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Lucius M. Lampton, MD EDITOR D. Stanley Hartness, MD Richard D. deShazo, MD ASSOCIATE EDITORS Karen A. Evers MANAGING EDITOR PUBLICATIONS COMMITTEE Dwalia S. South, MD Chair Philip T. Merideth, MD, JD Martin M. Pomphrey, MD Leslie E. England, MD, Ex-Officio Myron W. Lockey, MD, Ex-Officio and the Editors THE ASSOCIATION Tim J. Alford, MD President Thomas E. Joiner, MD President-Elect J. Clay Hays, Jr., MD Secretary-Treasurer Lee Giffin, MD Speaker Geri Lee Weiland, MD Vice Speaker Charmain Kanosky Executive Director JOURNAL OF THE MISSISSIPPI STATE MEDICAL ASSOCIATION (ISSN 0026-6396) is owned and published monthly by the Mississippi State Medical Association, founded 1856, located at 408 West Parkway Place, Ridgeland, Mississippi 39158-2548. (ISSN# 0026-6396 as mandated by section E211.10, Domestic Mail Manual). Periodicals postage paid at Jackson, MS and at additional mailing offices. CORRESPONDENCE: JOURNAL MSMA, Managing Editor, Karen A. Evers, P.O. Box 2548, Ridgeland, MS 39158-2548, Ph.: (601) 853-6733, Fax: (601)853-6746, www.MSMAonline.com. SUBSCRIPTION RATE: $83.00 per annum; $96.00 per annum for foreign subscriptions; $7.00 per copy, $10.00 per foreign copy, as available. ADVERTISING RATES: furnished on request. Cristen Hemmins, Hemmins Hall, Inc. Advertising, P.O. Box 1112, Oxford, Mississippi 38655, Ph: (662) 236-1700, Fax: (662) 236-7011, email: cristenh@watervalley.net POSTMASTER: send address changes to Journal of the Mississippi State Medical Association, P.O. Box 2548, Ridgeland, MS 391582548. The views expressed in this publication reflect the opinions of the authors and do not necessarily state the opinions or policies of the Mississippi State Medical Association. Copyright© 2011 Mississippi State Medical Association
MAY 2011
SCIENTIFIC ARTICLES
VOLUME 52
NUMBER 5
New Technologies for the Management of Major Extremity Wounds
143
The Hidden Burden of Atrial Fibrillation on Healthcare Spending and Resources in Mississippi
148
Marcus David Walkinshaw, MD, FACS; John Hunter Berry, BS and Andrew James Kochevar, MD Karen A. Evers, Managing Editor
PRESIDENT’S PAGE Dad / Paw Paw
152
Tim J. Alford, MD, MSMA President
EDITORIALS
Joseph and Jefferson Davis, The Community Health Centers, Mississippi, and 11 Billion Dollars
155
Richard D. deShazo, MD, Associate Editor
SPECIAL ARTICLE
Impressions of Rural Medical Care in Kenya
159
Philip L. Levin, MD
RELATED ORGANIZATIONS
Mississippi State Department of Health Mississippi Professionals Health Program
165 168
Letters MSMA Legal Ease Placement/Classified
163 169 171 172
DEPARTMENTS
ABOUT THE COVER:
Sign of a Healthy Garden — Dr. Martin M. Pomphrey, Jr. took this extreme close up of a bumblebee on a purple coneflower in the yard of his Mayhew home. One of Dr. Pomphrey’s favorite native wildflowers, this Echinacea purpurea (Asteraceae) image reveals a geometric pattern that is at the center of the cone. As with all Asteraceae, the apparent “flowers” are actually inflorescences that include showy strap-like ray flowers forming petals surrounding numerous disc flowers on the dome. Healing properties have been linked to echinacea since the Native Americans employed it to treat skin wounds and snakebites, which is why it is also called snakeroot. Later, its medicinal virtues were reported in more than 400 scientific journal articles from the 1930s to the 1980s when U.S. herbalists “rediscovered” the herb, claiming echinacea boosts the body’s immune system to help it fight off disease and has antibacterial properties. The therapeutic use of echinacea in cultural and traditional settings may differ from concepts accepted by current Western medicine because echinacea has not been evaluated by the FDA for safety, effectiveness, or purity. For a time, echinacea enjoyed official status being listed in the U.S. National Formulary from 1916-1950. However, use of echinacea fell out of favor in the United States with the discovery of antibiotics and the lack of scientific evidence. Dr. Pomphrey is a semi-retired orthopaedic surgeon sub-specializing in sports medicine who practiced with Oktibbeha County Hospital (OCH) Bone and Joint Clinic in Starkville. ❒ May
VOL. LII
Official Publication of the MSMA Since 1959
2011
No. 5
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• SCIENTIFIC ARTICLES •
New Technologies for the Management of Major Extremity Wounds
A
Marcus David Walkinshaw, MD, FACS; John Hunter Berry, BS and Andrew James Kochevar, MD
BSTRACT
Soft tissue reconstruction for large or difficult defects, particularly of distal extremities, may be associated with a variety of problems. Crush injuries and infection are often background settings requiring use of considerable resources, time, and skilled personnel for appropriate treatment. Harvested tissue, known as a flap, is used for transferring healthy, viable tissue from one location to the area of tissue loss. Conventional techniques, procedures, and imaging studies used in soft tissue wounds are associated with limitations that often mandate the use of microvascular tissue transfer for lack of a clear alternative. Newer technology, however, may provide an alternative in a significant number of cases. The developments of the perforator flap, digital subtraction angiography, and realtime laser-assisted indocyanine green fluorescent-dye angiography have enabled the use of local tissue for reconstruction heretofore not thought possible. Three cases with distal extremity soft tissue defects were reconstructed using local perforator flaps designed by using these innovative technologies.
KEYWORDS: PERFORATOR FLAP, FLUORESCENCE ANGIOGRAPHY, ANGIOGRAPHY, DIGITAL SUBTRACTION
BACKGROUND
A complex wound, for our purposes, can be defined as one which cannot be closed by simple suture, a skin graft, or even secondary intention. For these wounds a flap, a block of multiple tissues with a preserved blood supply, is often required. AUTHOR INFORMATION: Dr. Walkinshaw is the Chief of Plastic Surgery in the Department of Surgery at the University of Mississippi Medical Center. Mr. Berry is a second year student at the University of Mississippi Medical Center. Dr. Kochevar is a second year plastic surgery resident at the University of Mississippi Medical Center.
CORRESPONDING AUTHOR: Marcus Walkinshaw, MD; Chief, Division of Plastic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216. Telephone: (601) 984-5180 (office) Fax: (601) 984-5183 (mwalkinshaw@umc.edu).
These injuries may involve large areas of soft tissue damage of the distal extremity complicated by extensive crush or infectious insult. Distal extremity wounds have the tendency to suffer from ischemia and succumb to necrosis due to poor circulation. Management of these problems requires large surgical teams and resources. A free flap is defined as movement of tissue and its isolated blood supply from its original location, known as the donor site, to a separate location, known as the recipient site.1 Isolated arteries and veins from the flap are then connected into the circulation at the recipient site using microvascular surgical technique. Historically, this has been the only viable approach when local tissue adjacent to the defect was not available. Over the years there has been a progression in the design of the flaps used for extremity wounds. The extensive blood supply of muscle led to success of the musculocutaneous flap. The musculocutaneous flaps differ from free flaps in that the pedicle (blood supply) remains attached to the donor area. The benefits of musculocutaneous flaps include a consistent known blood supply, versatility in use, and appropriate bulk for large soft-tissue deficiencies. However, limitations have also been encountered. Often musculocutaneous flaps can be too bulky for certain defects. Also, their availability can be very limited for some wounds, particularly in the distal third of the lower leg and around the ankle. This is the application in the extremities where microvascular free flaps have proved most useful, at least until now. Although the blood supply contained in the large muscles is essential for viability of a myocutaneous flap, it was later discovered that isolating the vessels that penetrate the muscle and go to the skin, and excluding muscle tissue, can successfully supply this skin territory on their own1. These “perforators” can then become the sole basis of a successful reconstruction. This type of flap is known as the perforator flap and has some significant advantages. It decreases the morbidity of the donor site by preserving most or all of the underlying muscle. Excluding the muscle reduces the sheer size of the tissue transferred and
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eliminates bulkiness experienced with some musculocutaneous flaps. Another benefit is the flexibility of selection. Flaps can be developed based on perforators at any anatomical site. One just needs a reliable way to find them and know what area any particular perforator is perfusing. Flap design is based on knowledge of perforator location as well as its variations. Imaging studies are often utilized to achieve identification and confirmation. Some instruments used are handheld Doppler probe, Duplex ultrasound, arteriography, magnetic resonance angiography, and high resolution computed tomographic angiography.2 These imaging studies are used not only in Figure 1. Magnified real time Indocyanine green visualization of potential perforator preoperative planning for surgery flap with SPY machine. but also in monitoring vascular compromise after tissue transfer. Though emitted by the diode laser, and this causes excitation of the dye these studies have aided in vessel identification and assessment with fluorescence 745 to 779 nm wavelength.5 This is collected of tissue perfusion, they are also severely limited. None can by a detector and turned into a real time video image. identify a particular perforator and perfusion from that vessel The SPY machine created by Novadaq Technologies, Inc to a particular area, much less be easily and frequently repeated is an intraoperatively imaging system that is based using the while in surgery. aforementioned indocyanine green for fluorescent angiography. Pre-operative planning frequently employs digital subIndocyanine can penetrate deeper into the skin, inducing fluotraction angiography in order to delineate vascular anatomy of rescence from blood vessels within the deep dermal plexus and an injured extremity and where concentrations of perforators subcutaneous fat instead of only the superficial dermis.6 The near the area of injury may be located. Conventional angiogshort half life of 3-4 minutes provides an accurate picture of raphy usually cannot identify vessels as small as the ones in current perfusion. This allows the SPY machine to be used mulquestion here. Bone or dense soft tissue can obscure identificatiple times intraoperatively with no concern of viewing retained tion by regular imaging techniques. Digital subtraction angiogdye from previous administration. Using the SPY angiography raphy allows surrounding dense soft tissue and bone to be system allows visualization of microvascular anatomy and consubtracted out of the image while the contrasted vasculature is firmation of arterial inflow, venous outflow, and perfusion visualized.3 through-out the flap tissues.7 It provides the opportunity to deThere is a high degree of variability at the microvascular sign a successful flap on a particular patient where it has heretolevel, not to mention the areas that these small vessels actually fore been believed that local tissue is unavailable and a perfuse. In the clinical situation in question, crushing extremity microvascular free flap was the only reconstructive option. injuries, tissue perfusion is further altered by the nature of the problem itself.4 Recently, a real-time, light-emitting diodeCASE REPORTS based imaging system has been developed to delineate miCase 1: A 39-year-old male employed as a heavy equipcrovascular anatomy and tissue perfusion. This technology ment operator was involved in a motor vehicle collision resultprovides instant video imaging allowing identification of vessels ing in a severely comminuted right ankle fracture involving the in real-time using indocyanine green as a marker. The dye is an distal tibia and fibula. His additional injuries included left foot approved U.S. Food and Drug Administration fluorescent metatarsal fractures, rib fractures, spine fractures, and mandible marker. Indocyanine green (IC-Green) is a water-soluble dye fracture. The patient underwent three orthopedic procedures to that is excreted exclusively by the liver into the bile and is addebride and eventually perform open reduction and internal fixministered via peripheral or central intravenous access. The ation of his right ankle injuries. Plastic Surgery was consulted near-infrared fluorescence imaging system is positioned over when the patient developed a right ankle non-healing wound the surgical field with a working distance of 18 inches above (Figure 1). On exam, the patient was found to have a 5 cm x 3 the subject. Light of 400 to 650 nm (nanometer) wavelength is
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Figure 2. (Left) Non-healing open wound, 5 cm x 3 cm, overlying right ankle following traumatic fractures and multiple orthopedic debridement and repair procedures Figure 3. (Above) Right lower extremity radiographs demonstrating orthopedic hardware needed to repair multiple fractures Figure 4. (Left) An area identified intraoperatively by laser angiography as having diminished perfusion corresponded to the same area demonstrating difficultly with healing 1 month post-operatively Figure 5. (Bottom left) At two months post-operatively, the patientâ&#x20AC;&#x2122;s wound is almost completely healed
cm area of full thickness skin loss with a wound bed with various stages of inflammation and exudate. Right lower extremity angiogram demonstrated patent 3-vessel runoff to the foot. The Plastic Surgery team performed a posterior tibial artery perforator flap to cover the right ankle defect and a split-thickness skin graft was used to cover the defect resulting from flap mobilization. The posterior tibial artery perforator flap was designed around perforating vessels identified intra-operatively using a combination of Doppler U/S and laser angiography. The flap was then elevated, and laser angiography was used to evaluate the flap before inset. When the distal portion of the flap demonstrated ischemic changes, this segment was excised, but enough flap remained to adequately cover the defect (See Figure 2). After the flap was rotated and inset over the defect, laser angiography identified an area of the distal flap with questionable perfusion, and the Plastic Surgery team elected to observe this portion of the flap. Interestingly, this region corresponded to an area of delayed healing seen post-operatively (Figure 3). A skin graft measuring 0.012 inches in thickness and meshed 1:1.5 was used to cover the flap defect site. Two months following repair,
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the patient’s wound is shown almost completely healed (Figure 4). Case 2: A 16year-old male involved in a golf cart rollover sustained right lower extremity open anterior tibia and fibula fractures. The patient underwent orthopedic surgery for open reduction and internal fixation of his injuries which were complicated by wound necrosis resulting in two chronic, non-healing wounds on the patient’s Figure 6. (Above) Preoperative photo of right lower extremity tibial defects, pre right lower extremity. and (Top right) post debridemont. Two months after the patient’s original injury, Plastic Surgery was consulted for debridement and soft tissue coverage of two areas on the patient’s right lower extremity (Figure 6). Right lower extremity angiogram demonstrated patent 3-vessel runoff to the foot. On exam, the patient was found to have two areas of eschar on the proximal medial and distal anterior surfaces. Following Versajet debridement in the operating room, these areas measured 7 x 14 cm and 10 x 6 cm, respectively. Additionally, the proximal medial wound had exposed orthopedic hardware. A posterior tibial artery perforator flap was designed around perforating vessels identified intraoperatively using Doppler U/S and SPY angiography. The flap was then elevated and laser angiography was used to evaluate the flap before and after inset over the proximal medial wound. The distal aspects of the flap were viable and had adequate blood supply and adequate rotation. Split-thickness skin grafts 0.012 inches thick and meshed 1:1.5 were used to cover the flap defect site and the distal anterior defect site. Following repair, the patient’s wounds are shown healed (Figure 7).
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Figure 7. (Above) Postoperative photo of right lower extremity demonstrating complete healing of repaired areas
Figure 8. (Left) Preoperative picture of left heel ulcer Figure 9. (Above) Postoperative photo of completely healed repair of left heel ulcer
Case 3: An 18-year-old male involved in an MVC suffered a posterior knee dislocation including popliteal artery damage, anterior tibial plateau and tibial shaft fractures and received multiple vascular and orthopedic surgical interventions. The patient experienced left lower extremity compartment syndrome necessitating fasciotomy and subsequent left femoral-topopliteal artery bypass (using right superficial femoral vein) to restore vascular perfusion. Orthopedic surgery performed operative fixation of the tibial shaft fracture, but this was compli-
cated by osteomyelitis (S. Aureus) and nonunion necessitating numerous irrigation and debridement procedures as well as placement of antibiotic beads in conjunction with a prolonged course of intravenous antibiotics. The patient was determined free from infection and demonstrated normal healing bone 5 months after his initial injury at which time Plastic Surgery was consulted for a non-healing wound over the patient’s left heel. On exam, the patient demonstrated a 2 x 3 cm left heel ulcer with full thickness skin loss (See Figure 8). Preoperative angiography verified that the patient had good collateral flow and three-vessel runoff. Intraoperatively, the posterior tibial artery was identified on the patient’s left leg using a Doppler ultrasound and SPY angiography. A 7 x 15 cm posterior tibial artery flap was harvested near the posterior tibial artery perforators on the distal third of the patient’s leg. The flap was elevated from distal to proximal and the perforating vessels were identified at the pivot point of the flap. Then the flap was examined by the SPY machine and determined viable, except for 0.5 cm x 1.5 cm of the distal edge; this portion of the flap was excised. The remaining flap demonstrated viable perfusion under the SPY machine. The flap was then inset and sewn to the underlying fascia. A 0.015 of an inch split thickness skin graft measuring 5 cm x 15 cm in length and meshed to a 1:1.5 ratio was sewn into the defect left by the flap rotation. Postoperatively, the patient’s wound is shown completely healed (Figure 9).
with existing angiographic techniques, reconstruction can confidently be performed using perforator flaps. Using the SPY Intra-operative Imaging System technology, 3 patients with complex distal lower extremity wounds were successfully reconstructed with perforator flaps with no complications. Heretofore, the only reconstructive option for these patients would have been microvascular free flaps requiring far more time, resources, and expense than the relatively simple procedures that we were able to employ here.
With the use of intra-operative laser assisted fluorescence angiography (SPY Intra-operative Imaging System) combined
7.
CONCLUSION
REFERENCES 1. 2. 3. 4. 5.
6.
Blondeel PN, Van Landuyt KH, Monstrey SJ, Hamdi M, Matton GE, Allen RJ, Dupin C, Feller AM, Koshima I, Kostakoglu N, Wei FC. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112(5):1378-1383.
Lee BT, Lin SJ, Bar-Meir ED, Borud LJ, Upton J. Pedicled perforator flaps: a new principle in reconstructive surgery. Plast Reconstr Surg. 2010;125(1):201-208.
Bakal CW, Silberzweig JE, Cynamon J, et al. Vascular and Interventional Radiology, ed 1, Lyons KP (ed) New York, NY: Thieme Medical Publishers; 2002:20-21.
Hallock GG. Lower extremity muscle perforator flaps for lower extremity reconstruction. Plast Reconstr Surg. 2004;114(5):1123-1130.
Matsui A, Lee BT, Winer JH, Vooght CS, Laurence RG, Frangioni JV. Real-time intraoperative near-infrared fluorescence angiography for perforator identification and flap design. Plast Reconstr Surg. 2009;123(3):125e-127e.
Holm C, Mayr M, Höfter E, Becker A, Pfeiffer UJ, Mühlbauer W. Intraoperative evaluation of skin-flap viability using laser-induced fluorescence of indocyanine green. Br J Plast Surg. 2002; 55(8):635-644.
Pestana IA, Coan B, Erdmann D, Marcus J, Levin LS, Zenn MR.Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg. 2009;123(4):1239-1244.
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• SCIENTIFIC •
The Hidden Burden of Atrial Fibrillation on Healthcare Spending and Resources in Mississippi
I
Karen A. Evers, Managing Editor
NTRODUCTION
Despite the high costs and heavy demand for health services associated with atrial fibrillation (AFib), a recently released report suggests that states may not be providing residents with the necessary resources to address and manage this common chronic disease. The Journal MSMA participated in a webinar held March 22, 2011, to release state specific data which illustrates a disconnect between AFib’s impact and the public health resources available. AFib in America: State Impact Reports identifies key stateby-state statistics, resources, and state health department programs related to the burden of AFib. It was written by The George Washington University School of Public Health and Health Services (GWU) and funded by sanofi-aventis U.S. LLC, the sponsor of AF Stat™: A Call to Action for Atrial Fibrillation. The full interactive reports are available at www.AFStat.com. “This report provides an excellent summary in our struggle with one of the newer epidemics. Atrial fibrillation has affected many people around our state and nation,” said Dr. J. Clay Hays, Jr., a cardiologist with Jackson Heart Clinic and MSMA secretary-treasurer. “I can remember when I first started my residency, President George H.W. Bush was diagnosed with it, Barbara Bush had it, and even their dog later developed it. That was in 1991. Since then a number of new medications and procedures have been researched and brought to market. Our own electrophysiologists are also working hard to refine their skills in ablation techniques. The physicians of Mississippi will continue to educate and aggressively treat patients with this condition.” Characterized by a rapid and irregular heartbeat, AFib is the most common form of heart arrhythmia. It affects approximately 2.5 million Americans, and its prevalence is expected to increase as the U.S. population ages.1 It increases risk for stroke by five times,2 worsens other heart diseases,3 and doubles the risk of death.4 Patients with AFib tend to use more healthcare services than patients without AFib, including time in the hospital.5 “Atrial fibrillation is costly and can become debilitating as it worsens, yet it does not share the same priority on the public health agenda that other chronic diseases have,” said Christy Fer-
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guson, Professor, Department of Health Policy, School of Public Health and Health Services, GWU. “This report calls attention to the lack of resources about AFib, alerting policymakers, state health officials, and other health leaders to better educate residents about this common but misunderstood disease.”
SUMMARY
Among the key findings, the reports show that AFib has an immense, but unrecognized, burden. In fact, Medicare payments where AFib was the primary diagnosis totaled almost $2.3 billion in 2007. Nearly half of these costs were related to hospital inpatient stays – a burden specifically felt by local healthcare providers. However, despite the significant health and economic burden of AFib, not a single state has a public health program specifically dedicated to educating or supporting patients with AFib. State-level public health programs that do address AFib tend to include only the disease as a part of stroke and heart disease prevention efforts rather than focusing on the specific risks and consequences of AFib. “Just as patients need to comprehensively manage their AFib, health leaders need to develop and implement comprehensive programs that address the impact of AFib in their home states,” said Senator Bill Frist, MD, former Senate Majority Leader and policy advisor for AF Stat. “The AFib in America: State Impact Reports are an important first step to helping them recognize that need and put an AFib action plan in place.”7 The webinar also introduced AF Stat, the AFib Evaluator (http://www.afstat.com/AF_Stat_Resources/AFib-Evaluator. aspx), an online self-assessment tool with a downloadable desktop widget designed to provide insight into a user’s risk for developing AFib or a diagnosed patient’s baseline knowledge of AFib. The AFib Evaluator serves as an example of the type of patient education tools that AFib patients need but currently lack. According to Senator Frist, these two new resources take on particular significance as federal and state policymakers join private payers to reduce the cost of healthcare. “It may appear that many of AFib’s costs are assumed by the federal government through Medicare, but the disease also inflicts a significant burden at the state level,” he said. “Individ-
ual states feel AFib’s impact on their residents’ health, productivity, and quality of life. Local hospitals and providers often assume the burden of repeated hospitalizations and care for AFib patients. As health leaders work to lower the costs of expensive chronic diseases, AFib must be a part of the discussion.” “Professionally, I diagnosed AFib as a medical student and described its pathophysiology, but I had little understanding of its association with other clinical conditions. As a cardiac surgeon, I appreciated how important it was just after surgery to keep the heart in normal sinus rhythm to maximize left ventricular function and heart performance. But for the most part, other cardiovascular diseases, such as atherosclerosis, heart attack and stroke, overshadowed AFib,” Senator Frist said. “Politically, during my time in Congress (1995 – 2007), I was one of only two physicians in the Senate and was a lead author of legislation for a prescription drug benefit (Part D) in Medicare. Yet, there were no advocates talking to me about AFib, even though the risk for the disease increases with age. In hindsight, I wish we had taken advantage of that opportunity to encourage an earlier dialogue about this costly, progressive disease that disproportionately affects the growing Medicare population,” Senator Frist explained. “Personally, the impact of AFib hit home when two of my immediate family members who had no apparent risk factors for AFib were diagnosed with the disease. My active and upbeat brother-in-law felt discouraged and helpless as he struggled to manage his AFib. In addition, my older brother, physically active throughout his life, grew increasingly frustrated when AFib caused him to limit his daily routine. From my conversations with each of them, I learned that ways to manage the disease were not obvious, and reliable and accurate educational resources were hard to find. It was this personal experience that forced me to re-examine AFib and see that much needs to be done to raise awareness of this disease on the public health agenda. This is why I am part of this initiative,” he said.
IMPORTANCE
Why the urgency? Here are a few key reasons:6 1. High costs. AFib can be costly, driving up health system expenses and increasing hospitalization and emergency care services. Today, because AFib increases healthcare utilization, medical costs for a person with AFib are as much as five times higher than those without the disease. We have to reverse this trend if there is any way we are going to manage the influx of people enrolling in the Medicare program. 2. Worse health. With AFib comes not only an increased risk of stroke but also a deterioration of other cardiovascular conditions. AFib can be a disease accelerator of other illnesses as well. Perhaps most distressing is that people with AFib are twice as likely to die from any cause than those without the disease. The current estimate of 2.5 million Americans with AFib is expected to double as our population ages. Now is the time to better prepare our healthcare system to deal with this chronic disease and improve the quality of life of those with AFib.
3. Life on the sidelines. AFib compromises people’s quality of life, keeping them from enjoying their family and social activities, and can even lead to forced retirement. In fact, one study shows that various measures of quality of life are lower in people with AFib than in those who have suffered a heart attack. AFib in Mississippi: Analysis of a costly and progressive disease7 The report provides a detailed look at how AFib affects Mississippi. It provides selected demographic, cost and healthcare utilization information about AFib patients in the state for the year 2007, the most complete year of data available at the time this analysis was done. Additionally, it provides a listing of state-specific AFib public health resources.
Mississippi Medicare AFibQuick Facts 27,141 —Number of Medicare beneficiaries in Mississippi who used healthcare services due to AFib in 2007 $21.5M —Total payments by Medicare in 2007 in Mississippi for healthcare services due to AFib $5,200 —Average Medicare payment in 2007 in Mississippi for hospital inpatient stays due to Afib
The AFib in America: State Impact Reports7 unveils original data demonstrating the effect of atrial fibrillation on Mississippi’s public health burden. Based on research conducted by The GWU School of Public Health and Health Services, the state of Mississippi has a lower burden of atrial fibrillation measured against the national average. In fact, total Medicare payments in 2007 for healthcare services due to AFib were approximately $21.5 million, or about $7.30 for each Mississippian. Furthermore, the medical and economic burden of AFib is expected to grow as the population continues to age. Given the expected Mississippi state budget deficit in 2011, important decisions will be made about the allocation of public health resources. These AFib statistics serve as a call-toaction for health leaders to prioritize AFib and implement programs, evaluation, assessment and policy changes that will reduce the burden of this costly and progressive disease.
Medicare Population Medicare is the primary payer for healthcare services used due to AFib.8 Using information collected by Medicare to pay for healthcare services provided to Medicare beneficiaries, it is possible to examine use and spending for a broad range of healthcare services due to AFib. Although limited to the Medicare population, these data allow for consistent measurement and comparisons across states as Medicare is a nationwide program. The following statistics and charts highlight the demographics of beneficiaries using services due to AFib, their levels of use of various services and Medicare’s payments to providers for this care.
METHODS
To illustrate the role of AFib with regard to healthcare service utilization and costs in each state, GWU conducted a descriptive analysis of AFib patients using Medicare Standard An-
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alytic Files for 2007, including 5% sample and 100% files. To assess use and costs for AFib patients insured by other payer types, GWU supplemented the analysis with data on hospital inpatient stays using 2007 discharge data for all payers from State Inpatient Databases compiled by the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality.8 GWU conducted this analysis for 25 states for which these data were available for public use.9 To determine which state AFib-related programs were available at the state level, GWU:10 • Reviewed the literature published between 2000 and 2010 concerning state efforts related to public awareness of AFib and whether there are best practices for public health programs for AFib. • Reviewed materials from Medicare, federal initiatives (CDC, NIH), and state health departments in all 50 states and the District of Columbia. • Evaluated data sources including standard legal databases, CDC and NIH programs, and publicly available state program resources. • Examined all 50 state websites. • Contacted state health officials to confirm website findings and request any additional written information.
AFIB PUBLIC HEALTH RESOURCES FOR MISSISSIPPI
The Delta States Stroke Consortium (DSSC) The University of Alabama School of Public Health serves as coordinator of DSSC. Funders include the Alabama Department of Public Health and the U.S. Centers for Disease Control and Prevention. Member states include Alabama, Arkansas, Louisiana, Mississippi and Tennessee. The Delta States Stroke Consortium (DSSC), a five-state collaborative effort, brings together academic, government, business, and community leaders to identify and address factors associated with the high rate of strokes in the Southeast. 11 • The TriState Stroke Network Website describes risk factors for stroke and links to the American Stroke Association Risk Assessment Form, which includes AFib.12 • Delta States Stroke Network, Stroke Awareness and Education Toolkit denotes AFib patients as high risk for stroke. The toolkit provides resources and information for healthcare providers including risk factors, signs, symptoms and treatment protocols.13, 14 Contact Information: Division of Public Health 1915 Mail Service Center Raleigh, NC 27699 (919) 707-5360 http://www.tristatestrokenetwork.org Mississippi Department of Health, Heart Disease and Stroke Prevention Program The mission of the Heart Disease and Stroke Prevention Program is to implement heart disease and stroke prevention interventions to reduce morbidity, mortality, and related health disparities. The Heart Disease and Stroke Prevention staff addresses this mission by working with partners to educate, implement policy, and make system changes to increase heart
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disease and stroke prevention with emphasis on our six program priority areas. • The Mississippi Heart Disease and Stroke Prevention Program Website links readers to the home pages of national heart disease and stroke organizations that produce AFib resources. • The Heart Disease and Stroke Prevention Program Website includes a link to the Delta States Stroke Network, Stroke Awareness and Education Toolkit. The toolkit provides resources and information for healthcare providers including risk factors, signs symptoms and treatment protocols.15, 16 Contact Information: MSDH Heart Disease and Stroke Prevention Program 570 East Woodrow Wilson Drive Jackson, MS 39216 (601) 576-7781 http://msdh.ms.gov
SUMMARY
AFib: Time For Action There is a lack of urgency to change the status quo surrounding AFib, according to interviews with the broad spectrum of organizations and individuals participating in AF Stat™: A Call to Action for Atrial Fibrillation. These interviews revealed that this lack of awareness might be due to the following key barriers: • Limited understanding about the array of potential AFib consequences, including disease progression from episodic to a permanent state, structural and electrical remodeling of the heart, worsening of other cardiovascular diseases, increased hospitalizations and/or death — Often, key stakeholders do not fully understand the health risks associated with AFib and the importance of comprehensive management. — Currently available information about AFib is not adequately reaching or sufficiently educating patients. • Disconnected dialogue between AFib patients and healthcare professionals about the disease, including its symptoms, management and treatment options — Restricted time with patients is a widespread and ongoing problem in our healthcare system and prevents healthcare professionals from having detailed discussions with patients. Experts believe this is exacerbated in the treatment of patients with AFib due to the complexity of AFib management and the high prevalence of co-morbidities that often take precedence in patient/physician discussions. • Lack of comprehensive and consistent management across medical practices and specialties treating AFib patients — Competing priorities in managing cardiovascular disease make it difficult for healthcare professionals to manage AFib comprehensively and often result in an exclusive focus on stroke prevention. — Professional organizations note that caring for the AFib patient is complex, requiring a clear management plan across multiple providers. Overall, experts interviewed agreed there is a need for enhancing the availability of and access to education, resources and tools to help improve the AFib understanding, dialogue and management.
AF Stat™: A Call to Action for Atrial Fibrillation is a collaboration between healthcare leaders and organizations working to improve the health and well-being of people affected by atrial fibrillation. AF Stat will raise awareness of AFib as a complex, costly, progressive and often debilitating disease. It will call for and help promote a change in attitudes and behaviors to enhance AFib understanding, diagnosis and management. AF Stat is an initiative sponsored by Sanofi-Aventis U.S. LLC. Some healthcare professionals and experts providing information on this site are retained and compensated for their services by Sanofi-Aventis U.S. LLC.
About the AF Stat Report Series The AF Stat Report Series is designed to better illustrate the burden of atrial fibrillation and to address the four priority areas recommended by the AF Stat Call to Action document: policy and advocacy, management, education and quality. The fourth report in this series, AFib in America: State Impact Reports, was written by GWU and funded by Sanofi-Aventis U.S. LLC, which is the sponsor for AF Stat: A Call to Action for Atrial Fibrillation. It is designed to help health leaders measure the prevelance and impact of AFib on Medicare spending and state health resources; define health service utilization patterns surrounding AFib; and identify state-based programs to manage the disease. GWU maintained editorial control and the conclusions expressed in the report are those of the author.
REFERENCES 1.
2. 3.
4. 5. 6. 7. 8. 9.
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Go AS. “Prevelance of Atrial Fibrillation in Adults: National Implications for Rhythm Management and Stroke Prevention: The Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.” JAMA. 2001 May 9;285(18):2370-5.
Wolf PA, Abbott RD, Kannel, WB. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke. 1991;22;983-988.
Fuster V, Rydén LE, Cannom DS, et al.ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114: e257-e354.
Benjamin EJ, Wolf PA, D’Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: The Framingham Heart Study. Circulation. 1998;98:946-952.
Lee W. Lamas G. Balu S., et al. “Direct treatment cost of atrial fibrillation in the elderly American population: a Medicare perspective.” J Med Econ. 2008;11:281-298.
Foreword to AF Stat website. Available: http://www.afstat.com / docs/ pdf/AF%20Stat%20Call%20to%20 Action_Foreword.pdf . Accessed April 11, 2011.
AFib in America: State Impact Reports. Available : http://www.afstat .com /Docs/Pdf/AFib_State_Impact_Reports.pdf. Accessed April 10, 2011.
Sullivan, E et al. (September 2010). Health Services Utilization and Medical Costs Among Medicare Atrial Fibrillation Patients. Washington, DC: Avalere Health. Avaiable: http://www.afstat. com/AF_Stat_Resources /Health_Services.asp.
HCUP State Inpatient Databases (SID). Healthcare Cost and Utilization Project (HCUP). 2007. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/sidoverview .jsp. Accessed February 8, 2011.
10. The states included in our HCUP SID analysis are: Arizona, Arkansas, California, Colorado, Florida, Hawaii, Iowa, Kentucky, Maine, Maryland, Massachusetts, Michigan, Nebraska, Nevada, New Jersey, New York, North Carolina, Rhode Island, South Carolina, South Dakota, Utah, Vermont, Washington, West Virginia and Wisconsin.
11. Delta States Stroke Consortium. Available: http://www.tristatestroke network.org/deltapage.html. Accessed October 19, 2010. 12. American Stroke Association. Stroke Risk Assessment Form. Available: http://www.tristatestrokenetwork.org/media/riskassessment.pdf. Accessed October 19, 2010. 13. Delta States Stroke Network. Stroke Awareness and Education Toolkit for Health Care Providers. Available: http://www.healthy.arkansas. gov/programsServices/chronicDisease/HeartDiseaseandStrokePrevention/dssNetwork/Documents/ResourcesTools/DSSNStrokeHealthcareProviderToolkit.pdf. Accessed October 19, 2010.
14. Delta States Stroke Network. Stroke Awareness and Education Toolkit for Health Care Providers. Available: http://www.healthy .arkansas. gov/programsServices/chronicDisease/HeartDiseaseandStrokePrevention/dssNetwork/Documents/ResourcesTools/DSSNStrokeHealthcareProviderToolkit.pdf. Accessed October 19, 2010. 15. Mississippi State Department of Health. Heart Disease and Stroke Prevention Program. Available: http://www.msdh.state.ms.us/msdhsite/_static/43,0,297.html. Accessed October 16, 2010.
BRANDON BYRAM CANTON CLINTON JACKSON LAUREL MADISON PEARL RICHLAND RIDGELAND
We look forward to hearing from you! Toni Jordan 601-898-7535
Rachel Williamson 601-898-7527
1-800-844-6503 Recruiter@mms-ms.com
17. Delta States Stroke Network. Stroke Awareness and Education Toolkit for Health Care Providers. Available: http://www.msdh. state.ms.us/msdhsite/_static resources/3904.pdf. Accessed October 19, 2010.
18. Delta States Stroke Network. Stroke Awareness and Education Toolkit for Health Care Providers. Available: http://www.msdh. state. ms.us/msdhsite/_static/re sources/3904.pdf. Accessed October 19, 2010.
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• PRESIDENT’S PAGE •
Dad / PawPaw
y tour as your President is over and so are these writings but the work of this Association never ends. I pass the torch to Tom Joiner, whom I have known since childhood. He brings his unique strengths to this Association. He will need strength! Charmain Kanosky, your able and talented Executive Director, has repositioned the office of your Association to handle the formidable challenges ahead. Your login number for this Association’s website is the same as your membership number on the card you receive every year. Use this number! Get engaged. The following is the eulogy that I delivered at my father’s funeral (John M. Alford, MD) nearly three years ago. He is the reason that I went to medical school. He was not big on organized medicine. Actually, at one point he resigned his membership to this Association. It was Ed Hill who convinced him to reconnect. Despite his renewed membership, he remained a most vocal critic. Thank you to all the family for allowing me this opportunity to say a few words from TIM J. ALFORD, MD the family on Daddy’s behalf – particularly to my siblings John, Helen, and Peter. We were children of the ’50s and ’60s: fringe baby boomers. We were a curious band 2010-11 MSMA PRESIDENT of kids and often found ourselves experiencing a firm hand. And guess whose hand we got? The rod was spared but the fingers from a size nine hand were applied. The thump on the head was quick and decisive. When the concussion wave ended, you found yourself seriously re-evaluating whatever situation it was that you had just disturbed. Those hands! When you saw Dad coming down the hall with those long arms, it looked as if he were holding two smoked hams. Those same hands delivered babies, set bones, and repaired fractured hips. I can remember Dad grasping son-in-law Bob Redding’s round face and pushing his broken nose back into place with his thumbs…the sound was unforgettable. It was my errant elbow that broke Bob’s nose in a pick-up basketball game played in our driveway at 709 River Road in Greenwood. Dad’s signature wave while driving was to raise his index fingers. Therefore, they were not only hands of authority but they were hands that welcomed and comforted. These same hands built three sailboats; the most notable was the Mandala – a 32-foot wooden masterpiece. The keel for the Mandala was laid in a cotton warehouse in Greenwood. He built it on the banks of the Yazoo River and after five years of construction it was launched and navigated down the Yazoo into the Mississippi to Vicksburg, Baton Rouge, New Orleans, and finally through the south pass of the Mississippi River where it was finally moored in Ocean Springs. The Mandala survived Hurricane Camille. On it, we vacationed and experienced the power and ferocity of nature. Dad taught us to tie knots and we did some serious problem solving in tight situations. We learned tolerance for each other in close quarters on the Mandala and a greater respect for authority, from not only our father but our Captain as well. When the sailing was good, Dad would start into song with his rendition of ‘Casey Jones,’ which he had learned during his childhood, having everything to do with a train and nothing to do with a boat. We didn’t just sail around in the bay. We took trips into the Gulf of Mexico in high seas. I can remember one August squall losing the mast into the drink as we took on its headwinds. Peter and Dad heaved all the sail and rigging back on board in 6-8 foot seas, while key members of the crew were losing their lunch over the side. Dad stood up against social and racial injustice during a most difficult time in our nation’s history. He wrote in his memoirs of the courthouse meeting organized by Byron De La Beckwith who, as you will recall, was later convicted of murdering Medgar Evers. This meeting was organized on a local level to run against the recent court rulings in favor of desegregation. Our high school football coach, Hollis Rutter, now in the Mississippi Sports Hall of Fame, courageously spoke at the gathering saying, ‘My job is to engineer sportsmanship and to teach boys to play the game of football. If they want to learn, I will teach them. I don’t care if their skin is black or white.’ Dad rose in this same town meeting speaking of the friendships that his children had already forged with our black fellow students making it clear that we would not follow the majority to the private academy. This was not a popular position in the community. As for his calling and vocation, medicine, Dad was saddened to see it taken over by big business. He used to say that medicine was oversold and overbought and that the doctor-patient relationship was a sacred trust. He believed this trust was being eroded. As most of you know, Dad was a voracious letter writer, and in one of his letters, he wrote about the doctor – patient relationship, ‘ Caring finds its golden opportunity where person meets person. Empathy of one with another creates the doubly fertile seed that grows into a gift given a gift received. That is the essence of healing. The caring mystery perforates flesh, mind, and spirit – a binder that cannot be institutionalized.’ Dad loved his family. During John’s college days, he kept John on course after a rather rocky start at Mississippi State. In large part, it was Dad’s compass that enabled and encouraged John to go on to dental school. He was so proud to later have John practicing dentistry in Greenwood for several years.
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He was surely proud of his only daughter, Helen, and shared a love for music with her. I remember his joy when he listened to her senior recital at Southwestern, now Rhodes College, laughing aloud because he thought Bella Bartok’s composition was funny. We were embarrassed, but he couldn’t understand why we weren’t laughing, too. Peter was supposed to have been, according to Dad, the strapping athlete – a slight miscall on Dad’s part. Even in his last year though, he would often ask, ‘ Have you heard from Peter?’ He shared Peter’s love for the water and sailing. Not too long ago while at the VA Nursing Center, Dad had reached the later stages of his dementia and I found him pulled up against the hall handrail at the VA ‘ tying off the boat.’ He was telling Peter that he was doing it wrong. And Wentris, now almost 28 years of marriage – it is hard to believe. How wonderful you were with Dad, especially during the most difficult and challenging phase of his life. I know that you loved him deeply, and he loved you as well. His ten grandchildren: Daniel, Kate, Jenny, Timothy, Tyler, Leah, Davis, Amy, John Paul and Conner, I know that PawPaw was proud of each of you, and I trust with time you will each come to value increasingly his uniqueness. Dad was not too big on organized religion; in fact, at times he was rather cynical about it. He knew too well the hypocrisy that is in all of us. Yet he searched as all of us do and so religion was deep within him – not worn on his sleeve. As many of you will recall, Dad was a student of the Swiss psychologist and philosopher, Carl Jung. Carl Jung was definitely a chief agent in Dad’s search for meaning upon this earth. Jung once wrote, ‘ I could not say I believe. I know! I have had the experience of being gripped by something that is stronger than me – something that people call God.’ Dad frequently alluded to such a holy feeling while sailing. Later in life, Dad developed a curiosity for the Wesley brothers who were the founders of what we now know to be Methodism and composers of some of the most famous hymns we often sing. (In some of his letters and writings, I stumbled across the best summation statement of why I think Dad was so pre-occupied with Carl Jung.) Only Dad could connect the Wesley brothers and Carl Jung. Dad wrote, ‘Jung’s spiritual archetype (what he was describing as spirit) was exhibited in the dying words of the Wesley brothers’ father, April, 1735, who told his sons, “The Christian faith will survive. You shall see it though I shall not. The inward witness, son, the inward witness – that is the strongest proof of Christianity.”’ I believe Dad thought you simply have to get things right in your own heart. And if there is a silver lining in the late phases of his illness I think that his religious spirit was a witness to others. The charge nurse at the VA would say, ‘ All I got to do is start “I’ll Fly Away” and he takes over from there – all four verses.’ He also loved to sing ‘Amazing Grace’ and ‘I Need Thee, Lord, I need Thee.’ Of course some of this singing was inspired by his very kind VA roommate, a former evangelist, who played gospel music all day long. Dad’s last admission to our local hospital about two weeks ago (September 2008) was most remarkable. I was sure that he was about to die then. I felt that he had reached the terminal stages of his illness and he would not respond to anything or anyone. Sunday morning after his Saturday night admission I was standing by his bedside with Wentris and called to him. There was no response. Wentris said, ‘John, Tim is here – can you say anything?’ No response. I indicated to Wentris that I would need to make rounds since I was on call that day and as I left his room I stopped in my tracks – what I heard was the old familiar ‘Casey Jones,’ all three Ryan Hutchison, MD, a Nashville verses.
“Casey Jones”
“Come all you rounders if you want to hear The story of a brave engineer Casey Jones was the rounder’s name On the big six wheeler boy He made his fame.
internal medicine physician, painted this watercolor from a photograph of Dr. John Alford, who learned the art of casting net in the marshes of Southeast Louisiana while growing up.
‘ Well, I’ll be!’ Wimpy Winters, an experienced ICU Well, they called Casey nurse, witnessed the whole Bout half past four thing standing at the door. He kissed his wife at the station’s door I like to believe that at this He stepped into the cabin with his orders moment Dad was hearing a In his hand chorus from ‘the other side.’ In the bass section, I can see his old friend, Walter Walt – Said I’m gonna take my trip to the Promised Land. what a character. Dad wrote about a conversation that he had with Walter Walt – the only place you could put him is in the bass section. Walter’s lovely wife, Elizabeth, was Casey Jones stepped into cabin Casey Jones orders into his hand also among the River Road gang that included Howard and Elma Nelson, Reed and Casey Jones stepped into his cabin Evelyn Carroll. His older sister, Beryl, was playing the organ and Uncle Ez, his brother, Said I’m gonna take a trip to the Promised Land.” singing tenor. I also see Bob Hodges, Speedy Thorpe, and Van Arnold, who worked on Dad from the Protestant side and Monsignor Chatham from the Catholic side, and the many that throughout his fifty years of medical practice he had helped to step into the cabin to prepare for the Promised Land. This rendition of Casey Jones he sang softly, clearly, and lightly. As my sister Helen would say, it was done poco allegro. It was no dirge. It was done unmistakably in a spirit of celebration. His search was over and he was ready for the Promised Land. As far as I am concerned, Dad has added a new hymn to the Wesley collection of hymns. So thanks, Dad, for life itself – moreover for the spiritual thump on the head that you imparted to all of us that causes each of us to think, to challenge social injustice, to meditate and to pray and moves us toward a more abiding faith in our Creator.
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JOURNAL MSMA MAY 2011
• EDITORIALS •
Joseph and Jefferson Davis, The Community Health Centers, Mississippi, and 11 Billion Dollars
T
Richard deShazo, MD, Associate Editor
COMMUNITY HEALTH CENTERS: A GROWING CLINICAL AND ECONOMIC FORCE IN MISSISSIPPI
he healthcare reform package of 2010 provides 11 billion dollars for expansion of community health centers in the United States.1 Few people know what community health centers are, how they function and how they will influence the way health care is delivered in the future. Fewer know that the concepts of community centers were profoundly influenced by historical events in Mississippi. The 21 federally qualified community health centers (FQHC), 157 rural health centers and 6 Indian health centers in Mississippi are a health resource for poor and rural patients and a growing financial force in the state. And believe it or not, the roots of community health centers can be traced to the Davis Bend plantations of Joseph and Jefferson Davis below Vicksburg.
JOSEPH DAVIS’S DREAM
Joseph Davis, like most successful white southerners of his time, considered owning a plantation the pinnacle of success. By 1818, he was already a successful lawyer in Natchez and had accumulated 11,000 acres of low land within a bend in the Mississippi River, some 20 miles below that city. Shortly thereafter, Davis visited with the Welsh social reformer, Robert Owen, during a stagecoach ride to New York.2 Davis was familiar with Owen’s essays in A New View of Society and subsequently incorporated many of the utopian ideas Owens had pioneered at New Lanark Mills in Scotland and New Harmony in Indiana into the operations of his new plantation, Hurricane.3 These were progressive ideas for the time and included programs for education, self governance, preventative medicine, healthcare and job training for slaves. An infirmary with slave caregivers and contract physicians from the community was established at Davis Bend early on. Subsequently, Joseph helped his brother Jefferson Davis establish his own plantation, Brierfield, at Davis Bend. Joseph stayed put while Jefferson Davis continued to travel in the military service and later serve as a Mississippi member of the US House of Representatives and, later, the US Senate. He needed help to keep things moving at Brierfield while he was away. Enslaved Africans, present in Mississippi since they were first bought by the French to build Natchez, were plentiful and relatively inexpensive. In 1837, Joseph bought Benjamin Montgomery, a 12-year-old slave, at Vicksburg and gave him to his brother Jefferson, who was home on leave from a US cavalry unit.4 Jefferson Davis took him to be his body servant and subsequently “private secretary” and taught him to read, write, and do accounting, much to the consternation of local planters. Over time, Benjamin Montgomery assumed numerous management roles on the Davis plantations including operation of a plantation store and ultimately manager of the entire Brierfield plantation. During the Civil War when Joseph served as Brigadier General in the Army of the Confederacy and Jefferson moved from Montgomery, Alabama, to Richmond, Virginia, as President of the Confederacy, Montgomery became the on-site manager for both of the Davis brothers. To the further consternation of their neighbors, the Davis brothers sold their plantations at Davis Bend to Benjamin Montgomery and his sons for $300,000 before the fall of Vicksburg to prevent federal confiscation. Montgomery then operated the plantations as a freedman’s colony with citizen governance under his management. The history and successes of the colony at Davis Bend and Ben Montgomery’s role in it were featured in a New York Times article in September of 1893.4 It functioned throughout Reconstruction under the protection of the Freedman’s Bureau and until 1873 when the Davis family regained title to the property. At that time, the Montgomerys and the majority of the “colonists” left Davis Bend to join the southern exodus of freedmen to points north as Jim Crow continued to march across the South.
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Figure 1. Isaiah Montgomery who founded Mound Bayou, Mississippi with his brother Thornton and his cousin Ben
Figure 2. Left to Right: Walter Lear, MD, Robert Smith, MD, and J.S. “Mike” Holloman, MD, picket the AMA meeting in Atlantic City, N.J. in 1963
MOUND BAYOU
Benjamin’s sons also had financial success as entrepreneurs at Davis Bend (Figure 1). After their exodus from Davis Bend, Isaiah and Thornton Montgomery and their cousin Ben Green purchased 840 acres of undeveloped bottomland in the Mississippi Delta at a place called Mound Bayou along a new railroad right of way in 1887.5 They cleared the swamp for planting there as other freedmen arrived to help. The all black community that developed from that startup was initially successful. Resident-owned farms, homes, businesses, a bank, medical offices, and a mill were constructed. The success of their efforts along with a number of photographs was published in a second New York Times article in June of 1910.6 Opening of the mill was celebrated in 1912 with a visit from George Washington Carver. Hospital services were limited for Mississippi African Americans at this point, but there were 2 in Mound Bayou, the Sarah Brown and the Taborian Hospitals. The Taborian Hospital, supported by the black fraternal order, the Knights of Tabor, opened at Mound Bayou in 1942 with TRM Howard, MD as chief of surgery. A system of pre-paid health insurance was implemented as had been done at the Afro-American Hospital in Yazoo City, founded in 1928, and was a forerunner of the health maintenance organization (HMO) concept.7 In 1956, after receiving threats for criticizing the FBI’s investigation of Emmitt Till’s death, Dr. Howard left Mound Bayou. This was a major blow to the Taborian Hospital, but it remained in operation through the civil rights era in Mississippi when Mound Bayou was increasingly troubled by out migration of educated descendants, a series of crop failures, fluctuation of commodity prices, and retribution for civil rights activities there. However, Mound Bayou would soon come to influence the future of American medicine again.
FREEDOM SUMMER AND THE MEDICAL COMMITTEE FOR HUMAN RIGHTS
Dr. Robert Smith was raised on a prosperous family farm in Terry, Mississippi. He was a Tougaloo College and Howard Medical School graduate who was called back to Mississippi in 1962 from his residency in Chicago by his local draft board to await military deployment late in the Berlin Crisis. While waiting for the deployment which never occurred, he became active in civil rights activities taking place in Jackson and participated with other local black physicians in forming a group which eventually became the Medical Committee for Human Rights (MCHR).8 In June of 1963, he joined others to picket the American Medical Association meeting in Atlantic City in order to force state medical societies in the South to admit black physicians to the membership (Figure 2). Local medical society membership was required to obtain hospital privileges in private hospitals but denied black physicians returning to Mississippi from state sponsored training at Meharry, Howard and Morehouse medical schools.9 In 1964, following the murders of Michael Schwerner, Andrew Goodman, and James Chaney near Philadelphia, the state was flooded with civil rights advocates from around the world for “Freedom Summer.” Most Mississippi physicians refused to provide medical care for them fearing retribution by the Ku Klux Klan, White Citizen’s Councils, and the state Sovereignty Commission. A call for medical support help was sent to physicians in the north by the MCHR of which Dr. Smith had become the Southern Field Director. Ninety-eight doctors, nurses, social workers, and medical administrators quickly arrived in Jackson for deployment throughout the state.9 Two white physicians, Jack Geiger, a fellow in epidemiology at Harvard Medical School, and Count Gibson, Chair of the Department of Preventative Medicine and Community Health at Tufts Medical School, were among the volunteers. Dr. Smith became friends with these men at orientation sessions he conducted at the Central Methodist Church in Jackson and subsequently assisted them in the establishment of the Mileston Clinic in Holmes County. Geiger and Gibson became increasingly exasperated at
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the lack of access to medical care for the sick poor in Mississippi and discussed possible solutions with other MCHR members. Geiger recalled the community-based health clinics he had seen during travels to South Africa, and the group shared experiences at the Mileston Clinic. At a meeting of the MCHR in Greenville in December of 1964, there was consensus to push forward with development of community healthcare in the United States where local clinics would be governed by a board of directors of patients and offer team-based support for medical care, sanitation, food, and social services. With the establishment of the Office of Economic Opportunity (OEO) early in the administration of President Lyndon Johnson, Geiger, Gibson, Smith, and others presented their proposal for health centers with community governance at Sergeant Schriver’s OEO Director’s office. They proposed 2 model clinics, an urban community health center in Boston and a rural health center in a “southern state.” Mound Bayou was the desired site of the rural clinic because of Mound Bayou’s connections to black history, long involvement in civil rights, and the struggling medical establishment there. Hoping that medical schools in the Deep South could have easy access to federal OEO dollars, southern members of Congress inserted a stipulation in the OEO enabling legislation that a governor could not veto OEO grants for community health centers affiliated with an academic health center. This exception provided the loophole that trumped gubernatorial vetoes of community health center funding in Mississippi until the gubernatorial veto option was no longer available.
THE MOUND BAYOU CLINIC OPENS
President Johnson signed the OEO-enabling legislation in 1965, and Tufts Medical Center immediately submitted grant applications for the Boston and Mound Bayou centers. The Mound Bayou center was funded as the first rural community health center in the US under the legislation and Figure 3. Location of Community Health Centers in Mississippi opened in a church parsonage in Mound Bayou in 1967.10 Dr. Helen Barnes, a Mississippi native obstetrician/gynecologist was recruited to join the full-time clinic staff the same year. Dr. Robert Smith, and subsequently Dr. Aaron Shirley, who had been the first black pediatric resident in the UMC pediatric training program, commuted from Jackson to assist. Federal dollars poured in and by 1969 the Wall Street Journal published an article on the 4,000 square foot Tufts Delta Health Center then staffed by 5 MDs, 6 social workers, 10 registered sanitarians, and a host of nurses.11 The center not only treated illness but also worked to secure safe water, plumbing and sewage, eradication of round worm infection, decreases in infant mortality, and immunizations. Medical students from Tufts, Howard and Meharry and other medical schools rotated there. After the Mound Bayou clinic was operational, Drs. Smith, Anderson, and Shirley subsequently established the Jackson-Hinds Community Health Center in Jackson in 1970. Daniel Rumsfeld, Director of OEO at the time, over-rode the governor’s veto. Recently, the University of Mississippi primary care residency clinics at the Jackson Medical Mall came under management of the Jackson-Hinds Community Health Center through a cooperative agreement with the University of Mississippi Medical Center.
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• EDITORIAL •
THE HEALTH REFORM PACKAGE AND COMMUNITY HEALTH CENTERS
The healthcare reform package of 2010 contained a total of 11 billion new dollars for community health centers over 5 years starting in 2011 (Table 1). In addition to funding for operations, the package includes 1.5 billion dollars for expansion of existing facilities and construction of new buildings. This supplementary funding was made to help accommodate the influx of previously uninsured or under-insured patients who will now receive health insurance into the health system. This is estimated to be between 300,000 and 400,000 people in Mississippi. Twenty-one FQHCs in Mississippi provide healthcare at 170 sites, including sponsored satellite clinics, school based clinics, homeless clinics and mobile units (Figure 3). Table 1
Community Health Center Operations Funding, 2011-2015
Fiscal Year
Trust Fund +
FY 2011 FY 2012 FY 2013 FY 2014 FY 2015
$1 Billion $1.2 Billion $1.5 Billion $2.2 Billion $3.6 Billion
Discretionary Funding (est.) $2.19 Billion $2.19 Billion $2.19 Billion $2.19 Billion $2.19 Billion
Total Annual Funding (est.) $3.19 Billion $3.39 Billion $3.69 Billion $4.39 Billion $5.79 Billion
Total Annual Increase $1 billion $200 million $300 million $700 million $1.4 billion
+ New dollars allocated in 2010 health reform package. The package also authorized permanent funding of the program at increased levels 2010-2015 and subsequent increases based on a formula. Source: National Association of Community Health Center Bulletin. Health Centers and Health Care Reform: Health Center Funding Growth. April 2010. www.nachc.org
HOW WOULD JOSEPH DAVIS FEEL ABOUT ALL OF THIS?
Robert Owen ended up being labeled a socialist and atheist by detractors and a genius by supporters. Although other plantation owners disliked the utopian ideas of Owen adopted by the Davis brothers at Davis bend, the Davis family’s standing and the subsequent destruction of the plantation system during the Civil War shielded the family from the angry criticism experienced by Owen. New Lanark, New Harmony, Hurricane, and Brierfield all failed, and Owen and the Davis brothers spent their later years far from the adulation that their previous wealth and positions had earlier afforded them. Nevertheless, the fact that they cared for those less favored than them and sought to provide opportunities for people thought unworthy by others was meritorious. The history of the community health movement in the United States is shared by the Davis brothers, the Montgomery family, Mississippi’s civil rights struggle, and courageous black and white physicians like Drs. Smith, Geiger, and Gibson who gave operational structure to President Johnson’s War on Poverty. Now, it is a pivotal component of the health reform legislation of 2010 and the future of our healthcare system.
REFERENCES
1.
http://www.healthcare.gov/news/factsheets/increasing_access_.html
2.
Hermann JS. Joseph Davis: Pioneer Patriarch University Press of Mississippi. 2007.
4.
Anonymous, Story of Ben Montgomery. Jefferson Davis’ Private Secretary and Slave. New York Times, Sept 17, 1893.
3.
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8. 9.
Harrison, JFC. Quest for the New Moral World: Robert Owen and the Owenites in Britain and America Routledge, New York. 2009. Hermann, Janet Sharp. The Pursuit of a Dream. The University of Mississippi Press, Oxford, MS. 1999. Arnold TH. Ex-Slaves Dream of a Model Negro Colony Comes True. New York Times, June 12, 1910.
Beito DT, Beito LR. Let down your bucket where you are: The African American hospital and black healthcare in Mississippi 1924-1966. Social Science History 2006; 30: 551-569. Robert Smith, MD. Conversation with the Author, March 2011.
Dittmer J. The Good Doctors. The Medical Committee for Human Rights and the struggle for social justice in health care. Bloomberg Press. NY 2009.
10. Maxwell, N. The Ailing Poor. Medical Team Combats Negroes Dismal Health in Mississippi Delta. Wall Street Journal. Jan 14, 1969.
11. Lefkowitz B. Community Health Centers. A Movement and the People Who Made It Happen. Rutkers University Press. New Brunswick NJ. 2007.
ACKNOWLEDGEMENTS: The author thanks Leigh Wright, BA, UMC Research Librarian, Helvi McCall Price, BA, Michael Jones, BSN, RN, and Robert Smith, MD for assistance in preparation of this manuscript.
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• SPECIAL ARTICLE • Impressions of Rural Medical Care in Kenya
A
Philip L. Levin, MD
THE KEUMBU SUB-DISTRICT HOSPITAL
merica has the most advanced medical care in the world: sophisticated diagnostics, therapeutics, and interventions. Being immersed in the system, we can become distracted by our amazing technological achievements, losing focus on the patient’s needs. In September 2010, I spent three weeks providing medical care in a Kenyan rural hospital where there was no x-ray machine, a choice of only two IV antibiotics, and, most daunting of all, no running water. “Keumbu Sub-District Hospital” near Lake Victoria in western Kenya provided care with thirty ward beds and an outpatient clinic treating about a hundred patients a day. There were no actual physicians at the hospital. The head matron, Beatrice, was trained as a Gulfport board-certified emergency medicine physician Philip L. Levin, MD was placed in Keumbu, Kenya by an aid agency out of New Zealand, the first doctor ever to be physician assistant though she stationed there. Keumbu is just south of Kisumu near Lake Victoria. Swahili was universal, didn’t provide patient care. The but since Kenya was a British colony English was common. Occasionally the patients spoke “hands-on” care was provided by only their tribal languages. two physician assistants, two nurses, and a small cadre of medical assistant students. A midwife provided obstetrical care. There was a surgery theatre but no surgeons. In typical African style, the hospital featured open windows without screens, wide breezeways, and rooms without doors. The lab, pharmacy, and cashier office shut and locked their doors only at night. Shaking hands was a routine custom even in the hospital where no one washed. Due to the shortage of staff, standard nursing care was unreliable. Medications were often missed, vital signs were rarely taken, and when sheets were dirty, the patient moved to another stretcher, the old sheets being washed in the creek and hung on the line to dry. I trained a couple of the students on how to take blood pressure on the hospital’s old mercury column sphygmomanometer. This was a government hospital with free family planning services that included condoms, depo-provera shots, birth control pills, and IUD insertions. All prenatal visits were free as well as any care provided for a child under five. The immunization schedule was similar to America’s with the addition of Yellow Fever. For adults, daily hospital costs were $1.80 US a day. If you couldn’t pay for your hospital stay, you were “locked in” – not allowed to leave until you paid your bill. The walk-in clinic charged twenty-five cents for evaluation. Dental care ran sixty cents for exam, $1.80 for fillings, and $3 for extractions.
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The most amazing person at the hospital was the cook, a fellow providing three meals a day for all the hospitalized patients. Working from a dirt-floor kitchen without electricity or water, he cooked over two wood chip stoves using a half dozen blackened pots and pans. Not surprisingly, none of the staff took their meals out of the hospital’s kitchen.
HOSPITAL ROUNDS AND AMBULATORY CARE
Patient care began at 9 am with one of the physician assistants running hospital rounds and the other opening the clinic. The spectrum of diseases ran heavily into tropical infections, agents I had rarely seen since I studied them 35 years before in medical school: malaria, typhoid, brucellosis, scrub typhus, and leprosy. We also had our share of TB, AIDS, and the types of problems seen everywhere: trauma, asthma, and diabetes. An adolescent with a seizure disorder had fallen into The medical care was provided by Dr. Angela Onsongo a fire. Like many of our patients, he couldn’t afford his (right). She had a 3 year degree and one year internship, had medication, consequently having six seizures daily. Once we been there 3 years, and basically ran the hospital. The other started him on Dilantin, he immediately became seizure free. P.A., Dominique, had finished his training and was waiting for the government to assign him an internship. Unable to work In the outpatient clinic, three out of four walk-ins had without one, he “volunteered” his services. They also had a typical malarial symptoms: fever, body aches, nausea, contingent of students who helped with ward rounds and other vomiting, diarrhea, and cough. We ordered thin and thick services. Notice the mosquito netting and the rotting roof tiles. slides for malaria parasites on every patient with fever as well as the Widal Typhoid test and Brucella testing. We hospitalized those appearing ill, initiating oral medication called A/L (artemisinin /lumefantrine), sometimes adding IV quinine. A/L treatment takes three days, twice a day, with remarkable resolution of symptoms within 24 hours. For typhoid or brucellosis, we administered Rocephin 1 gm IV twice a day and added metronidazole for GI symptoms. Medications for both inpatients and outpatients were usually free. The government provided big bottles of Panadol and Amoxicillin, requiring patients to supply their own small bottles for the pharmacy to dispense their dosages.
DIAGNOSIS, METHANOL AND HIV
Diagnosis usually required guesswork as our laboratory had a menu of only 20 tests. Our only blood count was hemoglobin, though rarely ordered as the doctors preferred to diagnose anemia by checking the color of the conjunctiva and the mucous membranes. We hadn’t any electrolyte testing though capillary blood glucose was available. X-rays required shipping the patient to the larger city of Kisii. EKGs were available but never done. Urinalysis cost eighty cents and was rarely ordered. HIV testing, pregnancy tests, and all testing on children were free. No one wore masks, including the patient with rampant active TB (her sputum was loaded with AFB). TB tests were not performed since everyone would be positive. We had one fellow in a coma for 36 hours surviving on alternating D5W and Ringer’s Lactate IVs. We presumed he had taken a methanol overdose from some local brew. Eventually he woke up enough to waddle out with his wide-based ataxia. Kenya has one of the lowest prevalence rates of HIV in Africa at about 5%. The government encourages free HIV testing and provides free retroviral treatment for those with qualifying CD4 counts. However, many patients refused to be tested, preferring the ignorance of denial. One patient had rampant Kaposi’s sarcoma. Both her husband and her daughter had died of HIV complications, but she still refused to admit she had HIV and refused to take the medicine.
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Keumbu Subdistrict Hospital - Located about 0.2 Km uphill from the main drag, this “level III” hospital provided the only medical care available unless one traveled 50 kilometers west to the “level V” hospital in Kisii. It’s open air: no doors, no screens, wide open windows. Keumbu Hospital had: • A surgical theatre but no surgeons • Forty ward beds but only two nurses • A needy patient population but no doctors • A trained pharmacist but only two IV antibiotics • Plumbing but no water • A cook without an oven • Spirit with plenty of determination
Pediatric Ward - There were five wards, each with eight beds, nominally separated into adult male, adult female, children, and maternity with an extra for spill-over. A day in the ward cost $1.80 US.
Boys drink from the creek â&#x20AC;&#x201C; The community is faced with a series of health issues due to the lack of safe drinking water and safe toilet facilities. Due to the lack of water, no toilets were available in the hospital and patients used an outhouse.
The biggest problem was the water shortage. The village had no water pump, no water system, and no sewage system. The hospital had been built with complete plumbing and now featured sinks with dry taps, disconnected drainage pipes, and chained off useless toilets. Our hospitalâ&#x20AC;&#x2122;s water supply came from a dirty creek and from collected roof rainwater run-off. Toilet facilities consisted of two outhouses. I had brought disinfectant hand gel I used between patients, but most of the staff never actually touched the patients, apparently not big believers in the physical exam part of the medical work up. Cheap latex gloves were available, but if used the patient was charged for them. Hospital Kitchen - This one remarkable fellow provided three meals a day for every hospitalized patient. His kitchen had a dirt floor, no running water, no electricity, two wood burning stove pots, and a dozen beat up pots and pans. "I never sampled his food," said Dr. Levin.
Exterior Hospital Signage - The walls of the hospital displayed rules, such as this customer responsibility. Note the last one requesting patients to report any corruption.
Scrub Typhus - Scrub typhus is transmitted by some species of trombiculid mites (chiggers) which are found in areas of heavy scrub vegetation. The bite of this mite leaves a characteristic black eschar. Treatment is doxycycline. According to Dr. Levin, other common diagnoses include malaria, typhoid, brucellosis, and leprosy. "We also had our share of TB, AIDS, and the types of problems seen everywhere: trauma, asthma, and diabetes," Dr. Levin said.
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Most women did home delivery so that in our hospital we had only the complicated cases (Deliveries cost $9 US). Although the midwife hoped I would do caesareans, I bowed out, and they continued sending those cases to the regional referral center. Our suite delivered one or two babies a day, sending the mother and unwashed baby home at four hours. One afternoon just as I was finishing an I & D on a massive breast abscess, the midwife told me she was planning to transfer a premie baby, and I volunteered to come look. The baby, now six hours old, appeared to be 32 or 33 weeks – dusky, tachypneic, with a weak cry, and a heart rate of forty. The hospital had no warmer, warmth being provided by heated saline bottles wrapped into the blankets. Nor was there any resuscitation equipment. I performed CPR with subcutaneous epinephrine and atropine and urged prompt transfer. African bureaucracy set in. We had to wait for a copy to be made of a blank form, we had to wait for the Matron to release us, and we had to wait for the ambulance to be ready. I’d performed over an hour of CPR before we finally loaded into the ambulance. The ride to the referral hospital took fortyfive minutes, including a stop for petrol. The baby’s heart stopped about ten minutes before arrival. We were directed not to the urgent center but to the nursery where a nurse took the baby from us and declared it dead. It was the teenage mother’s third baby, and all three had died from premature birth complications. This was the saddest case for me: a life lost that easily could have been saved in America. The medical staff was a bit mystified why I had tried to save this infant who obviously was not going to survive anyway.
ENCOUNTERS WITH BUREAUCRACY
Providing medical care in a third world country brings you down to the basics: diagnosing by history, treating those who are truly sick, and accepting that you can’t help everyone. I learned how to recognize and treat tropical illnesses. I made friends and perhaps saved a few lives. Returning to United States medicine was a bit of a culture shock with its emphasis on treating pain and frailty rather than disease and holistic needs. I’m glad to be home with our hot showers and clean food, but I’m looking forward to my return to Africa. The joy of healing the ill comes in many flavors. ❒ Dr. Levin is a board-certified emergency medicine physician practicing at Memorial Hospital in Gulfport. He is president-elect of the Coast Counties Medical Society and serves as president of the Gulf Coast Writers Association.
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Charges for Services Rendered - It cost 20 Kenya Shillings, or about twenty-five cents US, to receive an out-patient chart. Other charges are added on as above.
Dr. Levin, Dr. Onsongo and the Physician Assistant Jared Okoyo- Medical Care in Africa gives the provider a new perspective on diagnosing without tests, treating with limited resources, and distinguishing between futility and possibility. "I’m arranging to bring Dr. Onsongo here to our hospital for exposure to Western Medicine," said Dr. Levin. Contributions are being accepted for funds and equipment for her to take back with her to her Kenyan hospital.
JOURNAL MSMA MAY 2011
• LETTERS •
A Delta Child: J.D. Upshaw
D
ear JMSMA Editor,
I found your picture in the Journal of a young J.D. Upshaw, Jr. very interesting [Lampton L. Images in Missisippi medicine: A Delta child. J Miss State Med Assoc. 2011;52(3):96]. During my medical training in Memphis in the late ’70s / early ’80s, one of my attendings was a hematologist by the name of J.D. Upshaw, Jr. He averaged 40 patients daily in the “late” Baptist Hospital. Rounds took about 3-4 hours. In the middle of rounds he would leave only to come back in 15-20 minutes; it was rumored that he would be found smoking behind the elevators (rumor or truth I don’t know, but you could smell the smoke). His mother lived in Louise, Mississippi, not too far from Yazoo City. I wonder if the picture is of the same individual. Robert Q. Argo, Jr. MD, Jackson
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• MSDH • Mississippi Reportable Disease Statistics
February 2011
For the most current MMR figures, visit the Mississippi State Department of Health web site: www.HealthyMS.com MAY 2011 JOURNAL MSMA
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This Month in the Mississippi Morbidity Report
Volume 27, Number 2-3; February / March 2011
Escherichia coli O157:H7 Outbreak in Public Health District IV
Introduction: In November 2010 the Mississippi State Department of Health (MSDH) investigated a cluster of Escherichia coli (E. coli) O157:H7/HUS cases in the Tombigbee Public Health District IV (Starkville/Columbus area). The initial report received by MSDH indicated that three children were hospitalized with HUS, and other family members were ill with vomiting and diarrhea. The investigation identified thirteen confirmed and probable cases of E. coli O15:H7/HUS in a close knit family living in three separate households. While no single point source for the infections was identified, two households were located on property with a failed onsite wastewater system, and the investigation further revealed limited access to soap and water and minimal understanding of basic hygiene and sanitation, likely contributing to person to person transmission. A brief report of the investigation follows. The full report may be accessed at http://HealthyMS.com/mmr. Brief Background: The family consists of 19 members (13 children, aged six weeks to eight years, and six adults) who reside in three separate households designated A, B, and C. Households B and C, located about one fourth of a mile away from household A, are on a small piece of property where a total of six homes share a sewage system. The children in the three households frequently spend time in both households B and C with an adult in household B and older children often caring for younger siblings and cousins. An environmental investigation of the site of households B and C was done in February 2010 in response to a neighbor complaint about sewage run off. The investigation indicated a failed onsite wastewater system, and a notice of violation was given. Investigation Results: A confirmed case was defined as anyone associated with the three households and with HUS or laboratory confirmed E. coli O157:H7. A probable case was defined as anyone associated with the three households and with diarrhea and/or vomiting, but with no laboratory confirmation. Nine confirmed and four probable cases were identified with cases occurring in all three households. In household A, which has ten individuals, all eight children (age range six months to eight years) were cases. In household B, which has four persons, an adult and a one year old child were cases, and in household C, which has five members, all three children were cases. The cases ranged in age from six months to 57 years (the only adult case) with a median age of three years. The ill adult was the primary caregiver in household B. Of the 13 children, only the six week old did not become ill. The predominant symptoms were vomiting (92%), diarrhea (92%), abdominal cramps (69%) and bloody stools (23%). The onset of illness ranged from November 7 to November 14. A total of five individuals were hospitalized, three with HUS. Six stool samples were culture positive for E. coli O157:H7 (at least one positive culture in each household). PFGE analysis of the positive cultures identified three distinct patterns. An environmental assessment within the households indicated a lack of basic sanitation. In household B, where the children routinely spent time, the only source of water was a bathtub where dishes were routinely rinsed. Children were often responsible for changing the diapers of younger children and were not given hand washing instructions. No soap for hand washing was available in the house. A repeat environmental investigation of the property where households B and C are located showed all six dwellings were connected to one wastewater syst $PNQSFIFOTJWF .BOBHFNFOU tem. Onsite wastewater system failure was noted in the form of a pool of t $PNQSFIFOTJWF $POTVMUJOH untreated sewage contained in what appeared to be an excavated area with t #JMMJOH "DDPVOUT 3FDFJWBCMF .BOBHFNFOU a small berm located at the edge of the property line. Useable space to ret $PEJOH %PDVNFOUBUJPO place or repair an onsite system at this site is extremely limited due to the number of dwellings on the small property. t 1SBDUJDF "TTFTTNFOUT 3FWFOVF &OIBODFNFOU Discussion: The PFGE analyses of the positive stool samples t 1SPĂśUBCJMJUZ *NQSPWFNFOU demonstrated three distinct but closely related patterns indicating that t 1SBDUJDF 4UBSU VQT the bacteria causing the illnesses were three different strains. Mixed outt 1FSTPOOFM .BOBHFNFOU breaks caused by multiple strains are often the result of non-point source contamination, such as sewage run-off. While the pooled sewage was not a new finding, it is possibly the source of the initial contamination followed by person-to-person transmission. The CDC issued two reports in 1999 that outlined public health achievements and listed the control of infectious diseases as one of the ten great achievements of the 20th century. One of the most important ways this was accomplished was through improved sanitation and hygiene to /PSUI 4UBUF 4USFFU 4VJUF prevent infection by providing clean drinking water, proper sewage disposal and education regarding proper food handling and hand washing. In +BDLTPO .4 places where safe sewage disposal does not occur, persons exposed are at 5FMFQIPOF risk for diseases that can cause severe illness and even death, such as E. coli 8"54 O157:H7. â&#x20AC;&#x201D;Presented and edited by Paul Byers, MD, XXX NQTCJMMJOH DPN Acting State Epidemiologist, Mississippi State Dept. of Health
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• MSDH •
Mississippi Now Nationally Recognized as No. 1 in Childhood Immunization Rates
M
ississippi is now the national leader – ranked No. 1 – in immunizations for children 19-35 months of age, according to 2009-2010 data released by the National Immunization Survey (NIS). Mississippi was also named “most improved.” For the 20082009 year, Mississippi ranked 18th.
Mary Currier, MD, MPH Mississippi State Health Officer
With an average immunization rate of 81.1% for the major childhood vaccinations for children 19-35 months of age (including DTaP, Polio, MMR, and other recommended vaccinations), Mississippi exceeded the national average rate of 71.5%. The Mississippi State Department of Health (MSDH) gives about 40% of all childhood vaccinations, while private providers throughout the state give about 60%.
“We focus on making sure each child has the best possible protection against vaccine-preventable diseases,” said MSDH State Health Officer Dr. Mary Currier. “Our immunization nurses in health department clinics and health care providers – especially pediatricians and family practitioners – across the state have been essential in achieving this goal.”
“That we lead the nation in immunization rates speaks highly of the diligent work of our state’s physicians, largely pediatricians and family docs, who take the lead in immunizing our children,” said Dr. Lucius “Luke” Lampton, Chairman of the Mississippi State Board of Health. “It also speaks volumes for the excellent field work of our department of health, especially the clinic nurses and staff. Immunizations are a fundamental part of public health, and high immunization rates increase both quality and length of life of our citizens. I can’t repeat enough how important high rates of immunization are for our state’s overall health,” he added.
Dr. Currier said new tools such as the MSDH statewide Immunization Registry also help MSDH track when vaccinations are due for children, and help notify parents with reminders and recalls. Providers of immunizations record vaccines administered in the statewide Immunization Registry. Records for most children are available for parents and qualified professionals.
Dr. Lampton said, “The board and Dr. Thompson made improving our immunization rates a priority on his return as state health officer back in 2007, and Dr. Currier has continued its emphasis. This number one ranking stresses how important a coordinated statewide plan and adequate funding are in protecting the health of Mississippians. It also shows that being the poorest state doesn’t prevent you from being the healthiest. We need to approach many of our public health problems with the same zeal and planning.” The NIS is a telephone survey conducted in each of the 50 states, in the six cities that receive Section 317 immunization grant funding, and in other selected large city/county areas. For more information or to view a list of recommended and required childhood vaccinations, visit the MSDH website at www.HealthyMS.com or call 1-866-HLTHY4U (1-866-458-4948). ❒
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• MPHP • Addiction As a Brain Disease
I
have at least one conversation per day in which someone asks why it is necessary for a participant in the Mississippi Professionals Health Program to go to treatment for chemical dependence if he or she has not used the substance in several weeks or months. For example, a physician diagnosed with alcohol dependence was very angry that residential treatment was required. His wife was also very worried about financial insecurity from loss of income during treatment. She asked, “Why is it necessary? He has not had a drink in three weeks. Things are better at home than they have been in years.” This is a very common question asked by family, friends, employers, regulatory agencies, and health care providers, including physicians. The answer to the question is very interesting and one of the reasons that I decided to do a fellowship in addiction medicine. It involves the concept of addiction as a brain disease. To begin, it is helpful to consider some of the consequences of addiction. By the time a patient is diagnosed with alcohol dependence or any substance use disorder, especially a physician, the progression of the disease is often very advanced. The consequences of continued use are often quite severe, including damaged relationships with spouse, children, employers, co-workers, and close Scott L. Hambleton, MD friends. The use of alcohol or drugs becomes progressively more important while Medical Director Mississippi Professionals Health Program significant relationships become progressively less important. The behavior of the addicted person frequently becomes unpredictable with mood swings and abusiveness. A personality change often occurs. Depression becomes very common and is present in at least 25% of the MPHP participants with chemical dependence. Other consequences include financial problems, loss of employment, legal problems such as arrest for DUI, increased likelihood of mal practice lawsuits, loss of interest in hobbies or other previous interests such as going to church or socializing with friends. The result of untreated addiction is disruption in every area of life, including the home and workplace. For most physicians, disruption in the workplace is a significant indicator of end-stage addiction. By the time substance use affects the physician’s practice, problems have already manifested themselves in almost every area of the physician’s life. Health problems also become more likely as does the risk of accidental injury. Ultimately, the addicted person becomes totally socially isolated. In the most severe cases, the only significant relationship that remains is the relationship with alcohol or drugs. At this point, death becomes likely to be the final consequence of addiction. Treatment centers and 12-step programs refer to the problems as “unmanageability” referring to the first step which states, “We admitted we were powerless over _______, that our lives had become unmanageable.” The blank can be filled with any substance or pathological process, like gambling. One translation of this step could be that a person is unable to stop using a substance, despite negative consequences. Amazingly, when the addicted person is confronted with the “unmanageability” or consequences, he or she often minimizes them and says, “It’s not that bad, yet.” One addicted physician explained the loss of his driver’s license as the result of his third alcohol related arrest as “bad luck.” His loss of employment and pending Medical Board investigation were attributed to “they never did like me.” He explained his divorce, “She couldn’t accept me the way I was.” In addiction medicine, we refer to this as cognitive distortion, or lack of insight. Everyone else calls it denial! A logical assumption would be that if a person stopped using the substance, all the “unmanageability” would disappear. However, this assumption minimizes the significance of the changes that take place in the brain of the addicted patient. A hallmark of addiction is that the addicted person can’t “Just say no!” and control their substance use like other people. Many people attribute this to lack of will power or weakness. “Why can’t he drink one or two beers and stop?” is another commonly asked question. After a significant consequence like a DUI, an addicted person may quit drinking for several weeks or months, but they invariably start using again, with loss of control, until a new problem develops. Everyone is confused and cannot understand why the addicted person does what they do, which is to continue to use the substance. A basic review of neuroanatomy and neurophysiology is very helpful. Research using PET scans and Functional MRIs has demonstrated that the survival and pleasure centers of the brain are the same areas of the brain involved with addiction. This part of the brain generates very primitive, instinctive behaviors, like hunger, thirst, and sexual urges. These powerful instinctive urges are necessary for survival of a species and are linked to the sensation of pleasure. continued from page 170
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• MSMA •
MSMA offers new benefit to members: M.D. Financial Smart Key Organize your Portfolio and your Life
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his year, 2011, marks my 30th year in the world of insurance and financial management. When I started, an old agent told me that I would not fully appreciate the job I was doing until I experienced my first death claim. Well, I am 30 years in, and I have experienced over 70 death claims. Do I have some stories to tell! Yes, I do fully appreciate the work a good advisor can do, but I also saw a real need that was common with every claim that involved a surviving widow. Here are a few of the most common statements I hear: “Where is all his stuff? Whom do I need to talk with? I have no idea what we have and where we have it. Do you think this is all of it?” The most common question is, “Where do I start?” Let me tell you, this is not a fun time. Every claim required digging through checking accounts looking for bill payments to see what else may be out there. When a widow is grieving, the last thing she wants to do is by Robert G. Dye, Sr., CLU have to organize their financial mess. This is when she is most Dye Resource Management, LLC vulnerable to what I call “financial predators!” M.D. Financial, LLC What I have experienced at claim time is mostly confusion and concern of the location of assets. In many cases, if not most, the client has good advisors, but they have never really communicated with each other and changes were made without their knowledge. Most of their time was spent jockeying for control. They simply needed all to work together in a coordinated, efficient effort to meet a client’s needs before and after a need occurs. The problem is the widow is left alone to pull all the documents together for the different attorneys, insurance agents, bankers, and stockbrokers. Usually, there are only two accountants – one personal and another for the business. Do you see the big problem here? We set out to find a solution for the two most common problems in a professional’s financial life. One is the organization of the portfolio while you are living and the other occurs at a time your survivors least want to deal with it – at your death. We know the best time to deal with it is before death occurs. We encourage being proactive rather than reactive. We offer a program that will coordinate all of your advisors, organize all of your documents, and download it on a secure memory key that looks identical to your everyday house key. The key is simply plugged into your USB port on your computer and can be reviewed and updated by you as often as your portfolio changes. It keeps you up to date and accurate and can be readily available to any of your financial advisors in minutes. Honestly, the hardest part of this program is the initial collection from you of all the documents that we download for you. Just imagine how difficult it would be for your widow if this were not available. The best part is once it is organized, we keep it updated for you at least twice a year. We review it for you and if needed, we will make recommendations for you to talk with your advisors. We sit on “your side of the table” in our recommendations and do not intend to take the place of your other specialists. We simply help coordinate them and make sure they are all on the same page, so to speak. We make your financial life easier to manage now and later. Your time, as a physician, is very limited. If you are not working, you want to spend time with your family or pursuing a particular enjoyable hobby. Neglecting your financial responsibilities by not giving them the proper attention is more a norm than an exception. Your MSMA understands this. They have collaborated with M.D. Financial to offer our unique program at a discounted cost available only to their members. You can find out more about us on the MSMA website under Preferred Partners. You are welcome to call our office to schedule a free, no obligation consultation to determine if this service would be a benefit to you. Our mission is to find ways to save you more money than the cost of the program. If we are not able to accomplish our mission, we will tell you up front so you can make the decision if you still want to organize your portfolio at a discounted rate. Your Medical Association expects us to give you our objective opinion and to help their members take care of this very common problem. They have given their time and energy to help you and to help you protect your loved ones and business associates you leave behind. Legendary football coach, Vince Lombardi once said, “For a team to be successful, they must work together in a coordinated efficiency.” I cannot think of a better description of our program with you as the owner of the team. Put us all to work for you! ❒
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Addiction As A Brain Disease continued from page 168
We sometimes refer to this as the “lizard brain.” The nucleus accumbens, ventral tegmental area, amygdala, and other structures in this mid-brain (mesencephalon) region are virtually identical in humans and some animals with brains that are more primitive like rats. Because of the similarity of this brain tissue, we are able to conduct experiments with rats in laboratory settings and infer similar results in humans. The nucleus accumbens is considered the “pleasure center” of the brain because its activation results in increased concentrations of dopamine, the principle neurotransmitter involved in the sensation of pleasure and the activation of the reward pathways. In 1954, the researchers, Dr. Olds and Dr. Milner implanted metal electrodes into the nucleus accumbens of rats, connected to levers, which enabled the rats to self stimulate this area of their brains, resulting in the sensation of pleasure. The rats would continue to press the lever, ignoring thirst and hunger, eventually dying of exhaustion. Later, it was discovered that rats would also self-administer heroin and other drugs of abuse. These substances also activated the nucleus accumbens and reward pathways, resulting in release of supernormal concentrations of dopamine and intense pleasure. The actual pathways and cellular interactions are tremendously complex; however, this simplified description is sufficient for a better understanding of addiction. In the addicted patient, using the drug becomes the most important behavior and eventually is interpreted as a necessary survival behavior, sometimes surpassing other survival impulses like hunger, thirst or even the “fight or flight” instinctive behavior. This partially explains why addicted patients continue to use substances despite terrible consequences like imprisonment, divorce, or loss of career. An understanding of drug or alcohol “cravings” helps to explain why the brain of an addicted patient attaches such importance to using substances. Dr. Nora Volkow, Medical Director of NIDA, refers to this as “impaired salience attribution and response inhibition.” Cravings are the most powerful motivator for an addicted person, resulting in an uncontrollable compulsion to seek and use drugs or alcohol. Cravings are one of the major causes of relapse. It should be noted that cravings are different from the physical symptoms caused by drug or alcohol withdrawal. Cravings can occur with or without physical withdrawal, are made worse by physical withdrawal and can occur months or even years after the last use of the substance! The process of drug cravings is an almost identical process to situations in which survival is threatened, like dying of thirst, starving from lack of food, or smothering from lack of air. In these situations, all thoughts are focused on obtaining water, food, or air. We call this preoccupation, or obsession, and it intensifies as each minute goes by without water, food, or air. The mood becomes progressively more dysphoric, which is an extremely unpleasant state marked by sadness, despair, fearfulness, panic and generalized irritability. These symptoms are relieved instantly when water or food is consumed or air is breathed. In fact, the reward pathway is activated with subsequent release of dopamine and other neurotransmitters at the first sight of food or water before they are ingested! Cravings cause the addicted person to become totally preoccupied with drug seeking and drug use. The preoccupation and obsession intensifies as each minute goes by without using drugs or alcohol. The mood becomes progressively more dysphoric. These symptoms are relieved instantly when drugs or alcohol are consumed in the same way that obsessional thinking and dysphoria are relieved in a dehydrated person when they drink water. In the addicted person, the survival centers and reward pathways of the brain are diseased and not functioning normally. Using the substance becomes necessary to ensure survival, just like water, food, or air. The brain abnormally attributes importance to the substance, primarily because of the release of dopamine that occurs with use of the substance. The power of choice becomes nonexistent. This is the basis of the “weakness” or “lack of willpower.” To expect an addicted person to exert successfully willpower to control cravings would be very similar to expecting a non-addicted person not to crave food when they are starving or water when they are dehydrated. Cravings are one of the most pathological manifestations of addiction as a brain disease because they become the ultimate reinforcement for continued use of the substance and destruction of the host. Cravings guarantee that the addicted person can’t “Just Say No!” Luckily, addiction is a treatable condition! However, effective treatment involves much more than abstinence. The welldocumented success of physician health programs in the Project Blue Print Study which retrospectively followed 904 Physicians under contract with physician health programs in 16 states over a 7.2-year period. 78% maintained sobriety without relapse during the entire monitoring period of 7.2 years. In Mississippi, 84% maintained sobriety during this period. These statistics represent a sharp contrast to the general population relapse rate of 82% at the end of one year! A key factor in the success of physician health programs is that participants received treatment in facilities approved by their respective state medical boards for a period of 90 days. The facilities were skilled in treating impaired health care professionals. During treatment, after medical stabilization, intensive effort is dedicated to addressing the cognitive distortion and denial which are present in every addicted patient. Eventually, insight into the severity of their condition as well as the harmful effects of their addiction behaviors on others is gained, and recovery is facilitated. Drug and alcohol cravings are constantly addressed in a safe environment, and healthy coping skills are developed. This type of recovery is not possible without treatment, and this is the reason that abstinence is not enough! —Scott L. Hambleton, MD MPHP Medical Director
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• LEGAL EASE •
State Nullification of The Patient Protection and Affordable Care Act of 2010: Is It an Option?
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he Patient Protection and Affordable Care Act of 2010, signed into law on March 23, 2010, has become one of the most controversial pieces of legislation ever to affect the medical-legal community. The Act is currently facing a number of legal challenges within the federal court system. To date, three federal district courts have rejected constitutional challenges to the Act, and two federal district courts have ruled that the Act is unconstitutional. Opponents of the Act, including 28 states, have raised a number of legal objections to the validity of the federal mandate. Those objections have sparked an intense debate involving legal principles that have their origins with our Nation’s Founding Fathers. In the forefront of the debate are arguments over “states’ rights” under the Tenth Amendment to the United States Constitution, ratified as part of the Constitution in 1791. In its essence, the Tenth Amendment guarantees that powers not expressly delegated to the federal government are reserved to the states. The new health care law has brought the concept of federalism back into the arena of political and legal debate. Blake Bell Federalism is the relationship between a central federal government and its constituent sovereign states bound by a covenant – the Constitution – that establishes their respective powers to govern. The battle lines over federalism, as they relate to the debate over the legality of the new health care law, have been drawn in both judicial and legislative battlefields. The judicial challenges to the Act are well chronicled in the various lawsuits filed to have the Act declared unconstitutional. The largest and perhaps most visible of the lawsuits has been the lawsuit filed in Florida by Florida’s previous Attorney General Bill McCollum. General McCollum’s lawsuit has been joined by 25 other states with all of the states asserting that the 111th Congress in passing the Act and President Barak Obama in signing the Act have overstepped the powers granted to the federal government under the Constitution. The states argue that the federal government cannot constitutionally require individuals to purchase health insurance. They argue that the individual mandate requiring individuals to purchase health insurance is a power not granted to the federal government by any provision of the Constitution. Under federalism principles, the argument postulates that since there is no explicit grant of authority under the Constitution for the individual mandate, the Act violates the Tenth Amendment because such power is reserved unto the states. In an effort to counter the Tenth Amendment argument presented in the Florida lawsuit – Florida et al. v. Department of Health and Human Services – the federal government argues that the Commerce Clause in Article 1 of the Constitution is the authorizing provision that grants to Congress the power to regulate interstate commerce. The federal government’s argument is that the Act, including the individual mandate, is constitutional because the new law regulates interstate commerce. On the other hand, the states argue that the Commerce Clause empowers the federal government to “regulate commerce, not create it.”1 The legal argument presented to the federal court is that Congress does not have the power to compel a person to engage in commerce by requiring such person to purchase a product – health insurance. The requirement of one to engage in commerce – so goes the argument – is not the same as the power to regulate commerce of individuals who have elected by their own acts and deeds, in the first instance, to engage in commerce. In the Florida case, U. S. District Judge Roger Vinson has sided with the states and has ruled that the Act is unconstitutional. He has ruled that the individual mandate provision of the Act does not fall within the power of Congress to regulate commerce. Judge Vincent’s decision is now on appeal to the U. S. Fifth Circuit Court of Appeals. A decision from the Fifth Circuit which will then set up the ultimate constitutional test of the Act in front of the United States Supreme Court will most likely be handed down prior to the end of the year. Challenges to the legality of the Act have not, however, been limited to judicial actions. Given the unpopularity of the Act in many sections of the country, it is not surprising to see that its opponents have deployed other strategies. One such strategy sweeping the country is the concept of “state nullification.” State nullification is a legal theory also based on the concept of federalism having its roots in the Tenth Amendment of the Constitution. State nullification is perhaps the ultimate exercise of “states’ rights” by a growing number of state legislative bodies. Nullification is the legal theory that a state has the right to nullify legislatively a federal law that is deemed by that state to be unconstitutional. This theory is based upon the same concept that is being used to challenge judicially the Act as unconstitutional. Here, however, the theory espouses the view that an inherent power of a state exists to declare a federal law unconstitutional if that state deems the law to be in excess of the power granted to the federal government by the covenant or compact entered into between the states and the federal government when the Constitution was written.2 Though seldom used and rarely invoked, the concept of state nullification is not new. In fact, two of our country’s legendary founders, Thomas Jefferson and James Madison, famously promoted the idea as a means of protesting the Alien and Sedition Acts
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of 1798. Jefferson authored a series of resolutions known as the Kentucky Resolutions of 1978-1799. Simultaneously, Madison penned a similar series of resolutions on behalf of the Virginia legislature known as the Virginia Resolutions of 1798-1799. In the Kentucky Resolutions and the Virginia Resolutions, both Jefferson and Madison asserted on behalf of the two protesting states’ legislatures that the states have the authority to determine ultimately the validity of a federal law. The state legislature deems this an infringement upon the rights of the states which exceeds the grant of power to the federal government as constrained by the Tenth Amendment. Jefferson and Madison took the position, as expressed in the Resolutions, that a state had the right to nullify – invalidate – a federal law that was not within the express authorization contained in the compact between the states and the United States Government. A violation of the compact – the Constitution – could and should be declared by a state to be unconstitutional and invalid because a state has an “equal right to judge for itself” the scope of federal authority under the Constitution.3 Under this legal concept, a state is not compelled to subjugate its own sovereignty to that of the federal government’s.4 This issue of state nullification has been raised a number of times in the history of our nation. Nullification has been a somewhat frequent subject of debate in issues involving pre-Civil War federal slavery laws, federal laws imposing taxes and tariffs, and school desegregation actions. A more recent example of the display of the nullification argument has been seen in protest to the REAL ID Act of 2005 (the RIA). The RIA was a federal mandate imposed upon states requiring states to adopt standardized and centralized personal identification policies and procedures. In a push back against unpopular federal authority, forty states have passed legislation or have legislation pending calling for the nullification of the RIA. While the RIA remains current law, the dissatisfaction expressed by state legislatures to the federal intervention into this field has made the law all but unenforceable. While the law has not been confirmed as an official act of nullification, the expression of unpopularity of the Act has achieved a significant political objective. In the face of massive resistance, the federal government has not elected to aggressively defend and enforce the legislation. Instead, the political wheels have turned and there are signs that RIA will be severely limited by pending eviscerating amendments before Congress.5 Despite the storied history of nullification as a clarion call of states’ rights advocates, there has never been a federal court decision to uphold the right of states to nullify a federal law. The limited court decisions on the topic have favored the Supremacy Clause of Article VI of the Constitution that makes federal law supreme to state law. However, there has not been a definitive Supreme Court decision on the issue at least as modernly argued. Given the fact that many legal and political scholars view the current make up of the United States Supreme Court as one of the more conservative Courts of recent memory, there is renewed interest in the use of a nullification strategy in connection with an effort to have the new health care law declared unconstitutional and unenforceable against the states. In fact, the State of Idaho has recently become the first state to have at least one of its state legislative bodies adopt a bill nullifying the entire Act. The Idaho House of Representatives adopted the bill declaring the entire Act unenforceable; however, to date, the bill has not passed the Idaho Senate. There are at least thirteen other states that have had similar bills introduced into legislative consideration, including Arizona, Idaho, Indiana, Maine, Montana, Nebraska, New Hampshire, North Dakota, Oklahoma, Oregon, South Dakota, Texas, and Wyoming. Given the fact that no federal court has ever sided with a state on the nullification issue, a legislature body - emboldened by the states’ victory in Judge Vincent’s decision – may feel that the time is ripe to pass a state law nullifying the Act. In such an event, the strategy of those opposing the Act would take on both a judicial and a legislative prong, neither of which would be resolved until the U. S. Supreme Court rules on the constitutionality of the Act. 6 The medical and legal community awaits the Supreme Court’s decision. PHYSICIANS NEEDED
MedPlan works with hospitals and healthcare systems in Mississippi and throughout the Southeast to identify qualified physicians of all specialties. We are retained by the healthcare systems and hospitals, so we are able to save you time as we provide information concerning multiple opportunities, without charging fees. Many of the positions have very competitive compensation packages and, in some cases, school loan repayment. All inquiries are kept confidential. If you would like more information, please contact us at medplankab@aol.com or 205.8707068.
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REFERENCES
1. http://www.politico.com/static/PPM152_100617_dojhcrsuitbrf.html. Florida et al. v. United States Department of Health and Human Services, Politico, Accessed March 1, 2011.
2. Woods, Thomas E. (2010). Nullification: How to Resist Federal Tyranny in the 21st Century. Washington, DC: Regnery. 3. http://www.constitution.org/cons/kent1798.htm. The Kentucky Resolution of 1798, Constitution.org. Accessed March 18, 2011. 4. http://www.constitution.org/cons/virg1798.htm. The Virginia Resolution, Constitution.org. Accessed March 18, 2011.
5. http://www.realnightmare.org/news/105/. Status of Anti-Real ID Legislation in the States, ACLU. Accessed March 20, 2011. 6. http://blog.american.com/?p=26201. ObamaCare’s Day in Court, Enterprise Blog, David B. Rivkin Jr. Accessed March 20, 2011.
Blake Bell is a law clerk for the Mississippi State Medical Association and a 3L student at the Mississippi College School of Law.
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