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.”

MedEd in an AI Era

I’ve been thinking a lot about medical education lately, for two unrelated reasons.  The first is the kerfuffle between US News and World Report and some of the nation’s top – or, at least, best known – medical schools over the USN&WR medical school rankings.  The second is an announcement by the University of Texas at Austin that it is planning to offer an online Masters program in Artificial Intelligence. 

Credit: AAMC

As the old mathematician joke goes, the connection is obvious, right?  OK, it may need a little explaining. 

USN&WR has made an industry out of its rankings, including for colleges, hospitals, business schools, and, of course, medical schools. The rankings have never been without controversy, as the organizations being ranked don’t always agree with the methodology, and some worry that their competitors may fudge the data.   Last year it was law schools protesting; this year it is medical schools.

Harvard Medical School started the most recent push against the medical school rankings, based on:

…the principled belief that rankings cannot meaningfully reflect the high aspirations for educational excellence, graduate preparedness, and compassionate and equitable patient care that we strive to foster in our medical education programs…Ultimately, the suitability of any particular medical school for any given student is too complex, nuanced, and individualized to be served by a rigid ranked list, no matter the methodology.

Several other leading medical schools have now also announced their withdrawals, including Columbia, Mt. Sinai, Stanford, and the University of Pennsylvania. 

Now, I am no expert on the methodology and don’t have any particular love towards USN&WR, but I do find rankings to be informative.  As the USN&WR CEO said in response to the HMS withdrawal: “Our mission is to help prospective students make the best decisions for their educational future…we believe students deserve access to all the data and information necessary to make the right decision.”  I mean, who could argue that?

Evidently the medical schools.  I’ve seen lots of reasons cited for their withdrawals, but what I have not seen are suggestions for alternatives – how to make the rankings better, how to more accurately gauge “quality” of medical schools, how to fairly compare different medical schools.  I guess if you are Harvard or Stanford you believe your superiority is obvious.

I’ve brought this up on Twitter and gotten some interesting responses, especially from physicians – e.g., that medical school attended isn’t an indication of how good or bad a doctor will be, and that medical school actually doesn’t matter as much as where doctors do their residency. Those may be very valid arguments, but they leave me to conclude that we not only don’t know which medical schools are the “best,” we don’t even know if medical school has any real bearing on the quality/competence of the physicians it produces (not that we can measure that either). 

As with most things in healthcare, quality is too complex for the professionals to figure out, so they’ll punt to the patients to figure it out for themselves.

I’ve written before about how, in 2023, it makes no sense that we have parallel educational tracks for M.D.s and D.O.s, or, indeed, that our medical education system takes such a narrow and outdated view towards “health.”  Medical schools and graduate medical education programs have become an end unto themselves, and it’s no surprise that training physicians in the U.S. is a longer and more expensive process than anywhere in the world – not that we can show we have better physicians or those physicians achieve better outcomes as a result, of course.

We should be fundamentally rethinking how we train physicians, which brings me to the UT AI program. 

Credit: UT News

Online graduate school programs are no longer new.  There are a number of them now, for a number of degrees (and, in fact, USN&WR has rankings for them).  It’s not new for UT either; UT started offering an online masters program in computer science in 2019, and in data science in 2021.  But with the explosion of interest in AI, and taking advantage of $20 million in funding from the National Science Funding, UT is now adding this program.

The UT announcement brags that its Master of Science in Artificial Intelligence (MSAI) “will be the first large-scale degree program of its kind and the only master’s degree program in AI from a top-ranked institution to be priced close to $10,000.”  That is considerably cheaper than an in-person program.

The program will not require an undergraduate degree in computer science but candidates will need some technical expertise.  Professor Adam Klivans, director of the new program, told The New York Times the degree was “something working professionals can participate in to learn the expertise their companies need without leaving their jobs.”

He further says:

The fields of artificial intelligence and machine learning have seen unprecedented growth over the last 10 years. Our goal is to ensure that every qualified student can access a premier education in AI, one that is keeping pace with this rapidly evolving field. With the MSAI program, we have removed geographic barriers entirely and significantly lowered the cost barrier of graduate study. For our students, this a game changer.

Eric Busch, director of the Computer and Data Science Online program, added: “It’s not just an ‘online degree.’ It’s an immersive and connected community of learners and a credential from UT Austin that opens doors.”

Healthcare does have many online programs, but not, as far as I can tell, for medical school.  Medical schools are starting to use virtual reality, but only as a training tool, not as a replacement for in-person classes.  They’re tip-toeing when they should be taking great leaps.

Where are the medical schools that are seeking, to paraphrase Professor Klivans, to ensure that every qualified student can access a premier medical education, one that is keeping pace with that rapidly evolving field, to remove geographic barriers and to significantly reduce the cost barrier of medical education?

The future of MedEd? Credit: Medicine at Michigan

So to all the medical schools upset about the USN&WR rankings: yeah, keep worrying about that.  Keep raising your prices, while raising alarm bells about looming physician shortages (and associated need for funding increase).  Meanwhile, someone, somewhere, is going to take UT’s AI example and develop an online medical school program that is more geographically available, more open to a wider range of students, more immersive and interactive, and much cheaper. 

Welcome to MedEd in an AI Era. 

Ultrasound is Ultra-Cool

AI continues to amaze – ChatGPT is now passing Wharton Business School exams, Microsoft and Google are doubling down in their AI efforts – and I’m as big a fan as anyone, but I want to talk about a technology that has been more under the radar, so to speak: ultrasound. 

Ultrasound Direct Sound Printing. Credit: depositphotos/New Atlas

Yes, ultrasound.  Most of us have probably had an ultrasound at some point (especially if you’ve been pregnant) and Dr. Eric Topel continues his years-long quest to replace the ancient stethoscope technology with ultrasound, but if you think ultrasound is just another nifty tool in the imaging toolbox, you’ve missed a lot.

Let’s start with the coolest use I’ve seen: ultrasound can be used for 3D printing.  Inside the body.  

This news on this dates back to last April, when researchers from Concordia University published their findings in Nature (I found out about it last week).  Instead of the more common “Additive Manufacturing” (AM) approach to 3D printing, these researchers use Direct Sound Printing (DSP).  

The paper summarizes their results: “To show unique future potentials of DSP, applications such as RDP [Remote Distance Printing] for inside body bioprinting and direct nano particle synthesizing and pattering by DSP for integrating localized surface plasmon resonance with microfluidics chip are experimentally demonstrated.”

As lead author Mohsen Habibi explained it:

We found that if we use a certain type of ultrasound with a certain frequency and power, we can create very local, very focused chemically reactive regions.  Basically, the bubbles can be used as reactors to drive chemical reactions to transform liquid resin into solids or semi-solids.

The authors believe that DSP can have applications where AM cannot be used, particularly because sound can penetrate objects that light cannot (e.g., the human body).  Bioprinting inside the body is not, in itself, new, but has required open surgery, which DSP would not.  “DSP introduces the possibility of noninvasive deep inside the body printing,” they explicitly point out. 

"Also we can do the repairing of inside bio-organs. That's a future possibility,” corresponding author Muthukumaran Packirisamy said.  Here’s their video:

I’ve been fascinated with 3D printing for a long time, especially for its healthcare-related uses (e.g.., prescription drugs, blood vessels, prosthetic devices, even organs), but tell me we’ll be able to do those noninvasively, using sound waves – well, consider me entranced. 

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All that is cool enough, but ultrasound is being used for many more healthcare applications, such as destruction of tumors.  In fact, that was one of the motivations for the Concordia efforts; Professor Packirisamy noted: “Ultrasonic frequencies are already being used in destructive procedures like laser ablation of tissues and tumours. We wanted to use them to create something.”

“Focused ultrasound” is the term commonly used; there is actually a Focused Ultrasound Foundation. “Focused ultrasound is a noninvasive therapeutic technology,” Dr. Neal Kassell, founder and chairman of the Focused Ultrasound Foundation, told CNN. “We’ve said that focused ultrasound is the most powerful sound you will never hear, but sound that someday could save your life.”

Credit: Focused Ultrasound Foundation

Some of the uses include:

• Earlier this month Canadian surgeons used ultrasound to deliver chemotherapy to an inoperable brain tumor, the first time this has been accomplished.  “Focused ultrasound is an innovative and non-invasive approach to more effectively deliver chemotherapy directly to the tumour,” one of the researchers said. “Our hope is that this continued research will bring us closer to enhancing treatments to help change the course of the disease.”
• Focused ultrasound has been shown to be equally effective in pain management and quality of life measures for painful bone metastases as external radiation beam therapy, with low adverse even rates. 
• Late last year the FDA approved focused ultrasound to treat the second side of patients with essential tumors; use for the first side was approved in 2016.  New research confirmed the long term effectiveness of its use for essential tremors.
• Researchers at UT Southwestern are using high-intensity focused ultrasound to treat medication refractory tremor in essential tremor and tremor-dominant Parkinson’s Disease, which the researchers believe “enables more precise targeting of the brain, decreases treatment times, reduces side effects, and improves treatment response.” 
• Researchers at West Virginia University Rockefeller Neuroscience Institute used Low-intensity focused ultrasound (LIFU) in the treatment of Alzheimer’s patients.  “This study is also a major step forward for the exciting possibility of combining focused ultrasound with targeted delivery of medications or antibodies that normally have limited capability to cross the blood brain barrier from the blood to the brain.”
• Similarly, researchers at Yonsei University College of Medicine (South Korea) found that focused ultrasound improved the delivery of Alzheimer’s drugs by over eight times.  “While there is no complete cure for dementia, we hope that open BBB [blood brain barrier] surgery using FUS surgery can help give hope to dementia patients,” the lead researcher said.
• LIFU is showing “promising results” for treatment of major depressive disorder, according to a paper from Delft University.  The paper describes LIFU as “an emerging neuromodulation method with disruptive potential since it allows for non-invasive stimulation across the whole brain with milimetre precision.”
• Focused ultrasound has been found safe and effective for intermediate risk prostate cancer. 
• A 2020 study suggested that focused ultrasound could be used for patients with depression or obsessive-compulsive disorder.  “We demonstrated that FUS is effective in significantly improving symptoms of patients with treatment-resistant OCD and depression,” the lead author said.

That is by no means a complete list. The Focused Ultrasound Foundation claims that focused ultrasound is currently (at this writing) being used by 65 device manufacturers, for 170 clinical indications, in 424 research sites and 895 treatment sites.  Impressive numbers, but still small in the scheme of healthcare. It warns:

Unfortunately, the evolution of a new therapeutic medical device from concept to standard of care can take decades. Complicated and inefficient, the process requires the interaction of many organizations with differing agendas and timelines. There are also numerous technology, economic, regulatory and reimbursement obstacles to overcome.

Too often, the mechanisms that healthcare has developed supposedly to protect us also work against us.  As the Foundation also warns: “Decades is too long for patients and their families to wait for medical breakthroughs.

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Clifford Marks, MD, writes in The New Yorker about ultrasound replacing the stethoscope, citing miniaturization, lower costs, and application of AI as factors, but I think he’s not being ambitious enough.  As Diku Mandavia, MD, told him, “But ultrasound—it’s low-cost, no radiation, has so much value for patient care . . . it’s going to be ubiquitous.” 

Let’s hope so. 

Fighting the Wrong (Culture) Wars

News flash from the culture wars: they’re coming to take our gas stoves!

Well, actually, “they” are not, but the kind of people who got alarmed about it are a threat to our health, and to theirs.

Credit: Shutterstock

The gas stove furor started with a Bloomberg News interview that Richard Trumka, Jr, a Consumer Product Safety Commission commissioner.  “This is a hidden hazard,” he said. “Any option is on the table. Products that can’t be made safe can be banned.”

He was referring to the well known but little acknowledged fact that gas stoves emit various pollutants, especially nitrogen dioxide. Last year the AMA adopted resolutions about the risks of gas stoves, and urged migration efforts to electric stoves.  Shelly Miller, a University of Colorado, Boulder, environmental engineer has said:

Cooking is the No. 1 way you’re polluting your home. It is causing respiratory and cardiovascular health problems; it can exacerbate flu and asthma and chronic obstructive pulmonary disease in children...you’re basically living in this toxic soup.

So one can see why the CPSC might be concerned. But the outcry about Mr. Trumka’s comments were immediate and vociferous.  “I’ll NEVER give up my gas stove. If the maniacs in the White House come for my stove, they can pry it from my cold dead hands. COME AND TAKE IT!!” Rep. Ronny Jackson (R-TX) tweeted.  The Atlantic further reported:

Governor Ron DeSantis tweeted a cartoon of two autographed—yes autographed—gas stoves. Representative Jim Jordan of Ohio declared simply, “God. Guns. Gas stoves.” Naturally, Tucker Carlson got involved. “I would counsel mass disobedience in the face of tyranny in this case,” he told a guest on his Fox News show.

Ron DeSantis' stoves

Almost as immediately, Mr. Trumka clarified: “To be clear, CPSC isn’t coming for anyone’s gas stoves.  Regulations apply to new products.”  CPSC Chair Alexander Hoehn-Saric issued a statement making it clear that, while “emissions from gas stoves can be hazardous…I am not looking to ban gas stoves and the CPSC has no proceeding to do so.”  The White House issued its own denial.  Case closed, right?

Wrong.  House Republicans have already introduced a bill to block such a ban; 20 states, mostly Republican-controlled, have already passed such bans.  It has become, as Slate put it, “the culture war of the week.”  It joins, for example, masking, vaccines, abortion and climate change as issues that become political divides not on their merits but on the statement they make. 

As Brady Seals, a renewable energy expert at the Rocky Mountain Institute, told Jacob Stern of The Atlantic, “I don’t know if this discourse that we’re seeing now could have happened five years ago.” 

It doesn’t matter that gas stoves may be bad for the health of people in your house; it doesn’t matter that they’re bad for climate change either, with one study equating them to emissions of a half a million gas-powered cars.  Natural gas is good for the U.S. economy, proponents argue, and, in any event, if people want to use gas stoves, they have the right to do so.  Senator Joe Manchin, a Democrat but from a deeply Red state, tweeted: “The federal government has no business telling American families how to cook their dinner. I can tell you the last thing that would ever leave my house is the gas stove that we cook on.

Huh?

It’s similar to the arguments about regulating guns; demonstrably, they’re dangerous for the households they’re in and for the general public, but individuals’ supposed rights to them supersede rational discussion about the risks.  Or abortion; for all the impassioned talk about the sanctity of the life of the fetus, states with more restrictive abortion laws do worse for moms and young kids.

The culture wars about masking, shutdowns, social distancing, and vaccines had real consequences; COVID death rates were higher among Republicans, at the county, state, and national level.  It probably impacted the recent mid-term elections, blunting the expected Red Wave.  Similarly, no one should be surprised that childhood vaccination rates are falling.  We’re already seeing measles outbreaks and we can expect others.

Credit: Politico illustration; photos: Getty, AP

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My “favorite” other recent example of health-related culture wars comes from climate change.  For all the denialism from the fossil fuel industry and the politicians who enable it, a new study found that not only did Exxon know about the risks of global warming for the past 50 years, its scientists had extremely precise predictions about exactly what that impact would be. 

Lead author Geoffrey Supran charged:

This is the nail-in-the-coffin of ExxonMobil’s claims that it has been falsely accused of climate malfeasance…Our analysis shows that ExxonMobil’s own data contradicted its public statements, which included exaggerating uncertainties, criticizing climate models, mythologizing global cooling, and feigning ignorance about when — or if — human-caused global warming would be measurable, all while staying silent on the threat of stranded fossil fuel assets.

The study’s authors concluded: “ExxonMobil understood as much about climate change as did academic and government scientists…Yet, whereas academic and government scientists worked to communicate what they knew to the public, ExxonMobil worked to deny it.”  One has to wonder how many other climate change deniers the same would be true of.  Fighting a culture war against climate change trumps the very real, and apparently widely known, risks of it. 

Exxon, of course, denies these latest findings too. 

Credit: Angela Weiss/AFP via Getty Images

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America knows how to react when attacked by other countries (e.g., Pearl Harbor) or terrorists (e.g., 9/11), but we’re pretty terrible about more insidious risks.  The current pandemic would qualify as a national crisis, but aside from vaccine development and throwing lots of money at it, we’ve handled it pretty badly.  Our public health system is in a shambles a every level, our hospitals and healthcare workers are overwhelmed, and whatever warp speed our COVID vaccine development was at in 2020 is now more like impulse drive.   

And House Republicans and Republican Presidential candidates like Florida Governor Ron DeSantis appear more interested in fighting the culture war aspects of COVID than in, you know, fighting COVID. It’s not our health they’re focused on.

Add up the health risks from all the culture wars and it’d be a pretty scary number.  Culture wars may make great Twitter, but they make bad health policy.