by Robb Davis –
The Reuters news item was startling:
The WHO [World Health Organization] has convened a special meeting on Wednesday [March 21, 2012] to discuss whether the emergence of TB strains that seem to be resistant to all known medicines merits a new class definition of “totally drug-resistant TB”, or TDR-TB.
If so, it would add a new level to an evolution over the years from normal TB, which is curable with six months of antibiotic treatment, to the emergence of MDR-TB [multi-drug resistant], then extensively drug-resistant TB (XDR-TB).[1]
In the event, the WHO decided not to add this new class due to a lack of information. And while TB has declined over time in the US and is, according to the Centers for Disease Control[2] at its lowest level since 1953 (when national reporting began), it is on the rise in Great Britain (according to Reuters) and the extensively drug resistant strains are emerging in prisons and poor populations around the world.
It is important to note that the emergence of these strains is not part of the natural evolution of the TB bacterium but rather as the Reuters’ article notes:
What’s so frustrating about that progression, says Lucica Ditiu of the WHO’s Stop TB Partnership, is that all drug-resistant TB “is a totally man-made disease”.
Dr Ditiu is referring to improper or incomplete treatment regimens that help spawn drug resistant strains. TB treatments can take 6 months or more to complete and in simple terms, taking a partial treatment has the effect of “killing” the “weakest” forms of the bacterium and allowing the “strongest” to survive and propagate more resistant strains. Essentially, this is how drug resistant strains of a bacterium (or a parasite as in the case of falciparum malaria) are created.
TB is not (nor is malaria thank goodness!) a major concern for Davis or Yolo County at this time but, arguably, the practice of medicine for the “indigent” populations in Yolo County is creating risks that more resistant strains of bacteria will emerge in this county. Yolo County does have a health care program for our poor and homeless called YCHIP: Yolo County Healthcare for Indigents Program. This is not to say that YCHIP is a failure but it is being stretched and the treatment options for poor or indigent people are often not conducive to creating healthy outcomes and do run the risk of helping create drug resistant strains.
A recent case illustrates this point: “M”, a homeless individual living in Davis, contracted pneumonia in January of this year. M was fortunate enough to spend dry nights in one of the several shelters provided by a variety of providers in Davis, however, he spent his days trying to stay out of the inclement, wet weather. It is important to note that YCHIP recipients can access a clinic behind Sutter Hospital (Communicare) during the day without an appointment, and wait in hopes to be seen. Unfortunately M’s symptoms became severe after the clinic had closed down leaving him no other option than the Sutter Hospital emergency room one evening when he experienced a worsening cough and shortness of breath
At the ER he was diagnosed with pneumonia and given a partial course of treatment with a standard antibiotic. By partial course I mean that he was given the initial dose, which is enough for the initial first day of a 5-day treatment. He was also given a prescription to obtain the remaining 4 days of treatment at a pharmacy.
It is not common knowledge, perhaps, among Davis residents that there is NO pharmacy in Davis that currently accepts YCHIP client prescriptions. Rumors among homeless individuals are that the Communicare Clinic will soon be filling prescriptions). As a result, M, who was sick with pneumonia, was required to take two buses to arrive at the pharmacy at Raley’s in Woodland that does accept YCHIP client prescriptions.
There is a great deal wrong with this story and it leads to several questions: 1) Why would a health care provider provide part, but not all of an anti-biotic treatment knowing that the use of partial treatments can lead to drug resistant strains of bacteria? 2) What if M had been too sick or lacked the resources to take the bus to Woodland? 3) Why has there been no pharmacy in Davis for YCHIP clients for several years?
Discussions with homeless individuals reveal that the experience of M is not unusual. In addition, any poor or homeless individuals in our community can relate stories of not only walking significant distances to get to a health care clinic and, at best, hoping to be seen only then needing to take buses to the Woodland pharmacy while seriously ill in order to obtain appropriate medications.
A few issues in this story should concern us all. While some may question the value of the YCHIP “welfare” program believing that homeless (especially!) populations find themselves in their situation because of bad choices or various addictions, we should keep in mind that drug resistant strains that can emerge with the inappropriate and partial treatment practices described above affect all of us. Say what you will about homeless individuals (and I have heard a great deal that is disturbingly dehumanizing of this diverse group of human beings), their health, or lack thereof, is tied to your own. In the end, caring about the appropriate use of medications by the poor (or the rich for that matter) has nothing to do with empathy for their plight and everything to do about self-interest.
You might say that “M’s” case is a single anecdote and an aberration. Perhaps it is. But not according to the many poor and homeless individuals with whom I interact on a daily basis. As a community we can’t afford to be ill informed about the treatment options available to our poor neighbors. This is not a call for any particular form of health care but rather a plea for us to acknowledge the need for more community conversations about how health care is dispensed in our County. I am talking about primary health care here-the basic level of care that helps people, should they choose or need to access the system, deal with regularly occurring illnesses like acute respiratory infections, skin infections and food borne illnesses, to say nothing of the complications of their untreated mental health.
Robb Davis
First I would like to thank you for the timely and thoughtful article. I would like to share one initial thought I had after reading it.
“You might say that “M’s” case is a single anecdote and an aberration. “
While “M’s” case is an anecdote, it is far from an aberration. In my now more than thirty years in medicine, I have seen many people come in and out of regular health care based on whether or not they are employed or whether their job provides, or pays enough, for them to buy their own health care insurance.
People that I speak with across the political spectrum seem to agree that there is a role for the federal government in protection on the population from outside military threat. It is interesting to me that many do not seem to see any role for the government in terms of protection from internal, natural biological threat. Given the nature of epidemics which are capable of devastating a population as efficiently as any military force, we ignore other threats to the health of individuals and to our society as a whole at our own peril. Conditions that we allow to exist as a society, homelessness, inavailability of appropriate medical care and medications, added to those we cannot affect (the existence of antibiotic resistant strains of bacteria, the ease of world wide travel) are a major risk and one we are incredibly ill prepared to address.
During the recession, I have seen public health resources gutted due to lack of financial resources in both Yolo and Sacramento counties.
The services that have been devastated are precisely those that are most likely to provide early detection of developing public health risks.
Public health nurses (numbers cut in half in Yolo County), school nurses, home health care aids.
From many years in medicine, I can clearly state that access to adequate health care is a societal as well as an individual problem and should be addressed as such. If this can be adequately addressed through the public sector/marketplace, fine. However, I see little evidence that our system of private insurance has so far even admitted that the problem exists let alone developed a plan for addressing it. We need a radically different approach whether public or private. Unfortunately what I continue to see in medicine is squabbling and positioning to protect ones own financial best interest.
We have no difficulty mouthing patriotic phrases and talk of shared sacrifice when it comes to military threat, but seem content to fall back on our every man for himself mindset when it comes to health care. We do this at our own risk, as individuals, and as a society.
Oh good grief – this seems to me to be a simple solution. The clinic should have given the homeless person the whole prescription rather than just part of it – bc it will be cheaper even for the clinic in the long run. If the homeless person is given only one day’s worth of an antibiotic, the chances are good he may not go get the rest of the prescription for whatever reason, and then be right back in the clinic a week or two later for more treatment. Wouldn’t it have been cheaper just to dispense the full regimen of antibiotics (relatively inexpensive compared to another doctor visit or hospitalization for the now out of control pneumonia) in the first place? Or am I missing something here?
Would the homeless person sell the full regimen of drugs instead of taking them? I’m thinking that the protocol to dispense partical doseages might have something to do with this concern, and/or the concern that the drugs can be stolen or lost given the patient does not have a place to store and protect them.
I think the bigger problem is the lack of a pharmacy that serves YCHIP patients. Here we are the most liberal city on the planet and yet we don’t allow the development of business that can serve the needy.
[i] we don’t allow the development of business that can serve the needy.[/i]
There are, what, five pharmacies in Davis? More? Why are “we” responsible for the fact that Rite-Aid, CVS, and even Kaiser’s pharmacy won’t accept YCHIP?
I don’t know Don. Why do the Woodland pharmacies serve YCHIP recipients but not the Davis pharmacies?
I’ve had conversations with prominent Davisites that claim they are the “most liberal on the planet”, but then complain about the community church plan to expand their program to feed the homeless because it will bring more of “these people” to the downtown area.
I have my Davis hypocrite meter on and the lack of YCHIP service is causing it to beep loudly.
Elaine
I completely agree with you that in the case of “M” the solution would appear to be obvious. Just give him a full course of the medication.
However, it may not be quite that easy.
1) Not all clinics or even small hospitals have fully stocked outpatient pharmacies open 24/7. The “single day” dose he got may have been administered intramuscularly or by IV and the appropriate oral medication may not have been available.
2) If this was a simple case of pneumonia, giving a five day course of antibiotics all at once is reasonable. But this would not be the case if he were diagnosed with something more serious such as a multiply drug resistant form of tuberculosis requiring prolonged and complicated medical regimens. Until recently, most counties had outreach workers whose job was to ensure that such patients received and took their medication.
In Sacramento and Yolo counties, adequate support in these positions is largely a thing of the past.
Jeff and Don
“Why are “we” responsible for the fact that Rite-Aid, CVS, and even Kaiser’s pharmacy won’t accept YCHIP?”
I do not know why any of these pharmacies do not accept YCHIP. But since these, with the exception of Kaiser, are for profit companies, I suspect it has more to do with their assessments of profitability, or lack there of, than any concern they might have about street resale,loss , or theft of medications. Especially in a case like this since antibiotics would have essentially no street resale value.
I am unaware of any evidence to support the notion that “we” as a liberal community are in any way keeping “business” as represented by the drug stores from “serving the needy”. If you have any evidence supporting this claim, I would be very interested to see it.
I believe there is a new program for reduced cost of prescriptions which is accepted at Davis pharmacies. [url]http://www.davisenterprise.com/health-news/new-program-cuts-prescription-drug-costs-for-yolo-residents/[/url]
To medwoman: Thanks for the fuller explanation. And I agree that antibiotics would have no street value…