March 2013 Archives

Since March 4th, workers have fished 3,300 5,916 6,601 13,000 (03/18/13) dead, bloated pigs out of a river in Shanghai. Last week there was little information about where they were coming from, how they got there, or what they died from, only general agreement, as Bloomberg put it, that "nothing good comes from a dead-pig tide".

The Huangpu River feeds the drinking water supply for some of the city and although officials have so far assured citizens that the water is safe, and that they're taking water samples regularly, doubts persist.

If Pigs Could Fly

How the pigs got there is still a bit of a mystery. The carcasses are ear-tagged but officials can't decipher the tags, so they don't know the exact situation. Most likely, farmers dumped diseased pigs (some are infected with porcine circovirus) into the river at some upstream province. Despite the gruesome pig panorama, citizens are told not to fear the safety of pigs originating from the suspect provinces.

Piglets
via Wikicommons.

China produces half the world's pigs, five times what the U.S. produces. Pork is so central to the economy that pig price fluctuations effect the cost of living. This means that the large scale pig deaths over the past several months, albeit only tens of thousands in a pig population of millions, concern not only water drinkers and pork consumers but economists too.

When other food products befall catastrophe, the story may be different. When frosts freeze orange groves in Florida, for instance, producers warn consumers in the Northeast U.S. that orange juice prices might go up, that's it. Pig parts, however, are found in hundreds of products besides rinds and bellies and chops and loins. For instance, eighty percent of the U.S. heparin supply comes from pigs raised on farms in China, according to the director of Pharmacy at Boston Children's Hospital.

A few years ago, an epidemic of blue ear pig disease (porcine reproductive and respiratory syndrome virus (PRRSV)) ended up killing so many pigs that producers met the demand for heparin by adulterating the drug with a chemically similar substance. As the crisis unfolded, analysis detected oversulfated chondroitin sulfate that caused hundreds of severe allergic reactions and 175 deaths worldwide.

In the aftermath, journalists investigated the supply chain and found that the FDA had alarmingly little oversight into the production practices on pig farms in China. Since then, the FDA has increased its oversight. However, even last year, the Wall Street Journal reported that the FDA found contaminated heparin from fourteen more Chinese suppliers. The FDA put them on a watchlist with eight others.

They'd Fly Away?

In light of these investigations, consider that pigs provide material for many human life-saving technologies. A recent study describes the possibility of using porcine small intestine patches for pediatric patient cardiovascular reconstruction. Scientists are experimenting with porcine (and bovine) matrices for things like abdominal wall reconstruction.

Although some medicines, like insulin, are no longer made from pigs, the widespread use of pig parts in medicine often goes unacknowledged. Some religions forbid the use of pigs even for medical treatment, and some people get squeamish about pig body parts, according to designer Christien Meinderstsma in this Ted Talk. One Dutch heart valve company wouldn't send her their valve because they didn't want people associating their life-saving technology with pigs.

In her talk on the book, "Pig 05049", Meinderstsma highlights 185 products made with a pig she followed. A Greek cigarette uses pig parts to make a more "healthy", lung-like filter. Some frozen beef steak is made with beef bits glued together with pig fibrinogen or "meat glue". Some collagen injections for facial rejuvenation come from pigs. Pigs are also used to make soap, train brakes, fine bone china, and bullets (not silver, according to the picture...), and more than one hundred other things. They're amazingly ubiquitous, pigs, and floating in China's rivers too.

-------------------------

Some related posts include Avian Flu In China (2005); Streptococcus suis in China (2005); a note on the heparin adulteration (2008) the H1N1 pandemic - (2009), and here.

Many people muster strong opinions about Oscars - not I. Having enjoyed some of 2012's awarded movies, I watched the Oscars with appreciation, albeit distracted by the din of our crowd. The only thing that always disappoints me, every year, is how many important subjects and films get left out. The 2012 documentary movies "Escape Fire" and "The Waiting Room" focus on healthcare in the U.S.

"Escape Fire"

Escape Fire airs this weekend on CNN. The film isn't shy about its agenda, as one commentator puts it: "We don't have a healthcare system, we have a disease management system." The disease management system in the U.S. comprises many industries - pharmaceutical, insurance, hospital chains, and doctors' groups, so the film covers a lot of ground.

Doctors and patients dependence on pharmaceutical drugs gets shown via an arresting story of a veteran being weaned off of painkillers. The pharmaceutical industry's economic calculations, deadly to patients, are recounted by Dr. Steven Nissen and the familiar story of Avandia. The insurance industry's stake in it all is discussed and memorably captured in a shot of all the insurance company representatives sitting around the table negotiating Obama's healthcare plan. The filmmakers somehow patch together an optimistic if controversial package of solutions for the impenetrable seeming morass they depict. A Safeway executive marshals employees to exercise and lose weight. Media-popular doctors hold forth with various remedies.

The story thread I appreciated most was that of a primary care doctor. To her dismay, time with patients kept being shortened to meet new economic demands. Supervisors told her to "get her productivity up", so she changed jobs more than once, hoping for a position that allowed her to adequately care for her patients.

Aside from patients, primary care physicians have taken the toughest hit in our *efficiency* driven system. There aren't enough of them, and the care in some parts of the country has become so slapdash it's dangerous. Yet at the bottom of every health article, at the end of every pharmaceutical ad, in every news piece about this or that medical research is a bright, incongruous little instruction: "Ask Your Doctor". As if. As if we had the same level of medical intimacy and trust, just technologically superior, as when my great grandfather worked through nights, house to house in his little town.

Interestingly, the system depicted by the riveting film "Escape Fire", however sickly, is what the healthiest patients get, those who have the very best insurance in a places chocked full of excellent hospitals. Fifty million uninsured patients in the U.S. don't get that.

"The Waiting Room"

Which brings us to the excellent film "The Waiting Room", by Steven Nicks, shortlisted in the top 15 Oscar picks. The movie's setting is Oakland, California's Highland Hospital waiting room, over 24 hours. It focuses on a different aspect of the problem than "Escape Fire" and takes a different tone. If on the continuum of polemic reporting, Michael Moore's "Sicko" scored a 9-10, "Escape Fire" might get a 6-7, and "The Waiting Room" would score a 0-1. Healthcare has been ruthlessly politicized in the U.S. and most people will bring some opinion to this film. In turn, the film strives to be empty of politics. It provides details for its characters, but doesn't do voice-overs, doesn't judge, and doesn't demand your defined conclusion.

Deplore the public cost of diverse homeless populations plagued by addictions, unemployment, poverty and in need of medical care? Those people end up at Highland Hospital. Disdain college grads who don't pay for health insurance? They too, sit in this waiting room. Despair a healthcare system that allows people to get sick and sicker until they end up in emergency rooms instead of getting primary care? Those sick people are here. Agonize how social services have been ruthlessly cut in poor cities? Highland Hospital helps these people also.

They sit shoulder to shoulder in our emergency rooms - our institutions of last resort. Every age, gender, and nationality, they're all here, men plagued with chronic labor-related injuries, primly dressed women abruptly out of work, twenty-year olds surprised by tumors, stroke victims who couldn't afford medicine, kidney dialysis patients from other states, and alcohol/drug addicts living on the streets.

But the film doesn't run all their stories together like I just did, in a big forgettable jumble. It follows each person. How did a little girl with tonsillitis end up in the emergency room instead of in primary care? Her parents are separated, but both show up at the hospital. Her dad lost his job and missed his day with her yesterday on account of transportation. He anxiously hops around her during intake. His son died at two. The nurse, half his size, counsels him to settle down so he doesn't scare his daughter. The girl seems numb to it all.

Triage

Whatever you feel about their plight, whatever sentiment or opinion, the frenzied emergency room healthcare system doesn't have time for any of it. Sentimentality? No. Compassion? Yes. Medical technicians and intake nurses and doctors and interns triage when all beds are full and patient tempers are short. They treat patients as best they can, when specialists have months long waiting times, when "non-profit" hospitals turn away poor patients, and when community safety-nets like churches run out of giving.

The outcomes at Highland Hospital can stretch the boundaries of adequate medical care. Fresh gunshot wounds get run into a trauma room, a steady stream of community catastrophes delivered by ambulance, while men with not fresh but unhealed gunshot wounds groan for hours, days, in the waiting room. A homeless man occupies one bed for too long because he has no place to go. Someone who can't get surgery seems pleased with a pain med prescription. This is where the 50 million uninsured people who are not short-changed in the scenes of "Escape Fire" land sometimes enduring hours of wait before they see a doctor.

At discharge, patients summon fragments of pride. They negotiate payments and answering questions about unemployment checks and family resources awkwardly, over a small desk, everyone caught up in unfortunate circumstances. "The Waiting Room" captures the tension of these situations in a refreshingly empathetic way.

If the movie doesn't hammer home a message, it embraces realism. A new doctor, stunned, is told what to say to a family, told exactly which forms of the verb "to die" to use. After one trauma team struggles to save a gunshot wound victim, they attach a tag to a fifteen year old's toe and he gets wheeled into the morgue. We read a small sign next to the refrigerator door: "Put The Body in Any Available Space".

The film, being so good, won't say this, but economically, ethically, and psychically, everything that brought this Oakland boy to that place costs society. Whatever your politics - in every way, it costs you.

Escape Fire and The Waiting Room, two films highly worth seeing.

-----------------

The Waiting Room played all over last fall, and aired on PBS. It is now playing a few other places around U.S., and is also available for purchase. The film team also produces an interactive multi-media site.