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Wednesday, June 26, 2013

Pandemics, and humans as 'part of the main'

Life is stressful enough without anticipating the next great pandemic. There is the inevitable turmoil in the Middle East, North Korea's nuclear program, cancer-causing genes, the risk of calling your organization something that will make the IRS go through your underwear drawer, and doubts about the right amount of salt to eat. Really, that ought to be enough! We just don't need pandemic influenza or a new coronavirus to keep our adrenal glands stimulated.

But need them or not, folks, they are out there. And since we do, perennially, have plenty to worry about, it won't help much to add new worries to the list. But it might help a whole lot if we skipped worry altogether, and went directly to work. It might help a whole lot if forewarned produced collective responses that led more reliably toward forearmed. The basic requirement here, other than the allocation of some resources to support public health, is a willingness to think of ourselves in a context larger than ourselves. We'll come back to that.

First, a brief orientation to two of the more imminent threats about which we should not worry, but for which we should prepare.

The first is a new variant of avian influenza, H7N9. We have been fussing about pandemic flu for some years now, and have watched bird flu and swine flu contenders come and go without recent global catastrophe. That's great, and let's hope the trend continues, but dodging bullets for a while should not cause anyone to think that bullets are reliably innocuous. Only one needs to hit you.

The new flu strain has thus far infected only relatively few people, and only in isolated areas in China. But the mortality rate appears very high. The virus is different enough from recent flu strains that our immune systems would likely be caught largely unprepared by it were it to circulate globally. Those are the hallmarks of a pandemic threat. It doesn't mean this is the bullet we won't dodge; it just means it could be.

The coronavirus in the Persian Gulf seems to be a new infection in humans. Like the current avian flu strain, it has infected few people, and only in one part of the world. But it, too, has thus far killed a high percentage of those infected. I was in commentary on these topics, some of which has recently graced the pages of the New York Times, has placed an emphasis on inter-species transmission of germs. As noted, the new flu strain is avian, meaning it incubates in birds, poultry specifically in this case, before humans get involved.

The coronavirus, which has thus far infected fewer than 100 in the Persian Gulf region, but killed 55% of those infected, almost certainly originates in animals as well. A variety of bat is a prominent suspect at present.

The transmission of pathogens from animals to humans, either directly or through the intermediacy of other animals, produces zoonoses: human diseases of animal origin. Most of the great outbreaks of the modern era involve this mechanism. It is almost certainly true of HIV, and we know it to be true of influenza, including the infamous pandemic of 1918.

Various factors contribute to this risk. An ever-growing human population, our crowding into the last few enclaves of wild species, is an important issue, discussed too seldom and addressed too feebly. Our various assaults on the planet and climate are forces favoring genetic change in all species struggling to adapt, and in some cases, those adaptations may come at our peril. If nothing else, climate change invites the spread of microbes to areas from which cooler temperatures once barred them.

The world is ever smaller. Flu strains incubating in China can be in New York or Los Angeles or Washington, D.C., in the span of a day. This is a world in which an incurable bacterial disease, spread by a tiny insect native to Asia, decimates the citrus crop in Florida.

The concept that we, the planet, and all other species are in this together has a name: One Health. The One Health movement emphasizes the need to monitor the places where people and wild and domestic animals interact as potential sites of new human perils, and the need to manage ecosystems in ways that preserve their native health and balance. The movement, catalyzed a decade ago in large part by my friend and colleague, veterinarian Dr. Steve Osofsky, and his colleagues at the Wildlife Conservation Society, also emphasizes the importance of critical support for public health, including surveillance for emerging diseases, because we can either pay a bit now, or pay dearly later. And there is, of course, attention to the relentless growth of the human population as well.

We speak as if humans are somehow separate from all else: There is natural, and "man-made." But we are, inescapably, part of the main. We can pretend we are not all in this together. We can pretend there is us, and them. We can pretend that what we do to the planet will not come back to haunt us. We can pretend that there is space on earth for continued growth of the human population. We can pretend that the ills of other species are not our problem.

But reality is asserting itself ever more ominously. The only real defense we have against the looming perils is an end to all the pretense. For there is just one health, and there is just one game, and everyone's skin is in it.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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