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Lead Pipe Cinch

By KIM BELLARD

The term “lead pipe cinch” means something that is very easy or certain. Here’s two things that are lead pipe cinches: first, that ingesting lead, such as from the water or the air, is bad for us. It’s especially bad for children, whose cognitive abilities can be impaired. Second, that the Biden Administration’s latest proposal to reduce the lead in our drinking water is not going to accomplish that.

The new proposed rules would require that lead service lines be replaced within ten years; there are estimated to still be some 9.2 million such lines in the U.S. The trouble is, no one really knows how many there are or where exactly they are, making replacement difficult. So step two of the rules is for an initial inventory by next October. The “acceptable” parts per billion would drop from 15 to 10. Utilities would also have to improve tap sampling and consumer outreach.

“This is the strongest lead rule that the nation has ever seen,” Radhika Fox, the E.P.A.’s assistant administrator for water, told The New York Times. “This is historic progress.”

Erik Olson, an expert with the Natural Resources Defense Council is also hopeful, telling NPR: “We now know that having literally tens of millions of people being exposed to low levels of lead from things like their drinking water has a big impact on the population. We’re hoping this new rule will have a big impact.”

The EPA estimates the replacement will cost $20b to $30b over the next decade; the 2021 Infrastructure Act allocated $15b, along with $11.7b available from the Drinking Water State Revolving Fund. Of course, the cost will be much higher.

Chicago alone claims it will cost $10b to replace its estimated 400,000 lead pipes. The Wall Street Journal reports: “David LaFrance, CEO of the American Water Works Association, a trade group, said the total cost could “easily exceed” $90 billion. He said the average cost to replace a single lead service line is more than $10,000, nearly double the EPA’s estimate.”

If the federal funds aren’t enough, Ms. Fox says: “We strongly, strongly encourage water utilities to pay for it,” but you should probably expect customers will end up paying – or that some of those pipes won’t be getting replaced.

It’s not like any of this is catching us by surprise. You probably remember the 2014 scandal with the Flint (MI) water crisis, with all those people lining up for bottled water. You may not remember similar crises in Washington D.C., Newark (NJ), or Benton Harbor (MI). “The Washington, D.C., lead-in-water crisis was far more severe than Flint in every respect,” Yanna Lambrinidou, a medical anthropologist at Virginia Tech and co-founder of the Campaign for Lead Free Water, told AP.

The EPA issued a set of rules around lead pipes in 1991, but those rules were watered down, and little progress has been made since. Ronnie Levin, an EPA researcher at the times, also told AP: “But, you know, we’ve been diddling around for 30 years.”

Because, you know, that’s what we do, especially when fixing a problem costs too much money.

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What Would John Henry Rauch Do Today As A HIT Entrepreneur?

BY MIKE MAGEE

Health entrepreneurs today tend to give themselves very high grades, and seem surprised when their creations fall short of expectations due to a disconnect with funders or regulators with legal authority. But Medicine isn’t fair, and genius is not that common.

What other conclusion can you draw from the thousands of references and citations featuring Philadelphia physician Benjamin Rush and his wild ideas on how to heroically treat Yellow Fever in 1793, but likely never heard of Dr. John Henry Rauch. The former signed the Declaration of Independence but directly or indirectly contributed to many an unpleasant death.  The latter saved millions and helped the AMA and the AAMC find their way out of their post-Civil War professional wilderness.

Dr. Rauch’s career, its’ span and breadth, is startling and could well serve as a yardstick for medical imagineers today. Born in Lebanon, PA in 1828, he received his Medical Degree from the University of Pennsylvania, and then opened a practice in Burlington, Iowa. He was there in 1850 for the birthing of the Iowa State Medical Society, and with their encouragement published (just five years after Iowa achieved statehood) the epic “Medical and Economic Botany of Iowa” listing 516 species, fully 23% of the known flora of the state today.

Two decades later, he was onsite in Chicago from October 8-10, 1871, when 3.3 square miles of Chicago burned to the ground taking 300 souls with it, and managed the emergency medical aftermath for the city. By then he was all too familiar with conflagration and disaster, having earned the  imprimatur of lieutenant-colonel from the Union Army as assistant medical-director of the famed Army of Virginia during the Civil War.

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Let’s Do Public Health Better

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BY KIM BELLARD

Eric Reinhart, who describes himself as “a political anthropologist, psychoanalyst, and physician,” has had a busy month. He started with an essay in NEJM about “reconstructive justice,” then an op-ed in The New York Times on how our health care system is demoralizing the physicians who work in it, and then the two that caught my attention: companion pieces in The Nation and Stat News about reforming our public health “system” from a physician-driven one to a true community health one. 

He’s preaching to my choir. I wrote almost five years ago: “We need to stop viewing public health as a boring, not glamorous, small part of our healthcare system, but, rather, as the bedrock of it, and of our health.” 

Dr. Reinhart pulls no punches about our public health system(s), or the people who lead them:

…the rot in public health is structural: It cannot be cured by simply rotating the figureheads who preside over it. Building effective national health infrastructure will require confronting pervasive distortions of public health and remaking the leadership appointment systems that have left US public health agencies captive to partisan interests.

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Does Surviving The Plague Mean You Will Eventually Contract An Autoimmune Disease?

BY MIKE MAGEE

This Fall, I am teaching a 4-week course on “How Epidemics Have Shaped Our World” at the President’s College at the University of Hartford. It is, of course a timely topic, but also personally unnerving as we complete a third year under the shadow of Covid-19.

Where does one begin on a topic such as this? Yale historian, Frank M. Snowden, in his book “Epidemics and Society: From the Black Death to the Present”, made his intentions obvious. He would begin with the plaque. Why? His answer, “The word ‘plague’ will always be synonymous with ‘terror’”, and especially references:

Virulence: “It strikes rapidly, causing excruciating and degrading symptoms, and, if untreated, achieves a high case fatality rate (CFR)…of at least 50%.”

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Yes, Shit

By KIM BELLARD

The Conversation had a provocative article by Stanford professor Richard White about how America has a bad pattern of wasting infrastructure spending.  In light of the surprisingly bipartisan $1 trillion infrastructure bill recently passed by the Senate, this seems like something we should be giving some serious thought to. 

I’ll posit that we’re doing it again, by not adequately addressing the potential that our excreta, to be polite, offers to detect health issues, including but not limited to COVID-19. 

No shit: excrement can be an important tool in public — and personal — health. 

Take wastewater monitoring.  It is not a new concept – for example, to track polio – and has been used during much of the current pandemic.  According to the COVIDPoops19 dashboard, run by UC Merced’s School of Engineering, there are 55 countries with 89 dashboards monitoring the wastewater in 2,428 sites for signs of COVID-19.  The project even has its own Twitter handle (@CovidPoops19). 

According to Kaiser Health News, the University of California San Diego’s program has identified 85% of COVID-19 cases over the last year, using a largely automated monitoring system.  Infected people shed virus particles long before they show symptoms, allowing such programs to act as an early detection system. 

“University campuses especially benefit from wastewater surveillance as a means to avert COVID-19 outbreaks, as they’re full of largely asymptomatic populations, and are potential hot spots for transmission that necessitate frequent diagnostic testing,” said UCSD study first author Smruthi Karthikeyan, PhD.  Any university debating vaccine or mask mandates in order for students to return to campus should seriously be considering this kind of monitoring mechanism.

Similarly, the University of Minnesota has been sampling the wastewater of 65% of the state’s population, and has correctly predicted the rise and fall of each of the three waves in the last year.   North Carolina has also had success. 

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Make Some Microbe Friends

By KIM BELLARD

It’s the coolest story I’ve seen in the past few days: The New York Times reported how an Italian  museum cleaned its priceless Michelangelo sculptures with an army of bacteria.  As Jason Horowitz wrote, “restorers and scientists quietly unleashed microbes with good taste and an enormous appetite on the marbles, intentionally turning the chapel into a bacterial smorgasbord.”

And you just want to kill them all with your hand sanitizers and anti-bacterial soaps. 

The Medici Chapel in Florence had the good fortune to be blessed with an abundance of works by Michelangelo, but the bad fortune to have had centuries of various kinds of grime building up on them.  In particular, over time the corpse of one Medici “…seeped into Michelangelo’s marble, the chapel’s experts said, creating deep stains, button-shaped deformations…”

This is, I assume, why they tell you not to touch the art.

Scientists picked a bacteria — Serratia ficaria SH7, in case you’re taking notes – that ate the undesired grime without also eating the underlying marble.   It wasn’t hazardous to humans either and didn’t create spores that might go elsewhere.  “It’s better for our health,” one of the art restorers told NYT.  “For the environment, and the works of art.”

The technique was a success, allowing the sculptures to look like they did centuries ago. 

Using such bacteria to clean art has been around for at a decade, and not just for sculptures.  Perhaps more surprising is bacteria isn’t just cleaning art, it’s also creating it; the American Society for Microbiology hosts an annual Agar Art Contest. 

If you’re impressed by that, researchers are teaching bacteria to read, or at least to recognize letters.  That’s not all they might learn to do.  “For example, the framework and algorithm in our study can be used to facilitate the design of living therapeutics, such as targeted drug release systems based on engineered probiotic bacteria systems,” the researchers say.   

The thing is, we not only don’t know what microbes do, or could do, but we have only a vague understanding how they surround us.  That’s starting to change.  We’ve known for some time that each of us has a unique microbiome (including mycobiome!).  What we didn’t realize until recently was that each urban area has its own microbiome as well. 

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Public Health Nurses Once Again Asking, “What Are They Thinking?”

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Whitney Thurman
Karen Johnson

By KAREN JOHNSON and WHITNEY THURMAN

One recent Friday night, we huddled with our colleagues in the pouring rain at a movie theater parking lot– our cars packed with supplies for our mobile vaccine clinic— trying to find someone who wanted an extra dose of Pfizer’s COVID-19 vaccine before it expired. Five months ago, we would have been inundated with people desperate for that extra dose. But that has changed now that the most willing and able segments of the population have largely been vaccinated.

Amidst this backdrop of slowing vaccination rates in the U.S. and many miles to go before reaching all of those willing to be vaccinated, the CDC has released updated recommendations for mask wearing that we believe to be premature and contrary to the ethic and mindset of public health. Buoyed by mounting evidence supporting the effectiveness of vaccines, the CDC—  cheered by the Biden administration— gave fully vaccinated Americans the green light to ditch their masks. As fully vaccinated public health nurses who are as excited as anyone about the vaccines’ real-world effectiveness, we nonetheless find ourselves again asking: what are they thinking?

To be clear, we do not question the evidence showing that all COVID-19 vaccines currently approved in the U.S. are safe and effective. We also crave good news, hope, and allowing the bottom half of our faces to see the light of day. We have also appreciated the Biden administration’s commitment to “following the [biomedical] science” in pandemic policymaking. Our concerns lie with the timing of the recommendation; the lack of regard for social science demonstrating the importance of public policy in influencing community norms and human behavior; and the blatant disregard for health equity. That the nation’s preeminent public health institution has fallen prey to the individualistic mindset that typifies American society, as CDC director Dr. Rochelle Walensky stated herself on Sunday regarding this “science-driven individual assessment” of risk, is frustrating, to say the least.

Currently, only one-third of the U.S. has been fully vaccinated. The news media has been full of accounts of many sub-groups who stubbornly defend their right to refuse a COVID vaccine, but the majority of those in the U.S. who remain unvaccinated belong to communities that have been unable to access a vaccine due to difficulty navigating online appointment scheduling, inability to take time off of work, poorly translated informational resources, or being ineligible due to age restrictions or other medical contraindications. Universal mask-wearing has been a critical stopgap measure to protect these at-risk populations until the majority of Americans are vaccinated. The CDC’s recommendation is therefore not only premature: it sends the message to individuals and other governmental entities alike that we don’t need to care about our neighbors.

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Healthcare’s Million Dollar Blocks

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By KIM BELLARD

Since I first heard about them, I have been fascinated, and dismayed, by the concept of “million dollar blocks.”  For those of you unfamiliar with the term, it doesn’t refer to, say, Beverly Hills,  Chicago’s Gold Coast, or Manhattan’s Hudson Yards — areas where the wealthy congregate.  No, it refers to city blocks for which society spends over a million dollars annually to incarcerate residents of that block.

I, of course, have to think about the healthcare parallels.

The concept dates back many years, credited to Eric Cadora, now at Justice Mapping, and Laura Kurgan, a professor of architecture at Columbia University, where she is the Director of the Center for Spatial Research (CSR).  The power of the concept is to use data visualization to illustrate the problem. 

Here, for example, is CSR’s map of Brooklyn for prison spending:

CSR describes the findings as follows:

The maps suggest that the criminal justice system has become the predominant government institution in these communities and that public investment in this system has resulted in significant costs to other elements of our civic infrastructure — education, housing, health, and family. Prisons and jails form the distant exostructure of many American cities today.

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Now Is Not the Time to Forget About the AIDS Epidemic

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By SOMA SEN

I keep hearing the voices of colleagues and friends that have been part of the AIDS epidemic compare it to the current COVID-19 pandemic. In fact Dr. Kathy Creticos, Director of Infectious Disease at Howard Brown Health spoke about the politicization of both the pandemics. 

“Here we are in 2020 with this disease that kills people, that we don’t have any treatments for, that we really don’t understand the full manifestation and presentation biology of the virus,” Creticos said In the final segment of an interview with Contagion during International AIDS Society (IAS) AIDS 2020 Virtual Sessions. “We’re really dealing in the same situation as in the HIV epidemic.” 

Her words make me reflect on the levity with which the Raegan administration treated the AIDS epidemic and it’s parallel to the Trump administration’s treatment of the current pandemic. However, she makes an important distinction between the two when she says, “I think a lot of it has to do with the fact that COVID affects everybody, but HIV was certainly perceived as not affecting everybody.”

As an Asian American researcher with more than 15 years of experience in this area, whenever, I bring up the issue of the scourge of HIV/AIDS in our community, the common response both from inside and outside the community is “It’s not a problem in this community.” 

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Doctors and Democracy: Why Vote-By-Mail is Good Public Health

Rob Palmer
Josh Hyman
Isaac Freedman

By ROB PALMER, ISAAC FREEDMAN, and JOSH HYMAN

Suppose tomorrow you were informed that patients could no longer have medications delivered to their homes. Thus, in the midst of the worst pandemic in recent history, your patients would have to go to pharmacies to get essential medications. Undoubtedly, you’d be puzzled, wondering why your patients must needlessly put themselves and others in harms’ way to care for their own health. In light of the change, you might even debate if it’s worth the risk of getting your own medications. 

Thankfully, the common-sense practice of delivering medication to people’s homes seems here to stay. Yet many people will face a similar issue on election day this November: Fifteen states severely restrict who can vote by mail. In these states, millions of citizens will be forced to choose between exercising their right to vote and safeguarding their own health. 

So long as SARS-CoV-2 remains a threat, in-person voting is a public health crisis. Unless we want to risk a spike in new COVID-19 cases, with the concomitant deaths and strain on the healthcare system, it is critical to ensure that anyone who wants to vote in the upcoming general election can use mail-in voting. Indeed, a peer-reviewed study published in May found a statistically significant increase in COVID-19 cases in the weeks after the Wisconsin primary, specifically in counties with higher in-person votes per voting location. The study also found a decrease in COVID-19 cases in counties with the highest rates of absentee ballots. Unsurprisingly, the study’s authors exhort policy makers to “expand the number of polling locations or encourage absentee voting for future elections.”

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