How the Cleveland Clinic grows healthier while its neighbors stay sick


The Clinic is a global success story, but its host community remains mired in poverty.

On the Cleveland Clinic’s sprawling campus one day last year, the hospital’s brain trust sat in all-white rooms and under soaring ceilings, looking down on a park outside and planning the next expansion of the $8 billion health system. A level down, in the Clinic’s expansive alumni library, staff browsed century-old texts while exhausted doctors took naps in cubbies. And in the basement, a cutting-edge biorobotics lab was simulating how humans walk using a cyborg-like meld of metallic and cadaver parts.

And about a block away — and across the street that separates the Clinic from the surrounding Fairfax neighborhood — a woman named Shelley Wheeler was trying to reattach the front door of her house. She’d had a break-in the night before.

Wheeler has lived in the neighborhood for almost 50 years and seen it wither; her street is dotted by vacant lots and blighted homes. Infant mortality is almost three times the national average. But she’s also warily watched as one player continues to grow: The health system with gleaming towers that are visible from her front stoop.

“Cleveland Clinic is just eating everything up that they can,” she said, pointing to the 17-block stretch of land where the system has steadily expanded — to the frustration and protests of Wheeler and her neighbors.

“At some point, Cleveland Clinic is going to come” for her land, she added. “When, we don’t know. I’m trying to save my house,” Wheeler said — before excusing herself to meet with police investigating her break-in.

There’s an uneasy relationship between the Clinic — the second-biggest employer in Ohio and one of the greatest hospitals in the world — and the community around it. Yes, the hospital is the pride of Cleveland, and its leaders readily tout reports that the Clinic delivers billions of dollars in value to the state. It’s even “attracting companies that will come and grow up around us,” said Toby Cosgrove, the longtime CEO, pointing to IBM’s decision to lease a building on the edge of campus. “That will be great [for] jobs and economic infusion in this area.”

But it’s also a tax-exempt organization that, like many hospitals, fought to preserve its not-for-profit status in the years leading up to the Affordable Care Act. As a result, it doesn’t have to pay tens of millions of dollars in taxes, but it is supposed to fulfill a loosely defined commitment to reinvest in its community.

That community is poor, unhealthy and — in the words of one national neighborhood-ranking website — “barely livable.”

More than one-third of residents in the census tract around the Clinic have diabetes, the worst rate in the city, according to the latest data from the Centers for Disease Control and Prevention. That’s just one of numerous chronic and preventable health conditions plaguing the area around the Clinic. Meanwhile, neighborhood residents say there are too few jobs and talk of hearing gunfire every night.

It’s the paradox at the heart of the Cleveland Clinic, as it lures wealthy patients and expands into cities like London and Abu Dhabi. Its stated mission is to save lives. But it can’t save the neighborhood that continues to crumble around it.

The neighborhood

The area around the Cleveland Clinic’s main campus has higher rates of diseases such as coronary heart disease, cancer, diabetes and chronic kidney disease.

An oasis of prosperity

The local joke is that Cleveland’s economy is powered by its basketball team’s superstar LeBron James. But leaving the airport, the first billboard advertises the real engine of the city: its local hospitals. And no hospital is bigger, richer or more influential than the Cleveland Clinic — which was praised by both Mitt Romney and Barack Obama in their 2012 debates, a rare point of agreement between the candidates. (The Clinic took out full-page ads to celebrate.)

While Cleveland isn’t especially prosperous, the Clinic’s campus is a world apart, evoking an upscale resort or an airport’s international terminal — an alternate universe where smokers and fast-food restaurants are banned, where foreign-language speakers are numerous and where live music and farmers markets are frequent.

The streets of the Clinic’s 165-acre campus are smooth; the bike lanes paved; a 77-foot-wide fountain greets visitors outside the main lobby. The buildings are all sleek steel and glass — a deliberately white color scheme that resembles an Apple store. Guests can take tours to see the thousands of pieces of art dotting the rooms and walls, picked out by the Clinic’s three full-time curators. A spine of green parks wind between more than a dozen buildings. High-profile speakers like Facebook’s Sheryl Sandberg and Microsoft’s Satya Nadella drop by for televised conversations with Clinic CEO Cosgrove.

All the major buildings are connected by skyways, some of which feature flat-screen TVs that loop ads for the Clinic’s own services. A doctor on staff could spend years entirely inside this bubble, from parking in an adjacent garage every morning — where art prints from artists like Andy Warhol and Roy Lichtenstein hang in the corridors — to eating at the 24-hour Au Bon Pain, never setting foot on the sidewalks outside.

The beautiful, sheltered campus reflects decades of willful development, says Richey Piiparinen, who studies urban planning at Cleveland State University and says that the Clinic — like many big-city institutions — has deliberately walled itself off. “It’s divorced from the neighborhood. It’s [even] policed differently,” Piiparinen said, referencing the Clinic’s private force of 122 officers.

Step off campus, and the cracked sidewalks and trash welcome you to a different world; a dozen empty liquor bottles littered one half-block alone.

Just a few blocks from the Clinic’s high-end Intercontinental Hotel — where the flagship restaurant serves $49 steaks and $220 bottles of Dom Perignon — a McDonald’s sign announces $1 soft drinks. There are boarded-up buildings and weed-choked vacant lots. One store advertises bail bonds.

The population of the two neighborhoods that surround the Clinic — Fairfax and Hough, which are about 95 percent African-American — dwindled to 18,000 as of 2010, down from more than 38,000 in 1980 and more than 100,000 in 1960. There’s visible blight and houses with peeling paint. One fence was draped by an assortment of raggedy clothes, slowly getting soaked in a rainstorm. Unlike the Clinic just blocks away, there are no bike lanes.

And the poverty manifests in poor health outcomes, with the rate of preventable illnesses like chronic heart disease and high cholesterol well above the local and national averages. The Clinic’s own community assessment, published last year, ranked Fairfax and Hough as “highest need” possible in terms of health care access.

“You have one of the best global brands in health care, but some of the worst health care disparities” next door, Piiparinen said. “That’s the impact of not being connected to the neighborhoods.”

A climate of mistrust

It wasn’t always this way.

Almost a century ago, when the Cleveland Clinic set up shop on Euclid Avenue, the street was known as Millionaire’s Row. Industrialists like John Rockefeller and other elites made their homes on the boulevard. But the neighborhood turned over as taxes went up and wealthy residents fled to the suburbs. Today, there’s a very different millionaires row: The line of doctors’ luxury cars every morning, driving in from Cleveland’s suburbs in their high-end SUVs and even a few Teslas.

That daily traffic helped lead to a $331 million construction project called the Opportunity Corridor, a new three-mile highway that’s backed by the Clinic, run by the state transportation department and involves ripping up streets and tearing down dilapidated parts of town. (When asked about the project’s purpose, the Clinic’s top tour guide explained that the current road to campus “goes through neighborhoods that people don’t want to go through” and the Opportunity Corridor would help staff and patients get to the hospital faster.)

The construction project has been bogged down by controversy, however. A local councilman, T.J. Dow, temporarily blocked the project in early 2016, warning that the redevelopment wouldn’t benefit the residents of his community. The city later withheld millions of dollars in funding, saying the state wasn’t meeting its promised goals for minority hiring, before reaching a new deal last year.

Area residents circulate scare stories about the Clinic that are a mix of half-truths and outright myths. Several old churches in the neighborhood have burned down in recent years, and after the Clinic bought one newly vacant lot, some residents engaged in wild speculation — without any evidence — that the Clinic was responsible for the blaze. The Clinic has built power stations in the neighborhood that, despite no scientific proof, have alarmed locals who are worried about health risks.

That fear goes both ways: Even longtime Clinic leaders are uneasy about the neighborhood that they’ve spent years in. “I should’ve warned you: Don’t walk around here at night,” one 15-year executive advised.

Neighborhood residents are especially dismissive of the disproportionately white or foreign patients they see flock to the Clinic, suggesting that their presence is subtly gentrifying the neighborhood. A signature project by the local development corporation — which is backed in part by Clinic donations — was a large Middle Eastern market that’s a few blocks off campus and clearly intended for international customers. Over the course of four nights in an on-campus hotel last year — no matter the hour — as many as eight Middle Eastern men would sit around a table off the lobby, drinking tea and wearing garb that stood out in gloomy, rainy Cleveland. The hotel also offered subtle cues about who its best customers are; in the gym, there wasn’t a working channel showing the NCAA men’s basketball tournament, but there were nearly two dozen international channels, mostly in Arabic.

International patients are especially appealing to the Clinic and other top hospitals because they pay full fare — much more than the Medicaid rates for poor patients and a lot more than the fractional pay or charity care write-offs from treating the uninsured.

The campus’ expansion and seeming priorities aren’t lost on residents. One elderly African-American woman, a retired nurse who worked for decades in the city’s public hospital, said she’d talk about the Clinic only if I didn’t use her name. “You know what we call it?” she said, lowering her voice. “The plantation.”

“Cleveland Clinic and Toby Cosgrove really need to renegotiate their relationship with the black community,” said John Boyd, whose family has lived about two blocks away from campus since 1923 — and who says he’s scared to go to the Clinic for treatment. “[They’ve] been absolutely no benefit to the black community.”

Tensions break out

Those tensions spilled out at a community meeting in March 2016, as more than 100 black residents vented for hours about the Opportunity Corridor project.

The standing-room-only meeting — deliberately held in an events room at a local police station, Councilman Dow told the crowd, because previous meetings had been so rowdy — was framed as a chance to discuss the Opportunity Corridor’s effect on the community. Dow and two other black councilmen, Zack Reed and Jeffrey Johnson, stood at the front of the room — along with a pair of white out-of-town developers, who had projects tied to the corridor.

The atmosphere was heated from the opening moments, as some community members stood to harangue Dow, asking if he was holding up the project to seek side deals; others worried that the community was giving up valuable land for too little return.

But after a rough start, the councilmen began winning over the crowd after channeling their frustration toward the out-of-town developers and invoking the community’s distrust of the Clinic.

“I told Dr. Cosgrove, the people in my neighborhood don’t trust the Clinic,” Reed said, warning that the system’s vague promises of helping the community didn’t usually end well. “We the people of color, the poor people, get what I call the hot dog and beer jobs.”

“I said to Dr. Cosgrove, you got to take down that invisible wall,” Reed added. “If you only believe you can work across the street if you’ve got a medical degree, then it’s us against them … We’ve got to train people in the neighborhood to work there.”

“Now you’re talking,” a woman shouted from the crowd.

“We need a hand up, not a handout,” Dow added.

After the meeting, the councilmen acknowledged the difficult relationship between the city and its flagship institution.

“If there’s anything that Cleveland Clinic does for the neighborhood, it’s that they’re located in Cleveland — and everyone who works there pays taxes,” Johnson said. But the hospital doesn’t do enough to provide emergency care, he charged; unlike its neighbor University Hospitals, it’s not a Level 1 trauma center, and the Clinic was sued by the city in 2010 and again in 2011 for failing to provide sufficient services when it closed one of its hospitals in economically deprived East Cleveland.

That lawsuit was resolved, but some bad feelings still linger — along with the perception that the Clinic is more concerned with complex procedures that attract foreign patients than the well-being of its neighbors.

“You can come from the Mideast and get a heart, but you can’t run down there” for an emergency, Johnson complained. “There’s something fundamentally wrong with that.”

‘We have more than fulfilled our duties’

Clinic leaders see it differently – and not just about its commitment to the neighborhoods. The hospital that the Clinic closed in East Cleveland was replaced by a new community center that leaders tout as a “model of success.”

“We have three obligations,” Cosgrove told POLITICO in a nearly hourlong interview. “We need to provide great health care, we need to provide great jobs and we need to support education. And we have done all those three things.”

The Clinic is ranked second in the U.S. News & World Report hospital rankings, an ever-present point of pride around the campus and in its marketing materials. It employs nearly 50,000 people in Ohio, just a few hundred jobs behind the state’s top employer, Walmart. And it spends millions of dollars on its own physician education as well as making community investments, like partnering with a local high school on a fast-track health and science program.

The Clinic also has put $500,000 into a program to get rid of blighted homes in the neighborhood, Cosgrove said, and has channeled funds and support into the Fairfax Renaissance Development Corp., which is involved in job training and other community services.

“This particular area of town, 40 years ago, was way worse than it is now,” Cosgrove said.

One of the Clinic’s most significant community investments is in the Langston Hughes Community Health and Education Center, a facility that’s a mile from campus and which offers services like free exercise equipment, adult day care and even some primary care. It’s a hub for uninsured neighborhood residents to be steered toward health coverage, and patient navigators on staff said they end up directing about 90 percent of residents with medical needs to the Clinic. And it has devoted fans who say the center is one of the only safe places in the neighborhood.

“I wish we had more [services] like it,” said Juliet Jones, a retired nurse who lives two blocks away — and who carries a miniature baseball bat whenever she leaves her house, worried about community violence and drug dealers. Jones says she can barely sleep at night, hearing gunshots and prowlers. Nearly every lot on her street is vacant, including the house Jones owns next door; after repeated break-ins, her daughter moved out.

Donnell Ezell is another patron of the center and, in many ways, a clear Clinic success story: The former occupational therapy assistant worked for the Clinic for years and got thousands of dollars in financial assistance to help buy a home and move into the neighborhood. Now retired, Ezell uses the Langston Hughes center to exercise and help his daughter, who was born with special needs, and he speaks with pride about what the hospital has done for him; a Clinic-branded chair, emblazoned with his name, is prominently displayed in his living room.

But the question isn’t whether the Clinic is doing good things for the community, critics say. It’s whether it’s doing enough.

Thanks to a loosely defined 50-year-old IRS regulation, the hospital is required to provide only “community benefit” in exchange for its tax exemption — no matter what those taxes would be worth. And in late 2013, three social advocacy groups concluded that the Clinic’s tax-exempt property in Cleveland was worth $1 billion, which meant the hospital was saving $35 million in annual property taxes alone. (The value of that property, and the forgone taxes, has only gone up since.) That money could go toward schools, roads and other city projects that desperately need funds, advocates say.

“It’s crazy to ask the everyday common person to invest in the city when you have these enormous nonprofits that aren’t,” saidScherhera Shearer, head of Common Good, one of the three advocacy groups, at the time.

But the clinic rebutted that report and has fiercely defended its tax-exempt status, successfully defeating regulators in 2014 after a decade-long battle when they attempted to strip property tax exemptions from a pair of satellite offices.

Cosgrove consistently argues that taxes would only worsen the financial pressures on hospitals like the Cleveland Clinic, and in his interview with POLITICO he pointed out that 23 percent of hospitals lost money last year. But that ignores that the Clinic isn’t one of them. Cosgrove’s hospital system cleared $514 million in profit last year and $2.7 billion the past four years, when accounting for investments and other sources of revenue.

And since the ACA coverage expansion took full effect, the Clinic’s been able to spend a lot less to cover uninsured patients; its annual charity care costs fell by $106 million from 2013 to 2015. But its annual community benefit spending only went up $41 million across the same two-year period, raising a $65 million question: Did the Clinic just pocket the difference in savings?

“I think we have more than fulfilled our duties,” Cosgrove said in response, pointing to the system’s total community benefit spending, which was $693 million in 2015. The majority of that spending, however, wasn’t free care or direct investments in community health; about $500 million, or more than 70 percent, represented either Medicaid underpayments — the gap between the Clinic’s official rate, which is usually higher than the rate insurers pay, and what Medicaid pays — or Clinic staffers’ own medical education.

Clinic leaders also argue that the hospital is a magnet that attracts talent and revenue to Ohio. The system calculated that its direct economic impact on Ohio in 2015 was $6.8 billion and its indirect economic impact was $5.8 billion.

“There are people like me who have moved to Cleveland to work for the Cleveland Clinic,” said Chief Financial Officer Steven Glass, who came to the system 15 years ago from Maryland-based MedStar.

“It’s not just how many people are employed at the Clinic,” Glass added. “When you’re drawing in world-renowned physicians, these are well-paying jobs in the community that then create [a] cascading effect.”

But community residents say those dollars are largely spent in other neighborhoods and they don’t see much trickle-down effect on their own; Glass himself lives in a suburb a half-hour away. “Other than fast-food chains, there’s nothing else around,” said Jones, the retired nurse.

Teenagers who live in the neighborhood and were interning at the Clinic said that’s where they want to work as adults; they were stumped about where they would work, if not at the Clinic. “Construction,” said one 14-year-old girl — gesturing to the hospital’s in-progress project across the street.

There’s also a perception problem, at best, with what the Clinic thinks it does for the community versus what it actually does. Several Clinic PR staffers suggested that Microsoft CEO Nadella’s interview with Cosgrove was an example of how the hospital opens itself up, with community members welcome to drop by. But the free tickets to the one-hour session had been pre-booked online well in advance, and the overflow room was packed by staffers wearing doctor’s coats and Cleveland Clinic badges. (Many neighborhood residents said they weren’t especially interested in the talk, and didn’t know who Nadella was.)

Several Clinic officials pointed to a weekly farmers market on campus as another service for the community, which lacks grocery stores. But the vendors at the market tell a different story, both in terms of their products — many of which are upscale conveniences like flowers or dog treats — and their clientele.

The customers at the market “are mostly doctors and nurses,” said one vendor operating a stand that sold wool and honey products. That account was confirmed by residents. “Too expensive,” said 76-year-old Betty Moise, who’s lived in the neighborhood for almost five decades.

How much more should be done?

One way the Clinic could make a difference, some activists say, is by working out what’s called a payment in lieu of taxes — essentially, keeping their valued tax-exempt status but making a partial contribution instead. Hospitals have struck deals to do so in Boston and other cities, but Cosgrove isn’t keen on the idea in Cleveland. “As soon as they start doing the same thing with the churches and the Salvation Army and the Red Cross and all the other tax-exempt organizations, we’d be happy to do our part,” he said.

The Clinic also could ramp up investments in out-of-hospital care and social supports, part of a movement toward what’s called population health — where fixing community problems like lead exposure and food deserts are viewed as equally important as treating heart attacks. There’s a financial incentive for doing it well: Hospitals that succeed at population health are being rewarded with higher payments from insurance companies and the federal government.

But Cosgrove hesitates on committing wholeheartedly to that idea, too. “That’s a good direction to go,” he allowed. “But how much can we do in population health?”

“We don’t get paid for this, we’re not trained to do this, and people are increasingly looking to us to deal with these sorts of situations,” Cosgrove added. “I say that society as a whole has to look at these circumstances and they can’t depend on just us.”

Job counselors say there’s one move the Clinic can easily make: Be more generous with its approach to neighborhood hiring. Deborah Copeland, who does workforce development and career coaching at Fairfax Renaissance Development Corp., says she’s seen community members get hired at the Clinic in entry-level jobs — and promptly fired because they didn’t fit in right away or had problems managing themselves in the workforce.

“They call all of their employees caregivers. And I like that,” Copeland said. “But all caregivers are not caregivers every day,” she added, saying it’s important to realize that “people come with a lot of baggage sometimes and need to be developed.”

Copeland says her team has helped a few dozen community members get jobs at the Clinic over the past few years — a step in the right direction. But given the generations of built-in poverty and the neighborhood’s deep disparities, experts say it’s like hoping a sand wall will hold back the tide.

“How do you [intentionally] break down the barriers, after they … built them up?” muses Piiparinen, the Cleveland State University researcher. “The two easiest ways to do it are have your employees live in the neighborhood, and have your tenured residents work in the anchor institutions themselves,” he offered — not easy to do when the neighborhood is so poor and the Clinic wants to hire highly skilled doctors, researchers and managers.

Piiparinen and others acknowledge that while the Clinic is investing off campus, it will take more investment and commitment — much more — to really reverse a decades-long trend. But the Clinic’s eyes are elsewhere. Its most visible projects and leaders’ excitement center on a new on-campus building that’s designed by Norman Foster — “the world’s leading architect,” as various staff members enthused — and its planned hospital in London, overlooking Buckingham Palace.

And more expansion in Cleveland is inevitable. In the hospital’s master planning room, tucked behind an unmarked door just steps from the main lobby, the footprints of the Mayo Clinic in Rochester, Minnesota, and Johns Hopkins in Baltimore are laid over maps of the Clinic, which dwarfs them. Those maps are a reminder, said a Clinic spokesman, that “our national rivals, Mayo Clinic [and Hopkins] … they don’t own the buildings around them, they have no place to grow but up.” In contrast, “we own much of the neighborhood around us and can really grow.”

There’s certainly plenty of opportunity, between the property the Clinic already owns and the empty patches that increasingly dot the neighborhood as it slowly dies. And that’s what folks like Moise, who moved to Cleveland in 1968 and sat with friends on a sidewalk, half-expect to see happen.

“I sat and watched them cut that field yesterday. The city cut it. It looks so pretty,” she said, gesturing to the vacant lot across the street, covered in grass. “But I often wondered … I might be dead and gone … I often wonder, what would they build there?”

Gun Death Rate Rose Again in 2016, C.D.C. Says

The rate of gun deaths in the United States rose to about 12 per 100,000 people, the second consecutive increase after a period of relative stability.

The rate of gun deaths in the United States rose in 2016 to about 12 per 100,000 people, the Centers for Disease Control and Prevention said in a report released on Friday. That was up from a rate of about 11 for every 100,000 people in 2015, and it reflected the second consecutive year that the mortality rate in that category rose in the United States.

The report, compiled by the C.D.C.’s National Center for Health Statistics, showed preliminary data that came after several years in which the rate was relatively flat.

“The fact that we are seeing increases in the firearm-related deaths after a long period where it has been stable is concerning,” Bob Anderson, chief of the mortality statistics branch at the health statistics center, said in a telephone interview on Friday. “It is a pretty sharp increase for one year.”

Mr. Anderson also said the rates for the first quarter of this year showed an upward trend, compared with the same three-month period of 2016.

“It clearly shows an increase,” he said, while emphasizing the data was preliminary. “With firearm-related deaths it is seasonal — the rates generally are a little higher in the middle of the year than they are at the end of the year,” he added. “Homicides are more common in the summer.”

More than 33,000 people die in firearm-related deaths in the United States every year, according to an annual average compiled from C.D.C. data.

The data released on Friday did single out other causes of death in the United States that were higher than the firearm-related rate. The drug overdose rate, for example, was almost 20 deaths per 100,000 last year, up from 16.3 in 2015.

The death rate for diabetes was about 25 per 100,000 people; cancer was 185 per l00,000, and heart disease about 196 deaths per 100,000 people.

But statistics about gun deaths, nearly two-thirds of which are suicides, have been ingrained in the national discourse in the United States, particularly after mass shootings, such as the one in Las Vegas last month in which 58 people were killed, and in debates over legislation related to guns.

In June 2016, the 49 fatalities in the Pulse nightclub shooting in Orlando represented one of the highest death tolls in a single mass shooting in recent United States history. But gun violence researchers note that although mass shooting fatalities account for no more than 2 percent of total deaths from firearm violence, they are having an outsize effect.

Garen J. Wintemute, director of the Violence Prevention Research Program at the University of California, Davis, School of Medicine, wrote in the Annals of Internal Medicine after the Las Vegas shooting that mass killings are “reshaping the character of American public life.”

“Whoever we are, they happen to people just like us; they happen in places just like our places,” he wrote. “We all sense that we are at risk.”

Dr. Wintemute said the latest C.D.C. report means the nation is approaching two decades since there has been any substantial improvement in the rate of gun deaths. The rate for the first three months of 2017 was about the same as the corresponding period in 2016. Hopefully, that is a sign it will level off again, Dr. Wintemute told The Associated Press.

Mr. Anderson said the data was not broken down by states, which each have different levels of comprehensiveness in their reporting to the federal agency. “As they get more and more timely we hope to include state-level information in these reports,” he said.

Suicides account for about 60 percent of firearm-related deaths, and homicides about 36 percent, Mr. Anderson said. Unintentional firearm deaths and those related to law enforcement officials account for about 1.3 percent each. The rest are undetermined.

The final data for 2016 will be released in the first week of December, Mr. Anderson said. “It could be this is a sort of blip, where it will stabilize again,” he said. “It is hard to predict.”

4 in 10 healthcare professionals work when they’re sick, risking patients


Patients who are exposed to a sick healthcare worker are five times more likely to get a healthcare-associated infection.

A new study suggests that healthcare professionals should heed their own advice: Stay home when sick.

Some four in 10 healthcare professionals work while experiencing influenza-like illness, according to findings published in the November issue of the American Journal of Infection Control, the journal of the Association for Professionals in Infection Control and Epidemiology.

As in all workplaces, contagious employees risk infecting others when they turn up for work. But with higher concentrations of older patients and individuals with immunosuppression or severe chronic diseases in healthcare facilities, flu-like transmission by healthcare workers naturally presents a public health hazard.

The research pointed to an earlier study showing that patients who are exposed to a sick healthcare worker are five times more likely to get a healthcare-associated infection.

The annual study, conducted via a national online survey, collected data from from 1,914 professionals during the 2014-2015 flu season. Respondents self-reported influenza-like illness, defined as the combination of a fever and cough or sore throat, and listed factors that prompted them to turn up for work.

The survey assessed a variety of health occupations across multiple institutions: physicians; nurse practitioners and physician assistants; nurses; pharmacists; assistants/aides; other clinical pros; nonclinical pros; and students. Four types of work settings were assessed: hospitals, ambulatory care or physician offices, long-term care facilities and other clinical settings.

Of the 1,914 professionals surveyed, 414 reported flu-like illness. Of these, 183 — or 41.4 percent — reported working for a median duration of three days while experiencing flu-like symptoms.

Hospital-based healthcare professionals had the highest frequency of working with flu-like illnesses (49.3 percent), compared to those at long-term care facilities (28.5 percent). Clinical professional healthcare workers were the most likely to work with the flu (44.3 percent), with pharmacists (67.2 percent) and physicians (63.2 percent) among those with the highest frequency.

The survey found that assistants and aides (40.8 percent), nonclinical workers (40.4 percent), nurse practitioners/physician assistants (37.9 percent), and other clinical workers (32.1 percent) worked while sick.

The most common reasons for healthcare professionals to opt from taking sick leave included feeling that they could still perform their job duties; not feeling “bad enough” to stay home; feeling as if they were not contagious; sensing a professional obligation to be present for coworkers; and difficulty finding a coworker to cover for them. Among the workers who felt they could still perform their job duties, 39 percent sought medical attention for their symptoms, as did 54 percent of those who didn’t think they were contagious. Almost 50 percent of workers in long-term care settings who reported for work when sick reported doing so because they couldn’t afford to lose the pay.

Healthcare professionals with self-reported flu symptoms missed a median number of two work days. Of those, 57.3 percent visited a medical provider for symptom relief; 25.2 percent were told they had influenza. The Centers for Disease Control and Prevention recommends that anyone with such symptoms wait 24-hours after a fever breaks before returning to work.

Previously published results from the survey showed that only 77.3 percent of respondents reported getting a flu shot.

Gun Carnage Is a Public Health Crisis

Image result for Gun Carnage Is a Public Health Crisis

“We’ll be talking about gun laws as time goes by,” President Trump promised all too casually after the Las Vegas gunman took 58 lives in a rapid-fire slaughter. Time is indeed going by, and the silence is alarming as the Republican Congress and Mr. Trump, the devoted candidate of the National Rifle Association, duck their responsibility to confront the public health crisis of gun deaths.

There were so many hundreds of casualties in Las Vegas that many were treated by local Air Force surgeons who found themselves serving as specialists in triage — in a civilian fire zone. “These were definitely injuries you would see in a war zone,” one of the doctors told The Washington Post. Victims bled from single wounds through the chest and abdomen because the gunman shot from a high perch with military-style weapons adapted to shoot rapidly downward into the concert audience that was his chosen target.

This is the domestic war zone now bedeviling the nation as Washington looks the other way. Republican leaders are once again contriving to divert public attention to the challenges of mental illness, whereas the core issue is and has been the egregious availability of military-style weapons that the gun industry and the N.R.A. are lethally marketing to civilians. The talk of outlawing the “bump stock” device that heightened the Vegas gunman’s rapid fire is similarly diversionary, since the problem is the weapon, not the latest accessory.

Washington has also hobbled basic research into what is clearly a public health disaster. In 1996, the Centers for Disease Control and Prevention was barred from spending any funds “to advocate or promote gun control.” Full and accurate federal information has been choked off repeatedly since then. Research ordered by President Barack Obama following the Sandy Hook Elementary School massacre of 20 children in 2012 was never carried out. California, by contrast, has chosen a more enlightened path. Reacting to the 2015 gun killings in San Bernardino, the state in July created the Firearm Violence Research Center at the University at California at Davis to get beyond the hobbles the gun lobby and Congress have put on federal researchers.

If there is any bright spot it is that little more than a third of American households own a gun now, compared with 50 percent in earlier decades. Still, this has driven the industry to try to sell more guns to fewer Americans, from battlefield-type weapons to the concealed-carry pistols marketed as stylish vigilante accessories. According to a 2015 study by Harvard and Northeastern Universities, 3 percent of American adults own half the nation’s guns — averaging a startling 17 guns apiece.

The Las Vegas shooter was one of these hard-core arsenal owners. He stockpiled dozens of weapons, apparently with no one, and no law, to question the practice or his rationale. The government should be asking how he was able to do this, and how it could have been prevented. To the nation’s continuing sorrow, however, it’s clear little can be expected of the president and congressional leaders as time goes by and the next mass shooting draws nearer.


How investing in public health could cure many health care problems

Now that the Cassidy-Graham bill has been pulled, it’s a good time to think about concrete ways to improve health and health care in our country. Despite advances in medicine, U.S. health care spending grew to US$3.2 trillion in 2015, or 17.8 percent of the nation’s gross domestic product. To contain health care costs, the U.S. needs to invest in strengthening the public health system and reconsider approaches to making all Americans healthier.

Making Americans healthier should not be a partisan issue. Conservatives and progressives alike should agree on the importance of keeping Americans healthy – both on principled and financial grounds. The sicker the American people, the more expensive their care, and much of that cost will inevitably be borne by Medicare and Medicaid. Yet major challenges loom.

As the Dean of Columbia University’s Mailman School of Public Health, I have dedicated my career to the health of populations, using science and evidence to transition to a world where health and health care are collective priorities for all. My research and that of others suggests that this situation can be improved, but it will require a major national strategy and commitment to invest in public health – one that can be highly cost-effective.

Just the facts

Take, for example, the toll of chronic disease in the U.S. As of 2012, about half of adult Americans were living with one or more chronic health conditions, according to the Centers for Disease Control and Prevention, and one in four adults had two or more. Treating people with chronic diseases accounts for most of our nation’s health care costs. Eighty-six percent of the nation’s annual health care expenditures are for people with chronic and mental health conditions.

This problem will only grow as the U.S. population increases. And the census projects that the population will increase by 98 million between 2014 and 2060.

At the same time, America’s crumbling infrastructure is putting many Americans’ health at risk. The country’s drinking water systems, which are foundational to health, received a D grade on the 2017 Infrastructure Report Card of the American Society of Civil Engineers. Hazardous waste management and wastewater treatment earned only D+ grades.

The connection between health and infrastructure is strong: Infrastructure greatly affects access to healthy lifestyles. While access to clean drinking water and waste treatment are paramount, there are other examples, too.

Sidewalks and bike lanes encourage physical activity; public parks provide space for exercise and rejuvenation; and public transit is crucial to getting people out of cars, encouraging walking and, of course, reducing pollution and congestion. Subways and buses also enable older adults to reach needed services and remain in their homes longer.

Improvements to infrastructure are typically one-time expenses with recurring benefits. For example, one new sidewalk benefits an entire generation of walkers and runners. Research shows that every $1,300 New York City invested in building bike lanes in 2015 provided benefits equivalent to one additional year of life at full health over the lifetime of all city residents.

Other studies also have shown that preventing illness is far less expensive than paying for treatment. Trust for America’s Health estimates that “an investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years. This is a return of $5.60 for every $1.” With ever-rising health care costs, how can we overlook such opportunities?

Prevention policies and cessation help

The focus of American health care and health-related research needs to be shifted to include prevention, not just treatment. The “Cancer Moonshot,” which has strong bipartisan support, is a vital step in this direction, providing $1.8 billion in funding over seven years.

Cancer prevention must be a high priority, and the success of this effort could inspire a national consensus around future commitments to tackle other diseases and conditions.

Another prevention priority should be healthy aging. Today there are more than 46 million Americans aged 65 years or older; and by 2060, the number of seniors is expected to more than double, according to the Department of Health and Human Services and the Census Bureau. Promoting healthy aging for older Americans should, therefore, be paramount.

And healthy aging begins far earlier than 65 or 70. Obesity, in particular, may be determined in early childhood, even before. According to research by my Mailman School colleague Andrew Rundle, prenatal exposure to air pollution raises risk for obesity in childhood. His research shows that children who are overweight or obese at age five are more likely to be overweight or obese by age 50. We also know that these adults, and increasingly children too, will be more likely to have diabetes, high blood pressure and high cholesterol.

Efforts at smoking cessation should also be increased. The total economic cost of smoking in the United States is more than $300 billion a year in direct medical care and lost productivity, according to the CDC.

That’s more than we’re spending on the Cancer Moonshot annually.

Thinking big

America has extraordinary research capability. The NIH invests nearly $32.3 billion annually in medical research for the American people. Targeted cancer therapies, for instance, are the focus of much anticancer drug development, according to the National Cancer Institute. Precision Medicine is a top priority at the NIH and other research agencies. Even at $32 billion, Americans are investing in the NIH only 1 percent of what we spend on health care annually. The U.S. should build its advantage by increasing research funding to enhance the potential of breakthroughs in preventing known diseases as well as future threats.

There is reason for optimism. The good news stems in large part from the fact that chronic diseases and conditions – such as heart disease, stroke, cancer, Type 2 diabetes, obesity and arthritis – are among the most preventable of all health problems. At least half of these diseases could be prevented, and we are making strides. Death rates from heart disease, the No. 1 cause of death in America, have been reduced by nearly half, for instance, since 1990, according to the American Heart Association.

The growth and aging of the U.S. population and the epidemic of chronic diseases and conditions pose major challenges for America’s health care costs, no matter how health care is constructed. But a relentless focus on public health – and disease prevention in all its dimensions – is the best way to reduce pressure on costs.

Diabetic Amputation Rates Soar in California, Nationally

Image result for diabetic amputation

No clear cause, but experts suggest numerous possibilities.

Over the past 7 years, California clinicians have been amputating toes, feet, ankles and legs of patients with diabetes-related ischemia with much greater frequency than before, and public health officials, diabetes clinicians, and surgeons said they’re puzzled by the trend.

Statewide, there was a 31% increase in these non-trauma amputations after adjusting for changes in population from 2010 to 2016. Adjusted increases reached 66% in San Diego County, with a population of 3.3 million.

In other populous areas of the state, Riverside County (population 2.4 million) had a 62% increase in diabetes amputations among residents. San Bernardino County (2.1 million) had a 61% increase. Sacramento County (1.5 million people), 47%. And Los Angeles County, with more than 10 million people, saw a 20% increase.

By raw numbers statewide, there were 12,490 diabetes-related amputations in 2016, up from 8,980 in 2010, with almost all counties seeing steady increases year over year.

The data — filtered for more than 100 ICD-9 and ICD-10 codes by county, hospital, body part surgery, and payer — was requested from the Office of Statewide Health Planning and Development, the California agency that collects diagnostic codes for inpatients treated by all hospitals within the state. It was then analyzed to adjust for changes in population.

Asked for comment, officials for the California Department of Public Health responded with one sentence, saying it “does not have information” on possible reasons.

CDC Taking Note

Edward Gregg, chief of epidemiology and statistics for the CDC, said the trend is troublesome. National statistics for 2010 to 2014 show a 27% increase; before 2009, amputation rates had been dropping.

Gregg said that from a public health standpoint, “the rate of amputations is a very important indicator of overall diabetes care. If we see it going down, then it’s a good sign, because so many aspects of good diabetes care in theory are affected. And when you see it going up, that’s a concern,” he said.

He couldn’t say definitively why rates have been increasing, adding that the CDC will be working on the issue. But he and others offered theories.

For starters, the nation is aging, and advancing age is a risk factor for diabetes, and more people are being diagnosed with diabetes. But neither explanation can account for much of the recent increases, Gregg said. For one thing, rates in the diabetic population are increasing too, even after adjusting for age: from 2.7 per 1,000 in 2009 to 4.1 in 2014.

Clinician Factors

Though amputations can stop infection and save lives, diabetes-related amputations deprive patients of independence, increase the need for social services, and add to disability and medical costs. On occasion, they must be repeated when infections spread and amputation incisions don’t heal. But amputations are drastic, and should be performed only when other remedies fail, many experts stressed.

But too many clinicians are impatient, said Caesar Anderson, MD, a University of California San Diego diabetes wound and emergency medicine specialist, who said he was “shocked” by the data. He pointed to emergency room personnel and surgeons who he sees rushing to amputate “even when the wound is not that alarming.”

Anderson blamed a “culture of frustration” among clinicians who say to the patient “you’ll never get better; we’ll probably just save you the headache and just amputate … and we have some fantastic protheses we can get you into … let’s just get it over with.”

Misty Humphries, MD, a vascular surgeon and diabetes-related amputation researcher at the University of California Davis, also noticed the increase with data she collected between 2010 and 2013. She suggested hospitals may be more diligently coding patients with diabetes because of payment rule changes that increase reimbursement when health services involve patients with multiple comorbidities.

But that appeared unlikely, at least for parts of the California. According to the state’s data, the number of patients admitted to any San Diego hospital for any reason who were coded for diabetes increased only one-fifth of 1 percent from 2010 to 2016.

Humphries said that better medication and devices such as pacemakers are keeping people with high blood pressure and cardiac disease alive longer, but those medical advances don’t “protect the rest of their body from age-related deterioration” of blood vessels in their lower limbs. “We do see an increase in amputations for that particular group of patients who are now elderly, non-ambulatory, and not really doing as much but they are still alive.”

Patient Factors

Humphries said she believes a big part of the problem is how common diabetes now is, with an estimated 29 million nationally with the disease. Being diabetic may have become so much the norm, patients think they “can just take a pill … and you don’t really have to change your diet.”

Benjamin Cullen, MD, a foot and ankle surgeon with Scripps Mercy Hospital, noted that many patients may delay care until a family member notices the wound, and rushes them to the emergency room.

California’s data underscored Cullen’s point: At least in San Diego County, more than 76% of the patients who received an amputation entered the hospital through the emergency room, suggesting that patients waited, or even didn’t recognize a problem, until it became acute.

“With diabetes, patients have neuropathy, so they can’t feel their foot,” Cullen said. “They get a wound, don’t know it’s there, the wound gets infected and they don’t realize it. The first sign that they have is a foul odor coming from their foot, or a family member notices drainage.”

Often, the infection has gotten into the bone, he said, leaving “no choice but to go ahead with the amputation” to try to save other parts of the limb.

Cullen and others noted that after patients with diabetes-related infections or other wounds are seen by a doctor or at a hospital, surgeons often perform revascularization procedures to restore circulation.

Then, patients are often referred to wound clinics and given prevention instructions going forward.

System Factors

But those strategies don’t work for everyone, said James Longobardi, DPM, chief of surgery at Scripps Mercy’s Chula Vista campus, just north of the Mexican border, and one who specializes in diabetes-related foot care.

He blamed the increase at his hospital on health literacy. Many of his patients — for a variety of cultural, dietary and other reasons — “can’t grasp the seriousness of the situation, and it’s very, very frustrating to many of our clinicians.”

Gregg speculated that the American Diabetes Association’s 2010 recommendation that clinicians use A1c tests to diagnose diabetes may be capturing patients with “worse heath status, higher blood pressure, worse circulation” than fasting glucose tests. “That could affect rates of amputations too,” he said.

Other factors include less attention to risk factor management by patients or clinicians, and perhaps some subgroups getting screened later or less often than recommended, Gregg said.

Linda Geiss, director of the CDC’s diabetes surveillance section, postulated some of the increase may be delayed fallout from the 2008 recession, when people lost jobs and health insurance, and perhaps skipped medical care for several years. The Affordable Care Act’s health coverage expansions could explain increases from 2014 to 2016, but not those between 2010 and 2013.

In California, many clinicians had numerous explanations for higher numbers, especially in certain counties.

Jonathan Labovitz, DPM, a Pomona foot and ankle surgeon and podiatry researcher affiliated with the UCLA Center for Health Policy Research, blamed the state Medicaid program’s policy change in July 2009, and documented his reasons in this June policy brief.

That cost-cutting move excluded podiatry services from being reimbursed, except in certain situations. That may have reduced wound and foot care services that allowed conditions to worsen, said Labovitz, who also is assistant dean at Western University of Health Sciences College of Podiatric Medicine.

State health officials confirmed the policy change, but declined to comment on whether it increased amputations.

David Armstrong, DPM, MD, PhD, of the University of Southern California’s Keck School of Medicine, theorized that a small portion of the increase might be due to the American Diabetes Association’s broadened definition of diabetes in 1997, from at least 140 mg/dL fasting glucose to at least 126 mg/dL.

That lower threshold resulted in healthier people being captured in the denominator, and made the rate of amputations among people with diabetes appear to drop over the next decade or so, he said. It’s possible that over the next 10 to 20 years, as those people with diabetes progressed, more developed severe blood circulation problems that since 2010 resulted in them having to undergo limb surgery, Armstrong suggested.

But if that indeed is an important factor, the increased rates of amputations would not be as dramatic since 2010, he acknowledged. In the California data, the denominator is hospitalized patients with diabetes, not all diabetes patients.

“It’s just as likely, if not more so, that the economic funk in 2009, [which also was] when podiatric care was eliminated for people with diabetes, contributed to a bump in amputation rates,” he said.

Anne Peters, MD, director of the University of Southern California Clinical Diabetes Program, blamed regional impediments to access to care.

For example, she said, San Diego has no county hospital, like Los Angeles and many other large counties. She stressed the need for better access to care and stronger prevention messages, “letting people know what to look for and where to go should they develop a small lower extremity lesion so it can be treated before it becomes an amputation.”

Could more amputations be better?

Several diabetes specialists and public health officials suggested the increase in amputations could be a good thing, a sign that persistent diabetes-related wounds are not being allowed to fester. Maybe with more distal amputations of toes, and feet, ankles and legs are being spared, they said.

It could be “more a marker of success than failure,” said Philip Goodney, MD, a vascular surgeon and limb amputation researcher with the Dartmouth Institute in New Hampshire, which analyzes Medicare data to see health trends.

While it’s hard to know what California’s data means without more complicated analyses, Goodney said amputations of toes and transmetatarsal procedures across the foot may spare the ankle and leg, and still maintain enough of the foot so patients can still walk.

“I tell my patients that the toes are there for decoration. If we can help you keep your foot, then you can live at home and live independently. It’s when you get your below-knee amputation or your above-knee amputation that the sort of major impacts on quality of life starts to happen,” Goodney said.

The CDC’s Gregg, however, was doubtful. “It’s hard to buy the argument that an increase is good,” he said.

One in eight American adults is an alcoholic, study says

new study published in JAMA Psychiatry this month finds that the rate of alcohol use disorder, or what’s colloquially known as “alcoholism,” rose by a shocking 49 percent in the first decade of the 2000s. One in eight American adults, or 12.7 percent of the U.S. population, now meets diagnostic criteria for alcohol use disorder, according to the study.

The study’s authors characterize the findings as a serious and overlooked public health crisis, noting that alcoholism is a significant driver of mortality from a cornucopia of ailments: “fetal alcohol spectrum disorders, hypertension, cardiovascular diseases, stroke, liver cirrhosis, several types of cancer and infections, pancreatitis, type 2 diabetes, and various injuries.”

Indeed, the study’s findings are bolstered by the fact that deaths from a number of these conditions, particularly alcohol-related cirrhosis and hypertension, have risen concurrently over the study period. The Centers for Disease Control and Prevention estimates that 88,000 people a year die of alcohol-related causes, more than twice the annual death toll of opiate overdose.

How did the study’s authors judge who counts as “an alcoholic”?

The study’s data comes from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative survey administered by the National Institutes of Health. Survey respondents were considered to have alcohol use disorder if they met widely used diagnostic criteria for either alcohol abuse or dependence.

For a diagnosis of alcohol abuse, an individual must have exhibited at least one of the following characteristics in the past year (bulleted text is quoted directly from the National Institutes of Health):

  • Recurrent use of alcohol resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household).

  • Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use).

  • Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct).

  • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about consequences of intoxication).
“Facing Addiction,” a report, pulls together the latest information on the health impacts of drug and alcohol misuse, as well as on the issues surrounding treatment and prevention. (Department of Health and Human Services)

For a diagnosis of alcohol dependence, an individual must experience at least three of the following seven symptoms (again, bulleted text is quoted directly from the National Institutes of Health):

  • Need for markedly increased amounts of alcohol to achieve intoxication or desired effect; or markedly diminished effect with continued use of the same amount of alcohol.

  • The characteristic withdrawal syndrome for alcohol; or drinking (or using a closely related substance) to relieve or avoid withdrawal symptoms.

  • Drinking in larger amounts or over a longer period than intended.

  • Persistent desire or one or more unsuccessful efforts to cut down or control drinking.

  • Important social, occupational, or recreational activities given up or reduced because of drinking.

  • A great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking.

  • Continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking.

Meeting either of those criteria — abuse or dependence — would lead to an individual being characterized as having an alcohol use disorder (alcoholism).

The study found that rates of alcoholism were higher among men (16.7 percent), Native Americans (16.6 percent), people below the poverty threshold (14.3 percent), and people living in the Midwest (14.8 percent). Stunningly, nearly 1 in 4 adults under age 30 (23.4 percent) met the diagnostic criteria for alcoholism.

Some caveats

While the study’s findings are alarming, a different federal survey, the National Survey on Drug Use and Health (NSDUH), has shown that alcohol use disorder rates are lower and falling, rather than rising, since 2002. Grant says she’s not sure what’s behind the discrepancies between the two federal surveys, but it’s difficult to square the declining NSDUH numbers with the rising mortality rates seen in alcohol-driven conditions like cirrhosis and hypertension.

separate study looking at differences between the two federal surveys found that the disparities are probably caused by how each survey asks about alcohol disorders: It found that the NESARC questionnaire used in the current study is a “more sensitive instrument” that leads to a “more thorough probing” of the criteria for alcohol use disorder.

If the more sensitive data used in the current study is indeed more accurate, there’s one final caveat to note: The study’s data go only through 2013. If the observed trend continues, the true rate of alcoholism today would be even higher.

What do the researchers think is driving the increase?

“I think the increases are due to stress and despair and the use of alcohol as a coping mechanism,” said the study’s lead author, Bridget Grant, a researcher at the National Institutes of Health. The study notes that the increases in alcohol use disorder were “much greater among minorities than among white individuals,” likely reflecting widening social inequalities after the 2008 recession.

“If we ignore these problems, they will come back to us at much higher costs through emergency department visits, impaired children who are likely to need care for many years for preventable problems, and higher costs for jails and prisons that are the last resort for help for many,” University of California at San Diego psychiatrist Marc Schuckit said in an editorial accompanying the study.