Racism is a Public Health Crisis

Posted on by Grayson

More white people are waking up to how insidious racism is. It’s both great and upsetting at the same time. It should not have taken this long for people to see the issue and want to address it.

In public health, we often talk about the notion of racism and discrimination being a part of society’s culture. Some types of discrimination are especially clear in different types of settings. For example, ageism plays a huge role in pain management. Young people aren’t believed about pain. Older folks are presumed to have little quality of life, and are either over or undertreated.

While racism is not just an issue that affects only Black folx, I am focusing this piece mostly on Black pain due to racism.

When we say ‘racism is a public health crisis,’ what does that mean?

The following is from a Rolling Stone article entitled ‘Racism Kills: Why Many Are Declaring It a Public Health Crisis‘ –

When it comes to discussing racism and public health, words matter. Specifically, [Mary] Gregory says that it’s important to refer to racism as a public health “crisis” instead of an “issue.” Not only is it more accurate, she says that racism also meets the four criteria the CDC requires in order for something to be considered a public health problem. That means that (1) it places a large burden on society that continues to increase, and (2) impacts certain parts of the population more than others. In addition to that, (3) there’s evidence that preventative strategies could help, but (4) this hasn’t happened yet. And while we’re on the subject of words, Gregory wants to remind us that when we talk about “race,” we’re really talking about skin color. “There is one race on this planet — homo sapiens — and to use the word ‘race’ in talking about skin color is our first mistake,” she explains.

I highly suggest reading that article. It’s a fantastic picture of racism as a crisis.

Here in Wisconsin, it might be even worse than in some states. Still, despite Milwaukee being one of the most segregated cities in the US, Wisconsin was the first state to declare racism a public health issue.

Let’s examine just some of the ways that racism can impact someone’s life.

 

Environmental Racism

The Flint water crisis is still happening. They still do not have clean water, and it’s been SIX YEARS. The government continues to fail to address this issue in a way they wouldn’t be able to if Flint was full of white middle-class people. The only way they’re getting away with this is because the population is primarily BIPOC (Black, Indigenous, & People of Color) folx living in poverty.

 

Medical Racism

Black folx are around four times more likely to die of pregnancy complications than white folx.

Black people, on average, have a lower life expectancy than whites. In addition to outright physical violence, part of why this occurs is the chronic stress of being Black. As we well know, stress can cause and worsen chronic conditions. Combine this with a lack of access to medical care – or not trusting the medical system because it routinely engages in racism – and it’s a recipe for disaster.

Currently? We know that BIPOC are one of the groups dealing with the most impact from Covid.

 

Police

I recently covered the 2015 murder-by-cop of Madison-local Tony Robinson for my podcasts. You can listen here.

Police continue to murder Black folx at higher rates. The police ‘issue’ isn’t something we ignore, either, as half of all people murdered by cops are disabled.

A lot of people think that means the policing system needs reform. In reality, white people created policing exactly this way. The notion of police in America came out of that of the slave catchers. That’s right – the police developed from a system literally only designed to protect the property, livelihood, and well-being of white people. It likely goes without saying that, as time went on, this also meant the police attacked and oppressed anyone they saw as a threat to that – disabled, trans, queer, BIPOC, etc.

 

Institutional Racism

Each of these types of racism is a part of institutional racism. It’s much worse than most white folx realize.

Moving into the Civil Rights era, white people took special care to ramp up attacks on Black folx. Lawmakers drafted and passed laws around public housing, financial assistance, and many other areas. They did this to specifically target Black communities. These included laws against those convicted of felonies and drug charges living in public housing or lowering their job prospects. This combined with police increasing patrols and arrests in Black communities began to lead to the higher incarceration rates for Black folx – particularly Black men. That later transferred to affect all genders while simultaneously forcing those who are transgender or gender non-conforming into incorrectly gendered facilities where they face additional harm from guards and fellow inmates.

Combine all of that with the increase in social workers stealing children to put them in foster care under false pretenses, the school-to-prison pipeline, and rapid underfunding of any organization that might actually be able to help? It’s a recipe for disaster.

Black people are then gaslit and told that these systemic forms of oppression are their fault. While nothing could be further from the truth, the impact of those lies cannot be understated.

 

Epigenetics

Now, imagine this going on for any of our families for half a millennium. Consider what it would mean if we couldn’t even trace our ancestry back that far because no one had cared to collect our family stories. There’s a lot of trauma that can affect people in many ways.

Epigenetics is the study of how our DNA changes how it expresses itself in response to things like diet, exercise, and stress. Toxic stress can cause long-term problems including post-traumatic stress, changes in brain physiology, and more. These changes pass down through generations. The stress of going through abuse can be passed down to the abused person’s children, etc. This applies to historical trauma, such as slavery, too.

Epigenetics is such a new field of study that we have no knowledge yet around how to help heal those wounds. There is a specific type of post-traumatic stress called Post-Traumatic Slave Syndrome. Things like therapy can be helpful for our own experiences, but can they touch on historic pain? Not really.

 

What do we do now?

If you’re white – and, from my readership stats, I know you probably are – it’s time to start learning. Here are a few resources:

#WTFix Virtual Patient Panel

Posted on by Grayson

Earlier this month, I took part in the #WTFix Patient Panel.

Not heard of WTFix? What’s the Fix? (#WTFix) is a movement focused on helping the health care industry learn from patients while inspiring people to make change through even the smallest fixes. We do this by collecting and amplifying patient stories, seeking creative ways to get people to think differently and challenging the status quo of today’s health care system.

https://youtu.be/3gZVk0CSt3Y

ACR Applauds E/M Coding Changes, Telehealth Expansion in CY 2021 Physician Fee Schedule Proposed Rule

Posted on by Grayson

The following is a press release issued by ACR today:

The American College of Rheumatology (ACR) today applauded the Centers for Medicare and Medicaid Services (CMS) for taking steps to appropriately value cognitive care and expand telehealth access in its CY 2021 Physician Fee Schedule (PFS) Proposed Rule.

“The ACR commends CMS for recognizing the historic undervaluing of the services provided by rheumatologists and other cognitive care providers, and for taking steps in this proposed rule to more appropriately reimburse the complex care they provide to Medicare patients,” said ACR President, Ellen Gravallese, MD. “This is good news for the 54 million Americans who live with rheumatic disease – many of whom are current Medicare beneficiaries or will enter the Medicare system one day – and will help to ensure they continue to receive the healthcare services they need and deserve.”

Evaluation and management (E/M) services provided by cognitive specialists, including rheumatologists, have historically been undervalued by Medicare. A 2018 report from the Medicare Payment and Advisory Commission (MedPAC) found that healthcare services billed under E/M codes – which include examinations, disease diagnosis, risk assessments, and care coordination – are grossly under-compensated, creating significant patient access issues and contributing to workforce shortages.

If implemented as written, the 2021 PFS proposed rule will address these historic issues and increase patient access by improving office visit payments and expanding telehealth services.

ACR Offers New Recommendations Following COVID-19 Infection in Adults with Rheumatic Disease

Posted on by Grayson

The American College of Rheumatology has added two new recommendations to its COVID-19 Clinical Guidance for Adult Patients with Rheumatic Diseases. The new updates focus on treatment following a COVID-19 infection and include:

Reinitiating Treatment Following COVID-19

  • For patients with uncomplicated COVID-19 infections (characterized by mild or no pneumonia and treated in the ambulatory setting or via self-quarantine), consideration may be given to re-starting rheumatic disease treatments (e.g., DMARDs, immunosuppressants, biologics and JAK inhibitors) within seven to 14 days of symptom resolution. For patients who have a positive PCR test for SARS-CoV-2, but are (and remain) asymptomatic, consideration may be given to re-starting rheumatic disease treatments (e.g., DMARDs, immunosuppressants, biologics and JAK inhibitors) 10 to 17 days after the PCR test is reported as positive (H).
  • Decisions regarding the timing of reinitiating rheumatic disease therapies in patients recovering from more severe COVID-19-related illness should be made on a case-by-case basis (H).

The (H) at the end of both of these statements stands for “high” and is related to the consensus during voting by the task force on these two new recommendations.

You can read the full PDF here.

We Live on Stolen Land

Posted on by Grayson
If you are not indigenous, you live on stolen land.

 

“Okay, but why are you talking about it?”
I’m white. I also get that this site isn’t necessarily one that you’d all expect me to talk about this on. That doesn’t mean it’s not important or that those of us who want to end injustice should stay silent on. That combined with my new job in public health and us talking more in general about injustices and, well, here we are.

 

“So, what’s going on?”
The US government stole and conquered this nation, pushing indigenous folx to smaller and smaller spaces, violating treaties over and over again while openly engaging in genocide and causing irreparable harm to folx.
We then tried to steal indigenous culture by using social workers and others to steal their children and raise them in ‘boarding schools‘ [pronounced institutions] meant to make them more like white Christians. We stripped them of their native languages as well as family and tribal connections.

 

The harm continues.
Things like healthcare that our government stated they’d provide are woefully inadequate. Tribal services are often not culturally competent and there aren’t enough providers – or resources given to them – to actually provide care. Many indigenous folx have been pushed to reservations where water is scarce, they have little to no access to the internet and power or other services, and food doesn’t grow in addition to being miles away from grocery stores.
To top it off, we white folx have carved monuments to our whiteness into their holy areas like Mount Rushmore. When indigenous folx try to speak up about things like this or proposed pipelines like Standing Rock, they’re met with violence of the worst kind. The police have become increasingly militarized against the people we stole this land from. If you’re reading this the weekend of July 4, 2020, this is literally happening as you read.
That doesn’t even get into the inability of indigenous folx to arrest white folx committing crimes on their lands and against them. Law enforcement in the white world doesn’t give a shit and rarely does anything when there’s a ton of evidence, let alone if they have to actually investigate. This lends itself to the problem related to Missing and Murdered Indigenous Women. There are so many resources on MMIW that I can’t include them all, but please make sure to read more below:

There are also very real issues with policing harming indigenous folx, both directly and indirectly. For more, read:

So, today I urge y’all to learn about whose land you occupy by visiting https://native-land.ca/ I live on stolen land of the Kiikaapoi, Peoria, Ho-Chunk, Miami, Očeti Šakówin, and Sauk and Meskwaki tribes. What about you?

ACR Releases Two New COVID-19 Clinical Guidance for Pediatric Patients

Posted on by Grayson

ACR has created two new task forces to address pediatric concerns during the SARS-CoV-2 (COVID-19) pandemic. The first is the COVID-19 Pediatric Rheumatology Clinical Guidance Task Force and the other is the Multi-System Inflammatory Syndrome in Children (MIS-C) and COVID-19 Related Hyperinflammation Task Force.

On June 18th, both task forces have released new clinical guidance and recommendations for the care of pediatric patients in the context of COVID-19. All recommendations are based on current knowledge and will be updated as new scientific evidence accumulates.

For the COVID-19 Clinical Guidance for Pediatric Patients with Rheumatic Disease, recommendations include, but are not limited to, the following:

  • Routine ophthalmologic surveillance of patients at high risk for chronic uveitis or with a history of uveitis should continue on schedule via in-person visits with slit lamp examination.

In ongoing treatment of pediatric patients who do not have COVID-19 exposure or infection:

  • NSAIDs, hydroxychloroquine (HCQ), angiotensin-converting enzyme inhibitor (ACEi)/ angiotensin II receptor blocker (ARBs), colchicine, conventional DMARD (CDMARD), biologic DMARDs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs) may be continued or initiated to control underlying disease. Glucocorticoids may be continued or initiated, using the lowest dose possible to control underlying disease.
  • For pediatric patients with life and/or organ threatening manifestations, high dose oral or intravenous “pulse” glucocorticoids and cyclophosphamide may be initiated to control underlying disease.

In pediatric patients with ongoing treatment who have close/household exposure to COVID-19:

  • Initiation of high dose oral or intravenous glucocorticoids should be delayed for 1-2 weeks, if deemed safe by the treating provider, for pediatric patients with non-life and/or organ threatening manifestations. For those patients with life and/or organ threatening manifestations, the initiation of high dose oral or intravenous glucocorticoids should not be delayed.

In patients with ongoing treatment of pediatric patients with asymptomatic COVID-19 infection:

  • NSAIDs, HCQ, colchicine, cDMARDs, bDMARDs, tsDMARDs, cyclophosphamide or rituximab may be continued, if necessary, to control underlying disease.

In patients with probable or confirmed COVID-19 infection:

  • cDMARDs, bDMARDs (except IL-1 and IL-6 inhibitors), and tsDMARDs should be temporarily delayed or withheld, and IL-1 and IL-6 inhibitors may be continued, if necessary, to control underlying disease.

For the Clinical Guidance for Pediatric Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARS-CoV-2 and Hyperinflammation in COVID-19, the guidance offers direction on diagnostic evaluation of MIS-C, compares and contrasts MIS-C and Kawasaki Disease, and provides general recommendations for cardiac management, immunotherapy treatment, and anti-blood clotting therapies in MIS-C. Recommendations include, but are not limited to, the following:

  • MIS-C and Kawasaki Disease unrelated to COVID-19 infections may share overlapping clinical features, including conjunctival injection, oropharyngeal findings (red and/or cracked lips, strawberry tongue), rash, swollen and/or erythematous hands and feet, and cervical lymphadenopathy.
  • For cardiac management, EKGs should be performed at a minimum of every 48 hours in MIS-C patients who are hospitalized as well as during follow-up visits.
  • For anti-blood clotting therapy, the guidance recommends treatments of daily, low dose aspirin, of no more than 81 mg/day, be used in patients with MIS-C and Kawasaki Disease-like features and/or those with a high platelet count (≥450,000/𝜇L). This treatment should be continued until normalization of platelet count and confirmed normal coronary arteries at ≥4 weeks after diagnosis. Treatment with aspirin should be avoided in patients with a platelet count of ≤80,000/𝜇L.
  • Children with severe respiratory symptoms due to COVID-19 with any of the following should be considered for immunotherapy: acute respiratory distress syndrome, shock/cardiac dysfunction, elevated lactate dehydrogenase enzyme, D-dimer, IL-6, IL-2R, and/or ferritin, and depressed lymphocyte count, albumin, and/or platelet count. Glucocorticoids may be considered for use as immunomodulatory therapy in patients with COVID-19 and hyperinflammation (as outlined in the previous statement).

The full list of guidance statements can be found on the ACR website at https://www.rheumatology.org/announcements.

What is Public Health?

Posted on by Grayson

With the current pandemic, we’ve seen a lot about Public Health departments or professionals. From local news to national briefings, these individuals often share warnings and other information. But, what is Public Health?

Well, it’s a little complicated to explain.

Definitions of Public Health

The short version? Public health is the study of preventing disease and improving life for the general public.

One of the leaders in public health, Charles-Edward A. Winslow, described it as:

The science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individuals in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. (Schneider, Mary-Jane, 2006. Introduction to Public Health. pg 5)

This is a pretty confusing definition in my opinion. But, it also encompasses much of what those in this field do. Part of why it’s difficult to nail down is that this field is huge. It includes epidemiologists (those who study determinants of health and diseases), public policy personnel, and reproductive/sexual health educators. We often see medical professionals involved, too, such as nurses, doctors, and therapists.

The world of medicine is often focused on how to diagnose and treat conditions. In contrast, public health is focused on what makes people more susceptible, countering anti-vaccination misinformation, educating the public, and tracing infections. It takes an interdisciplinary team to handle the issues we find. That’s especially true in a pandemic! This includes the distribution of tests, recommendations for how to keep us safe, and tracing who infected individuals may have had contact with.

What does this look like in action?

One great illustration of what this field looks like is the Centers for Disease Control and Prevention, AKA the CDC. The main goal of the CDC is to protect the general public. They do this with a staff full of those who study diseases and outbreaks, health promotion, preventing injuries, and tracking chronic disease statistics. The CDC also talks a lot about emergency preparedness, something integral to the public’s wellbeing.

Another great example is your state’s Department of Health Services. Public health measures often live here and maybe their own department or division under the DHS umbrella. DHS may cover the following aspects of public health:

  • Certifications for caregivers
  • Alcohol licenses
  • Healthcare coverage information (particularly Medicaid & Medicare)
  • Long-term care information
  • Mental health resources
  • Climate change
  • Specific health challenges for marginalized communities (e.g., Black and Brown folx, migrants, refugees, LGBTQ+)
  • Nutrition and food assistance
  • Vaccination rates
  • Demographic and population information
  • Chronic disease statistics, interventions, and prevention

They also work on grants from places like the CDC to see how to make positive changes in communities, especially around chronic diseases.

Local universities will also often be involved in these efforts, especially in areas with world-renowned higher education facilities. Departments there involved might include the medical school, school of nursing, epidemiology, oncology, population health, and more.

Cool, right?

I’m a nerd, so, of course, I think it’s cool. I also just started officially working in public health!

I get to help improve communications for the chronic disease prevention team. They work a lot on efforts related to stroke, heart disease, type 2 diabetes, and oral health. I’m really excited!

So, do you have questions about Public Health?

Pandemic Birthday

Posted on by Grayson

Back in 2019, my partner and I talked about how odd birthdays are after you hit 30. Growing older as a kid and young adult, each age seems to bring new milestones. Turning 15 means you could get your driver’s permit, at 16 a license, and at 21 you can drink. I was excited about my 25th since I could start renting a car when I travel. Hell, even my 26th was exciting because it meant my arthritis was turning 21 in November. Turning 32 though? That’s not really a celebratory thing.

The biggest reason I was excited about this birthday was that I was scheduled to play in a hockey tournament this weekend. I was going to be busy and tired, but having a blast and being around my people. I honestly was a little worried about having time for self-care during all of this.

There were other reasons to be concerned, too, though. This was also the first birthday I was going to have had after getting divorced, moving, and losing my guinea pigs to old age. I started testosterone in January. Plus, I’m in the middle of a job change, too, so a lot of things are different for me this year.

Needless to say, I knew my birthday this year was going to feel weird. I couldn’t have any idea that a pandemic would be added to the mix.

I miss hockey and my friends. I miss the physicality of playing sports (Who have I become?). I miss going places, picking up groceries, and even running errands or going to the doctor. I miss seeing other people, from saying hi to neighbors to hugging my friends. More than anything, though, I miss not being afraid… well, as afraid as I am now. Knowing that I am , there are so many precautions I have to take just to grab the mail.

Granted, I also know I’m not taking quite as many precautions as some people have to.

I know that I’m privileged and lucky to be relatively safe, despite both me and my partner having a higher risk of catching Covid-19 and dealing with morbidity or mortality from it. The weight of the pandemic hitting and hurting people close to me is very real. I’ve got several friends now who have either tested positive and recovered or are mid-recovery. I know others whose relatives are ill and doing poorly. Like with Ian and I, there are other people I know who feel they had this but either were unable to get tests or whose tests came back negative, too. It’s a scary time, especially for anyone who is disabled, transgender, poor, or a person of color since each of these communities is being hit even harder.

So, today, instead of doing some big sort of celebration, I’m going to spend time talking with the people who are most important in my life. I baked a chocolate cake and I’ll make some frosting for it later. I’ll probably make something super tasty for dinner.

Mostly, I’m going to meditate on what more I can do to be part of the solution — something I hope that we can all try to focus on during this time.

COVID-19 Update: ACR Releases Clinical Guidance for Managing Patients with Rheumatic Disease

Posted on by Grayson

The following is information just released from the American College of Rheumatology:

ACR’s COVID-19 Clinical Guidance Task Force has released new clinical guidance for the care of patients with rheumatic diseases during the COVID-19 pandemic. The recommendations address various treatment options and provide general guidance, as well as direction for when to start, stop, or reduce medications. All recommendations are based on current knowledge and will be revised as circumstances and evidence evolve.

Guidance statements include, but are not limited to, the following:

  • Patients with rheumatic disease appear to be at risk for poor outcomes from SARS-CoV-2 (the virus that causes COVID-19) primarily because of general risk factors such as age and comorbidity.
  • Patients with rheumatic disease should follow all general COVID-19 preventive measures, but in addition, rheumatology patients and providers may discuss ways to reduce the number of healthcare encounters and potential exposure to SARS-CoV-2, (e.g., monitoring blood work less frequently, using telehealth, and increasing the time between doses of intravenous medications).
  • For ongoing treatment of stable patients with no SARS-CoV-2 exposure or infection:
    • Hydroxychloroquine or chloroquine, sulfasalazine, methotrexate, leflunomide, immunosuppressants (e.g., tacrolimus, cyclosporine, mycophenolate mofetil, azathioprine), biologics, Janus kinase (JAK) inhibitors and non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, naproxen) may be continued.
    • Denosumab, an injectable medication used for osteoporosis, may still be given, but the time between doses may be extended to as long as 8 months, to minimize healthcare encounters and if necessary due to limited access to infusions.
  • In patients with stable disease who have been exposed to SARS-CoV-2 (without known infection):
    • Hydroxychloroquine, sulfasalazine and NSAIDs may be continued, but immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily, pending a negative test result for SARS-CoV-2 or after 2 weeks without COVID-19 infection symptoms. IL-6 inhibitors may also be continued in this situation, in select circumstances.
  • In rheumatic disease patients with a confirmed SARS-CoV-2 infection, anti-malarial therapies (hydroxychloroquine, chloroquine) may be continued, but sulfasalazine, methotrexate, leflunomide, immunosuppressants, non-IL-6 biologics, and JAK inhibitors should be stopped temporarily. In select circumstances, IL-6 inhibitors may be continued.

The full list of guidance statements can be found here https://www.rheumatology.org/Announcements#ClinicalGuidance