2015-May/Jun - SSV Medicine by Sierra Sacramento Valley Medical Society

Sierra Sacramento Valley

MEDICINE Serving the counties of El Dorado, Sacramento and Yolo

May/June 2015

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Medicine 3

PRESIDENT’S MESSAGE The Value of “Thank You”

Jason Bynum, MD

EDITOR’S MESSAGE “Holy Public Health Issue, Batman!”

Clean Water: Better Than Gold

Bob LaPerriere, MD

Covered California – How About Sacramento?

Glennah Trochet, MD

SB 277: Halt VaccinePreventable Diseases

Richard Pan, MD, State Senator

A Posit on Immunizations

Nathan Hitzeman, MD

EXECUTIVE DIRECTOR’S MESSAGE Access to Care, Coding

Aileen Wetzel, Executive Director

Florence Nightingale – The Human Touch

The History of Leprosy

John Loofbourow, MD

George Meyer, MD

12 Remodeling Your Medical Home

Time of Life

Gerald Rogan, MD Pauline Grenbeaux, Planner

Charlotte Pickett, MSIII

Medical Student Die-In

John Loofbourow, MD

Jeremy Johnson MSII, Lucy Ogbu-Nwobodo MSII, Nhi Tran MSII

Board Briefs

Welcome New Members

Drought 2015: A Public Health Report

Donald Lyman, MD

We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to e.LetterSSV Medicine@gmail. com or to the author. All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the medical society for permission to reprint.

33 Fireflies

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Open free to the public 9 am–4 pm M–F, except holidays.

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx On December 10, 2014, close to 100 UC Davis health professional students silently laid their bodies on the ground in a peaceful “die-in” demonstration as a response to police violence against communities of color. Medical students Jeremy Johnson, MSII; Lucy Ogbu-Nwobodo, MSII; and Nhi Tran, MSII, discuss the event on page 15 of this issue. The cover photo, taken by Leonel Mendoza, MSII, was made with a Canon T3i (EF 28-135mm lens) and was taken from the UCDSOM second floor breezeway to maximize the number of people that fit into the shot. According to the photographer, “The day was calm and gloomy. It was as if nature itself was having its own moment of silence.”

May/June 2015

Volume 66/Number 3 Official publication of the Sierra Sacramento Valley Medical Society 5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

Sierra Sacramento Valley

MEDICINE The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community. 2015 Officers & Board of Directors Jason Bynum, MD, President Thomas Ormiston, MD, President-Elect José A. Arévalo, MD, Immediate Past President District 1 Seth Thomas, MD District 2 Laurie Gregg, MD Vijay Khatri, MD Christian Serdahl, MD District 3 Ruenell Adams Jacobs, MD District 4 Russell Jacoby, MD

District 5 Steven Kelly-Reif, MD Rajiv Misquitta, MD Sadha Tivakaran, MD John Wiesenfarth, MD Eric Williams, MD District 6 Kieu-Loan Luc, DO

2014 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Russell Jacoby, MD District 5 Maynard Johnston, MD District 6 Marcia Gollober, MD At-Large Alicia Abels, MD José A. Arévalo, MD Jason Bynum, MD Adam Dougherty, MD Alan Ertle, MD Richard Gray, MD Karen Hopp, MD Richard Jones, MD Charles McDonnell, MD Janet O’Brien, MD Thomas Ormiston, MD Richard Pan, MD, Senator Margaret Parsons, MD Anthony Russell, MD Kuldip Sandhu, MD James Sehr, MD

District 1 Kevin Elliott, MD District 2 Don Wreden, MD District 3 Ruenell Adams Jacobs, MD District 4 Courtney LaCaze-Adams, MD District 5 Robert Madrigal, MD District 6 Rajan Merchant, MD At-Large Natasha Bir, MD Helen Biren, MD Sean Deane, MD Kevin Jones, DO Thomas Kaniff, MD Olivia Kasirye, MD Vijay Khatri, MD Sandra Mendez, MD Patricia Samuelson, MD Armine Sarchisian, MD Vacant Vacant Vacant Vacant Vacant Vacant

CMA Trustees District XI Barbara Arnold, MD

Douglas Brosnan, MD

Richard Thorp, MD

Editorial Committee Nate Hitzeman, MD, Editor/Chair John Paul Aboubechara, MS II George Meyer, MD Sean Deane, MD John Ostrich, MD Adam Doughtery, MD Gerald Rogan, MD Ann Gerhardt, MD Glennah Trochet, MD Sandra Hand, MD Lee Welter, MD Albert Kahane, MD Robert LaPerriere, MD Gilbert Wright, MD John Loofbourow, MD Executive Director Managing Editor Webmaster Graphic Design

Aileen Wetzel Nan Nichols Crussell Melissa Darling Planet Kelly

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Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests.

CMA Imm. Past President Richard Thorp, MD AMA Delegation Barbara Arnold, MD

Membership Has Its Benefits!

SIERRA SACRAMENTO VALLEY

MEDICAL SOCIETY

Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2015 Sierra Sacramento Valley Medical Society Sierra Sacramento Valley Medicine (ISSN 0886 2826) is published bi-monthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.

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President’s Message

The Value of “Thank You” By Jason Bynum, MD THIS HAS BEEN A VERY EXCITING past few months at SSVMS, and we continue to work on several issues affecting physicians in the Sacramento region. A common theme unites our 2015 advocacy agenda – Access to Care. SSVMS’ Executive Director, Aileen Wetzel, just returned from Washington, DC, where she and CMA physician leaders met with members of Congress to urge them to pass legislation to eliminate the flawed Sustainable Growth Rate (SGR) once and for all. In addition to advocating for access to care for Medicare patients, SSVMS/ CMA are working tirelessly to increase access to care for Medi-Cal patients. On April 14, SSVMS leaders joined hundreds of physicians and medical students at CMA’s Legislative Leadership Day to lobby for adequate Medi-Cal provider reimbursement. At the local level, SSVMS’ Emergency Care Committee and Mental Health Task Force continue to work on solutions to improve mental health access in our region. I strongly believe there will be a lot to report in terms of mental health access in the months to come. I would also like to speak on a more personal level in this article, as my life has been consumed recently not by mental health advocacy or medical society meetings. It has been fully consumed with the health problems of my newborn son born in early February. To make a long story short, he was not feeding well and had significant difficulty breathing when feeding. Ultimately, he was diagnosed by flexible laryngoscopy with laryngomalacia, but was unable to breast feed, and ultimately to bottle feed. My wife and I spent, I believe, four days straight without sleep attempting to feed him with supplemental nutrition, where I had a tube taped to my finger which dripped milk into his mouth at a painfully slow rate. He continued to choke on this liquid, and ultimately had to

be hospitalized for six days for further tests as well as nasogastric feeding. The bottom line is that for several weeks, I was not a physician. Instead, I’ve been a father who saw his newborn son wasting away with failure to thrive, a husband helping his wife with postpartum stress, and a patient in the hospital with questions and concerns like any other. As I write this letter, my son is 10 feet away from me, with a tube in his nose, and my heart skips several beats each time he makes a sound. “Is he OK?” “Can he breathe?” “Is he in pain?” Suffice it to say, we have a long way to go; but as far as childhood maladies go, I am at least informed laryngomalacia is time limited, and he is getting the nutrition he needs to grow. The months of February through April of 2015, however, are best left forgotten for my family in hopes of less stressful memories to come. While this deeply personal experience has taken my focus recently, I also feel this will strengthen my resolve moving forward as a physician and physician leader. During my time off, I read a “physician satisfaction survey result” on one of the many aggregate medical websites. Approximately 55 percent of physicians would not choose to be a physician again in this particular survey. Results varied by specialty, but I initially found myself agreeing with these results. Increasing administration demands, worsening reimbursement rates, concerns for litigation, patient satisfaction, etc., etc., all came to mind. Is this the romantic Norman Rockwell painting I envisioned when applying to medical school? In my interviews, I remember talking about helping people. Now I complain about “needy patients,” and angry parents, and a system which, at times, seems destined to fail. For a few weeks this year, however, I experienced the other side. A kind word from a continued on next page May/June 2015

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com. 3

“Thank You” continued from previous page

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nurse. Some hope from a physician. The support of lactation consultants, all of whom said, “It will get better, I promise.” In our case, I believe this is true, but for many of the patients we see each day, hope may not be as great. And in those moments, I never realized, or remembered, the “Thank yous” I have received over the years. They came back to me, though, and I was proud to say maybe I have had the same impact on my patients my son’s providers have had on us. I would like to think this realization will drive me in the years to come, when the necessities of medicine attempt to outweigh the rewards again, and I will persevere through remembrance of my own family’s experience. I may not have much to report in this message in terms of the advocacy I was hoping to continue as the year started, but I am certain I can make up for it as the year progresses. We have a phenomenal staff at SSVMS, and I encourage you to read Aileen Wetzel’s article in this journal as she proves again that she is a tireless supporter of physicians. I would also like to encourage each of you, in the days of ACA-implementation, Medi-Cal cuts, SGR debates, and an uncertain future, at least we are all in a profession where people say, “Thank you,” because we have helped in their time of need. I know I will. jbynum23@me.com

Editor’s Message

“Holy Public Health Issue, Batman!” By Nathan Hitzeman, MD SPRING IS UPON US IN the Central Valley, showering us with the many particles from trees, weeds, and grasses – trying to reach fertile soil and our nasal turbinates. We, here on the SSVMS Editorial Committee, enjoy the diaspora of articles and particles that make it into our magazine. Occasionally, we try to craft a theme issue like the History issue of March/April 2004, or the Nutrition and Health issue of March/April 2012. But, mostly, we try to sample the local air, see what is passing through, and broadcast it to an engaged and curious physician audience – you! This May/June issue has become a happenstance garden patch of public healththemed articles that we hope you will enjoy. Dr. John Loofbourow enlightens us with the accomplished life of Nurse Florence Nightingale who is credited with large-scale hygienic nursing care and tracking of diseases during wartime activities. Dr. George Meyer tells us about his trip to, and the history of, Molokai as a leper colony. A garden needs water! Fast forward to modern times and here we have Dr. Donald Lyman writing about the public health effects of our fourth year of drought and Dr. Bob LaPerriere about his trip to a local water treatment facility. According to the U.S. Department of Interior’s website, we each use 80-100 gallons of water a day. Where does that come from? According to the U.S. Environmental Protection Agency, the average American generates four to five pounds of trash a day. Where does that go? We don’t have an article on the latter, but when I watched Morgan Spurlock’s “Inside Man” on CNN recently entitled, “The United States of

Trash,” I was amazed at how fast our country is filling up with trash and how limited it is to recycle plastic bags. What will our kids’ world look like decades from now? While you’re thinking of that, think of how your own home will look. Dr. Jerry Rogan writes on how to remodel your home for safety and senior living. How many of us see seniors who had an accident or a fall in their home? Everyone should read this article or share it with your family. Perhaps you won’t want to leave your home should State Senator, Dr. Richard Pan not get the vaccination loophole closed for personal exemptions. Read his piece and our members’ responses to a posit on how to deal with non-vaccinators. The topic that hits closest to home is how the uninsured among us die simply from being uninsured and not having access to continuity and meaningful care. Former public health officer, Dr. Glennah Trochet, writes about her attendance at a County Board of Supervisors’ meeting that is exploring the option of insuring the undocumented again. Lastly, our cherished local medical students remind us that the world is becoming an increasingly crowded and complex place where the degree to which we respect and tolerate each other will determine our survival. I commend them for their reflections on, and actions to combat, modern-day prejudice. So, sit back in your Batman and Robinesque tights, have a glass of water, and enjoy your Holy Public Health issue. Pow! Whamm!! Slam! Oooooff!! hitzemn@sutterhealth.org May/June 2015

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com. 5

Executive Director’s Message

Access to Care, Coding Two Examples of How SSVMS/CMA Have Your Back

By Aileen Wetzel, Executive Director

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

2015 HAS ALREADY STARTED to show new challenges: inadequate Medi-Cal provider reimbursement and the impending implementation of ICD-10 are just two examples of the challenges the medical profession faces this year. With each of these challenges, SSVMS/ CMA have your back. Inadequate provider reimbursement rates has impacted access to care for thousands of Medi-Cal patients. In 2011, Medi-Cal payment rates to doctors, hospitals, dentists and other providers were cut by 10 percent as a way to balance the state’s budget. California now has one of the lowest payment rates in the country. At the same time, the Medi-Cal program now covers more than 12 million patients − one in three Californians − as a result of expanded eligibility under the ACA. According to a 2011 survey, funded by the California HealthCare Foundation, over 1,500 Medi-Cal recipients identified difficulties in finding coverage. Thirty-four percent of MediCal recipients said it was difficult to find health care providers who accept their insurance, compared to 13 percent of people with other coverage. The survey found a higher percentage of adults with Medi-Cal say they have more difficulty getting appointments with specialists and primary care providers than adults with other health coverage (42 percent vs. 24 percent for specialists, and 26 percent vs. 15 percent for primary care providers). SSVMS has your back. CMA-sponsored legislation AB 366 (Bonta) and SB 243 (Hernandez) would not only restore a 10 percent cut to Medi-Cal reimbursement rates, but would also place reimbursement on par with Medicare. The transition from ICD-9 to ICD-10

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will result in substantial challenges due to changes in the code structure, rules and number of codes. ICD-10 will impact physician documentation requirements in both the office and hospital settings. SSVMS, in partnership with the California Medical Association (CMA), is offering a two-day ICD-10 code set seminar by the American Academy of Professional Coders (AAPC) July 15-16, 2015. The training is designed specifically for coding staff and intended to give attendees a comprehensive understanding of guidelines and conventions of ICD-10, as well as fundamental knowledge of how to decipher, understand and accurately apply codes in ICD-10. This course is being offered at tremendous savings for CMA/SSVMS members and staff and includes 16 hours of intensive general ICD-10 code set training along with hands-on coding exercises. Each attendee will receive the AAPC ICD-10-CM Workbook and recentlypublished 2015 ICD-10-CM Codebook. The training course, which will be held at SSVMS, 5380 Elvas Ave., Sacramento, is approved for 16 continuing education units through AAPC. Following the onsite training, attendees will be given an ICD-10 proficiency assessment to ensure understanding of ICD-10 concepts and guidelines. For more information and to register, visit www.cmanet.org. Whether it is taking the lead on increased access to care by restoring cuts made to the MediCal program or providing physician practices with cost-effective ICD-10 training, SSVMS and CMA are working hard for physicians and patients. awetzel@ssvms.org

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Florence Nightingale – The Human Touch By John Loofbourow, MD

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

FLORENCE NIGHTINGALE was born in Florence, Italy, almost 200 years ago, when her wealthy parents were on a two-year-long honeymoon. At the time, women were very seldom educated, but her father, feeling she was precocious, largely home-schooled her in the rigorous, classic style of the time: History, philosophy, literature, writing, mathematics, Latin, Greek, French, German and Italian. A Unitarian, at 16 she had an epiphany leading her to choose nursing as her life’s work, despite family objections. Nursing was seen as employment that needed neither study nor intelligence; some regarded military nurses as simply camp followers. She never married, despite several apparently lasting and serious relationships. In March 1853, in an earlier Crimea, Russia invaded. Britain and France went to Turkey’s aid. British soldiers began falling ill with cholera, malaria, and malnutrition, among other things. Within weeks, an estimated 8,000 men were suffering from these two infectious diseases alone, in addition to war injuries. A public outcry ensued, and Nightingale was commissioned to take a group of 38 nurses to the war zone. Her description of the “hospital” – a “filthy shut-in barracks without running water, hand washing, or sanitary food preparation, filled with parasite and vermin-infested wounded” – was shocking. But within weeks, the mortality there reportedly fell from 45 percent to 3 percent, not so much due to medical treatment as to basic physical and environmental changes, thanks to nursing care and administration. Always a 24/7 stickler for detail, Nightingale

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became known as the Lady of the Lamp because of her quiet nighttime rounds. While the hyperbole of wartime may have inflated reports, there is little doubt that the facts Nightingale reported were essentially accurate. In any event, the Crimea effort was costly to Nightingale. She contracted Malta Fever (brucellosis), endemic there among goats, and had to return to England, where she suffered from it for the rest of her life. Yet, she became a highly-regarded statistician, remained an active

advocate for women, and wrote extensively until her death at age 90. Her accomplishments include: 1) Formalizing nursing education by establishing the first scientifically-based nursing school − the Nightingale School of Nursing – in London in1860. 2) Promoting training for midwives and nurses in workhouse infirmaries. 3) Popularizing and promoting pie diagrams while analyzing the medical statistics of the Crimean War. 4) Developing a form of the pie chart now known as the polar area diagram,1 or circular histogram,2 to illustrate seasonal sources of patient mortality in the military field hospital she managed. She made extensive use of the charts to present reports on the nature and magnitude of conditions of medical care in the Crimean War to Members of Parliament3 and to civil servants who would have been unlikely to read or understand traditional statistical reports. 5) In 1859, Nightingale was elected the first female member of the Royal Statistical Society.4 She was first to effectively use pie histograms to

make raw numbers more visibly understandable. 6) She was consulted by the North during the American Civil War, and was also inducted into the American Statistical Society. (Her father was an abolitionist.) 7) In 1907, she was the first woman awarded the Order of Merit. In 1908, she was awarded the Freedom of the City of London. She received the German Order of the Cross of Merit and the French Gold Medal of Secours aux Blessés Militaires. On May 10, 1910, she was presented with the Badge of Honour of the Norwegian Red Cross Society. What would Nightingale think of today’s medical care? As I walk, today, through an emergency room, or down a hospital hallway, or trespass into an ICU, I am reminded of her book, “Notes On Nursing” (1859). The noise, the blinking, clacking, beeping cubicles, the voices sounding from the hallways, the intrusive gleaming, glaring screens, the soulless/mindless TV, the overhead calls, and the invasive chaos of modern technology that continues day and night…it all leads me to suggest we need to consider Nightingale’s advice now.

Her description of the “hospital” – a “filthy shut-in barracks ... filled with parasite and vermininfested wounded” – was shocking.

Florence Nightingale became known as the Lady of the Lamp because of her quiet nighttime rounds.

May/June 2015

She stresses attention to the personal, and environmental, esthetic and physical conditions affecting a patient’s well being, health, and animus: Fresh air and circulation of air; safe water; a stable and comfortable room temperature. Consider the average emergency department where the temperature appears to be adjusted to the needs of frenetic professionals, rather than a nearly naked patient! (Remember the warm blanket!) Florence appeals for touching − frequent physical attention and contact, including warm soapy water for bed bathing; for attention to the environment − airing and changing linens, fresh, clean, comfortable bed clothing; for good nutrition − healthy, appropriate, considerate serving of food and liquid; for thoughtful attention to the patient’s wishes, and personal comfort and preferences − minimizing all disturbance, especially from noise (and especially at night), including unsettling intrusions, business concerns, and visitors who may be unwittingly intrusive or thoughtless.

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(She includes a list of visitor comments and questions that serve no purpose, but can be stressful or counterproductive.) I was interested in tropical disease and started my internship at Gorgas Hospital in 1954 in the Panama Canal Zone. The sprawling hospital had been built by the French during their disastrous attempt to build the canal. Some 40,000 people died during that effort, largely due to malaria, yellow fever, and pulmonary and diarrheal disease. The old French Colonial hospital consisted of graceful white, wooden, one-story buildings set among hillside gardens, connected by covered walkways. Wards and treatment areas, including surgery, were simply screened to remain open to the relatively-cool westerly ocean breeze; yet there was a sense of grace, of quiet, of being nestled in the arms of nature; but only up to a point. During the entire year, I never saw a fly or a mosquito in the American Canal Zone, thanks mainly to the same sort of radical engineering that made the canal itself possible. The day I began my medicine rotation, the resident advised me to always speak with nurses before making a significant medical decision. That advice was among the best I ever was given. I recall it now, during this age of technologic marvels, and suggest we all listen to Florence Nightingale about order, cleanliness, quiet, environmental warmth, and the human touch. She calls for us to preserve these primal and essential aspects of medical care. She calls for us all to remember that an orderly and safe environment, and good nutrition are essential for health and recovery from illness or injury. She reminds us to both wash our hands and to touch our patients. She calls down the years for us all to be more empathetic and humane in our efforts, rather than to ritualistically impose our concepts of “modern” medicine on patients. Let the Lady of the Lamp guide us still.

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john@loofbourow.com 1 http://en.wikipedia.org/wiki/Polar_area_diagram 2 http://en.wikipedia.org/wiki/Histogram 3 http://en.wikipedia.org/wiki/Parliament_of_the_United_Kingdom 4 http://en.wikipedia.org/wiki/Royal_Statistical_Society

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• 16 CEUs

• Complete in-depth ICD-10 guidelines

• AAPC ICD-10-CM Code Set Course Manual

• Nuances found in the new coding system with coding tips

• AAPC ICD-10-CM Code Set Draft Book • AAPC Online ICD-10-CM Proficiency Assessment

PRICING:

(Required for current AAPC CPC’s to maintain their credential)

• $399 for CMA members & members’ staff • $499 for CA-MGMA members • $599 for non-members

• Access to AAPC’s Online ICD-10-CM Assessment Training Course Space through December 31, 2015

is Limite

*Comparable AAPC ICD-10 Boot Camp Costs $799

SACRAMENTO DATES & LOCATION: July 15-16 Sierra Sacramento Valley Medical Society • 5380 Elvas Avenue • Sacramento, CA 95819 8 a.m. - 5 p.m. each day with an hour break from 12 - 1 p.m.

REGISTER: CALL (800) 786-4262 OR VISIT WWW.CMANET.ORG/AAPC-ICD10 INFORMATION: CALL JULI REAVIS AT (916) 551-2046 OR EMAIL JREAVIS@CMANET.ORG In partnership with: For more information about SSVMS please visit: www.ssvms.org

May/June 2015

Remodeling Your Medical Home By Gerald Rogan, MD, and Pauline Grenbeaux, Planner THIS ARTICLE OFFERS TIPS for home remodeling in order to improve safety, assist recovery from illness and injury, and accommodate chronic illness. When my parents, Al and Elaine, reached their tenth decade, they moved to assisted living in Sacramento and regularly visited our home. With their walkers and various maladies, my wife, Pauline, and I soon recognized obstacles to activities of daily living posed by our 1960 single-story ranch house. So we had it remodeled to help them. We quickly discovered that our remodel serves us, too.

Comments or letters, which may be published in a future issue, should be sent to the authorâ&#x20AC;&#x2122;s email or to e.LetterSSV Medicine@gmail. com.

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Ingress and Egress: One requires a walker after lower limb repair, bladder surgery, or chronic ambulatory maladies. We ramped up the new cement walkway to our front door threshold, eliminating one step (two risers). The top of the cement is covered with embedded small stones which improves traction when wet. To protect the entrance from sun and rain, we extended the roof. We added porch and walkway lights, activated by nocturnal motion detectors. Outside the sliding door to the patio, my mother struggled with the eight-inch riser devoid of handrails, so to accommodate her

walker, we added a four-inch platform step, 24” deep by 52” wide. We watched my parents enter and exit our car. We had to step onto the lawn to assist them, so we widened our driveway by two and one-half feet on each side along its proximal 20 feet. In front of the garage doors, we added a nine-foot overhang to protect from the rain and illuminate the drive at night. Bathroom: Use of a toilet requires arm support to help with post-surgery recovery, a balance disorder, weakness, or dementia. Our toilets are now large bowls 18” high. Behind and aside each are grab bars attached to horizontal studs, strategically placed. We installed a heated washing toilet seat powered through a nearby GFCI-protected1 electrical outlet. The toilet tissue holder is portable to accommodate a visual field or rotator cuff disorder. Lighting: The overhead light turns on when one enters the room, and off after leaving. You don’t even have to clap! The color of the floor tile is distinct from the wall, to assist spatial perception. Washing: The sink is attached to the wall without a vanity cabinet underneath to accommodate a wheelchair. A nook for soap, an electrical socket, and vanity light switch are at chair height. The faucet can be turned on with a finger touch. Bathing: We replaced a small bathtub with a shower stall. The weighted bottom of the shower curtain hangs inside a four-inch riser. One can step over it when using a walker. The removable shower head slides on a threefoot vertical bar so that a person may sit on a portable stool in the stall to bathe, just like is done in a Japanese bath house. Several grab bars and towel racks are bolted to vertical and horizontal wall studs. Access: We enlarged the two-and-one-halffoot bathroom doorway to three feet. The distance between the toilet and shower stall is 48 inches to accommodate the radius of a wheelchair. A portable chest of drawers can be moved out for caregiver space. Kitchen: The handles of the kitchen cabinets and drawers are “C” shaped to accommodate an

arthritic or bandaged hand, or a casted forearm. The faucet can be turned on with a finger touch. Augmented illumination options accommodate looming reduced vision. One cabinet stores a four-foot-high, light aluminum three-step ladder to access high cabinets. The ladder is sided by grab bars to mitigate imbalance and prevent a fall. Doors: Door handles are levers, not knobs. Garage: The garage is brightly illuminated with fluorescent lights for navigation and projects, such as shining shoes.

May/June 2015

Remodeling an older home for the convenience of aging parents can serve younger generations, too.

Requirements:

Want to lead a Walk with a Doc event? We are planning for one Walk with a Doc event per quarter in 2015. Saturday, March 14, 2015

LOCATION: Howe Park, 2201 Cottage Way, Sacramento

Saturday, June 6, 2015

LOCATION: Morse Park, 5540 Bellaterra Drive, Elk Grove

Saturday, August 15, 2015

An interest in talking to a group of walkers about health and wellness for 10 minutes before the walk. Ability to walk for 30 minutes and chat with walkers.

To volunteer, or for more info., contact Kris Wallach at 916 453-0254 or kwallach@ssvms.org

Sponsored by:

LOCATION: Valley Hi Community Park, 8185 Center Parkway, Sacramento

Saturday, October 10, 2015 LOCATION: Sheldon Park, 600 Orange Ave, Sacramento

jerryroganmd@sbcglobal.net Supported by:

Garden: Outdoor structures and plants provide privacy, pleasant smells and colors, bird habitat, and shade during warm weather. Planning: To accomplish our remodel, we worked with a design-build firm that offers a CAD2 program by which we can immediately visualize our plans in three dimensions. Our contractor’s cabinet maker provided a similar service. Every inch of construction was detailed in advance, so we could avoid expensive design changes once remodeling commenced. Some solutions we found on websites, in books, and in plumbing stores. Whether for yourself, your friends, or your parents, your home has a medical function. Design it to help prevent and accommodate illness and injury.

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1 Ground Fault Circuit Interrupter – required where water may be nearby as in kitchens and bathrooms. 2 Computer Assisted Design.

Medical Student Die-In A Reflection on Racial Bias in Health Care

By Jeremy Johnson, MSII; Lucy Ogbu-Nwobodo, MSII; Nhi Tran, MSII “THE IDEA THAT SOME LIVES matter less is the root of all that’s wrong with the world.” −Dr. Paul Farmer. On December 10, 2014, close to 100 UC Davis health professional students silently laid their bodies on the ground in a peaceful “diein” demonstration as a response to the ongoing police violence against communities of color. The failures to indict the police officers involved in the deaths of Michael Brown in Ferguson, MO, and Eric Garner in New York are symptoms of a larger illness of explicit and implicit racial biases. We UCD med students, in solidarity with well over 2,500 colleagues from 70 medical schools nationwide, made the decision that we can no longer stand by idly. The intent of the Twitter #whitecoatsforblacklives movement is to bring awareness to how racism and violence affects our country’s health, and to create a space for meaningful dialogue and constructive solutions. At the UC Davis white coat induction ceremony, held prior to the beginning of the first year, every medical student makes a commitment under oath to care for the health and well-being of all lives. In doing so, we are obligated to examine social determinants of health and confront racial health disparities. This is what we know to be true: Despite comparable documented pain complaints for long bone fractures, black patients are two out of three times less likely to receive analgesics1; the black infant mortality rate is 2.4 times higher than the white infant mortality rate; after adjusting for resources, black Medicaid recipients with mental illness are less likely than white Medicaid beneficiaries to receive

treatment in community-based settings and more likely to be hospitalized for psychiatric reasons2; the mortality rate from diabetes is double for black patients compared to white patients. African Americans comprise 40 percent of our nation’s prison populations while only constituting 13.1 percent of the nation’s overall population. Between 1983 and 1993, black defendants in Philadelphia, Pennsylvania were 38 percent more likely to receive the death penalty out of all death-penalty-eligible defendants. The NAACP found that in Oakland, CA, between 2004 and 2008, no weapon was found on 40 percent of individuals shot by police, all of the individuals shot by police were people of color, and 82 percent were black.3,4 Recently, the Department of Justice released a report on the Ferguson Police Department (FDP) that demonstrates systematic excessive use of force and racial bias, as exemplified by FPD K-9 units only being used on AfricanAmerican residents. Although these problems may seem like something confined to the nightly news, some of our classmates have experienced excessive use of force first-hand themselves. Even our mayor, Kevin Johnson, has been racially profiled: according to a September 28, 2014, Sacramento Bee article, he recalled being pulled over for driving a Porsche, and he sat in the back seat of a police car until it was confirmed that the Porsche was not stolen. We need to acknowledge the pervasive problem of excessive use of force and racial bias. We need to look at the conditions that led to the deaths of Mike Brown, Renisha McBride, John Crawford, Tamir Rice, Trayvon Martin,

May/June 2015

Jeremy Johnson, MSII

Lucy OgbuNwobodo, MSII

Nhi Tran, MSII

Kenneth Chamberlain, Sr., Oscar Grant, Sean Bell, Jonathan Ferrell, Aura Rosser and now, Antonio Zambrano-Montes. As we collectively lay on the cold concrete in front of our Medical Education Building, we asked everyone to think about the following questions: • Why do some people watch the video of Eric Garner’s death and perceive him as transitioning from indignant to acutely distressed, while others view him as lying by virtue of his ability to verbalize that he can’t breathe? • Why did the 911 caller in the open-carry state of Ohio see John Crawford as a threat? • Why did law enforcement shoot 12-yearold Tamir Rice within two seconds of when they arrived to the area where he was playing in the park? Why did it take the arrival of an unrelated FBI agent, and not one of the initial two officers on scene, to administer CPR, administered a full four minutes after Tamir was shot? Why was Tamir Rice’s 14-year-old sister pushed to the ground and UC Davis health professional students conducted a peaceful “die-in” demonstration against police violence in communities of color.

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then forced to sit in the back of the police car next to where her brother lay dying? • Why do some people believe that, having been shot multiple times, Mike Brown had his hands up in surrender while others believe he chose to charge through bullets? • Why do we see these events so differently? We asked these important questions because the answers suggest racial bias is widespread among ourselves. Likewise, for medical providers, several studies affirm the existence of provider-implicit racial bias which influences patients’ treatments and health outcomes.5 Despite the altruistic nature of the practice of medicine, implicit bias skews our view of reality, creating the potential for harm. It is non-maleficence that requires us to acknowledge, reflect and question what role our biases play in fomenting disparity. You, the reader, may want to ask yourself what your biases are and what has informed those biases? This is not an easy task; it asks us to question whether our merit and bootstraps alone control destiny. It asks us to see how we are all connected to history and to each other. It asks us to utilize our newfound understanding for open dialogue. It shows us that racism persists through unconscious bias because good intentions are not enough. We hoped to foster this thought process and action through our die-in. We do not practice medicine in a vacuum; instead we are all integrated in many aspects of our communities. The shameful legacy of racism that has plagued our nation has created deeply-rooted disparities that have trickled into our health care system; and whether conscious or not, bias and prejudice affect the care received and provided for communities of color. Physicians and all health professionals must be aware of their biases towards patients and should aim to deliver care based on clinical effectiveness, compassion, and utilitarianism. #Whitecoatsforblacklives is a starting point − a commitment to recognizing the historical and present injustices. If we can create a safe, respectable and open space where these issues can be addressed, we can reach

more comprehensive solutions to create a more equitable and healthy society. As health care students and providers, we hold trusted and respected roles within our communities. Make your voices and votes heard. Advocate for our community’s wellbeing, whether it be health care access, healthy living, education, youth and mentoring programs, or neighborhood safety. Let’s continue to call out discrimination when we see it and pull the weeds out before they seed. We went into medicine to make a difference. Let’s not let what happens outside our hospitals dictate what happens on the inside. We must do better! nhitra@ucdavis.edu References 1 Todd KH1, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000 Jan;35(1):11-6. www.ncbi. nlm.nih.gov/pubmed/10613935. 2 Centers for Disease Control and Prevention. CDC health disparities and inequalities report— United States, 2011. MMWR 60(Suppl):1–116. 2011. 3 Race and the Death Penalty. (2003, February 26). Retrieved

March 3, 2015, from www.aclu.org/capital-punishment/race-anddeath-penalty. 4 Lee, J. (2014, August 15). Exactly how often do police shoot unarmed black men? Retrieved March 3, 2015, from www.motherjones.com/politics/2014/08/police-shootings-michael-brownferguson-black-men. 5 Chapman EN1, Kaatz A, Carnes M. J Gen Intern Med. 2013 Nov;28(11):1504-10. doi: 10.1007/s11606-013-2441-1. Epub 2013 Apr 11.Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities.

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May/June 2015

Drought 2015: A Public Health Report By Donald Lyman, MD, Chair, SSVMS Public and Environmental Health Committee

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

WATER HAS BECOME AN important issue for the Sierra Sacramento Valley Medical Society (SSVMS) through its Public and Environmental Health Committee. The issue of too much water came up several years ago when the Sacramento region suffered flooding and was listed as “next up” by federal authorities as the highest risk area in the nation for catastrophic floods after the New Orleans, Louisiana, area. As part of that listing, the Sacramento region undertook a long-term regional planning effort, and a draft FloodSAFE Strategic Plan was released in 2008.1 SSVMS’ Public and Environmental Health Committee reviewed that plan and concluded it would benefit from a perspective which includes human health. Today, California is in a drought situation which appears to be part of a global climate change dynamic. While the drought situation in the Sacramento region is projected to be shortterm, the southern part of California is projected to have a long-term problem. We are now in the fourth year of markedly-reduced precipitation. However, the Federal Bureau of Reclamation projects that the Sacramento watershed will sustain its usual quantities of rainfall for the next few decades. Winter temperatures are projected to be somewhat higher.2 That means that the precipitation for the first half of the winter will all fall as rain with no accumulation of snowpack in the Sierra Nevada mountains. The snowpack is our reservoir storage area for water supply later in the year. The second half of winter will see some snowpack accumulate. Areas to the south of us will see significant reductions in total quantities of precipitation. These altered dynamics will change the ways we deal

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with water supplies statewide. So, we in the Sacramento watershed have a current, but probably short-term, drought situation. However, we will have logistic problems with storage of adequate quantities for the rest of the year. In summary, the issues for us are: • Short term – how to deal with lower-thanexpected rainfalls for the next two to three years; and, • Long term – how to deal with altered delivery patterns (no adequate storage in our snowpack) and increased demands on our waters from populations and industries, such as agriculture, to the south of us. The question for the health community is how to preferentially protect human health as water delivery agencies deal with reduced volumes of water in our region for the next two to three years. Curiously, we are in fairly good shape because we live in a desert; that is, we have built out to accommodate long, dry periods. We have rainfall only in the winter season and are mostly dry for the rest of the year. We are also an exceptionally-abundant agricultural area with fertile soil, good climate and, up until now, adequate and well-structured water sources managed for delivery year round. We have dammed rivers, reservoirs, pipe and canal delivery systems, groundwater, a population responsive to calls for conservation, and state and local government agencies which monitor and control deliveries of water. However, in any desert, water is like gold. It is more precious than many other commodities. We suffer many disagreements about use. While laws guide much of water distribution, many laws are vague and manipulable, and many

different interests are engaged in how the rules are effected. Drinking water is a small part of the state’s water distributions. About 80 percent is used for agriculture. Most of our drinking water is acquired by wholesalers (e.g., Metropolitan Water District of Southern California − the MET, serving 18 million customers), processed and sold to retailers who, in turn, sell it to industries, commercial corporate entities and to individual households. Wholesalers tend to have dedicated sources or entitlements to their sources (e.g., the MET processes California’s share of the Colorado River). Retailers tend to blend wholesale waters with their other supplies from surface waters (e.g., the City of San Diego uses the Tijuana River which arises in the United States) or ground waters (e.g., retailers in the Sacramento region). As water sources start to dry up, each of these distributors tries to rebalance its accounts with a mix-and-match of its sources and calls for conservation from its customers. There are potential compromises on human health in all these equations. Clearly, we can expect generic problems in the following areas:

due to reduced water flows (think: hands and edible produce). • Vulnerable Populations • Increased irrigation of crops with untreated recycled waters.

Water Quality for Drinking • Contamination of raw water sources in private wells, small water retailers (from agricultural ditches) and unregulated bottled water purveyors.

Mental Health • Documented increased suicide rates among small farmers. Part of the solution is a focused participation by health professionals in the policy-making dynamics of drinking water providers. Yes, each provider will cite mandatory and emotional

Environmental • Dust/respiratory diseases from dry soils and winds (think: Coccioidomycosis or Valley Fever, and asthma). • Vector-borne diseases (e.g., West Nile virus) as migratory birds and mosquitoes all congregate at smaller water areas. • Recreational risks from shallower lakes and rivers; increased concentrations of untreated surface waters with pathogens. • Wildfires from dry forests. • Socio-Economic • Job losses due to plant closures and agricultural dislocations. • Sanitation • Inadequate washing and cleaning

May/June 2015

commitments to human health protections. However, policy implementation outcomes are often unclear (e.g., how do job losses balance against increased salinity in water when a common well source is over-drafted?). Industrial interests often outweigh individual needs in the political world, and mandatory compromises in conservation seldom balance many commercial demands (e.g., will that brick in my toilet tank really save the farmer who guessed wrong five years ago and planted the wrong crop?). SSVMS’ Public and Environmental Health Committee calls on all physicians to be part of the solution with advice to their patients and to the world of water purveyors, to ask the “human health questions” and to assure this perspective is included. So, there is no clear answer to the question of minimum amounts-per-capita to protect human health. We are just one of many voices in the policy making process, but one of the most important ones! We call on physicians to be aware of the

health implications of the drought. SSVMS will continue to monitor the situation and monitor local and state authorities who control our water supplies. We will continue to support local and state health officers’ efforts to protect the public’s health. As the organization representing physicians and the patients they serve, SSVMS will continue to assure that human health is paramount in all policy considerations. Donald.o.lyman@gmail.com

1 FloodSAFE Strategic Plan – Public Review Draft, June 2008 www.water.ca.gov/floodsafe/docs/FloodSAFE_Strategic_PlanPublic_Review_Draft.pdf 2 West-Wide Climate Risk Assessment Full Report: −Reclamation Managing Water in the West, West Wide Climate Risk Assessment−Sacramento and San Joaquin Basins, Climate Impact Assessment www.usbr.gov/WaterSMART/wcra/docs/ ssjbia/ssjbia.pdf Resources concerning drought related health problems: ”When Every Drop Counts,” Centers for Disease Control and Prevention www.cdc.gov/nceh/ehs/docs/when_every_drop_counts.pdf “Health Effects of Drought: a Systematic Review of the Evidence” http://currents.plos.org/disasters/article/dis-13-0001-health-effects-ofdrought-a-systematic-review-of-the-evidence/ “Public Health and Drought: Challenges for the Twenty-First Century,” Centers for Disease Control and Prevention www.cdc. gov/features/drought/

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The Drought’s Impact on Public Health — How Physicians Can Help Look for high risk families – have your staff routinely check the addresses of your patients if they live in rural areas and have water from wells or very small water systems. Ask your patients, “Is your water supply OK?” If no, ask “Do you have any restrictions in how much water you may use?” If yes, help patients prioritize health protection, such as hand washing, sanitation, and the safety of foods and drinking water. Remind patients to be wary of drought-related problems such as dust, mosquitoes, wildfires, and the dangers of swimming and diving in shallow waters.

Clean Water: Better Than Gold By Bob LaPerriere, MD VIVID DESCRIPTIONS FROM diaries of pioneers coming to California in the 1800s illustrate the challenges they faced: “Once we came to a puddle where the rain water had been standing til green on top and so muddy that if there had been hogs about, I should have set down at once as one of their wallowing places, yet this stuff which would have been rejected very suddenly by my stomach at home I drank with considerable relish, by shutting my eyes and holding my breath.” − (From Gold Rush Diary: Being the Journal of Elisha Douglas Perkins on the Overland Trail in the Spring and Summer of 1849) “Our drinking water is living − that is, it is composed of one third green fine moss, one third pollywogs, and one third embryo mosquitoes.” − (From Mexican Gold Trail: The Journey of a FortyNiner. The Huntington Library Classics, Oct. 4, 2006, by George W.B. Evans and Glenn S. Dumke) Drinking water did not improve once the gold seekers arrived in Sacramento. The lack of pure drinking water contributed to the death from cholera of 1,000 Sacramentans in a threeweek period in 1850, in addition to many other diseases and a death rate of 10 percent for infants. What a contrast to the tour I took with the Public and Environmental Health Committee of the E.A. Fairbairn Water Treatment Plant on February 17th. It is one of two plants serving Sacramento City. Located near California State University, Sacramento, and just a long stone’s throw from the Guy West Bridge, it has a maximum capacity of 160 million gallons per day. (On the day of our tour, output was 38 million gallons).

Built in 1963 and upgraded in 2001, it can be operated by a small staff that can monitor and control all functions and equipment from the control room. Monitoring includes ensuring the pressure is maintained at 40 psi at all pumping stations and controlling all the steps the water goes through. Today, the majority of city water processed at Fairbairn comes from the American River. Only a very small percentage comes from wells. The other city facility, the Sacramento River Water Treatment Plant, has the same maximum capacity. In the summer, with both plants operational, the daily demand can be as high as 180,000 million gallons. Well water requires only chlorination and fluoridation, whereas river water flows through several treatment modalities. These include, as a simplified list: 1) Water is pumped from the river into an influent channel to a grit basin, where it is pre-chlorinated and large particles are allowed to settle out. 2) A coagulant (alum or aluminum sulfate) is added to the water to settle out small particles. 3) It continues its flow through several flocculation ponds where propellers on the bottom gradually stir the water, with more particles settling out as it progresses to the sedimentation ponds. 4) The water is then filtered through layers of anthracite and sand. 5) More chlorine is added at the post chlorination station. 6) Lime, used to control pH, and fluoride are then added.

May/June 2015

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

The E.A. Fairbairn Water Treatment Plant is one of two plants serving Sacramento City.

7) The water then goes into the reservoir where it is pumped through the distribution system, as needed. 8) All the sediment is transferred to sludge ponds and then transported to an off-site approved dump. Due to contamination by materials, such as various heavy metals, it is not used for fertilizer or other purposes. Sewage is handled by a totally different facility, but Fairbairn does make sure all of the

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156 sumps (lift stations) that pump up to 580 million gallons of the combined sewage and storm drain effluent for processing and then out to the river, are operating properly. Yes, Sacramento City’s “historic” pipes combine sewage and storm drain effluent. If an extremely heavy rain occurred and exceeded the maximum capacity of the system, it is possible that raw sewage would go into the river. The only other alternative is flooding the city, as the levees protect us from river flooding, but in reverse, would contain flood waters and sewage within Sacramento. This has not occurred in the past five years. 0.3 inches of rain in one hour is the critical point when additional staff is mobilized. New concepts, such as permeable paving/concrete, allow a lot of rain to drain to the earth rather than being “run off” and adding to the effluent level. Upgrades are almost a routine, as the efficiency of a water purification facility is about 30 years. Currently, the major upgrade is adding two centrifuges to spin out the water in the sludge so it can be moved to the landfill more rapidly and efficiently. After seeing the complex process that our water goes through to prepare it for making our coffee and tea, and to quench our thirst, it seems a waste to use it for watering lawns, washing cars, etc. Hopefully, the future will be to use “gray water,” recovered from waste water and purified but not to potable quality, for lawn irrigation. Laguna, in south Sacramento, is phasing this in. San Diego is going one step further, initiating plans to turn wastewater into potable water. The project, dubbed Pure Water San Diego, is expected to

provide more than a third of the city’s potable water by 2035. “Toilet to Tap” is a kind of aqueous version of “Farm to Fork.” Actually, some sewage has been converted to drinking water over the past 30 years in regions from Singapore to Orange County, California. On January 5th, Bill Gates featured an invention on his blog, the Omniprocessor.1 It inexpensively treats sewage water and turns

it into electricity and clean drinking water. Through the ingenious use of a steam engine, it produces more than enough energy to burn the next batch of waste. It powers itself with electricity to spare, and could be very functional in third-world countries. So, there is hope beyond our current serious need to reduce water consumption due to our drought. continued on page 25

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May/June 2015

Covered California − How About Sacramento? By Glennah Trochet, MD, former Sacramento County Public Health Officer

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

THE COUNTY´S MEDICALLY Indigent Services Program (CMISP), in existence since 1983, and extending basic health services to very low income adults in Sacramento County, did not ask about legal residency status until 2009, when the Board of Supervisors voted to require proof of legal residence in order to qualify for county health services. In the past few months, several organizations, including Building Healthy Communities, Area Congregations Together, and your own SSVMS, have met with members of the Sacramento County Board of Supervisors to advocate that they reverse this policy decision. As a result of this advocacy, the Board of Supervisors held a workshop on March 18th to educate themselves and the community about the issue. The staff report presented several options for restoring these services as well as an option for doing nothing and for waiting to see what the State legislature might do. Senator Ricardo Lara has a bill, SB4, that would make state-funded Medi-Cal and possibly a health insurance exchange available for undocumented residents of California. The bill has support in the legislature, but even if it passes, it is not known if Governor Jerry Brown would sign it. Also, county staff listed the other counties in California that serve undocumented residents and mentioned that, in Fresno County, the Board of Supervisors provides funding for specialty care and relies on community clinics to provide primary care. The workshop audience numbered over 400, and was overwhelmingly in favor of restoring services. So many people attended the meeting that they did not all fit into the Board chambers,

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and chairs were set up in the lobby where those who arrived late could view the proceedings on television monitors. Dr. José Alberto Arévalo presented in support of the restoration of these services on behalf of SSVMS, and reminded the Board of Supervisors of the contributions of the SPIRIT Project (the Sacramento Physicians’ Initiative to Reach out, Innovate and Teach) which has placed both primary care and specialty physician volunteers in county and community clinics and has provided thousands of dollars in free care and donated surgeries. Several elected officials testified in support of restoring services, including Mayor Kevin Johnson, Council Members Steve Hansen and Jay Schenirer of the City of Sacramento, as well as State Senator, Dr. Richard Pan and Assemblymember Kevin McCarty. There were also members of the Boards of Supervisors of Yolo and Kings Counties who supported restoration of services and said that the eyes of the region were upon Sacramento. Former Supervisor Roger Dickinson recommended that the Board of Supervisors restore these services now. Bishop Jaime Soto spoke in support of making health care available to everyone who lives in our community. The Sierra Health Foundation, Sacramento Latino Medical Association, Building Healthy Communities, medical students from UC Davis, Health Access and other health-related organizations presented testimony in support of changing the policy back to including all residents of Sacramento County in the services offered by the county. Several medical students gave their own personal histories that included

coming to this country as children and being undocumented. Brian Jensen, Regional Vice President of the Hospital Council, and Jim Ellsworth, Executive Director of the Capitol Health Network, offered to work with county staff to develop a program that would work efficiently. Seventy people signed up to speak during the public comment period, but many left before their names were called. There were personal stories of people who were unable to work or who suffered pain and disability because they could not access basic health services outside of the emergency room. Most speakers agreed that there is a moral imperative to have access to health care for our entire population. Some mentioned studies that show how access to primary care reduces expensive hospitalizations, while others quoted research which shows that undocumented residents of California pay taxes and contribute to the economy in many ways. One individual spoke against giving any services to undocumented residents. He denied that they contributed in any way to our community. He said he represented an organization called “Save Our State.” He became angry when he was not given additional time to make his case. During the deliberations at the end of the meeting, Supervisor Don Nottoli said he was struck by the number of people whose personal stories showed lack of access to specialty medical care. He wanted county staff to develop a plan with the community clinics and hospitals to see

if Sacramento County might provide funding for specialty care as they do in Fresno County. Supervisor Patrick Kennedy stated that he supports extending services to undocumented residents of Sacramento, as did Supervisor Phil Serna. Supervisor Susan Peters wondered if we shouldn’t wait until they know what the state is going to do, and said that she didn’t know where the funding would come from. Supervisor Roberta MacGlashan said that she worried there were other needs such as mental health, and wanted to know the “whole picture” before she made a commitment. The county executive stated that anything the Board did to help the undocumented was discretionary and not required by law. The Board then directed county staff to consult with community clinics and hospitals and return in six to eight weeks with a proposal and budget for increasing access to health care for the undocumented residents of Sacramento County. The exact date of this next presentation was not determined. The meeting was scheduled to end at 5:00 pm, but the public testimony went until 7:10 pm. I was glad to attend this event; I hope that some of these ideas will lead to actions – and a truly “Covered” California. The entire meeting and supporting documents are archived on the internet and can be viewed at www.agendanet. saccounty.net/sirepub/mtgviewer.aspx?meetid=1153 9&doctype=AGENDA

The workshop audience numbered over 400, and was overwhelmingly in favor of restoring services.

trochetg@gmail.com

Clean Water continued from page 23 Water must meet the following goals before distribution to the consumer − a pH of 8.2 (established by taste tests), chlorine at 0.8 mg/l and turbidity of 0.05 NTU. By way of reference for turbidity, the river water was 1.5 NTU on the day of my tour, but can be as murky as 50 NTU after heavy rains. So, the next time you turn on the tap,

remember the long, complex path the water has traversed to get to you, and please think of everything you can do to conserve this precious liquid we so often take for granted. ssvmsmus@winfirst.com 1 www.gatesnotes.com/Development/Omniprocessor-From-Poopto-Potable

May/June 2015

SB 277: Halt VaccinePreventable Diseases By Richard Pan, MD, MPH, State Senator

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

I ATTENDED MEDICAL SCHOOL at the University of Pittsburgh where Dr. Jonas Salk invented the polio vaccine. As a medical student, I learned about vaccine-preventable diseases including measles and polio. My professors taught us that, due to vaccination, it was unlikely we would ever see these diseases while practicing in the U.S. In my senior year, I spent eight weeks with the U.S. Public Health Service at a community clinic in Philadelphia. An outbreak of measles spread across the city, starting with a group of children whose parents did not believe in vaccination. Measles was no longer a disease in a textbook, but a contagion that infected over 900 people and killed nine children. Also, when I attended medical school, Haemophilus influenza type b (Hib) was a leading cause of bacterial meningitis and invasive disease in young children who often ended up in the pediatric intensive care unit (PICU). Fortunately, widespread Hib vaccination just began and resulted in a dramatic drop in infections. During my pediatric residency, I cared for only a single PICU patient with invasive Hib. Unfortunately, out of sight meant out of mind for subsequent generations of parents. Having not seen vaccine-preventable illnesses, parents did not understand how serious they were. As physicians, we celebrated the development of new vaccines. Vaccines triggered the potency of our own immune system to prevent infection. But herd immunity requires that all families do their part. However, in 1998, Andrew Wakefield authored a now retracted study of 12

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developmentally-delayed children, which by parental report, were associated with measles vaccination. This purported link between autism and the measles vaccine led to numerous studies worldwide involving hundreds of thousands of children, proving that measles vaccination did not cause autism. Further investigation showed that Wakefield falsified data and that a product liability attorney paid him about $674,000 plus expenses prior to publication. By the time the truth was revealed, the damage was done. Many parents became anxious and hesitant about the vaccines that protected their children. Autism is a terrible disease, the symptoms of which appear at the same age as the administration of the MMR and other vaccines. Compared to seemingly non-existent diseases, even a slight possibility that vaccines might cause autism or other ailments, as trumpeted on talk shows and over the Internet, made many parents hesitate. Some companies, and even a few physicians, continue to profit by selling books and products that hype the risk of vaccines and minimize the risk of infection. The ironic truth is that they got away with it because vaccines work and enough people were previously vaccinated to keep the diseases at bay. But, as they have grown more successful in deceiving parents into not vaccinating their children, diseases are returning. In 2008, an unvaccinated seven-year-old patient of Dr. Bob Sears caught measles in Switzerland and spread the infection to 11 unvaccinated children in San Diego including a 10-month-old infant who continued on page 29

A Posit on Immunizations “It is unethical to deny care to patients who refuse immunizations.”

Background: Some physicians feel so strongly about the importance of immunizations that they ask their patients, or parents of patients, to seek another physician for their care if vaccines are refused. See the Boston NPR article from May 20, 2011, http://commonhealth.wbur.org/2001/05/ pediatricians-dilemma-vaccines. In a 2013 updated statement, the American Academy of Pediatrics recommended: “In general, pediatricians should endeavor not to discharge patients from their practices solely because a parent refuses to immunize a child.” http://pediatrics. aappublications.org/content/early/2013/04/24/ peds.2013-0430.full.pdf+html. Note: Posits are aggressive statements intended to promote discussion. Results do not constitute valid polling data and may not reflect the position of the Editorial Committee, or the SSVMS Board of Directors. Results: 33/Agree – 32/Disagree. Commentary follows: I agree. Continuing a long-term therapeutic relationship gives future opportunities to potentially change a parent’s thinking. − Russell Unger, MD I agree with the statement by AAP on ethics. −Linda Copeland, MD I agree. Immunization for infectious disease is important for public health to minimize spread. To become immunized is a desired behavior. Yet, in a free society, behavior cannot be successfully imposed. It must be taught, or become the societal norm. A physician has, I hope, the right to refuse care to anyone, but as a way to safeguard the public’s health, I believe that would be both unethical, and ineffective; it could feel good of course. −John Loofbourow, MD I disagree. Physicians’ ethics dictate

we provide the best care we can. Legally, we enter into a verbal contract with a patient to provide their care. A patient who refuses our recommendations also refuses to enter into a contract for care. Therefore, the physician has no ethical or legal obligation to provide continuing care, even though one may not feel correct about stopping other care for this patient. The physician is better in the long run for not caring for a patient who chooses to only select part of their recommendations. −Richard Park, MD, FACS I agree. A child (the patient) should not be made the scapegoat or victim of his/her parents’ ill-advised decision. −Ralph Koldinger, MD I disagree. I think that it’s fine not to accept such patients in your regular practice; but when they are acutely ill, we are obliged to assess and treat them. −Steven Dorfman, MD I agree. I am in pediatrics – definitely wrong to deny care to the patient when they have stupid parents. They are already at a disadvantage. −Victoria Link, MD I agree. To quote Lord Byron, “What would we do without the gluttons, fornicators, drunkards and sloths that make up the human race?” Seventy-five percent of disease is selfinduced. It is part of the human condition to make bad choices. Denying care is arrogantly appealing, but immoral. −William Lewis, III, MD I disagree. Very simply, they put others in my practice at risk and to whom I, as a physician, have a greater ethical obligation to protect. −Malcolm Ettin, MD I agree. As much as we may be unsettled by our patients’ scientific ignorance, we are bound to care for all seeking care. Having a respectful dialogue, as challenging as that may be, may eventually result in patients receiving

May/June 2015

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

Parental refusal of vaccinations for their children is not a rare occurrence anymore.

immunizations over time. −Peter Hull, MD I agree. In regards to pediatrics, it is not the fault of the patient that the parent is refusing immunizations. We should have a constant dialogue with the parent(s) while still taking good care of the patient(s). −Robert Madrigal, MD I disagree. I do not think it is unethical unless there is no other option for the patient’s care. −Robert Kahle, MD I agree. We need to do all we can to help our patients. It is unethical to deny care to patients who refuse immunizations, just like it is unethical to refuse care to patients who smoke or eat junk food or refuse to exercise. − George Luh, MD I disagree. The benefits of immunizations are unquestionable and an amazing opportunity to practice the preventive medicine we have been clamoring for. If we allow patients to consider immunizations (a longstanding cornerstone of preventive medicine) optional, what’s next? Blood pressure medication, diabetes medication? It is a slippery slope; we must make preventive medicine a regular practice of our patients from birth. If not, we are doing them a disservice as physicians. −Michael Mirmanesh, MD I agree. However, they do put others at risk. My concern is if we get a Rubella outbreak among child-bearing women, we will have a new group of deaf, blind, and mentallychallenged kids. −George Meyer, MD I disagree. I believe it to be unethical to allow unimmunized children to remain in your practice since they put children in your waiting room, who might be too young to be immunized, at risk. Such children can be home schooled and receive their medical care from like-minded pediatricians. −Gilbert Simon, MD I disagree. In general, I agree with the Academy’s statement; however, I think that a physician has a right to refuse seeing patients who don’t get immunizations for themselves or their children. The unimmunized are a danger to the doctor, to the staff, and to other patients. −Maynard Johnston, MD I disagree. It is unethical to refuse care to

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a patient because that patient makes decisions that the provider disagrees with. It IS ethical to decline treatment on the basis of risk to others. I can elect to decline to treat a patient that is, through action or inaction, actively threatening the health and wellbeing of my other patients. −Ryan Nicholas, MD Strongly disagree. Those families are a liability in a waiting room of children potentially too young yet to be vaccinated, and they do not trust doctors or the “system” and never will, unfortunately. −Brett Christiansen, MD I disagree. Parental refusal of vaccinations for their children is not a rare occurrence anymore. With some schools reporting up to a 20 percent refusal rate, unvaccinated children are rapidly becoming the biggest public health hazard of our generation. Just last month, a two-month-old infant died of whooping cough in Sacramento County. With 16 states in the Union refusing to allow unvaccinated children the ability to matriculate in public schools, California may join suit shortly. The position above is short-sighted. I counter that it is unethical to expose infants and children in medical clinics to potential hazardous infection from their unvaccinated peers. My clinic now has two waiting areas and is forced to segregate to avoid being a nidus of infectious dispersal. Community responsibility must be the position taken by our Medical Society. Trust my opinion that the AAP will waffle in their position as quickly as they did on circumcisions. Support the physician’s right to practice how they wish, rather than taking a position on such a volatile public issue. −Ravinder Khaira, MD, MPH I disagree. While patients do deserve autonomy and the ability to make their own decisions regarding medical care, physicians deserve the same right. If a patient refuses to be objective and decides to ignore the overwhelming evidence regarding vaccine safety, we, as physicians, should not be shackled to them in a forced and potentially toxic doctorpatient relationship. We can’t be pushovers on everything all in the name of service. −Mukesh Sahu, MD I agree and disagree. We wouldn’t drop

a patient who continued to smoke or drink alcohol or listen to Dr. Oz, even though those things clearly jeopardize public health. On the other hand, we were told over a decade ago that it was unethical to withhold pain medication from someone in pain, and look where that has gotten us! A physician’s discretion should be more valued; sometimes certain patients need to hear “no more.” −Nate Hitzeman, MD I disagree. This is a difficult ethical question; however, I wonder why patients or families who

reject some of the central tenets of modern medicine would want to see a physician whose philosophy of care is diametrically opposed to their own. For clinicians, particularly in the face of an outbreak of preventable disease, the key question may be whether it is ethical to allow a patient with ill-founded or even paranoid objections to place other patients at risk. I think not. −Francisco Prieto, MD

SB 277 continued from page 25 caught measles in a pediatrician’s office and was hospitalized. Every state passed laws requiring vaccinations for school entry to protect public safety and health. However, some states, including California, allow unimmunized children to enter school with a personal belief exemption. Initially, the exemptions were rarely used, so vaccination rates remained high enough to prevent outbreaks. However, over the past two decades, exemption rates have risen, concentrated in particular schools and communities. With each passing year, the number of unimmunized people, especially children and young adults, grows significantly. Concerned about this trend, I authored AB 2109 in 2012 to require parents to receive counseling from a licensed health professional before obtaining an exemption to enroll their unimmunized children in our schools. However, we saw a spike of almost 200 measles cases in 2013, 644 in 2014, and 170 in the first two months of 2015. While AB 2109 resulted in the first decrease in exemptions in 12 years, it is not enough to halt the growing outbreaks. The measles outbreak which began at Disneyland is a wake-up call that diseases will return if more people continue to go unvaccinated. In 2015, measles exposures have occurred in stores, restaurants, public transit, theme parks, schools, and day cares. Parents

are right to be concerned about bringing their infants, who are too young to be immunized, to schools and shops. People receiving cancer treatment who cannot be immunized, or who have immune deficiencies such as AIDS, should not have to fear leaving their homes. Many parents are speaking out; they demand leadership to halt the spread of preventable diseases. SB 277 will abolish the personal belief exemption for enrolling unvaccinated children in schools. A medical exemption will remain available for children who cannot be immunized. SB 277 will not remove a parent’s choice to vaccinate their child. However, choice requires responsibility, and under the measure, parents who decide to not vaccinate will be required to home-school their children. All children deserve to be safe at school, and refusal to vaccinate endangers other children at our schools and in our community. As a pediatrician, I have cared for children whose parents refused vaccination. I ask their parents to share with me what they have seen or read that worries them. Usually, it turns out to be vaccine misinformation, but then some say that the disease is gone, so their own child is not at risk. We no longer have that luxury. I ask your support for SB 277.

…choice requires responsibility…

senator.pan@senate.ca.gov

May/June 2015

The History of Leprosy By George Meyer, MD, FACP, MACG

Comments or letters, which may be published in a future issue, should be sent to the author’s email or to e.LetterSSV Medicine@gmail. com.

MY WIFE, LYNN, AND I WERE in Hawaii in October for a few days, mainly to visit a friend who was the primary doctor for the Hansen’s Disease settlement in Kalaupapa on Molokai Island. We were fortunate to spend a full day and night there to learn some of its history from S. Kalani Brady, MD. In Hawaii in 1835, a disease then called leprosy, was first being diagnosed and thought to be imported from China. In 1865, King Kamehameha V signed a bill authorizing a settlement to be created in a remote part of Molokai Island to house those unfortunate enough to be afflicted with what we now know as Hansen’s Disease (HD). The first 12 victims, 9 men and 3 women, were transported to Molokai in January of 1866 to live in isolation. Eventually over 8,000 Hawaiians were ostracized to this community. At its peak, the population was about 1,200. In 1969, over a century after the colony was created, Hawaiian law changed, allowing the residents of this part of Molokai to move freely again. There are a lot of Molokai residents “topside” who were not affected by the earlier law. Now, the Kalaupapa settlement has from 8-12 patients, about 40-50 state workers and 40-50 federal employees. The only access is by small aircraft to the 2,500-foot runway or by a winding path from the top of an 1,800-foot cliff. An enterprising Kalaupapa resident has established mule trips to show tourists the history of the place. By mule or not, unauthorized persons are not allowed onto the peninsula. The settlement is now part of the Kalaupapa National Historic Park. Josef De Veuster (later known as Father Damien) was born on January 3, 1840 in Belgium. After becoming a Catholic priest, he volunteered to be sent on a mission, eventually being sent to Honolulu in 1865. As the public health crisis developed, the local bishop desired

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to give Catholic support to those on Molokai. The plan was to send 4 priests for 3-month rotations. Father Damien was the first to go to Molokai in May 1873. In his first 6 months, not only did he attend to the ill, but he also built a church and a reservoir, made coffins, and dug graves. He organized schools, worked farms, painted houses, and encouraged residents to follow basic laws. (Kalaupapa was pretty lawless when Father Damien arrived.) After many months, Father Damien requested to remain in the settlement. He diagnosed his own HD in December 1884. He died on April 15, 1889, and was buried where he first arrived in the Kalawao area of the peninsula. His body was later exhumed and sent to Belgium at the request of King Leopold III. He is buried in Leuven. He was beatified in June 1995. His right hand was returned to Molokai and is buried in his grave on Molokai near the church he built. He received Sainthood status on October 11, 2009. Mother Marianne Cope of the Sisters of St. Francis of Syracuse, NY, led the nursing activities on the island. She was born in what is now Germany, but moved with her parents to Utica, NY, when she was 1 year old. She helped in the founding of hospitals in New York State and was involved in the founding of the medical school at Syracuse. Even though she was Mother Superior of her order, at age 45 she and several other nurses answered the call to go to Hawaii to help care for those afflicted with HD. She was canonized as a Saint by the Catholic Church on October 21, 2012. It is unclear where Hansen’s Disease originated, but there are descriptions of it from India, China and Egypt long before the Common Era. It seems clear that it was brought to Europe from travelers to India. The Hawaiian outbreak is considered to have been

imported from China. The disease is caused by the bacterium, Mycobacterium leprae. First described by a Norwegian, Dr. G.H.A. Hansen in 1873, it is the first disease to be described as being caused by a bacterium. Prior to that time, it was commonly thought to be inherited. In fact, Hansen’s thoughts were in contradiction to those of his father-in-law, Dr. Daniel Cornelius Danielssen, a proponent of the inheritance theory. The highest new case rates of Hansen’s Disease are in India, Brazil, Nepal and several African countries. M. leprae prefers cool environments and so tends to localize in the eyes, skin and nerves. It can also be found in nasal secretions. The method of transmission is unclear, but the upper respiratory tract route is the most likely place where the bacteria invade. Affected nerves develop anesthesia and granulomas. There are two different clinical forms: lepromatous and tuberculoid, a more benign form. Tuberculoid (TT), or paucibacillary, HD has a few skin lesions and is rarely fatal. On the other hand, the lepromatous (LL) form is more aggressive. Diagnosis is suggested by the anesthesia associated with a lesion and confirmed by skin biopsy. The World Health Organization (WHO) classifies HD by the number of skin lesions, either less than or greater than six lesions. Fewer than six lesions is associated with tuberculoid leprosy, and greater than six lesions is more consistent with as

lepromatous leprosy. In the early 20th Century, Chaulmoogra oil, taken from the seeds of a tree widely found in India and China, was thought to help many patients with HD, but it was not until the 1940s that sulfones were found to be effective. Dapsone was the first drug in this category to be used, but the M. leprae bacterium quickly developed resistance. Current treatment for multibacillary disease is a 3-drug regimen such as rifampicin, clofazamine, and dapsone, while the WHO recommends rifampicin, ofloxacin, and minocycline for single-lesion paucibacillary lesions. There are several clinics in the USA prepared to care for HD patients, including five in Texas and three in California (San Diego, Los Angeles and Martinez). We have come a long way since the leprosy colony of Molokai. geowmeyer1@earthlink.net Above are Father Damien’s headstone on Molokai and the mule and horse ride down to the former Hansen’s Disease settlement. At left is the beautiful island of Molokai.

May/June 2015

Time to go shopping... ...for a better deal on workers’ compensation.

There has never been a better time to shop the sponsored workers’ compensation plans offered through the Sierra Sacramento Valley Medical Society/CMA. That’s because workers’ compensation insurance rates in California continue to move upward. The Insurance Commissioner recommended an increase of 6.7% in pure premium rates for 2015 compared to the average premiums charged as of July 20141. Your plan may experience a higher or lower rate increase than recommended by the Department of Insurance. Don’t just sit back and accept higher rates! Call Mercer to see if you can get a better deal through the Sierra Sacramento Valley Medical Society/CMA. Working with Mercer as the program administrator, the Society sponsors best-in-class insurance plans at competitive premiums. By becoming involved with the sponsored plans you will receive valuable protection for your practice and employees while supporting the good work of your Society! Take control of your workers’ compensation costs. Call 800-842-3761 now for your free, no-obligation quote. Or visit www.CountyCMAMemberInsurance.com for more information and to download an application or premium indication form.