THCB Gang Episode 108, Thursday December 1, 1pm PT – 4p

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday November 17 are futurist Jeff Goldsmith; THCB regular writer and ponderer of odd juxtapositions Kim Bellard (@kimbbellard); patient safety expert and all around wit Michael Millenson (@mlmillenson); fierce patient activist Casey Quinlan (@MightyCasey); Jeff Goldsmith; and Olympic rower for 2 countries and all around dynamo Jennifer Goldsack, (@GoldsackJen).

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

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“True, True, and Unrelated” in the age of “Product Placement/Embedded Marketing.”

BY MIKE MAGEE

This is “high grandparenting season” at our home when you go “The Extra Mile.” That means it is possible on certain days on or between Thanksgiving and New Year’s Day to find up to 20 children and grandchildren under our roof. With my wife one of ten, and me, one of twelve, we are no strangers to chaos. Our kids believe we feed off it, and maybe they’re right.

With over 150 years under our collective belts, we two are – if nothing else – optimistic, resilient, and somewhat wiser then we were in our early years. For example, we know that the mere temporal or geographic approximation of two incidents or events does not necessarily prove cause and effect. 

That point was reinforced the morning after Thanksgiving when our 11 year old granddaughter informed me that the basement toilet was clogged. She then provided a thumbnail sketch of the events the night before after we had bailed early – the toilet overflowed (nobody knows how or why), a frantic search for a plunger failed even though all were enlisted in the effort, and eventually everyone retired satisfied that the now unusable toilet was quiescent.

Channeling my long gone and much beloved father, who had lived through and honorably managed many a clogged toilet in his tour of duty, all without much complaint, I focused on the plunger issue. First off, I knew we had one, and not just any plunger. I had an orange plastic bellows accordion MasterPlunger that was always surprisingly effective.

I thought it was is the garage, so I went there first. No plunger. Then successively I searched two different basement storage areas, three bathrooms multiple cabinets, and finally an outdoor shed, all the while still clad in my Nautica pajamas. Nothing. So I went back to ground zero, the garage, and after a careful piece by piece search, found the amazing tool under a mountain of outdoor collapsible beach chairs.

With two or three quick thrusts, the toilet outflow was liberated and back in service. No harm done. By Sunday afternoon, the house was emptied of family, most of the major clean up was done, and work began on Christmas decorations. That included multiple trips up and down to the basement, and the rebirth of a boxed 8 foot artificial Cosco Christmas tree, which, with some minor difficulty was assembled, and lit without incident, drawing the same response from my wife that it has for the past 5 years – “I wish we had gotten the colored bulbs instead of the clear ones.”

Anyway, shortly after the tree lighting, and before any ornaments resurfaced, my wife came up from the basement and asked that on my next trip underground I check one of the basement bedrooms adjacent to the toilet overflowing bathroom because it smelled “a little musty.” Not having had any sense of smell for over 30 years, I rely on her nose. So I went down to the bedroom, and noticed in the corner, bordering the bathroom, that the rug was wet and the sheet rock was soft in the area to a height of about 18 inches.

I freed up the wall-to-wall carpet and under padding, and figuring it was stained with toilet water, used my Ace Hardware Craftsman utility knife to cut away the damaged portion till I reached dry concrete floor. By now, my wife’s warnings of impending black mold were enough for me to cut back the affected sheet rock revealing wet framing and insulation, part of which had the trade mark droppings of house bound mice. No big deal – rural New England is rural New England. The clean up was quick and included the shop vac and a range of standard tools.

Opening the wall had exposed a 4 inch copper major drain pipe that seemed to be heading straight up to the main floor. Still believing the source of the mess was the clogged toilet, I brought my wife down to inspect my work and assure her that mold was not a threat. She agreed, but while we were standing next to the slightly exposed wall, she asked, “Do you hear something dripping?” And sure enough I did. There was a thin, but significant, stream of water coming from above streaming down the copper pipe.

So I asked her, do we have any water running, and she said only the washing machine on the floor above. So we turned it off, and the next morning we called MACCA the plumber, who promised to come on Thursday, but asked me to test other appliances that might be tied to this drainage line. So I turned back on the washer, and sure enough, recreated the stream. But by now I was curious enough to wonder where this vertical pipe went. So I took my handy Craftsman knife and removed an 8 foot by 8 inch piece of wall. Now a fuller length of the 1950’s vintage 4 inch copper pipe was exposed. The pipe went through a 2″ by 6″ stud into the ceiling. Above the stud, no water. Below the stud, water.

Having reached a decision point that involved deeply ingrained “there’s no going back now” brain circuitry, I got my DeWalt 20V MAX* XR Reciprocating Saw and freed the pipe from the wooden ceiling anchoring  that was obscuring the site of the leak. And I was rewarded with a diagnosis. Here fully exposed for the first time (except for the USAA Home Owners insurance people) was the hole at a soldered joint site in the copper elbow. 

It was now easy to establish that the only source of water came from the washing machine line, and not from any toilets or faucets in the house somehow tied to the line. And the plumber will easily replace the exposed ancient copper elbow with a PVC pipe replacement, and insurance will cover the bit of carpet and wall repair.

But what have we learned? First, the toilet overflow had nothing at all to do with the leak and mess just a few feet away. Second, had it not been for the toilet overflow, we may not have noticed the more significant problem for weeks. And by then, maybe there would have been black mold. And finally, everyone should invest in and have available an orange bellows accordion MasterPlunger, visible and accessible.

Now lastly, it is fair to ask, what does this have to do with health, beyond baseline sanitary prudence? Well, in our third year of Covid, it is not surprising that all of us have a tendency to associate are manners of symptoms and disorders with the virus or its vaccines. Like the overflowing toilet and latter pipe leak, it is guilt by association which may or may not prove to be true. The evidence required was initially lacking. So it is with Covid and/or the vaccines. Don’t jump to conclusions. Adjacent medical issues may or may not have anything to do with this infectious disease. Give evidence time to surface. And have tools, like the Siemen’s Covid Clinitest home tests, available and accessible as needed.

Mike Magee MD is a Medical Historian and author of CODE BLUE: Inside the Medical-Industrial
Complex.

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Barcodes Are Us

BY KIM BELLARD

Usually I write about things where I see some unexpected parallel to healthcare, or something just amazed me, or outraged me (there are lots of things about healthcare like the latter).  But sometimes I run across something that just delights me.

So when I inexplicably stumbled across DNA Barcoding Technology for High Throughput Cell-Nanoparticle Study, by Andy Tay, PhD, my first thought was, oh, nanoparticles, that’s always interesting, then it hit me: wait, DNA has barcodes? 

How delightful.

We’re all used to barcodes.  Pretty much every product in pretty much every store has a barcode.  The barcode was invented in the late 1940’s, but didn’t really take off in popularity until the UPC (Universal Product Code) barcode.  A Marsh’s Supermarket in Troy, Ohio, in 1974 was the first grocery item scanned (a pack of Wrigley’s Juicy Fruit Gum, if you are interested).  The UPC barcode encodes the Manufacturer of the product, and the product code.  

The now almost as ubiquitous QR codes are, essentially, two dimensional barcodes.  Accordingly, they can store significantly more information.  

But back to DNA barcodes.  The main purpose is, as you might guess from the name, is to have a standardized way to uniquely identify species, based on their DNA (think of species as the “product”).  The methods were first proposed in 2003, by Paul D N Herbert, et alia, and quickly gained traction.  

Guo, et. alia, describes DNA barcoding as follows:

DNA barcode is one or more short gene sequences (generally 200–900 base pairs) taken from a standardized portion of the genome to aid species identification and discovery by employing sequence divergence based on nucleotide alignment (Emerson et al. 2011; Hebert et al. 2003a, 2004). Thus, the fundamental function of this genetic tool seeks to compare barcode sequences to reference databases to efficiently and effectively assign any biological sample to its species regardless of the visual classification of the sample.

There are databases of DNA barcodes for a variety of life forms, including plants, animals, and/or fungi; these include the BOLD system (Barcode of Life Data system),  Unite, Diat.barcode, and iBOL (international Book of Life).  

Unlike, say, UPC codes, which can be simply assigned, there’s not a universal way to decide which DNA sequences can be used to barcode an organism, and great care must be taken to extract and analyze it.  To complicate things further, there are mini-barcodes and meta-barcodes.  I’ll leave it as an exercise for the very interested reader to learn more about exactly how all that is done; for my purposes, it may as well just be magic.

DNA barcodes allow us to look at a relatively modest DNA sequence and determine what species it belongs to, which is a great help if one is identifying new species or trying to do an assessment of an ecosystem.  For example, students from a collection of 50 schools in Australia collected some 14,000 specimens, submitted 12,500 new DNA barcodes to BOLD – 3,000 of which were entirely new.  Project lead Dr Erinn Fagan-Jeffries said: “It is highly likely that all contributing schools have found species new to Western science which is really exciting.” 

Lest you think that all DNA barcodes are good for are identification of species, researchers at the Garvin Institute of Medical Research barcoded cancer cells, in order to understand which ones were evading the immune system response and immunotherapies.  “We showed that there are rare cancer cells capable of escaping the immune system and escaping treatment with immunotherapy,” said first author Louise Baldwin.  

The researchers believe that “the mechanisms could be used as potential targets for therapies, to stop tumorous cells from adapting and spreading. Another future application could be in prognosis, where a high number of cells could indicate which patients might not respond to immunotherapy.”

Not bad for a barcode.

Back to the nanoparticles.  Dr. Tay says: “Recently, DNA barcoding technologies have been applied to generate barcoded cells and nanoparticles to investigate heterogeneous cell-nanoparticle interactions to boost the translational application of nanomedicine.”   The new techniques enable “millions of cells to be tracked over developmental and evolutionary time scales and to record cellular features in response to stimuli, including nanomedicine.”  

Dr. Tay points to research by Boehnke, et. al. that “made use of barcoded cell lines to discover cell and nanoparticle features to boost nanomedicine delivery.”  These and other new techniques made it easier and faster to understand which nanoparticle formulations are having the desired effects.  

I mean, really, is anything cooler than injecting DNA barcodes into nanoparticles to help achieve clinical results?   That’s some real 21^st century medicine.

—————

We are DNA creatures.  All life that we know are based on DNA, and it’s not clear to me that we’d even recognize an organism based on anything else as life.   Barcodes are not DNA’s only amazing trick.  It is the nonpareil storage device; someday all our storage needs may be met using DNA (yes, I know, some argue to diamonds as the storage medium, but, really, DNA is way cooler).  As Zhang, et. al. noted earlier this year,  “DNA has emerged as a powerful substrate for programming information processing machines at the nanoscale.”

There ae going to be DNA/RNA computers, DNA neural networks/AI, and DNA robots.   Who knows what else?  

Given all that, I’m still holding out hope that we’ll someday have a DNA EHR, with both the processing done in DNA and the data stored in DNA, and that we store all that in our own DNA.  Tell me that’s not something that a visitor from the 22^nd century wouldn’t appreciate.  

There’s a whole body of work in information theory/mathematical logic about the shortest way to define statements, numbers, etc.  DNA barcodes may do well at more simply describing species, but I don’t know that we couldn’t each have a unique DNA barcode – shorter than our entire genome – that could be used for many applications.  

Our world would be much different without UPC barcodes, QR codes, and computers based on silicon chips, but that’s all so 20^th century.  In the 21^st century, we better be getting used to more ways we can use DNA.

DNA barcodes — delightful, indeed.  

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

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THCB Quickbite: AJ Loiacono, CEO, CapitalRx

AJ Loiacono, CEO of CapitalRx, in a quickbite interview with The Health Care Blog’s Matthew Holt. CapitalRx is up to 1.5m members serviced both as a PBM and as a tech company administering pharmacy benefits using its tech platform. AJ says they’ve demonstrated to the market that they can service customers of any size, and the employer groups are starting to ask the right questions about pharmacy costs.

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Adventures in health care — Hinge Health

At the HLTH conference in Vegas the week before Thanksgiving, I decided to embark on another adventure in health care. Somehow I badly hurt my back and was barely able to walk when I found myself at the Hinge Health booth. Could they give me any help? As it turned out they could. I met physical therapist Lori Wolter who showed me (and used me as a guinea pig for) their Enso device and got a quick update on Hinge Health’s progress from its President Jim Pursley.

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America, the intolerant

BY ANISH KOKA

Historically, the great tension between liberty and authority was between government as embodied by the ruling class and its subjects.  Marauding barbarians and warring city-states meant that society endowed a particular class within society with great powers to protect the weaker members of society.  It was quickly recognized that the ruling class could use these powers for its own benefit on the very people it was meant to protect, and so society moved to preserve individual liberties first by recognizing certain rights that rulers dare not breach lest they risk rebellion.  The natural next step was the establishment of a body of some sort that was meant to represent the interests of the ruled, which rulers sought agreement and counsel from, and became the precursor to the modern day English parliament and the American Congress.  Of course, progress in governance did not end with rulers imbued with a divine right to rule being held in check by third parties.  The right to rule eventually ceased to be a divine right, and instead came courtesy of a periodical choice of the ruled in the form of elections.  The power the ruled now wielded over those who would seek to rule lead some to wonder whether there was any reason left to limit the power of a government that was now an embodiment of the will of the people.

But the reality of government-of-the-people as realized by the emergence of the democratic republics across Europe and particularly America, quickly made a mockery of the lofty ideas of self-government that people thought they were signing up for.  It turns out that the “people” who exercise power in this system may be completely separate from those power is exercised over.  Self governance was not government of each by himself, but of each by all the rest (JSM, On Liberty).  The threat of the majority to the individual was well known to America’s founding fathers, and the early implementation of the American experiment did not disappoint. 

Alexis de Tocqueville, a Frenchman who toured a young America in the early part of the 19th century, and wrote a volume widely regarded as the greatest critique of the American Democratic experiment titled “Democracy in America”, noted:

In America the majority raises very formidable barriers to the liberty of opinion: within these barriers an author may write whatever he pleases, but he will repent it if he ever step beyond them. Not that he is exposed to the terrors of an auto-da-fe, but he is tormented by the slights and persecutions of daily obloquy. His political career is closed forever, since he has offended the only authority which is able to promote his success. Every sort of compensation, even that of celebrity, is refused to him. Before he published his opinions he imagined that he held them in common with many others; but no sooner has he declared them openly than he is loudly censured by his overbearing opponents, whilst those who think without having the courage to speak, like him, abandon him in silence. He yields at length, oppressed by the daily efforts he has been making, and he subsides into silence, as if he was tormented by remorse for having spoken the truth.

This was an America that allowed freed slaves to vote in the North, but yet saw no blacks vote in elections lest they be maltreated if they had the temerity to actually show up at the polls.  This was an America that in 1812 saw a mob destroy the offices of a Federalist newspaper because its editors were against the war of 1812 against Britain and published an anti-war screed.  The mobs massed, destroyed the offices of the paper, killed one of the editors, and left the other editor badly beaten.  

In this world, legal protections or rights ‘protected’ by the government matter not.  The more fearsome power society wields is its ability to ostracize the individual by practicing a social tyranny that extends well beyond the political and legal system.  After all, what good are legal protections if the penalty for thought crimes may be your livelihood?  

The new wrinkle relates to the growing social media fueled power of an intransigent minority in making society bend to its preferences.  It turns out you don’t need the majority to control society, a small number of intolerant virtuous people will do.  The phenomenon was referenced by John Stuart Mill in his classic essay from 1859 as the will of the most active portion of society, but best described recently by mathematician/philosopher Nassim Nicholas Taleb as the Dictatorship of the small minority.  On the relatively benign front, the apathy of the flexible majority means that most everything you buy to drink is kosher.  On the more concerning front, it means moral values of society derive not from consensus of the majority but from the virtues of the most intolerant minority.  

Sites like twitter, facebook, and reddit allow these factions to coordinate in a matter of minutes.  In 1812 Baltimore it took a mob to leave the comfort of their houses, take up arms, and travel to the headquarters of the Federalist newspaper to unleash mayhem on the hapless editors who held an unpopular opinion.  In 2020, it takes a few taps on a keyboard and tagging an employer in a tweet to cancel a life and tarnish a reputation, or organize a violent mob to target a federal building.  

While all ideological stripes may use these tools to create mayhem in civil society, it is always the out group that bears the brunt of opprobrium.  In a prior age the social institutions were used to censure Jews and those with too much melanin.  Today, there’s a new sheriff in town, and there’s a new group that influencers and their sheep label as revolting and unfit for polite society. For four years the elite of society were free to label the Republican president an illegitimate stooge of Russia, attend political rallies and participate in marches that devolved into riots by some extremist minority with no fear they may not be let into work the next morning. But attending a Trump rally on January 6th and going back to your hotel to watch the violent shenanigans that followed runs the very real risk of leaving you destroyed and  destitute. 

The tyranny of the Democratic Republic is all encompassing precisely because it doesn’t require a government with camera’s tracking your every move, it enlists your even more ubiquitous virtuous neighbors to do its dirty work.  Putin may manufacture charges against his political opponents to put them in jail, but it isn’t some repressive government that gets Google engineer James Damore fired.. It is his colleagues who leaked his internal memo, and then demanded he be eliminated.  According to Damore, the penalty for thought crimes at Google were severe –  “employees who expressed views deviating from the majority view at Google on political subjects raised in the workplace and relevant to Google’s employment policies and its business, such as ‘diversity’ hiring policies, ‘bias sensitivity,’ or ‘social justice,’ were/are singled out, mistreated, and systematically punished and terminated from Google”.

Even the long venerated medical institutions of America are over-run. Publishing a peer-reviewed descriptive paper on the history of affirmative action in medicine lead to the cardiologist author of the article being immediately demoted and removed from interacting with trainees at a teaching hospital because a Twitter mob labeled the article’s views ‘racist’.  In the middle of the great pandemic that the experts told us was so bad that everyone had to isolate in a basement for two years, the Center for Disease Control (CDC) drafted a vaccine allocation strategy that suggested the consideration of race to “promote justice” and “mitigate health inequities”, despite the fact that prioritizing this particular factor over race neutral risk factors like age and health status would result in more overall deaths. 

After all, the goal of the CDC now isn’t just to maximize benefits versus harms, it is to also mitigate health inequities as the ethics table from that document makes clear.  It would be a laudable goal to improve health care for everyone, of course, but the practical translation of this ethos is to purposely and systemically treat certain racial groups in a poorer manner to balance the scales. Apparently, to the people that write these guidelines, more people dying of COVID is less of a concern if the deaths are more racially balanced.

It’s important to understand that the rationale for this overtly racist endeavor comes not from some fringe group, it comes from the seat of our most respected institutions because the fringe groups are in control of the institutions.

“Older populations are whiter,” public health expert Dr. Harold Schmidt of one of our esteemed universities told The New York Times in early December. “Society is structured in a way that enables them to live longer. Instead of giving additional health benefits to those who already had more of them, we can start to level the playing field a bit.”

There is little surprise why these messages go unchallenged at these institutions.  Unless you are independently wealthy or have tenure, keep your mouth shut about opinions that go against the consensus of the day if you value your job.  While some may take solace that the contemporary price paid in the civilized democratic republics for opinions that fly against the prevailing winds is different than that meted out to Socrates by his fellow Athenians (death by drinking hemlock), or to Christians by the Romans (thrown to the lions),  it should be reasonably obvious that these are far from enlightened times.

Anish Koka is a cardiologist. Follow him on twitter: @anish_koka

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One Person’s Trash…

BY KIM BELLARD

Gosh, so much going on.  Elizabeth Holmes was finally sentenced.   FTX collapsed.  Big Tech is laying off workers at unprecedented rates, except TikTok, which should, indeed, be cautionary.  Elon Musk’s master plan for Twitter remains opaque to most of us. Americans remain contentedly unworried about the looming COVID wave. 

With all that to choose from, I want to talk about space debris.  More specifically, finding opportunity in it, and in other “waste.”  As the old saying goes, one person’s trash is another person’s treasure, so one person’s problems are another person’s opportunities.  

And, yes, there are lessons for healthcare.

Getting to space has been one of humankind’s big accomplishments. We’re so good at it that earth’s orbit has become a “graveyard” for space debris – dead or dying satellites, pieces of rockets, things ejected from spaceships, and so on.  Space is pretty big, but the near-Earth debris is getting to the point when avoiding it becomes an issue for the International Space Station and other orbiting objects.  

Scientists now fear that climate change will impact the upper atmosphere in ways that will cause space debris to burn up in it less often, making the problem worse. 

Some countries see opportunity.  The Washington Post profiled how Japan, in particular, wants to be a leader in cleaning up space debris. “In space, Japan has always been a country of second gear. The first gear was always the United States, Soviet Union and, recently, China,” Kazuto Suzuki, a space policy expert at the University of Tokyo, told WaPo. “This is a golden opportunity for Japan, but the time is very short.”  

Jonathan McDowell, an astrophysicist at the Harvard-Smithsonian Center for Astrophysics, noted: “The problem is there’s no international air traffic controller for space.”  Getting countries to agree on the problem, he added, “only works if the countries are willing to put international interests ahead of their own paranoia about military concerns, and it’s not clear that China is, and the U.S. is definitely not.”

China’s space ambitions have become very clear – perhaps for commercial and scientific purposes, almost certainly for military – but so has its interest in space debris. China-based Space Technology Company recently demonstrated a robotic platform that uses a large net (or “sail”) to capture and “deorbit” space debris. “In the future, the NEO series satellites could clear space debris by dragging it out of orbit and burning it in atmosphere, and accurately capture space debris that may pose a threat to space spacecraft and other targets to protect the safety of space facilities,” Su Meng, founder and CEO of Origin Space, told the Global Times.

Not to be outdone, British companies are competing for contracts for what Sky News called “Britain’s first garbage truck for space,” while the U.S. Space Force’s innovation arm has awarded 124 Phase 1 contracts that will focus on “Active Debris Remediation.”  

Japan wants help to set standards and precedents. “Setting a precedent is a great way to hold other countries accountable,” Professor Suzuki told WaPo. “It will — not legally, but morally — bind other countries.”  Its Commercial Removal of Debris Demonstration (CRD2) claims to be “the world’s first technology demonstration of removing large-scale debris from orbit,” with hopes of an Active Debris Removal demonstration as early as 2025.  It hopes “to develop a new business market.”

I love it.

Of course, one country’s technology for Active Debris Removal/Remediation could be used to take out another country’s operating satellites and spacecraft, making some countries’ interests in it perhaps less than altruistic.

—————

The drive to make space debris not only a civic duty but also a business opportunity reminds me of the efforts to extract rare earth elements – critical to many electronics – not from mines (primarily located in China) but from landfills.  A 2020 study found e-waste from discarded electronics includes “14 rare earth elements, six platinum group metals, 20 critical metals, and 16 other elements, including some precious metals.”  

In Nature, Michael Eisenstein points out that “estimates suggest that precious metals might be up to 50 times more abundant in e-waste than in mined ores.” He goes on to argue: “The precious and scarce metals these devices contain can be reused near-indefinitely, and emerging technologies that make their recovery easier could drastically reduce the need for mining.” 

E.g., earlier this year, a Rice University lab reported that its flash Joule heating process “has successfully extracted valuable rare earth elements (REE) from waste at yields high enough to resolve issues for manufacturers while boosting their profits.”  

There’s gold – and even more valuable rare earth elements — in that waste.    

—————

Space debris and e-waste in landfills seem like a long way from healthcare, both figuratively and literally.  For most of us, they’re out of sight, usually out of mind, and, to the extent we think about them at all, problems for someone else to deal with, at some future time. 

In other words, pretty much like most big problems in healthcare.  

But when we can’t get a smartphone because its manufacturers can’t source the necessary rare earth elements, or when those smartphones can’t access GPS because space debris has taken out the supporting satellites, then we’ll care.  Then we’ll be wishing more people had been looking for the new business opportunities each represents.

Most people look at problems in healthcare and just shrug; that’s just the way it is, we lament.  Some innovators develop incremental solutions that make things at least a little less bad. We graft solutions on top of the existing system, add more layers, take a new slice of all that spending.  But turning “wasted” byproducts of our dysfunctional healthcare system into new business opportunities – that’s harder.

Here’s an example. Health systems take their medical debt – caused by their excessive charges and our inadequate health insurance system(s) – and monetize it.  That’s a creative way to make more money from a problem, but it doesn’t fix the problem for patients.   Toledo (OH) saw an opportunity: it is wiping out $240 million in medical debt for its citizens. Now, that’s some creative problem-solving. It doesn’t fix the problem of why there’s medical debt but at least it addresses the impact of it, at least for a time.

If only more of us turned problems into opportunities like that.

So, healthcare entrepreneurs: what is the space debris in healthcare, and what can you do about it?  Where are the rare earth elements in healthcare, and how do you reclaim them?   

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

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When Push Comes to Shove: The AMA v. Dobbs. Part 2.

BY MIKE MAGEE

On November 8, 2022, five days after the 2022 Midterm elections, the AMA raised its voice in opposition to Republican efforts to promote second class citizenship for women by exerting public control over them and their doctors intensely private reproductive decisions. At the same time they sprinkled candidates on both sides of the aisle with AMA PAC money, raising questions whether their love of women includes active engagement or just passive advocacy.

Trump and his now MAGAGA (“Make America Great and Glorious Again”) movement has now returned to center stage. With the help of Senate Majority leader McConnell, Christian Conservatives had packed the Supreme Court with Justices committed to over-turning Roe v. Wade. And they did just that.

On June 24, 2022, a Supreme Court, dominated by five conservative Catholic-born Justices, in what experts declared “a historic and far-reaching decision,” Dobbs v. Jackson Women’s Health Organization, scuttled the half-century old right to abortion law, Roe v. Wade, writing that it had been “egregiously wrong,” “exceptionally weak” and “an abuse of judicial authority.”

Not content to allow the decision to stand alone, in a consenting opinion, Justice Clarence Thomas, a modern day version of Anthony Comstock, suggested that this was just the beginning. The decision, he said, was part of a the “legal rationale” that could allow new challenges to legalized gay marriage, consensual homosexual conduct, and access to contraception.

It only took a few days for these true believers to realize that they had lit a political flame under the Republican party that would be difficult to extinguish. The September, 2021 amicus briefs and Congressional testimony of the AMA were easy enough to ignore. But when Kansans defeated an anti-abortion proposition on August 3, 2022, leading the Kansas For Constitutional Freedom, to call the 59%/41% victory “huge and decisive”, the path toward crushing Republican’s self-declared coming “Red Wave” was clear. Similar state abortion propositions were already cued up in Michigan, Kentucky, and Vermont, and now the successful messaging had been fleshed out ready to be applied to 30 and 60 second Ads.

In the Kansas Ad, the voice over stated “Kansans don’t want another government mandate that puts our personal rights at risk.” In Michigan, a burly, working class, white male declares “Let’s keep the government away from our doctors.” The Kentucky campaign put it this way, “The rights of people to control their own personal, private medical decisions are under attack across the country — it’s no different in Kentucky. … Don’t let politicians restrict your freedom.” 

And Vermont successfully went after its’ entire electorate with carefully constructed and poll tested messaging that emphasized preservation of enshrined Constitutional rights in a state with an historic commitment to personal freedoms.

But arguably the clearest messaging was constructed by successful Congressional candidate, Marie Gluesenhamp Perez (WA-3) who was running against incumbent Trump election denier, Joe Kent. Owner of a small auto-repair shop in rural Washington, she leaned into abortion when her opponent declared “I 100% support Roe v. Wade being overturned. I would move to have a national ban on abortion.” 

Congresswomen Gluesenkamp Perez’s response, enshrined in a 60-second tour-de-force:

“This is an extremist. Yeah, you know until you’ve been pregnant, you’re just not going to understand how complex pregnancies are, and how much can go wrong. And even if you have been pregnant, you know your sample size is pretty small. I miscarried. And you know what I needed? You know what the treatment for miscarriage is? It’s abortion. You know without treatment I might have not been able to have my son.. We deserve respect and autonomy in making those decisions, and privacy. I mean this is not about the minutia of constitutional law. This is about respecting people’s choices.”

The U.S. Constitution may be a living document, but as we recently witnessed, its capacity for movement is bi-directional. The Dobbs v. Jackson decision shifted our nation into reverse. But in over-reaching, MAGA (now MAGAGA) Republicans triggered and activated the Body Politic – Democracy’s corrective super-power.

From Michigan to Kansas, from Kentucky to Washington and Vermont, outraged citizens found their voices and uncovered messages that worked.

In the process, it proved three important points:

1. Rights should never be taken for granted. They must be protected at every turn.
2. Health rights are central to human rights. Autonomy and self-determination are determinative of life, liberty, and the pursuit of happiness.
3. We are mutually inter-dependent. As FDR said, “Necessitous men are not free men.”  If we wish to reject the “tyranny of the minority,” and rebuild a culture of compassion, understanding and partnership, we must redress the current injustices and begin anew with an equitable, just, and effective national health plan.

The reality is that decisions related to women’s reproductive rights are highly individualized, and remarkably complex. This is why we entrusted them to women themselves and their physicians in secure and confidential settings. Intrusion into this space by government fundamentally compromises women’s overall rights and autonomy, and triggers a broad range of Constitutional health concerns for the general public.

If the goal of the Theocratic Conservative Justices and their political allies was to turn back the clock of time, probe the weaknesses of our checks and balances, and stimulate a deep dive into Constitutional law, Dobbs v. Jackson was an enormous success. On the other hand, if the intent was to ignite a “Red Wave” in the 2022 Midterm Election, it proved a giant negative that will be difficult to escape.

Citizens in every state in the union need to feel the heat of the AMA and its Federation in this ongoing battle. This is the moment to fully engage your power and reach, the time to send messages that are clear and definitive. If you leave your patients in the lurch now, they will neither forgive nor forget in the future.

Mike Magee MD is a Medical Historian and author of “CODE BLUE: Inside the Medical-Industrial Complex.”

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When Push Comes to Shove: The AMA v. Dobbs. Part 1.

BY MIKE MAGEE

Should anyone present know of any reason that this couple should not be joined in holy matrimony, speak now or forever hold your peace.”     Book of Common Prayer, Church of England, 1549

Last evening Trump rose from the ashes and declared it was time to “Make America Great and Glorious Again” (MAGAGA).

This past week, five days after the Midterm elections, AMA President, Jack Resnick, Jr., MD, raised his voice from the podium at the AMA Interim Meeting in Hawaii with the AMA’s own version of a call to action:

“But make no mistake, when politicians insert themselves in our exam rooms to interfere with the patient-physician relationship, when they politicize deeply personal health decisions, or criminalize evidence-based care, we will not back down…I never imagined colleagues would find themselves tracking down hospital attorneys before performing urgent abortions, when minutes count … asking if a 30% chance of maternal death, or impending renal failure, meet the criteria for the state’s exemptions … or whether they must wait a while longer, until their pregnant patient gets even sicker…Enough is enough. We cannot allow physicians or our patients to become pawns in these lies.”

Over a year ago, they had signaled awareness that attacks on Roe v. Wade might fundamentally challenge patient autonomy and the sanctity of the patient-physician relationship. On September 21, 2021, the AMA with 25 other medical organizations filed an amicus brief in opposition to the restrictive Mississippi abortion law, Dobbs v. Jackson Women’s Health Organization.  And on  October 12, 2021, 19 medical societies, with the AMA in the lead, filed  an amicus brief in U.S. v. Texas, the abortion vigilante law signed by Gov. Greg Abbott.

Over the past year, the AMA had ample warning that the situation was spinning out of control. On June 27, 2022, I wrote: “My concern today, despite the strong messaging from Chicago, is that the AMA and its membership have not fully absorbed that this is a ‘mission-critical’ moment in the organization’s history… The strong words, without actions to back them up will permanently seal the AMA’s fate, and challenge Medicine’s status as a ‘profession.’”

I was reacting to the AMA’s statement three days earlier, on release of the Dobbs decision, which labeled the decision “an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient-physician relationship…the AMA condemns the high court’s interpretation in this case. We will always have physicians’ backs and defend the practice of medicine, we will fight to protect the patient-physician relationship.”

At the time, I recommended that the AMA mobilize and orchestrate their Federation state and specialty societies to pursue acts of “physician ‘civil disobedience’ where appropriate to protect the health and well being of all women, regardless of age, race, sexual identity, religion, or economic status.”

This warning came six months after I highlighted Charles Dickens words in a “Tale of Two Cities” – “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, …” – as a way to dramatize that we too are a “tale of two cities”  as this map of the United States, color coded for regressive legislation and tactics to disenfranchise women and children, people of color, the poor and the vulnerable, well illustrates.

On November 8, 2022, the AMA site posted a section titled “Advocacy in action: Protecting reproductive health.” But a constructive critic would be justified in suggesting that the plan is tall on “advocacy”, but short on “action.”

What does “action” look like? In Part 2 of this piece, I’ll provide examples from Michigan, Kansas, Kentucky, and Washington.

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Mike Magee MD is a Medical Historian and author of “CODE BLUE: Inside the Medical Industrial Complex.”

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THCB Gang Episode 107, Thursday November 17, 1pm PT – 4pm ET

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday November 17 are futurist Ian Morrison (@seccurve). delivery & platforms expert Vince Kuraitis (@VinceKuraitis); and fierce patient activist Casey Quinlan (@MightyCasey).

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

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