Let's Do Public Health Better

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.

Credit: University of Washington School of Public Health

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.

He notes the “gradual medicalization” of public health; every director of the CDC since 1953 has been a physician, despite the oft-cited fact that medical care only accounts for perhaps 10-20% of the factors that affect our health. “Clinical reasoning, ‘ he says, “is not only not the population-level logic of public health; it is frequently antithetical to it.”

As a result, Dr. Reinhart fears: “The marginalization of non-biomedical knowledge within public health administration and the corresponding elevation of physicians to power has had catastrophic consequences for population-level health.” 

Too much focus on doctors in public health? Credit: Shutterstock

Public health needs to think much more broadly:

The core tools of public health, then, are not just vaccines or lab tests but also policies pertaining to corporate regulation and consumer safety standards; labor protections; public jobs and housing programs; investments in community health workers, decriminalization, and decarceration; and civil rights lawsuits.

It is not, he stresses, that physicians should not be involved in public health; it is just that they shouldn’t be leading it.  “Rather than doctors perpetually running the show,” Dr. Reinhart says, “clinical and scientific experts need to acknowledge the limits of their knowledge and embrace supportive roles in a redesigned public health system that is guided by and accountable to the communities whose lives are most affected by public health policy decisions.”

E.g., “America doesn’t need a world-leading virologist in charge of responding to viral threats, for example. It needs need people prepared to work collaboratively to integrate virological insights — supplied by advisers who are world-leading virologists — with the on-the-ground realities of labor, political-economic, psychological, and cultural dynamics in order to produce effective policy.”

Public health needs to built up from the “bottom-up,” Dr, Reinhart suggests, recognizing: “It’s not about individual risk tolerance, but about government making use of population-level tools—such as infrastructural investments in clean air and water—to lower the level of risk to which individuals are exposed by living in society.” If we’re not recognizing and supporting the most vulnerable, the most at-risk, the most marginalized, then we’re not doing public health.

He acknowledges that public health is inherently political, but urges that we don’t allow it to be partisan, a distinction that is hard to draw in our polarized times.   

Gun violence is a public health problem. Opioid addiction is a public health problem. That 34 million people are food insecure is a public health problem.  The facts that 6 million homes are severely/moderately substandard and at least a half million people are homeless are public health problems. Two million people without clean water is a public health problem; 135 million people breathing polluted air is a public health crisis. Having almost 2.5 million people incarcerated is a public health problem. Having 38 million Americans living in poverty is a public health disgrace. The fact that our reading and math proficiency are at all-time lows is a public health embarrassment.

Need I go on?

Credit: Braveman, et. alia

The money we’re spending on acute medical care is well-intentioned but is driving out investments – and they are investments – in public health initiatives, broadly defined.  Where is our commitment to uniformly high quality public education?  Where’s our focus on clean water and air?  Where’s our push for more affordable housing? Where’s our universal basic income?  Where are our baby bonds? When do we celebrate teachers, community leaders, and public health workers rather than billionaires? 

We suffer from what Dr. Reinhart calls “clinicism,” addressing the immediate medical problem with a pill or a procedure while “normalizing” the social conditions that led to it. That’s great for clinicians’ incomes and the various health organizations that feed off them, but lousy for our collective health.

I also want to call attention to an essay by Aparna Mathur, Ph.D., a visiting Fellow at FREOPP, calling for modernizing our safety net. I remember thirty years ago that humorist P.J. O’Rourke “proved” there was no poverty in America; he added up all the spending on anti-poverty programs, divided by the number of people in poverty, and the answer was higher than the poverty level. I.e., the problem isn’t that we don’t spend enough money; the problem is that we don’t spend it effectively.

We have a crazy quilt of safety net programs, at federal, state, and local levels, and for the most part they’re not coordinated. Dr. Mathur shows that almost half the people who need assistance don’t get any, about a fourth only get help from one, and less than a third get multiple benefits. By creating such a number of different programs, with different eligibility criteria, different applications, overseen by different agencies, we turn seeking aid into a full-time job. And yet politicians are calling for kicking people off SNAP and Medicaid. 

Credit: PolicyEd

Dr. Mathur calls for a “one-stop shop” for safety net programs.  She also sees the need for direct cash support, even if for a time-limited period, to “buffer individuals need to weather the current hit to incomes and any benefits, and allows them the time to invest in job search, training, while feeling supported.”

Now, that’s public health thinking.

We spend enormous amounts on health care, and on safety net programs.  There are a lot of vested interests in maintaining what we’re doing.  But we’re being willfully blind if we think we’re achieving our goals.  I don’t know if the suggestions from Dr. Reinhart and Dr. Mathur have any chance in today’s polarized culture wars, but I sure applaud them for raising them.   

There Is Something About Trains, Indeed

Like many of you, when I heard about the Norfolk Southern train derailment in East Palestine (OH) on February 3, my heart went out to the people in that community. The train was carrying some hazardous materials, and no one was quite sure what was vented, especially when officials did a “controlled burn.”  Still, though, I didn’t think much about it; although I live in Ohio, I’m about as far away as one can be within the state.

East Palestine derailment.  Credit: CBS News

Yesterday my local water company shut off access to water from the Ohio River. “We are taking this preventative step to ensure the health, safety, and confidence of residents,” said Cincinnati Mayor Aftab Pureval.  (Note: it reopened access today).

East Palestine isn’t all that close to the Ohio River, but whatever chemicals got into the local streams eventually started reaching it, and a “plume” of them slowly meandered the 400 miles downstream to here. Initially, the water company noted how small the particulate levels were – well below any danger – and that normal filtering processes would take care of them. Then they announced that they’d add a second filtering step, just in case.  I guess people weren’t reassured, because they still closed the intakes, if only for a day.

I can only imagine how worried the people in East Palestine must be.

The scary thing is that this derailment was not a freak occurrence.  There are about 1,000 derailments every year. Fortunately, most don’t involve either hazardous materials or result in deaths. If it’s any consolation – and it shouldn’t be – most hazardous material spills come from trucks, not trains (but, then again, trucks carry the most freight).   The odds are against bad things happening. But, with 1.7 trillion ton-miles of freight carried by train every year, the odds eventually result in an East Palestine (and there were train derailments with hazardous materials ion both Houston and Detroit since East Palestine’s). 

Credit: Bureau of Transportation Statistics

When I first heard about the derailment, I assumed it was poorly maintained tracks. Although railroad infrastructure earned a “B” in the most recent civil engineers’ report card, the U.S. has a history of underinvesting in infrastructure, the recent Bipartisan Infrastructure Bill notwithstanding. The freight companies claim to invest some $20b annually on capital expenditures and maintenance, including both the trains and the tracks, but when I see railroad tracks or freight trains on them, I’m not usually particularly dazzled; both look like they’ve been there for fifty years.

There was also speculation that the crash was due to the lack of more modern Electronically Controlled Pneumatic (ECP) brakes, which in 2017 the railroad industry successfully blocked regulations requiring, but it appears that a wheel bearing overheated and failed.

One thing that critics point to is that the Norfolk Southern just recorded record profits, and had $18b in stock buybacks and dividends over the past five years, while seeing accidents rise.  They’re not alone. 

“For years, the railroads have fought all kinds of basic safety regulations — modern braking systems, stronger tank cars for explosive materials, even information about what’s on trains passing through communities — based on an argument that it simply costs too much to protect our lives, health, and our air and water,” Kristen Boyles, a managing attorney at Earthjustice, an environmental group, told The New York Times. “It’s disgusting to find out that at the same time these companies have been making massive shareholder payments.”

Keep in mind – these are the same railroad companies who do not give its workers paid sick leave, whose scheduling policies make Amazon look good, and who only averted a railroad workers’ union strike last December when Congress stepped in. 

Look: it could have been worse. The train could have been carrying liquified natural gas (LNG). Adele Peters, in Fast Company, warns:  “In a crash, a single train car filled with LNG could produce a fireball up to a mile wide and send shrapnel flying; 22 tank cars filled with LNG have as much energy as the bomb that destroyed the Japanese city of Hiroshima in 1945.”  And there are plenty of other dangerous materials traveling through our communities that we’ll only know about when their train derails.

Despite all this, freight trains are still probably safer than trucks (although when there is an accident, ones with trains are likely to be worse).  Our society could not exist without freight carrying them and the materials needed to make them. I just wish we prioritized safety more over profits.

Then, again, the civil engineers warn that our roads and bridges are crumbling, our airports and ports are a disgrace, our dams and levees are failing, our hazardous materials are poorly stored, and our water systems are extremely antiquated.  We’re living with Third World infrastructure, and we don’t seem to care. 

Credit: ASCE

One of my local news channels noted that, despite the water company shutting down access out of concern for minute exposures to the toxic materials from the derailment, there are some 37,000 water lines locally that have lead pipes, which put people at far more risk. The water company thinks it will take another thirty years to replace them. Out of sight, out of mind.

We respond in the short term to disasters, but we’re terrible about long term investments in averting or minimizing them. Despite the furors at the time, neither Jackson (MS) nor Flint (MI) yet have safe, reliable water after their respective disasters.  Houston is still at grave risk of future floods despite the 2017 disaster. Pick a disaster, fast forward a few years, and how often have major changes been made as a result?

And, of course, one only has to note that we could have both dealt with COVID much better than we did, or could be doing much more to prepare for the next pandemic, but, if anything, we’re less prepared than before it hit.  Planning, preparation, public health and safety are not our strong suits.    

I get that there will always be accidents.  Bad things sometimes happen. I get that more regulations won’t stop all of them. I get that, in total, there are probably too many regulations.  I hope that the Infrastructure Act starts to make a dent, soon.  But, come on, how many East Palestines do there have to be before we take safeguarding our health more seriously?

As a NYT opinion piece lamented: “It shouldn’t take a chemical cloud over a community in the American heartland to compel the government to protect its people.” Amen to that. 

Give Him a Hand -- No, Really

When I read The Washington Post article about how a Tennessee high school student’s engineering class built him a prosthetic hand, my immediate reaction, of course, was to be touched, but my bigger reaction was, wait – high school students can now create prosthetics? 

If you haven’t been paying attention, the world of prosthetics has been changing in amazing ways, and it’s not done. 

Image by Omkaar Kotedia, co-created with Dani Clode

The student, Sergio Peralta, was born with his right hand not fully formed, and for much of his life it was a problem.  As he wrote in his own account in Newsweek: “When I got bullied at my old school, the bullies would always compare me to them and make me feel like I am less of a person because of my right hand.”  His high school engineering teacher noticed his limitations, got permission from his mother to create a prosthetic for him, and assigned three students to the project.

Within a week, they’d used a 3D printer to create a prototype, and over the next couple weeks they’d iterated it to a version Sergio was happy with. “As he was adjusting it, I felt very happy,” Sergio writes.  “It looked cool and robotic, and it was grey and blue. We then tested weather [sic] I was able to grip objects with it…My teacher was so happy that the hand worked. It was exciting for him to see me catch a ball for first time in 15 years.”

Sergio and his classmates with the new hand(s). Credit: Kelly Flood

3D printing has been one of the big breakthroughs for prosthetics. The Afghan and Iraq wars unfortunately created a huge demand for them, and the military health services stepped up. Dr. Peter Liacouras, the Director of Services for the 3D Medical Applications Center at Walter Reed, says: “Over the past ten years, we have concentrated on filling the gaps in prosthetics through 3D printing. 3D printing has been highly flexible and applicable for specialty solutions of limited production needs.”  Ukrainian soldiers are now benefiting from this expertise.

Mr. Peralta’s classmates are not the only students helping to pave the way to more available, affordable prosthetics. For example, last September a group of students from a structural engineering class at University of California San Diego started LIMBER, whose mission “is to provide prosthetics and orthodic devices to the 9 out of 10 people who are left behind.”  

Their approach is “to integrate imaging, modeling, simulation, testing, and additive manufacturing to create affordable, unibody prosthetic devices that can be tailored specifically to each user’s needs.”  So far LIMBER has served 17 patients, in 3 countries, and expects to start selling more broadly in early 2024. 

The World Health Organization estimates that only 1 in 10 people who need assistive products have access to them, with cost often a major barrier in the case of prosthetics. 3D printing is lowering that barrier but hasn’t eliminated it yet. More needs to happen.

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I think it’s great that 3D printing is making prosthetics cheaper and faster to produce, but what particularly intrigues me is how people are personalizing them – not just for fit but also for style, for aesthetics, even for new purposes. Joanna Thompson writes in MIT Technology Review about “alternative prosthetics” – “a form of assistive tech that bucks convention by making no attempt to blend in.”

Well, that doesn't blend in. Credit: The Alternative Limb Project

Take Open Bionics, with its Hero Arm^TM, which it describes as “an advanced, lightweight, 3D printed bionic arm, with multi-grip functionality and empowering aesthetics.”  It comes with multiple grips, removeable covers “inspired” by characters from Disney, Marvel, and Lucasfilm, along with “a group of lights, sounds, and vibrations that give you feedback on the status of your bionic arm.” 

Or take The Alternative Limb Project, founded by artist Sophie de Oliveira Barata, to use “the unique medium of prosthetics to create highly stylised wearable art pieces.”  The website says: “Sophie’s creations explore themes of body image, modification, evolution and transhumanism, whilst promoting positive conversations around disability and celebrating body diversity.” 

Ms. Barata recently told Creative Bloom that she wants to help amputees: “To embrace your difference and send out a message without speaking, to say how you feel about your body."  She aims to balance comfort, function, and aesthetics, “But if you push one to the extreme, sometimes to other two suffer. For example, if it's a performance art piece, then it's not for everyday use.

Performance art prosthetics?  Just ask Sara Hughes, whom The New York Times recently profiled. Ms. Hughes got a new arm from The Alternative Limb Project for her wedding. “For me, it wasn’t a fancy gown. It was having a really cool arm.”  She and Ms. Barata worked on a design that deliberately didn’t attempt to look like a “real” arm. “There’s definitely a dreamlike quality about it,” she told NYT. “I’d like people to think that I was a freethinker and a dreamer.”  She feels there is a power in wearing an arm that deliberately tries to look different.

Or take Nerdforge’s Martina, who used an open source design from Danger Creations to replace a missing little finger:

Ms. Thompson profiled the work of Dani Clode, from the University of Cambridge Plasticity Lab. Her designs “include a clear acrylic forearm prosthetic with an internal metronome that beats in sync with the wearer’s heart and an arm made with rearrangeable sections of resin, polished wood, moss, bronze, gold, rhodium, and cork.”  She’s also been working on a “third thumb” to augment a user’s grip.

It turns out that the brain can adapt to prosthetics that don’t try to mimic the “normal” body template. Tamar Makin, who heads The Plasticity Lab, used fMRI scans to see how the brain responded to prosthetics. She found: “Prosthetics were not represented like hands, but they were also not represented like tools.”  They’re something in-between, “suggesting that most people can readily adapt to a wide variety of artificial-limb configurations, provided the device remains useful in their daily lives.”

Ms. Thomson also highlighted an artist who’d worked with The  Alternative Limb Project, Viktoria Modesta, to replace her conventional prosthetic leg with something more imaginative, “a gem-encrusted lower limb inspired by Hans Christian Andersen’s classic fairytale “The Snow Queen.”  Ms. Modesta says: “My leg went from life sentence to an object of love and desire.”

Wow.

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I view the work of organizations like The Alternative Limb Project, Open Bionics, The Plastics Lab, and Danger Creations as a form of biohacking, not using biology but still using technology to reimagine/expand what being “human” means/looks like.  After all, maybe we could all use that third thumb.

What Is Healthcare's LEGO?

Last week the esteemed Jane Sarasohn-Kahn celebrated that it was the 65^th anniversary of the famous LEGO brick, linking to Jay Ong’s blog article about it (to be more accurate, it was the 65^th anniversary of the patent for the LEGO brick). That led me to read Jens Andersen’s excellent history of the company: The LEGO Story: How a Little Toy Sparked the World's Imagination. 

Credit: The Art of the LEGO

But I didn’t think about writing about LEGO’s until I read Ben’s Cohen’s Wall Street Journal profile of  University of Oxford economist Bent Flyvbjerg, who studies why projects succeed or fail.  His advice: “That’s the question every project leader should ask: What is the small thing we can assemble in large numbers into a big thing? What’s our Lego?”

So I had to wonder: OK, healthcare – what’s your LEGO?

Professor Flyvbjerg specializes in “megaprojects” -- large, complex, and expensive projects.  His new book, co-authored with Dan Gardner, is How Big Things Get Done. Not to spoil the surprise (which would only be a surprise to anyone who hasn’t been part of one), their finding is that such projects usually get done poorly.  Professor Flyvbjerg’s “Iron Rule of Megaprojects” is that they are “over budget, over time, under benefits, over and over again.”

In fact, by his calculations, 99.5% of such projects miss the mark: only 0.5% are delivered on budget, on time, and with the expected benefits.  Only 8.5% are even delivered on budget and on time; 48% are at least delivered on budget, but not on time or with expected benefits.  

As Professor Flyvbjerg says: “You shouldn’t expect that they will go bad. You should expect that quite a large percentage will go disastrously bad.” 

Healthcare has nothing to brag about.
Credit: Engineering News Record

He has two key pieces of advice.  First, take your time in the planning process: “think slow, act fast.”  As Dr. Flyvbjerg and Mr. Gardner wrote in a Harvard Business Review article recently, “When projects are launched without detailed and rigorous plans, issues are left unresolved that will resurface during delivery, causing delays, cost overruns, and breakdowns….Eventually, a project that started at a sprint becomes a long slog through quicksand.”

Second, and this is where we get to the LEGOs, is to make the project modular; as Mr. Cohen puts it, “Find the Lego that simplifies your work and makes it modular.”

Professor Flyvbjerg writes:

Modularity is a clunky word for the elegant idea of big things made from small things. Look for it in the world, and you’ll see it everywhere…software, subways, hardware, hotels, office buildings, schools, factories, hospitals, rockets, satellites, cars and app stores: They’re all profoundly modular, built with a basic building block. They can scale up like crazy, getting better, faster, bigger and cheaper as they do.

Like LEGOs.  Or, in Professor Flyvbjerg’s description, “Repeat, repeat, repeat. Click, click, click.”   If you’ve ever played with LEGOs, you’ll know what that means. 

It’s worth pointing out, as Mr. Andersen does in his book, that LEGO took some time to become the LEGO we now know.  It made a wide variety of (wooden) toys in its first couple decades, didn’t stumble upon the interlocking brick idea until the late 1940’s (an idea it copied from an English company), didn’t switch to plastics until the early 1950’s, and didn’t patent LEGO bricks until 1958.  That was also the time that Godtfred Kirk Christiansen, the second generation of family leadership, wanted to pick one product that it could develop a “LEGO system in play,” a variety of toys that “were easy to play with, easy to produce, and easy to sell.”  That was the LEGO brick, and it is why you can now design and build your own town or build a replica Millennium Falcon^TM with them.

Yep, those are LEGOs. Credit: LEGO

Healthcare has plenty of megaprojects – costing $1b or more – and many smaller ones, and I suspect most don’t end up being delivered on time, on budget, or with the full set of expected results.  Some of that is no doubt because of the failure to spend enough time planning, as Professor Flyvbjerg stresses, but I suggest that much of those failures come because healthcare either doesn’t have its LEGO or has the wrong ones.

Healthcare’s LEGO should be the patient.

Let’s take software projects. How many of you have multiple electronic records, some of which may connect with others, but still leave you feeling somewhat schizophrenic?  They were not designed around the patient; they were designed for hospitals, health systems, health care professionals’ offices. Health plans’ eligibility, billing and claims systems were largely designed around employers.  And almost everything in healthcare is designed to ensure billing could be done.  If healthcare software already has a LEGO, it is billing codes, because people working in healthcare want, above all, to get paid.

Or take actual healthcare construction projects, such as hospitals, medical office buildings, or other facilities. Historically, they’ve been designed around physicians -- how to make it easier for them to see more patients (billing, again), to encourage them to practice there instead of elsewhere, etc.  That’s why doctors rarely make house calls anymore, why too many patients who could be treated at home end up in the hospital, and why patients end up spending so damn much time waiting.      

Some might argue that in the new era of Big Data and A.I., the new healthcare LEGO should be bits. Everything is going to run on them; everything is going to be connected by them. There’s a logic to that, and that approach may seem tempting, but it’s a dangerous path. We could end up with an even more impersonal healthcare system than we have today.

We’re the LEGO brick. We’re the unit. And when I say “patient,” I really mean more broadly: people, whether they’re current patients, former patients, or future patients. It matters how we’re connected, to whom we’re connected, what the end goal for us is.  The healthcare system often thinks of us as our diagnoses or our bodily systems, but unless and until it looks at us as the entire person – the LEGO brick, if you will – we’re neither going to be treated the way we want nor achieve the health results we hope for.

Credit: Arts Brookfield

So if you are working on a healthcare project, take that extra time that Professor Flyvbjerg urges to really think about which people will be impacted, where, how, when, and to whom they are or should be connected.  Build those connections to create something creative, sturdy yet flexible, and effective. As Dr. Flyvbjerg writes: “It’s remarkable what you can do with blocks of Lego.”