The problem of rural health care

There are many disparities in health care. Black mothers have a much higher rate of maternal death than do white women. All women are less likely to get guideline-advised cardiac care than do men. Among the many such examples, perhaps the hardest disparity to solve is that of the poorer access to health care faced by rural communities. People living in rural counties have higher death rates from cancer and heart disease than their urban counterparts, and there are more deaths from opioid overdose. Rural hospitals are closing every week, leaving their communities with less local access to needed services. Physicians practicing in rural communities are older and are not being replaced as they retire.

To keep small hospitals open, the federal government created the Critical Access Hospital program in 1997 that pays more to small (25 or fewer beds) and isolated (at least 35 miles from another hospital) hospitals. A friend who is an experienced nurse once told me she thought this was akin to the Chrysler bail-out, and these hospitals provided poor care and should be allowed to close. Many studies have documented poorer processes of care at small hospitals compared to larger one. It is certainly true that small rural hospitals do not provide the same level of service as do larger hospitals. They have few specialists and rarely have anything close to a critical care unit for truly sick patients.

I remember well an experience from many years ago. I was “moon-lighting” in the emergency department of a small isolated hospital when a patient came in with an obvious acute appendicitis that looked about to rupture. Unfortunately, the only surgeon on staff was quite inebriated after a night of partying and clearly in no shape to even drive to the hospital, never mind operate. The weather was foul and getting the patient to another hospital was going to be dangerous, so the nursing staff convinced me, a cardiology fellow, to operate. Luckily the OR nurses knew more about the procedure than I did, and I had assisted on a few appendectomies in medical school, so the patient survived, but at a larger hospital this dilemma would never have arisen.

What can be done? Better transportation would help. In truly isolated areas, air ambulances may be needed. Under our current system these are often exorbitantly expensive and a common source of “surprise medical bills” that run into the $10’s of thousands for non-Medicare patients. State governments and/or referral hospitals should establish fairly-priced air ambulance services if they cannot get commercial providers to bring down their prices. More use of tele-medicine would help, both in providing specialty consultation to the small hospitals and in allowing patients to avoid long drives. It has been found that pre-hospital personnel, EMTs and paramedics, can often avoid taking a patient to the hospital if they have telephone back-up at the scene. Consolidation of rural hospitals to provide more of a critical mass of physicians might require longer drive times but would provide better care in return. Medical schools should recruit more students from small communities, as graduates are much more likely to serve their own or similar communities than are students from an urban background, and rural students are now very under-represented among medical students.

In the meantime, if you are contemplating a move to the bucolic countryside after retirement, look carefully at the medical resources that would be available when you need them!

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Vaping - what we know and what we don't

Some 70 years after Doll and Hill published their landmark paper in the British Medical Journal linking smoking to lung cancer, we know a lot more about both the dangers of cigarettes and the predatory practices of the tobacco industry. A major public health campaign that included both education and regulation has led to decreased smoking and a corresponding drop in coronary disease. We still need on-going efforts, as the effects can be overcome by tobacco advertising. Banning flavored cigarettes or restricting their sale was shown to work in a study comparing youth smoking in Lowell, which had such a restriction beginning in 2016 and Malden, which did not. The consequences of smoking are still a huge problem in China and in many developing countries where tobacco ads dwarf public health measures, so we must stay vigilant.

The new epidemic which requires action is the use of e-cigarettes, or “vaping.” Vaping is the act of inhaling the aerosol produced by a battery-powered device. E-cigarettes contain pre-filled pods of liquids that the user adds to the device, and now are most commonly small devices that resemble a USB stick, and so are easy to carry and use. The liquids generally consist of glycerin, water, propylene glycol, nicotine and flavorings. Juul, by far the leading seller of e-cigarettes, has claimed that they are selling their product as a smoking cessation aid, and prominently feature adult smokers extolling the value of the product for this purpose. However, they clearly market to youth on social media, and by far the biggest selling products are those that are flavored. Flavor was the reason that about a third of users first tried e-cigs and most (63%) current users used flavors other than tobacco. Fruit flavors were most likely to motivate young adults to try vaping. In 2018, two thirds of U.S. middle and high school students had tried e-cigarettes or been exposed to second-hand aerosol in the previous 30 days. E-cigarette use is also a strong gateway to use of tobacco cigarettes among youth, with over 4-fold greater smoking among e-cig users.

Are e-cigarettes safer than combustibles? Clearly smoking causes cancer. Mint- and menthol-flavored e-cigarettes have very high levels of pulegone, a known carcinogen. E-cigarette smoke has also been shown to induce cancerous changes in the lung and bladder of mice. Smoking is a major contributor to coronary disease. What about e-cigarettes? They are associated with an increased risk of myocardial infarction that is similar to that of smoking conventional cigarettes, and dual use is riskier than using either product alone. Many women use e-cigarettes while they are pregnant, perhaps believing that they are safer than combustibles, but e-cig use has been shown to delay implantation and cause reduced weight gain of the fetus. While some short-term studies have shown minor improvements in measures of lung function among COPD patients who switched from combustible to e-cigarettes, vaping has been clearly shown to cause airway inflammation and lung disease. Finally, our dental colleagues have reported that e-cigarette aerosols increase the risk of cavities similarly to gelatinous candies.

Last, but far from least, is the mysterious and frightening epidemic of vaping-related lung disease. This was first reported from the upper Midwest in the spring of this year but has rapidly spread. Vaping-related lung disease has now been reported in 49 states (all but Alaska), DC and the US Virgin Islands. The number of cases is a moving target, but as of Oct 29, 2019, there were 1888 confirmed and probable cases and 37 deaths. The illness consists of early symptoms of nausea, vomiting and abdominal pain, followed by progressive shortness of breath, often leading to respiratory failure and the need for being placed on a ventilator. The chest X-ray shows diffuse infiltrates. The exact cause is still controversial. Among patients with full data, 86% reported use of THC-containing products, 64% nicotine-containing products and 52% both. No single compound has been shown to be the cause. The majority of those affected have been teens and young adults, though the death rate has been higher in middle-aged and older victims. Because the cause remains unknown, the CDC recommends against the use of any vaping products.

The bottom line: vaping is NOT safe, and best avoided.

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