the regulated exchanges in Obamacare and replace them with a more wide-open insurance market. Health policy expert Joseph Antos of the conservative American Enterprise Institute says customers would have more freedom to buy stripped down policies across state lines if they want to. And companies could offer a wider range of prices depending on a patient’s age.

JOSEPH ANTOS: If you want younger healthier people to sign on – you’ve got to – you have to mark it up so that young people will in fact be attracted to those policies.

HORSLEY: Customers would get a tax credit to help defray the cost of insurance. Though, the GOP is not saying by how much. The plan would also limit federal spending on Medicaid for poor patients, and it would eventually overhaul Medicare, so future retirees get a fixed subsidy they could use to help buy private insurance. Congressman Ryan’s been pushing that idea for years now. Though, Antos admits it’s a political hot potato.

ANTOS: It is a brave move. The intention is to give it a shot in the arm for the health sector to find more efficient and more effective ways of providing health care.

HORSLEY: The Republican plan preserves some of the more popular elements of Obamacare like letting young adults stay on their parents’ insurance, but it doesn’t guarantee coverage to those with pre-existing medical conditions if they allow their insurance to lapse. Sarah Collins of the Commonwealth Fund, which works to promote health access says that could put tens of millions of people at risk of losing coverage.

SARA COLLINS: It is very possible that people would have difficulty maintaining continuous coverage over their lifetime just based on past experiences.

HORSLEY: The plan calls for subsidized high-risk pools to insure those with especially costly medical conditions. Collins is skeptical about the Republicans’ plan. She says Obamacare has already pushed the number of uninsured Americans to a record low, even as health care costs have grown at a slower than expected rate.

COLLINS: Overall, the law has worked well to insure millions of people and also provide cost protection and some better access to care.

HORSLEY: Speaker Ryan conceded today the GOP plan is just an outline, and he’s not aiming to pass any legislation until a new Republican president is in office.

GOP White House hopeful Donald Trump has embraced some elements of the Republican plan, though not the Medicare overhaul. If nothing else, the plan gives Ryan and his colleagues a way to change the subject any time they’re asked about Trump.

(SOUNDBITE OF ARCHIVED RECORDING)

RYAN: Next question. I got nothing for you today, man. Nice try.

HORSLEY: Scott Horsley, NPR News.

Copyright © 2016 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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Health June 21, 2016

In Syria, Underground Efforts To Train Doctors Amid Regime Attacks

NPR’s Kelly McEvers talks to reporter Ben Taub of The New Yorker about efforts to spread medical knowledge in Syria. Taub chronicles underground efforts to train doctors in Syria amid ongoing attacks by regime forces against medical personnel and facilities.

Transcript

KELLY MCEVERS, HOST:

In March 2011, tens of thousands of protesters went out into the streets of Daraa, Syria. It was the beginning of the popular uprising against President Bashar al-Assad that eventually led to the Syrian civil war. Days after those first protests, government forces stormed the city hospital and positioned snipers on the roof. Snipers fired on people who were going into the hospital.

BEN TAUB: So one of the first victims of the revolution was a cardiologist who was shot in the head by these snipers on top of the hospital as he tried to reach the wounded protesters. And when people attended his funeral the next day, they too were shot with live ammunition. And for the next two years, those snipers stayed on the roof firing at people who attempted to approach the hospital.

MCEVERS: That’s reporter Ben Taub, who writes in this week’s New Yorker magazine about the Syrian regime’s attack on doctors, medical personnel and civilians. We should warn listeners some parts of this interview might be tough to hear. I asked Ben Taub why the Syrian government is targeting these people.

TAUB: So the U.N. did a commission of inquiry into crimes happening in Syria, and they determined that the government forces deliberately target medical personnel to gain a military advantage. Specifically, denying treatment to wounded fighters and civilians. And they determined that this was a matter of policy. Essentially, by making it impossible for people to seek treatment when they were injured – even civilians and children and women who had nothing to do with the anti-government uprising but happened to live in areas that were under the control of opposition groups – they were being collectively punished. And, you know, it was a strategy to make life completely unbearable.

MCEVERS: A way to win the war.

TAUB: Exactly.

MCEVERS: And so how are people in these opposition-controlled areas. I mean, we’re talking about big swaths of Syria here. How are they getting health care? How is health care continuing?

TAUB: So a lot of doctors who wanted to treat patients but realized they couldn’t do it in the hospitals started setting up an underground medical network, completely covertly. They were working in – you know, doing complex surgeries for gunshot wounds in people’s kitchens.

And once the rebels took over large patches of territory those patches of territory included former government hospitals which then became rebel hospitals in many cases. And so then the challenge became getting the right number of supplies, the right kind of equipment into these places and then having simply a factor of having enough doctors who were qualified to carry out these surgeries.

And 95 percent of the doctors in Aleppo have left since the beginning of the war. And so you had for years basically medical students trying to cope with the worst kinds of war injuries having no idea how to treat them.

MCEVERS: Right, so you have this underground railroad of sorts of hospitals, right, this connected network of hospitals run basically by medical students inside Syria. And so international doctors get involved, international organizations like Medecins Sans Frontieres, Doctors Without Borders get involved. And you talked to one in particular. His name’s David Nott.

TAUB: Right.

MCEVERS: How did he get involved?

TAUB: So David Nott had been working in war zones for the last 20 years or so. He began with the Bosnian War. And ever since, he’d taken weeks or months out of each year to work in areas afflicted by conflict and natural disaster. And so he went into Syria and started running lecture courses inside the basements of the hospitals. And the medical students and the general surgeons who didn’t know how to cut open a chest and do heart surgery, who didn’t know how to operate on lungs that had been injured by shrapnel or bullets, they would all come to his evening lectures as the shooting relented when the sun went down. And they’d go through all the cases that day – who lived, who died and why they lived and why they died. And then as the evening went on, more airstrikes would rain down on the city and he’d get back to operating.

MCEVERS: There’s one family that was victim to one of these barrel bomb attacks that you write about. And it’s several siblings, right, who…

TAUB: Yeah.

MCEVERS: …Come into the hospital. It’s just, you know, horrible to read. I wonder if you could just read the last paragraph.

TAUB: Yeah.

MCEVERS: And this is, you know, Dr. David Nott describing to you what was happening in that.

TAUB: Yeah, and in fact he has this on video. But after these five siblings came into the ward and they had really truly horrific injuries, the stuff of nightmares. So this boy came into the ward, you know, in loosely-connected pieces. He had no pelvis, and he was still alive. He was looking around the room silently, unable to make a noise. So (reading) the boy was dying. There was no treatment. He had lost too much blood, and his lungs had filled with concrete particles. Nott held his hand for four agonizing minutes. All you can do is just comfort them, he told me. I asked him what that entailed since the hospital had exhausted its supply of morphine. He began to cry and said all you can hope is that they die quickly.

MCEVERS: Dr. Nott, it’s – I’m sorry. OK. Let’s take a minute.

TAUB: Yeah. The Syrians that are still there – David hasn’t – David Nott hasn’t been back for more than a year and a half. He was – you know, he had a close call with abduction on his last…

MCEVERS: Yeah.

TAUB: …His last visit. But the Syrians that are still working there – there’s one in particular that he checks in with routinely, a young medical student who was in his fourth year of his residency in plastic surgery when the revolution began. And he can’t continue his qualifications. He’s just been dealing with trauma injuries ever since. I talked to this guy, his name is Abu Waseem. I talked to him last week and it was so hard because, you know, he – last week, in this month alone, four hospitals have been bombed in Aleppo.

And every time I had to call back and check with Abu Waseem to make sure that he was still alive because we weren’t done fact-checking the piece.

MCEVERS: Oh God.

TAUB: And (crying).

MCEVERS: Take your time.

TAUB: …And on the most recent one, he was fine. And in fact, all of the other doctors were also fine in the facility, even though it was completely destroyed. I asked – he doesn’t leave. He could leave Aleppo, and he could go to Turkey. But it would be permanent because he doesn’t have a passport. He has to get smuggled out. But he hasn’t done that, and he’s not going to.

There have been 700 medical personnel killed in Syria. And his friends keep dying around him. And I asked him, why don’t you leave? Why are you staying? And he just replied, it’s my duty. He knows – you know, he deals with hundreds of cases every month that are continuing to be the worst kinds of injuries, and he sees it as his duty to treat as many of them as he can before he gets killed.

MCEVERS: Ben Taub, thank you very much for being with us today and for your work.

TAUB: Thank you.

MCEVERS: Reporter Ben Taub of The New Yorker. His report in this week’s magazine is called “The Shadow Doctors.”

Copyright © 2016 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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Health June 20, 2016

Hospitals Face New Obstacles In Wake Of Mass Shootings

NPR’s Audie Cornish speaks with Dr. John Hick about obstacles hospitals and emergency responders encounter after shootings.

Transcript

AUDIE CORNISH, HOST:

In any situation like Orlando, there are a lot of what-ifs – questions about whether lives might have been saved if only something different had happened. The National Academy of Medicine has been trying to find some answers by studying recent mass shootings, including those at Virginia Tech, Boston and Aurora, Colo.

One of the authors of the Academy’s latest discussion paper is John Hick. He’s the medical director for emergency preparedness at Hennepin County Medical Center. That’s in Minneapolis. We reached him at the hospital, and I asked him about problems emergency response teams face when they arrive at the scene of a shooting.

JOHN HICK: I think too many times the active shooter incidents have been scenes where EMS has not been allowed to enter until law enforcement is content that the threat has been completely neutralized and that the entire building has been swept. And during that time, people die. And so we need to make sure that we get EMS into areas that are relatively secure – what we call a warm zone – as soon as it seemed reasonable by law enforcement to do that. But that involves a couple things.

Law enforcement’s priority usually is to get in and get after an active shooter as quickly as possible and engage them and neutralize them or at least contain them so that they can’t keep moving around a building. In the process, though, they have to be secondarily thinking about, where did I see victims, and can we get the responding officers behind me to secure entries so that EMS can get those victims out of there relatively safely and without having to worry about additional, you know, immediate threat?

CORNISH: Right, so traditionally the move has been to create a kind of staging area, right?

HICK: Yep, exactly and bring everybody there and then kind of figure what we’re dealing with. And so the new paradigm is to gain access as quickly as possible and get those transports done as quickly as possible, not taking time to do much on the scene.

CORNISH: Given what you’ve said, that means that in the past, hospitals were sort of waiting, I guess, for a semi-orderly entrance of victims – right? – even if there were a lot of them. What does it mean now?

HICK: So I think historically we have, you know, expected or at least hoped that EMS would bring the most injured victims to us first, and then we could devote the most resources to the people that needed it the most. But the reality of most incidents is that you will wind up getting people kind of by private car. And especially if our priority is on transporting patients as we find them from these type of scenes, you may not get the most critical first.

CORNISH: So quite literally knowing that you’re not seeing the worst of the worst injuries as there coming in.

HICK: Exactly. So you don’t know what you don’t know at that point, and there may be worse yet to come, that there’s not going to be a prioritization exactly by EMS about – these are the worst cases that we found. It’s just, these are the first cases we found, and here they are.

CORNISH: This has probably been a very dark bit of research for you. I know you are director of emergency services there. For you, what lesson are you learning about these last few years?

HICK: I think the main thing for me is that you really have to examine your surgical response. So just looking, you know, at the resources kind of top to bottom and figuring out from a space, from a staff, from a stuff standpoint, do I have the things that I need in place that if something like this goes down, you know, are we going to be prepared?

And the answer is, you know, we’re much better prepared. Fortunately or unfortunately, we’ve had to become better prepared for these type of events in the last five to ten years. But I think, you know, every trauma center in the U.S. is taking a very hard look at these type of incidents and really trying to improve their preparedness for them.

CORNISH: Dr. John Hick, thank you so much for speaking with us.

HICK: Thank you.

CORNISH: John Hick is one of the authors of a recent paper on responses to mass shootings from the National Academy of Medicine.

Copyright © 2016 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by Verb8tm, Inc., an NPR contractor, and produced using a proprietary transcription process developed with NPR. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

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Health June 18, 2016

Canada Legalizes Physician-Assisted Dying

Canadian Prime Minister Justin Trudeau, shown here in Japan last month, has publicly backed legislation on physician-assisted suicide.

Canadian Prime Minister Justin Trudeau, shown here in Japan last month, has publicly backed legislation on physician-assisted suicide. Koji Ueda/AP hide caption

toggle caption Koji Ueda/AP

After weeks of debate, Canadian lawmakers have passed legislation to legalize physician-assisted death.

That makes Canada “one of the few nations where doctors can legally help sick people die,” as Reuters reports.

The new law “limits the option to the incurably ill, requires medical approval and mandates a 15-day waiting period,” as The Two-Way has reported.

The Canadian government introduced the bill in April and it passed a final Senate vote Friday. It includes strict criteria that patients must meet to obtain a doctor’s help in dying. As we have reported, a patient must:

  • “Be eligible for government-funded health care (a requirement limiting assisted suicides to Canadians and permanent residents, to prevent suicide tourism).”
  • “Be a mentally competent adult 18 or older.”
  • “Have a serious and incurable disease, illness or disability.”
  • “Be in an ‘advanced state of irreversible decline,’ with enduring and intolerable suffering.”

As a safeguard, the law also requires that two independent witnesses be present when the patient signs a request for a doctor-assisted death.

A headed debate emerged over whether to require patients to prove that their “natural death has become reasonably foreseeable,” as the law reads.

Some lawmakers wanted to broader eligibility criteria that would include degenerative diseases, Reuters reports. “The key amendment that senators had been pushing for was to broaden the criteria for who qualifies for assisted dying,” reporter Dan Karpenchuk tells our Newscast unit. “They had insisted that it includes suffering Canadians who are not close to death.”

Ultimately, the senators dropped the amendment and adopted the bill with the more restrictive language – but Dan says the law will likely be challenged in courts. He adds:

“Some senators say [the law] is immoral, adding that there could be people facing years of excruciating suffering, but not yet close to death. And in launching expensive legal challenges many who are desperately ill and their families could go broke from court cases to determine if they have the right to an assisted death.”

Justice Minister Jody Wilson-Raybould had opposed the broader criteria, arguing that it would mean that patients with “any serious medical condition, whether it be a soldier with PTSD, a young person with a spinal cord injury, or a survivor whose memory is haunted with memories of sexual abuse” could be eligible for a physician-assisted death, as CBC reports.

After the legislation was passed, Wilson-Raybould said in a statement with the Attorney General and Minister of Health that it “strikes the right balance between personal autonomy for those seeking access to medically assisted dying and protecting the vulnerable.”

Canada’s Prime Minister Justin Trudeau had backed the legislation, which was introduced after Canada’s Supreme Court struck down a ban on doctor-assisted suicide last year.

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Health June 17, 2016

A Surgeon's Bloodstained Shoes Have Become A Symbol Of Orlando's Defiance

Dr. Joshua Corsa, a senior surgical resident at the Orlando Regional Medical Center, operated on victims of the Orlando gay nightclub shooting.

Dr. Joshua Corsa, a senior surgical resident at the Orlando Regional Medical Center, operated on victims of the Orlando gay nightclub shooting. Abe Aboraya/WMFE hide caption

toggle caption Abe Aboraya/WMFE

A pair of bloodstained shoes has become a symbol of Orlando’s defiance in the face of extraordinary trauma.

The shoes belong to Joshua Corsa, a senior surgical resident at the Orlando Regional Medical Center. They were almost brand new when the hospital received scores of victims of the mass shooting attack on a gay nightclub Sunday morning that left 49 people dead.

Corsa tells reporter Abe Aboraya of member station WMFE that he worked in packed operating rooms for some 30 hours. He finally got a chance to try to sleep — unsuccessfully, he says — and returned to work on Monday morning.

There to meet him were his bloodstained shoes from the previous day — and “that’s when a lot of the enormity of it kind of struck me … that tangible reminder,” he says.

Corsa posted this image of his bloodstained shoes on Facebook Monday morning after hours of caring for Orlando shooting victims.

Corsa posted this image of his bloodstained shoes on Facebook Monday morning after hours of caring for Orlando shooting victims. Courtesy of Joshua Corsa hide caption

toggle caption Courtesy of Joshua Corsa

Corsa then sat down and wrote a Facebook post reflecting on the events, which was shared hundreds of thousands of times:

“These are my work shoes from Saturday night. They are brand new, not even a week old. I came to work this morning and saw these in the corner [of] my call room, next to the pile of dirty scrubs.

“I had forgotten about them until now. On these shoes, soaked between its fibers, is the blood of 54 innocent human beings. I don’t know which were straight, which were gay, which were black, or which were Hispanic.

“What I do know is that they came to us in wave upon wave of suffering, screaming, and death. And somehow, in that chaos, doctors, nurses, technicians, police, paramedics, and others, performed super-human feats of compassion and care.

“This blood, which poured out of those patients and soaked through my scrubs and shoes, will stain me forever. In these Rorschach patterns of red I will forever see their faces and the faces of those that gave everything they had in those dark hours.

“There is still an enormous amount of work to be done. Some of that work will never end. And while I work I will continue to wear these shoes. And when the last patient leaves our hospital, I will take them off, and I will keep them in my office.

“I want to see them in front of me every time I go to work.

“For on June 12, after the worst of humanity reared its evil head, I saw the best of humanity … come fighting right back. I never want to forget that night.”

The powerful post has since been made private. You can listen to Corsa read it here:

He says he is still wearing the shoes — now wrapped in shoe covers, because of the blood.

To him, they serve as a reminder, “not of the terrible things that happened, but of the good that came from them … how the city came together, how the hospital came together.”

He adds: “These patients are some of the nicest people I’ve ever met and I think it’s good to have a tangible reminder to look at every day, remind yourself that there’s still good out there even in the face of this.”

Corsa started his medical training as an Army medic, an experience that he says “helped me to stay somewhat calm” as he treated the victims of the deadly attack.

He adds that he hasn’t had time to process the events. “You almost enjoy the work in that it keeps you from having to sit down and deal with it,” he says. “You’re able to focus on the patients, which is what’s truly important.”

Corsa says that the situation at the hospital is becoming calmer. “We finally started a turnaround where it’s less damage control and more starting to think long term, down the road,” he says.

And five days after he posted the viral photo, he is still vowing to continue wearing the shoes until the last victim of the Pulse nightclub shooting is discharged.

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