Category Archives: hospitals

Not a mosquito bite – Cover up in Trinidad and Tobago?

We all depend on honest reporting of cases of pandemic flu to alert us that a more virulent virus has evolved. Unfortunately, many politicians view H1N1 deaths as “bad press” that they’d rather not acknowledge. This creates a clear conflict of interest for public health authorities who are usually appointed by politicians. Do they do what is best for the public or what their politician-bosses tell them to do? Sadly, it’s usually the latter.

This dangerous drama may be playing out in Trinidad and Tobago.

From Trinidad Express, December 17, 2009:

THE NUMBER of swine flu-related deaths is continuing to rise, but the Ministry of Health refuses to come clean about the pandemic, says Opposition MP Subhas Panday.

Addressing members of the media at a briefing at the Office of the Leader of the Opposition in Port of Spain yesterday, Panday insisted that, since October, at least 18 people have died at the San Fernando General Hospital from flu-like symptoms, but the Health Ministry has yet to say why or even confirm what their blood samples show.

’These people died from swine flu, but the ministry is not saying that and they have the doctors fighting to save their jobs because they afraid to come out and tell anybody what really happening at that hospital,’ he said.

Panday admitted that he did not know what was happening at the other health facilities, but the death of his niece provided him with the opportunity to get inside the San Fernando General Hospital and question medical officials about the pandemic.

’Nobody wants to talk, they did not even want to talk to me. But I went in there, I went through the system and I asked them everything about this,’ he said while waving around the list he acquired of people who died since October.

The list, which predominantly names people of East Indian descent between the ages of 22 and 52, outlines the age, area and cause of death. And while it was not an official document, Panday said he was able to get the list legally through the Ministry of Legal Affairs.

[snip]

The doctors have not chosen me as their mouthpiece, but people in this country have a right to know … they listing all these deaths as pneumonia. This is not like a mosquito bite. How could so many people die in one month from the same symptoms?’

Of course, the government denies that it is covering up anything.

From the Trinidad Express, December 17, 2009

Medical Director of San Fernando General Hospital, Dr Anand Chatoorgoon, said last night that the hospital does not have information that 18 patients died at the institution from swine flu.

[snip]

Chatoorgoon told the Express that ’deaths from bronchial pneumonia as shown on Mr Panday’s list are not necessarily caused by the swine flu’.

He said, ’All patients showing symptoms of the swine flu are admitted to the institution. In some cases, they are sent to the ICU when they are having a breathing problem.’

Chatoorgoon noted that ’it is customary for patients to develop pulmonary embolism simply because they are confined to a bed and blood clots could develop’.

He added, ’The blood tests taken from patients are sent directly to the Ministry of Health in keeping with PAHO’s policy.’

Without the results of real time PCR tests, it is hard to know what is going on in Trinidad and Tobago. However, if an unusually large number of people younger than 65 are dying of a respiratory disease, it is highly likely that pandemic flu is the cause.

Trinidad and Tobago is a small country (population 1,339,000). The 18 deaths are all from one hospital. If there are more deaths in other hospitals, it is important that these be reported as well. If an unusually large number of people are dying, we need to know. It may be the only warning we get that a more dangerous virus is circulating.

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A thousand Memorial Hospitals now – What will your number be?

We have often heard the slogan: “A pandemic will be like a thousand Katrinas at the same time”.  But what does this mean? Concretely, it means that there won’t be enough essential services for those who need them. We have already seen some evidence of this with overly restrictive Tamiflu prescription practices and clinics that run out of vaccine before pregnant women, who have been waiting for hours, can get any. Emergency rooms are overflowing in many areas and ICUs are starting to fill up. What can we expect in the future, if we are using Katrina as guide? The worst case scenario is a Memorial Hospital event, or perhaps more properly, a thousand Memorial Hospital type events at the same time.

ProPublica has an outstanding investigative piece on what happened at Memorial Hospital in New Orleans during the Katrina aftermath. I highly recommend reading the whole article. Below, I include some excerpts:

The smell of death was overpowering the moment a relief worker cracked open one of the hospital chapel’s wooden doors. Inside, more than a dozen bodies lay motionless on low cots and on the ground, shrouded in white sheets. Here, a wisp of gray hair peeked out. There, a knee was flung akimbo. A pallid hand reached across a blue gown.

Within days, the grisly tableau became the focus of an investigation into what happened when the floodwaters of Hurricane Katrina marooned Memorial Medical Center in Uptown New Orleans. The hurricane knocked out power and running water and sent the temperatures inside above 100 degrees. Still, investigators were surprised at the number of bodies in the makeshift morgue and were stunned when health care workers charged that a well-regarded doctor and two respected nurses had hastened the deaths of some patients by injecting them with lethal doses of drugs. Mortuary workers eventually carried 45 corpses from Memorial, more than from any comparable-size hospital in the drowned city.

Investigators pored over the evidence, and in July 2006, nearly a year after Katrina, Louisiana Department of Justice agents arrested the doctor and the nurses in connection with the deaths of four patients. The physician, Anna Pou, defended herself on national television, saying her role was to ‘‘help’’ patients ‘‘through their pain,’’ a position she maintains today. After a New Orleans grand jury declined to indict her on second-degree murder charges, the case faded from view.

[snip]

It is now evident that more medical professionals were involved in the decision to inject patients — and far more patients were injected — than was previously understood. When the names on toxicology reports and autopsies are matched with recollections and documentation from the days after Katrina, it appears that at least 17 patients were injected with morphine or the sedative midazolam, or both, after a long-awaited rescue effort was at last emptying the hospital. A number of these patients were extremely ill and might not have survived the evacuation. Several were almost certainly not near death when they were injected, according to medical professionals who treated them at Memorial and an internist’s review of their charts and autopsies that was commissioned by investigators but never made public.

[snip]

The full details of what Pou did, and why, may never be known. But the arguments she is making about disaster preparedness — that medical workers should be virtually immune from prosecution for good-faith work during devastating events and that lifesaving interventions, including evacuation, shouldn’t necessarily go to the sickest first — deserve closer attention. This is particularly important as health officials are now weighing, with little public discussion and insufficient scientific evidence, protocols for making the kind of agonizing decisions that will, no doubt, arise again.

[snip]

…doctors and nurses decided that the more than 100 remaining Memorial and LifeCare patients should be brought downstairs and divided into three groups to help speed the evacuation. Those who were in fairly good health and could sit up or walk would be categorized ‘‘1’s’’ and prioritized first for evacuation. Those who were sicker and would need more assistance were ‘‘2’s.’’ A final group of patients were assigned ‘‘3’s’’ and were slated to be evacuated last. That group included those whom doctors judged to be very ill and also, as doctors agreed the day before, those with D.N.R. orders.

Though there was no single doctor officially in charge of categorizing the patients, Pou was energetic and jumped into the center of the action, according to two nurses who worked with her. Throughout the morning, makeshift teams of medical staff and family members carried many of the remaining patients to the second-floor lobby where Pou, the sleeves of her scrubs rolled up, stood ready to receive them.

In the dim light, nurses opened each chart and read the diagnoses; Pou and the nurses assigned a category to each patient. A nurse wrote ‘‘1,’’ ‘‘2’’ or ‘‘3’’ on a sheet of paper with a Marks-A-Lot pen and taped it to the clothing over a patient’s chest. (Other patients had numbers written on their hospital gowns.) Many of the 1’s were taken to the emergency-room ramp, where boats were arriving. The 2’s were generally placed along the corridor leading to the hole in the machine-room wall that was a shortcut to the helipad. The 3’s were moved to a corner of the second-floor lobby near an A.T.M. and a planter filled with greenery. Patients awaiting evacuation would continue to be cared for — their diapers would be changed, they would be fanned and given sips of water if they could drink — but most medical interventions like IVs or oxygen were limited.

Pou and her co-workers were performing triage, a word once used by the French in reference to the sorting of coffee beans and applied to the battlefield by Napoleon’s chief surgeon, Baron Dominique-Jean Larrey. Today triage is used in accidents and disasters when the number of injured exceeds available resources. Surprisingly, perhaps, there is no consensus on how best to do this. Typically, medical workers try to divvy up care to achieve the greatest good for the greatest number of people. There is an ongoing debate about how to do this and what the ‘‘greatest good’’ means. Is it the number of lives saved? Years of life saved? Best ‘‘quality’’ years of life saved? Or something else?

[snip]

Pou and her colleagues had little if any training in triage systems and were not guided by any particular triage protocol.

[snip]

On a seventh-floor hallway at LifeCare, Angela McManus, a daughter of a patient, panicked when she overheard workers discussing the decision to defer evacuation for D.N.R. patients. She had expected her frail 70-year-old mother, Wilda, would soon be rescued, but her mother had a D.N.R. order. ‘‘I’ve got to rescind that order,’’ Angela begged the LifeCare staff. She says they told her that there were no doctors available to do it.

[snip]

By Wednesday afternoon, Dr. Ewing Cook was physically and mentally exhausted, filthy and forlorn.

[snip]

Morphine, a powerful narcotic, is frequently used to control severe pain or discomfort. But the drug can also slow breathing, and suddenly introducing much higher doses can lead to death.

[snip]

Doctors, nurses and clinical researchers who specialize in treating patients near the ends of their lives say that this ‘‘double effect’’ poses little danger when drugs are administered properly. Cook says it’s not so simple. ‘‘If you don’t think that by giving a person a lot of morphine you’re not prematurely sending them to their grave, then you’re a very naïve doctor,’’ Cook told me when we spoke for the first time, in December 2007. ‘‘We kill ’em.’’

In fact, the distinction between murder and medical care often comes down to the intent of the person administering the drug. Cook walked this line often as a pulmonologist, he told me, and he prided himself as the go-to man for difficult end-of-life situations. When a very sick patient or the patient’s family made the decision to disconnect a ventilator, for example, Cook would prescribe morphine to make sure the patient wasn’t gasping for breath as the machine was withdrawn.

Often Cook found that achieving this level of comfort required enough morphine that the drug markedly suppressed the patient’s breathing. The intent was to provide comfort, but the result was to hasten death, and Cook knew it. To Cook, the difference between something ethical and something illegal ‘‘is so fine as to be imperceivable.’’

[snip]

Cook sat on the emergency-room ramp smoking cigars with another doctor. Help was coming too slowly. There were too many people who needed to leave and weren’t going to make it, Cook said, describing for me his thinking at the time. It was a desperate situation and he saw only two choices: quicken their deaths or abandon them. ‘‘It was actually to the point where you were considering that you couldn’t just leave them; the humane thing would be to put ’em out.’’

[snip]

Despite how miserable the patients looked, Cook said, he felt there was no way, in this crowded room, to do what he had been thinking about. ‘‘We didn’t do it because we had too many witnesses,’’ he told me. ‘‘That’s the honest-to-God truth.’’

[snip]

Cook said he told Pou how to administer a combination of morphine and a benzodiazepine sedative. The effect, he told me, was that patients would ‘‘go to sleep and die.’’ He explained that it ‘‘cuts down your respiration so you gradually stop breathing and go out.’’ He said he believed that Pou understood that he was telling her how to achieve this. He said that he viewed it as a way to ease the patients out of a terrible situation.

[snip]

According to statements made to investigators by Steven Harris, the LifeCare pharmacist, Pou brought numerous vials of morphine to the seventh floor. According to investigators, a proffer from Harris’s lawyer said that Harris gave her additional morphine and midazolam — a fast-acting drug used to induce anesthesia before surgery or to sedate patients for medical procedures. Like morphine, midazolam depresses breathing; doctors are warned to be extremely careful when combining the two drugs.

Kristy Johnson, LifeCare’s director of physical medicine, said she saw what happened next. She told Justice Department investigators that she watched Pou and two nurses draw fluid from vials into syringes. Then Johnson guided them to Emmett Everett in Room 7307. Johnson said she had never seen a physician look as nervous as Pou did. As they walked, she told investigators, she heard Pou say that she was going to give him something ‘‘to help him with his dizziness.’’ Pou disappeared into Everett’s room and shut the door.

As they worked their way down the seventh-floor hallway, Johnson held some of the patients’ hands and said a prayer as Pou or a Memorial nurse gave injections. Wilda McManus, whose daughter Angela had tried in vain to rescind her mother’s D.N.R. order, had a serious blood infection. (Earlier, Angela was ordered to leave her mother and go downstairs to evacuate.) ‘‘I am going to give you something to make you feel better,’’ Pou told Wilda, according to Johnson.

[snip]

According to Memorial workers on the second floor, about a dozen patients who were designated as ‘‘3’s’’ remained in the lobby by the A.T.M. Other Memorial patients were being evacuated with help from volunteers and medical staff, including Bryant King. Around noon, King told me, he saw Anna Pou holding a handful of syringes and telling a patient near the A.T.M., ‘‘I’m going to give you something to make you feel better.’’ King remembered an earlier conversation with a colleague who, after speaking with Mulderick and Pou, asked him what he thought of hastening patients’ deaths. That was not a doctor’s job, he replied. Patients were hot and uncomfortable, and a few might be terminally ill, but he didn’t think they were in the kind of pain that calls for sedation, let alone mercy killing. When he saw Pou with the syringes, he assumed she was doing just that and said to anyone within earshot: ‘‘I’m getting out of here. This is crazy!’’ King grabbed his bag and stormed downstairs to get on a boat.

[snip]

The debate among medical professionals about how to handle disasters is intensifying, with Pou and her version of the Memorial narrative often at the center. At a conference for hospital executives and state disaster planners a few months ago in Chicago, she did not mention that she injected patients, saying that helicopters arrived in the afternoon of Thursday, Sept. 1, and ‘‘we were able to evacuate the rest.’’

Pou projected the booking photo from her arrest onto the screen as she argued for laws to shield health workers from civil and criminal liability in disasters.

Before delivering the keynote address, Pou participated in a panel on the ‘‘moral and ethical issues’’ that could arise if standards of care were altered in disasters. At one point, one of the panelists, Father John F. Tuohey, regional director of the Providence Center for Health Care Ethics in Portland, Ore., said that there are dangers whenever rules are set that would deny or remove certain groups of patients from access to lifesaving resources. The implication was that if people outside the medical community don’t know what the rules are or feel excluded from the process of making them or don’t understand why some people receive essential care and some don’t, their confidence in the people who care for them risks being eroded. ‘‘As bad as disasters are,’’ he said, ‘‘even worse is survivors who don’t trust each other.’’

This is a sensitive subject. I understand that some would prefer that it not be discussed. But we are rapidly approaching the point where health care workers will be having to make similar decisions to those made by the staff at Memorial Hospital in New Orleans after Katrina. The National Emergency that was declared on October 24, 2009 lays the legal groundwork for moving patients to “alternative locations”, imo. These sites, hospital tents, hotels or convention centers, are unlikely to have the same level of facilities that regular hospitals do. What will happen to patients who desperately need a ventilator, but none is available for them? What about patients who are “terminally weaned” from a ventilator? How will this be done?

We have heard a lot about the impact of closing the schools on the economy. We have not given as careful consideration to the consequences of allowing the infections to spread unchecked.

A thousand Memorial Hospitals will scar our souls.

Close the schools now!

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Preparing for mass casualties

Counting of pandemic flu cases indicates that the number of Americans becoming infected is now increasing at an exponential rate. This has started within the last two weeks. Because deaths usually lag infections by several weeks, we won’t see most of the deaths from this rise in infections until November, although we are already seeing indications of an increase of severely ill people and deaths.

We don’t know if the current exponential increase in pandemic cases in the US will continue or if it will be blunted by vaccine. However, given the minimal amount of vaccine that has been deployed thus far, it seems likely that we will see many more infected people in the immediate future. As many others have suggested, the ability of our health care system to handle the surge in severely ill people is extremely limited. The natural consequence of this is that life-saving treatments will need to be rationed. The natural consequence of that is planned killings.

From the New York Times, October 24, 2009:

Federal officials say the possibility that America’s already crowded intensive care units would be overwhelmed in the coming weeks by flu patients is small but they remain vigilant.

The triage plans have attracted little publicity. New York, for example, released its draft guidelines in 2007, offered a 45-day comment period, and has made no changes since. The Health Department made 90 pages of public comments public this week only after receiving a request under the state’s public records laws.

Mary Buckley-Davis, a respiratory therapist with 30 years experience, wrote to officials in 2007 that “there will be rioting in the streets” if hospitals begin disconnecting ventilators. “There won’t be enough public relations spin or appropriate media coverage in the world” to calm the family of a patient “terminally weaned” from a ventilator, she said.

State and federal officials defend formal rationing as the last in a series of steps that would be taken to stretch scarce resources and provide the best outcome for the public.

The suggestion by federal officials that the possibility that  ICUs overwhelmed by flu patients is “small” is ridiculous. There are already indications that some ICUs are becoming overwhelmed. ECMO, which results in a much better outcome than ventilators, is already being rationed. People who would benefit from it  are already being denied access.

But it can get worse.

Yesterday, President Obama declared a National Emergency with respect to the H1N1 pandemic. Partisans eagerly engaged in a distracting war of words about what this means. It does *not* mean martial law. But it does mean that many rights that people take for granted when receiving medical care may be taken away during the pandemic.

From President Obama’s Proclamation:

…I hereby declare that the Secretary may exercise the authority under section 1135 of the SSA to temporarily waive or modify certain requirements of the Medicare, Medicaid, and State Children’s Health Insurance programs and of the Health Insurance Portability and Accountability Act Privacy Rule throughout the duration of the public health emergency declared in response to the 2009 H1N1 influenza pandemic.

What does section 1135 of the Social Security Act specifiy? Here are some excerpts:

Secretarial Authority.—To the extent necessary to accomplish the purpose specified in subsection (a), the Secretary is authorized, subject to the provisions of this section, to temporarily waive or modify the application of, with respect to health care items and services furnished by a health care provider (or classes of health care providers) in any emergency area (or portion of such an area) during any portion of an emergency period, the requirements of titles XVIII, XIX, or XXI, or any regulation thereunder (and the requirements of this title other than this section, and regulations thereunder, insofar as they relate to such titles), pertaining to—

(1)(A) conditions of participation or other certification requirements for an individual health care provider or types of providers,

(B) program participation and similar requirements for an individual health care provider or types of providers, and

(C) pre-approval requirements;

(2) requirements that physicians and other health care professionals be licensed in the State in which they provide such services, if they have equivalent licensing in another State and are not affirmatively excluded from practice in that State or in any State a part of which is included in the emergency area;

(3) actions under section 1867 (relating to examination and treatment for emergency medical conditions and women in labor) for—

(A) a transfer of an individual who has not been stabilized in violation of subsection (c) of such section if the transfer arises out of the circumstances of the emergency;

(B) the direction or relocation of an individual to receive medical screening in an alternative location—

The contingency plans for a severe pandemic include transferring flu patients from hospitals to “alternative locations”. These may include tent hospitals, hotels or convention centers. I believe the National Emergency proclamation was intended to lay the legal groundwork for directing and relocating flu patients to such treatment centers.

The thing is, severely ill flu patients aren’t going to find ECMO or even ventilators at these “alternative locations”. They will be lucky if they receive morphine to ease their dying.

And all of this, because the government chose not to close the schools.

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President Obama declares a national emergency with respect to the 2009 H1N1 Influenza

Here is the text of the document (from Politico):

THE WHITE HOUSE

Office of the Press Secretary

For Immediate Release October 24, 2009

DECLARATION OF A NATIONAL EMERGENCY WITH RESPECT TO THE 2009 H1N1 INFLUENZA PANDEMIC

– – – – – – –

BY THE PRESIDENT OF THE UNITED STATES OF AMERICA

A PROCLAMATION

On April 26, 2009, the Secretary of Health and Human Services (the “Secretary”) first declared a public health emergency under section 319 of the Public Health Service Act, 42 U.S.C. 247d, in response to the 2009 H1N1 influenza virus. The Secretary has renewed that declaration twice, on July 24, 2009, and October 1, 2009. In addition, by rapidly identifying the virus, implementing public health measures, providing guidance for health professionals and the general public, and developing an effective vaccine, we have taken proactive steps to reduce the impact of the pandemic and protect the health of our citizens. As a Nation, we have prepared at all levels of government, and as individuals and communities, taking unprecedented steps to counter the emerging pandemic. Nevertheless, the 2009 H1N1 pandemic continues to evolve. The rates of illness continue to rise rapidly within many communities across the Nation, and the potential exists for the pandemic to overburden health care resources in some localities. Thus, in recognition of the continuing progression of the pandemic, and in further preparation as a Nation, we are taking additional steps to facilitate our response.

NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.) and consistent with section 1135 of the Social Security Act (SSA), as amended (42 U.S.C. 1320b-5), do hereby find and proclaim that, given that the rapid increase in illness across the Nation may overburden health care resources and that the temporary waiver of certain standard Federal requirements may be warranted in order to enable
U.S. health care facilities to implement emergency operations plans, the 2009 H1N1 influenza pandemic in the United States constitutes a national emergency. Accordingly, I hereby declare that the Secretary may exercise the authority under section 1135 of the SSA to temporarily waive or modify certain requirements of the Medicare, Medicaid, and State Children’s Health Insurance programs and of the Health Insurance Portability and Accountability Act Privacy Rule throughout the duration of the public health emergency declared in response to the 2009 H1N1 influenza pandemic. In exercising this authority, the Secretary shall provide certification and advance written notice to the Congress as required by section 1135(d) of the SSA (42 U.S.C. 1320b-5(d)).

IN WITNESS WHEREOF, I have hereunto set my hand this twenty-third day of October, in the year of our Lord two thousand nine, and of the Independence of the United States of America the two hundred and thirty-fourth.

BARACK OBAMA

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Truth or Consequences – How wrong information from the public health establishment is killing people

People place enormous confidence in public health authorities. Just the name “public health” suggests someone who is devoted to, well, the public’s health. Unfortunately, people who call themselves public health authorities oftentimes have undisclosed conflicts of interest which render their advice anything but healthy to the public. For example, when Dr. Frieden was New York City Health Commissioner, he served at the pleasure of Mayor Bloomberg. If he had done anything to displease the Mayor, he would have been out of a job. So, when he advised keeping the schools open, was he doing it because he believed that no children would get sick and die or because Mayor Bloomberg told him that closing the schools would hurt New York City’s economy? We don’t know what was in Dr. Frieden’s mind. But we do know what happened: children got sick and died. Similarly, when Dr. Frieden strongly argued (some would say ordered) that schools stay open throughout the United States this Fall, was he saying that because he thought kids would not get sick and die or was he doing this because the White House told him that closing schools would hurt the US economy? Again, while we don’t know what was in Dr. Frieden’s mind, we do know what happened: kids got sick and died.

Dr. Michael Osterholm warned of the negative consequences of a pandemic for many years. He founded the Center for Infectious Disease Research and Policy (CIDRAP) which is associated with the University of Minnesota. This had been a reliable source of information on influenza and pandemic issues. All of information on this site is free and open to the public. However, a new site, called CIDRAP Business Source, was created a couple of years ago. This appears to be a for-profit business aimed at top executives. Peter Sandman, a highly paid PR consultant, played a key role in its creation. Dr. Sandman’s list of customers is heavily weighted towards large multinationals. Access to CIDRAP Business Source costs $897 per year. They also hold very expensive conferences. How much money do Drs. Osterholm and Sandman receive from large multinationals? Its hard to know. Does receiving money from large multinationals while giving advice to the public on what protective steps to take during a pandemic constitute a conflict of interest? In my opinion, yes, it does.

One of the big concerns businesses have about a pandemic is absenteeism. If too many people stay home, businesses will lose money, perhaps a lot of money. However, social distancing is well-established as the most effective strategy to limit the spread of the virus before a vaccine is available. And closing schools is the most effective of all social distancing methods.

From Glass et al. (2006) Targeted Social Distancing Design for Pandemic Influenza. Emerging Infectious Diseases:

For influenza as infectious as 1957–58 Asian flu (≈50% infected), closing schools and keeping children and teenagers at home reduced the attack rate by >90%

From Markel et al (2007) Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic. JAMA.

Those cities acting in a timely and comprehensive manner appear to have benefited most in terms of reductions in total EDR [weekly excess death rate]. For example, St Louis, which implemented a relatively early, layered strategy (school closure and cancellation of public gatherings), and sustained these nonpharmaceutical interventions for about 10 weeks each, did not experience nearly as deleterious an outbreak as 36 other communities in the study …

But we really don’t need these studies to know that school closures and other forms of social distancing are the most effective methods for slowing the spread of the virus. When schools let out in the summer, the number of infections with H1N1 went down. As soon as schools started up again, the infections, and deaths, immediately increased. This should be obvious to anyone paying attention.

So, we have a clear conflict between what is best for business and what is best for public health. Businesses will make the most money if the schools remain open and people continue to work normal hours. The public health is best served by closing schools. This will increase absenteeism as at least one parent will have to stay home with the kids.

Dr. Osterholm was asked about school closings in an interview on NPR yesterday with Larry Abramson:

Dr. MICHAEL OSTERHOLM (School of Public Health, University of Minnesota): Children are going to transmit the influenza virus whether they’re in school or not.

ABRAMSON: Dr. Michael Osterholm of the University of Minnesota says school closings cause huge problems. That has to be balanced against the slim chance that a closing will slow the spread of the flu.

So who was Dr. Osterholm representing in this interview, the public’s health or the businesses that pay him? We don’t know. There is no indication in the interview that he disclosed his conflict of interest.

Public health authorities are apparently spending a lot of time thinking about the impact of school closures on business profits. Here’s a suggestion, spend a little bit of time reading the stories of the children who have died from this virus, most of whom got it in schools. You won’t find this list at the CDC or CIDRAP.

But you can find it at PFI_Forum where Homebody and many others have painstakingly combed through news reports to put it together, oftentimes with keyboards stained with tears: US Child Deaths – August and September

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Lifeboat in the ICU

We don’t hear much about what is going on in Australia or New Zealand any more. One might get the impression that they have only lightly been touched by the pandemic. But the truth is a bit different:

From Bloomberg, August 21, 2009:

Swine flu filled up Geoff Shaw’s intensive care unit in Christchurch, New Zealand, last month, forcing some surgeries to be canceled as the hospital struggled to cope. As winter moves to the Northern Hemisphere, health officials from Chicago to London brace for a similar overload.

“We have run out of bed space, we have run out of nurses,” Shaw, 47, said after working in the ICU and being on- call for 185 hours over 11 days. “There will be people who die because they were denied access to other treatments.”

The quote uses the future tense to describe denial of care, but is that accurate? Have any patients in Australia or New Zealand already died because of over-crowded ICUs? Is there any legal requirement that patients or their families be told that they are being allowed to die because there are not enough resources available to them due to the pandemic? Or are they simply never offered appropriate care and allowed to die?

If we are going to start throwing people off the lifeboat, the least we can do is tell them.

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Pandemic Update – August 3, 2009

There have been at least 1,497 deaths due to the new H1N1 virus. There have been at least 383 deaths in the US. 88 of these are in California. However, New York City appears to have ceased reporting its deaths. So, the actual number of deaths in New York State is unclear. The US has also stopped reporting the number of cases within the country and ceased reporting the number of deaths from each state.

There are now over 300 deaths in Argentina. The number of deaths appears to be increasing rapidly in Brazil and Chile. However, there are some indications that school closures are having a positive effect on the number of new cases in at least some South American countries.

In Australia, shortages of ICU beds has become acute. In some hospitals, there are no more available beds. One patient had to be flown 7 hours away by helicopter because there were no available beds in Cairns and Townsville. The first ever Relenza-resistant influenza virus has been identified in a new H1N1 sample in Australia.

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