Not the Last of Them

I’m seeing two conflicting yet connected visions about the future. One is when journalist David Wallace-Wells says we might be in for “golden age for medicine,” with CRISPR and mRNA revolutionizing drug development. The second is the dystopian HBO hit “The Last of Us,” in which a fungal infection has turned much of the world’s population into zombie-like creatures.

Credit: HBO

The conflict is clear but the connection not so much. Mr. Wallace-Wells never mentions fungi in his article, but if we’re going to have a golden age of medicine, or if we want to avoid a global fungal outbreak, we better be paying more attention to mycology – that is, the study of fungi.

We don’t need “The Last of Us” to be worried about fungal outbreaks.  The Wall Street Journal reports:

Severe fungal disease used to be a freak occurrence. Now it is a threat to millions of vulnerable Americans, and treatments have been losing efficacy as fungal pathogens develop resistance to standard drugs. 

“It’s going to get worse,” Dr. Tom Chiller, head of the fungal-disease branch of the Centers for Disease Control and Prevention, warns WSJ.

A new study found that a common yet extremely drug resistant type of fungus -- Aspergillus fumigatus – has been found even in a very remote, sparsely populated part of China.  Professor Jianping Xu, one of the authors, points out: “This fungus is highly ubiquitous — it’s around us all the time. We all inhale hundreds of spores of this species every day.”

We shouldn’t be surprised, because fungi tend to spread by spores  In fact, according to Merlin Sheldrake’s fascinating Entangled Life: How Fungi Make Our Worlds, Change Our Minds, and Shape Our Futures, fungi spores are the largest source of living particles in the air. They’re also in the ground, in the water, and in us. They’re everywhere.

That sounds scary, but without fungi, we not only wouldn’t be alive, we never would have evolved. Fungi allowed sea-based plants to colonize land, which led to sea creatures moving ashore, which eventually led to us, among other species. Dr. Sheldrake notes that every plant growing under natural conditions has fungi living with it. They help break down minerals in the soil for plants, among other things. 

Without them, we’re nothing.

And that part about taking over animal’s brains, as in The Last of Us, is, in fact, true. For example, they are known to invade ants’ and mice’s brains, causing them to exhibit unusual behavior that gets the animal killed but cause the fungi to spread, which is their goal. As for influencing human’s behavior, the answer seems to be somewhere between “maybe” and “probably.”  If you are a fan of hallucinogenic mushrooms, then the answer is “yes.”

In an interview with The New York Times, Dr. Sheldrake argues: “Mycelium [networks of fungal threads] is ecological connective tissue and reminds us that all life-forms, humans included, are bound up within seething networks of relationships, some visible and some less so.” We can ignore them, we can try to fight them, but failing to recognize how we fit into those networks comes at our own risk.

“Fungi aren’t being given enough thought,” Dr. Peter Pappas, an infectious-disease specialist at the University of Alabama at Birmingham, told WSJ.  Dr. Andrej Spec, an infectious-disease specialist at Washington University, agreed, adding: “In medicine, fungi are an afterthought. We need a paradigm shift.”

Indeed. As WSJ went on to say:

Many medical schools aren’t adequately training aspiring doctors to identify and treat fungal disease, infectious-disease experts said. Some schools dedicate a couple of hours to the topic, those experts said. “Most fungal diseases are taught in medical school as being rare or unusual or some even regional, but we see these on a daily basis,” said Dr. George R. Thompson, an infectious-disease specialist at the UC Davis Medical Center in Sacramento. 

I’m glad that we’re at least realizing the issues that fungi can cause for our health, but I fear we’ll go down the same road we’ve gone down with bacteria.  We discovered they could harm us, then found we could kill them, developing an array of antibacterials that could wipe them out at scale, then proceeded to blithely overuse them.  To late, we eventually realized that, duh, bacteria become resistant to them over time, and, even worse, we need some bacteria.

We’re starting – barely – to recognize the importance that our microbiome plays in our health, but we haven’t significantly changed our medical education or our practice of medicine to recognize that role.  We’re even further behind when it comes to the mycobiome.  If we’re barely teaching how to identify and treat fungal diseases in medical school, imagine how much further behind we are in how to use our fungal companions to bolster our health.

Credit: Anders Nilson/The New Yorker

Immunologist Barney Graham, a central figure in the development of mRNA vaccines, told Mr. Wallace-Wells: “It’s stunning. You cannot imagine what you’re going to see over the next 30 years. The pace of advancement is in an exponential phase right now.”  But, I would argue, if all we do is to build a new array of vaccines and weapons against various microbes, I don’t expect a golden age for our health.

Mr. Sheldrake and others are looking at using, not killing, fungi. They can be used, for example, to create antivirals, to break down pollutants, to create food, to build materials (mycofabrication), and even, as Mr. Sheldrake describes in a new paper, to help us combat climate change through carbon sequestration.  They are not our enemy.  They were here before us, and they’ll be here long after us.

As Dr. Pappas said, we need a paradigm shift.

It’s amazing that we’ve cracked our genetic code, and even more than we’re now able to edit it.  It’s astonishing how we can use imaging to watch our bodies – and even our brains – function in real time, and can use those results to identify problems. It’s exciting that we can use DNA fragments to detect cancers and other illnesses at early stages.  But we’re still stymied as to what a “healthy” microbiome is and how that matters to us, much less how our mycobiome interacts with it, and with “us.”

The fact of the matter is that our concept of “us” is an illusion. We are a network, of our own DNA, cells and processes, and of all the other organisms that coexist with us.  Our health is a network effect; we’re only healthy when that network is in balance.

We’re not getting to a golden age of medicine and biomedical innovation without fungi.

Revisualizing and Recoding Health Care

Two new books have me thinking about healthcare, although neither is about healthcare and, I must admit, neither of which I’ve yet read. But both appear to be full of ideas that strike me as directly relevant to the mess we call our healthcare system. 

Credit: Mengxin Li/The New York Times

The books are Atlas of the Senseable City, by Antoine Picon and Carlo Ratti, and Recoding America: Why Government Is Failing in the Digital Age and How We Can Do Better, by Jennifer Pahlka. 

Dr. Picon is a professor at The Harvard Graduate School of Design, and Professor Ratti is head of MIT’s Senseable Lab. Drawing on the Lab’s work, they write: “We hope to reveal here an urban landscape of not just spaces and objects, but also motion, connection, circulation, and experience.” I.e. dynamic maps. Traffic, weather, people’s moment-by-moment decisions all change how a city moves and works in real time.

Dr. Picon says.

These maps are a new way to apprehend the city, They’re no longer static. Maps provide a way to visualize information. They’re crucial to diagnosing problems. I think they provide a new depth…It’s a little bit like the discovery of the X-ray. You can see things within cities that were not previously accessible. You don’t see everything, but you see things you were not able to see before.

Example of dynamic map. Credit" MIT Senseable Lab

So I wondered: what would a dynamic map of our healthcare system look like? 

I’m telling you, just a map of what happens between drug companies, PBMs, health plans, pharmacies, and patients would open people’s eyes to that particular insanity in our healthcare system.  Now repeat for the millions of other ecosystems in our healthcare system.  If that kind of dynamic mapping -- showing all the complexities, bottlenecks, circuitous routes, and redundancies within the system -- wouldn’t lead to health care reform, I don’t know what would.

Knowing there is a problem isn’t enough.  Effectively acting on the problem is the key, and this is where Ms. Pahlka’s insights come in. She is the Founder and former Executive Director of Code for America, a Deputy Chief Technology Officer in the Obama Administration, and Co-Founder of U.S. Digital Response. The common thread, as discussed in her book, is that governments and other non-profit entities can use technology much more effectively. 

Jennifer Pahlka

We often blame outdated technology for how slowly, and how poorly, government often responds to problems, and there is some truth to that, but Ms. Pahlka looks deeper.  “We’ve been trying to fix this problem with more money for technology in government, more oversight and more rules," she told WBUR. "And the evidence shows that's not working. We got to take a different approach.”

The key, she believes, is less emphasis on the policy – driven by legislators or the executive branches – and more on implementation.  “They see implementation as a sort of detail that less important people should deal with," she says. "And until we change that, we're going to continue to have problems getting the outcomes we want.”

Ms. Pahlka describes how hard working employees – some call them bureaucrats – try to respond to new laws/initiatives involving technology by generating massive requests for proposals, which they then try to outsource to vendors. It doesn’t usually work well (you could ask the VA and Cerner about that).

She urges that all those people who are charged with implementation must have more say in design and requirements. To use her example, just because someone tells you to build a concrete boat, you shouldn’t necessarily just try to build a concrete boat.

 “The alternative to the status quo is pretty fundamental,” she told Nextgov/FCW. “It is moving from a structure in government… in which information and power flows one way — down — to something that is far more iterative and collaborative, where we stop conceiving of the implementers as at the bottom of a waterfall.”

She went on to say: “Product managers are able to say, ‘this has to make sense to a person.’ They're translating. They're designing the policy in a way that makes sense to a person,”  In a different interview, she quotes General Stanley McChrystal: “Don’t do what I told you to do. Do what I would do if I knew what you know on the ground.” 

How many executives, healthcare or otherwise, give their employees that freedom?  How might our healthcare system be different if everyone involved in implementation of any policy stopped to ask: does this make sense to a patient?

In an article in The Atlantic, Nicolas Bagley offers: “In other words, Pahlka’s book isn’t just about tech. It’s about the American administrative state.”  They’re both referring to government, but I’d argue that, sometimes for the better but usually for the worse, that’s what our healthcare system has become. Not a place of caring but of administration. Shame on us.

It’s easy to blame design, but Ms. Pahlka has a different perspective. She described to Justin Hendix of Tech Policy Press how some government programs are so hard to use:

Really none of this is necessary and I think sometimes, we think the system is designed to make it hard and that is obviously sometimes true, but very often, it’s simply not designed at all. We have these policies and processes and tech systems like at the EDD that have simply accreted over time and it’s not so much the difference between user-friendly design and what we would call in tech user hostile design, but more kind of the difference between any design at all and just letting it accrue and accrete. Sort of a no design.

Tell me that all doesn’t ring entirely true for our healthcare system.

She offers another important piece of advice, aimed at government but applicable to healthcare: “I mean, I like to say technology and software is something you do. It’s not something you buy. You may buy tech tools, but if you’re trying to get things done through technology, it has to be a core competency and something you actually do.” 

In 2023, in healthcare, technology has to be something you do.

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Some people fear cities are dying.  Many believe governments can’t do anything right. And everyone thinks our healthcare system is dangerously dysfunctional.  We need new ways of seeing them, as Professors Picon and Ratti are trying to do, and new ways of bringing about change, as Ms. Pahlka is recommending. If you think that’s impossible, Ms. Pahlka reminds us: “First, it's important for people to understand that we the people have created this culture.”

Air, Air Everywhere, and Not a Breath Safe to Take

If you live, as I do, anywhere in the Eastern half of the country, for the past week you’ve probably been thinking about something you’re not used to: wildfires.  Sure, we’ve all been aware of how wildfires routinely plague the West Coast, particularly Oregon and Washington, but it’s novel for the East. So when the smoke from Canadian wildfires deluged cities through the East and Midwest, it came as kind of a shock.

NYC last week. Credit: Angela Weiss/AFP - Getty Images

For a day last week, New York City supposedly had the worst air quality in the world.  The next day Philadelphia had that dubious distinction.  The air quality index in those cities, and many others, got into the “Maroon” level, which means it was hazardous for everyone.  Not just for the elderly and other “sensitive” groups, and not just some risk for some people, but hazardous for everyone.   

If you didn’t know about AirNow.gov before, you should now.

New Yorkers are used to smog and air quality that is less than idyllic, but smoke from wildfires, containing fine particulates that easily get into the lungs, weren’t something anyone was prepared for.  “Wildfires were not really a scenario, in all honesty, that I recall us specifically contemplating,” Daniel Kass, New York City’s deputy commissioner for environmental health from 2009 to 2016, admitted to NBC News.   

“People on the East Coast aren’t used to seeing these types of situations. There was a much slower response,” Peter DeCarlo, an associate professor of environmental health and engineering at Johns Hopkins University, also told NBC News. “We can probably learn a thing or two from our West Coast friends.”

Even lessons from the West Coast might not have helped much.  An analysis by The Guardian revealed the smoke produced the worst readings since data on smoke conditions started being collected in 2006.  “It’s the worst by far, I mean, Jesus, it was bad,” said Marshall Burke, an environmental scientist at Stanford University who led the work. “It’s hard to believe to be honest, we had to quadruple check it to see if it was right. We have not seen events like this, or even close to this, on the east coast before. This is a historic event.” 

As numerous observers have noted, we’re three years into a pandemic that caused us to think about airborne particles – in that cause, coronavirus ones – in ways that we’d never had to before.  Wearing high quality masks become seen as life-critical, until not wearing them became a political statement for some, and the rest of us just got tired of them.  And, even then, most of us didn’t think we needed to wear them outdoors.  Now wildfire smoke caused many people dig out their N95s just to take a walk.

We once had smoke filled cities like Pittsburgh, when pollution caused it to be dark by noon and caused white collar workers to need to change their shirts before day’s end. We like to think that efforts like The Clean Air Act took care of that, but that is wishful thinking. Wildfires, for example, aren’t covered by it, and, Professor Burke says, “In the past five to 10 years, we’ve seen a slowdown of progress in the West. And in the Northern Rockies, we’ve seen a reversal.”

To make the problem worse, staying inside wasn’t necessarily protective enough. “People had terrible indoor air too, just really bad,” Professor Burke said. “Even staying at home is not fully protective.”

As Linsey Marr, an engineering professor at Virginia Tech, points out in The New York Times:

The National Ambient Air Quality Standards apply to outdoor air and are designed to protect health, but no such standards exist for indoor air quality for the public, even though we spend, on average, about 90 percent of our time indoors. Also, these standards don’t help when unstoppable plumes of wildfire smoke drift through our cities and towns.

She points out that during heights of the pandemic there was much discussion about, and many billions of dollars allocated to, improving indoor air ventilation and filtration, but, she laments, “much of this remains unspent or was slow to be used, possibly because of a combination of lack of appreciation for the benefits it could bring and lack of guidance on how to obtain and spend the funds.” 

It's not that bad - yet.

Francesca Dominici, an expert in air pollution and climate at Harvard University, told The Guiardian: “I hope as part of this crisis there is an opportunity to realize we need to act on climate change. We’ve gone from three years of not going out because of Covid and now we can’t go outside because of polluted air. The world and nature is telling us something, it’s sending us a very strong message.”

But, by all accounts, our public health system, and our confidence in vaccines, are both worse after three years of the pandemic than they were before, so there’s little reason to think these wildfires will result in sustained action about climate change.  The air has gotten better, most of us only got worried instead of sick, and if there were some extra hospital visits or even deaths because of the smoke, they weren’t enough to drive us out of our complacency. 

We conveniently forget that, even ruling out viruses and wildfire particulates, we have microplastics not just in our food and in our water, but in our rain and in the air.  This is true even in rural areas whose air we assume is pristine. We’re breathing them now, and there’s no visible smoke plume to tip us off.  We just don’t know what they’re doing to us…but I assume it’s not good.

I was especially struck by Professor Marr’s concluding remark: “As the saying goes, we wouldn’t accept a glass full of dirty water, and we should no longer accept a lungful of dirty air.” 

Of course, too many people (think Jackson MS or Flint MI) are still forced to drink that glass full of dirty water, and way too many of us are breathing those lungfuls of dirty air – be they from wildfires, industrial pollution, or omnipresent microplastics.

We can’t stop wildfires, and can’t control where their smoke will drift, but we can – we must -- think much seriously about air quality, and act with the urgency it requires. 

A Hand Up, Not a Hand Out

As many of you did, I followed the recent debt ceiling saga closely, and am relieved that we now have a compromise, of sorts.  The House Republicans demanded a lot of things, most of which they did not get, but one area where they did prevail was in toughening work requirements for food (SNAP) and income (TANF).  They somehow believe that there are uncounted numbers of “able-bodied” people sitting around on their couches collecting government benefits, a myth that goes back to Ronald Reagan’s welfare queen stereotype, and have long advocated work requirements as the remedy.

Credit: Giving Compass

Ironically, according to the CBO, the work requirements passed may actually increase federal spending by as much as $2b, and increase the number of monthly recipients by as many as 80,000 people, but who’s counting? 

All this seems timely because of some new studies that illustrate – once again -- that, yes, poverty is bad for people’s health, and helping them get even a little bit more out of poverty improves their health. 

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The first study, by Richterman, et. alia, looked at the impacts of cash transfers – i.e., giving poor people money with little or no strings attached – had on adult and child mortality. I might parenthetically add that the study looked at programs in low and middle income countries, to which some might argue that, well, America is neither, so the results don’t apply.  

To which I would counter: umm, have you looked at the percent of Americans below the poverty line?  Have you looked at the number of Americans who go hungry every night?  Have you looked at our mortality rates, especially for maternal and infant mortality?  Have you looked at health statistics for disadvantaged populations in the U.S.?  No doubt: we’ve got low and middle income colonies within our country, to co-opt the title of Chris Hayes’ searing book on criminal justice in America.      

Dr. Richterman and his colleagues looked at longitudinal data on some 7 million individuals – 4 million adults, 3 million people – from 29 countries that had cash transfer programs.  The transfers were often small, sometimes as little as $100, but the impacts were not. The result:

Our primary finding was that these programmes were associated with significant mortality reductions among women and children aged less than 5 years, indicating the important role that these anti-poverty initiatives have had in promoting population health over the last 20 years.

The mortality reductions were on the order of 20% for women and 8% for children under 5, and grew over time.

Importantly, the effects were greatest among populations that started with the lowest health spending and shortest life expectancies.  The largest impacts were among women; the authors note: “This adds to previous evidence that cash transfers may disproportionately benefit women, or be more effective when women are the primary beneficiaries.”

Credit: Asian Development Blog

Critics fear that such payments might be misused – e.g., buying junk food, drugs, or alcohol – but Audrey Pettifor, a social epidemiologist at the University of North Carolina who studies such things (but was not involved in this research), told The New York Times: “the data just doesn’t back that up.”

The second study, by Dillman et. alia, in NEJM Catalyst, looked directly at SNAP; specifically, the impact on enrollment in SNAP had on health and cost outcomes.  It looked at health care utilization (inpatient hospitalization, ED visits, and unplanned care) and health care costs (medical, pharmacy, and total cost of care) during the first two years of having SNAP, versus a matched comparison group without SNAP.

Again, the results were striking: SNAP enrollees had 16% lower medical costs and 21% lower pharmacy costs in their first year of enrollment, and 16%/20% lower costs in the second year.  That’s remarkable.

If, for example, you had responsibility for a state Medicaid program, you might want to think about that when your Representatives and/or state legislators starts talking about restricting SNAP benefits.

The third study, by Pollack et. alia, in JAMA Network, looked what happens to asthma morbidity among children when their families get the opportunity to move from disadvantaged, low income, urban neighborhoods to low poverty neighborhoods.  Asthma is known to be more prevalent in such high poverty neighborhoods, due to sub-standard housing stock and other environmental factors. 

The findings: asthma flare-ups (“exacerbations”) dropped by more than half (0.88 per person year to 0.40) after such a move.  The authors further noted: “Measures of stress, including social cohesion, neighborhood safety, and urban stress, all improved with moving and were estimated to mediate between 29% and 35% of the association between moving and asthma exacerbations.”

One might reasonably speculate that the impact on other health conditions – e.g., COPD, diabetes, obesity, gun violence, drug overdoses – would show similarly positive results as well. 

Where you live is how you breathe. Credit: AP/Rachelle Blidner

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The New Yorker recently profiled public health researcher Arline T. Geronimus, whose new book introduces us to a word I wish we never had to think about: Weathering: The Extraordinary Stress of Ordinary Life in an Unjust Society.  “Weathering” in this context refers to the cumulative stress of racial and economic inequality, such as inadequate medical care, hazardous living environments, or insufficient diet.

The result, Professor Geronimus found, is that “people who endure chronic stressors and other forms of structural violence can biologically age faster than their peers.”  Thus the various disparities in morbidity and mortality that we see – and that cash transfer programs can help ameliorate.

If all this sounds like I’m arguing for guaranteed income programs, it’s because I am. I’ve written about universal income programs (UBI) and baby bonds, because what we’re doing now is not working.  The COVID relief payments, which were perhaps the closest the U.S. has come to UBI, may now be viewed by some conservatives as wasteful spending, but it had “historic” impacts on lifting more families out of poverty. 

I’m thrilled that there are as many as 130 guaranteed income programs, in places like Stockton (CA), Atlanta, Austin, Chicago, Jackson (MS), Long Beach, NYC, Philadelphia, and St. Paul (MN), and the evidence is that such programs work. But they’re still too little, impacting too few.

If certain politicians can’t get past their “moral” or political principles against guaranteed income, perhaps the above studies might help convince them that the improvements in health/health spending such programs bring makes them in everyone’s best fiscal interests.

The New Yorker article quotes Dr. Vicente Navarro, a professor emeritus of health and public policy at Johns Hopkins University:, “It is not inequalities that kill people. It is those who are responsible for these inequalities that kill people.”

We are those people.  We can do better.