Friday, September 22, 2017

More Dumb Things Leaders Say About Health Policy

These days, legislative efforts to change US health care, especially to "reform and replace" the Affordable Care Act [ACA or "Obamacare"] seem to inspire displays of jaw dropping ignorance by political and sometimes business leaders on behalf of "reforming" health care.  We last posted examples on July 7, 2017.  Now there is a new game afoot to reform and replace, and it is generating new - not to put too fine a point on it - foolishness.

So herein is a roundup of a two more examples from July after our last post, plus two more revently "ripped from the headlines," actually ripped from relatively obscure media articles, because the anechoic effect persists, and the media still does not cover these sort of things much.  In chronological order:

Vice President Pence Makes "False" Statement About Ohio Medicaid Problems, Per Ohio's (Republican) Governor

Reported by the Hill on July 15, 2017...

Ohio Gov. John Kasich's (R) office has flatly rejected Vice President Pence's claim that nearly 60,000 disabled Ohioans are on waiting lists for Medicaid’s home and community-based services.

Kasich spokesman Jon Keeling told The Washington Post that such an assertion is 'not accurate' and that suggesting Medicaid expansion hurt the developmentally disabled system 'is false, as it is just the opposite of what actually happened.'

At that time, while the previous push to "repeal and replace" was still going on, and Vice President Pence was apparently trying to make a point about how bad "Obamacare" is:

'I know Gov. Kasich isn’t with us, but I suspect that he’s very troubled to know that in Ohio alone, nearly 60,000 disabled citizens are stuck on waiting lists, leaving them without the care they need for months or even years,' Pence said in a speech Friday at the National Governors Association summer meeting in Providence, R.I.


According to the Post, waiting lists for such Medicaid services are common and are typically longer in states that did not take ObamaCare's Medicaid expansion than in those that did.

Ohio was among a number of Republican-controlled states that took the ACA's Medicaid expansion, which dramatically expanded the number of people who qualify for the program.

President Trump Makes Multiple Misleading Claims About His Efforts to Reform the Veterans Administration

We know that interesting things often happened at Mr Trump's campaign events, and at his later "campaign style" events as President.  Stat reported on July 28, 2017:

President Trump paints a rosy picture of an improved Department of Veterans Affairs under his watch, where accessing electronic medical records is 'so easy and so good' and health care is freely available without any delays.

The problem: It’s not true.

At a campaign-style event in Ohio this week, Trump’s claims of progress were so overstated that even his own VA secretary, David Shulkin — who stood right next to him — would have to disagree.

The article went on to list a number of specific claims which were false or misleading, including:

- Claims of huge improvements in VA information technology.  Unfortunately, a multiyear effort to improve health care IT "has barely even begun."

- Claims that the VA had doubled the number of veterans given approval to see  a "doctor of their choice" outside of the system.  In fact, the troubled VA Choice program increased the number by only "26 percent", and the program was facing new budget problems at the time Mr Trump made the claim.

- Claims that the administration had published wait times for all VA sites.  This actually started more than a year previously, under the Obama administration.

- Claims that the VA now offers same-day mental health services.  "This may be the case, but it happened before Trump took office."

In the "good old days," vice presidents and presidents who spoke publicly about issues like health care, about which one could not expect them to be expert, might have sought detailed briefings and/ or deferred some issues to their own experts.

White House Economic Advisor Misstates Basic Concept of Health Insurance

Reported by RawStory on September 19, 2017:

Donald Trump’s top economic advisor Stephen Moore on Tuesday demonstrated an apparent lack-of-knowledge of just how insurance works, telling CNBC’s John Harwood 'people want insurance for their own families, not other peoples.' Moore was explaining why it’s unfair to have an insurance system where healthy people subsidize sick people.

Trump adviser Moore on unfairness of the healthy subsidizing the sick: 'people want insurance for their own families, not other peoples' — John Harwood (@JohnJHarwood) September 19, 2017
Moore's implication seemed to be that people should not pay for insurance programs which might pay for health care for other people.  Yet the simple minded notion of insurance is that it is a tool to pool the resources of the many to pay for costs that only some will incur during a given time period.

The article went on to describe the withering responses on Twitter.  But for those who do not follow Twitter, I could only find a clear explanation of the problem with Mr Moore's statement in a column by Jodine Mayberry in the Delaware County (PA) Daily Times:

U.S. Sen. Ted Cruz, R-Texas, believes that people should be able to buy only the insurance that suits their needs. But there is no way anyone can ever know exactly what their needs will be, tomorrow, six months from now or six years from now.

You may not have diabetes or heart disease today, but a year from now, who knows?

A Trump economic adviser, Stephen Moore, said earlier this week, 'People want insurance for their own families, not other people’s families.'

He knows he is distorting how insurance works.

Our insurance premiums go to cover other people’s disasters as well as insure against our own.

That’s known as spreading the risk – the more people you can have in a pool of insureds, the more likely you’ll have affordable coverage for your own family.

I had a bad house fire in 1987 that cost about $50,000 to repair.

I certainly had not paid anywhere near $50,000 in homeowners’ insurance premiums up to that point (or ever).

Other people paid for my fire and I have helped pay for other people’s over the years.

We must have home and auto insurance, unless we don’t live in a house or drive.

We are all born and we all get sick and we all die, without exception, which is all the more reason for all of us to have affordable health insurance.
 So here we had the example of a top executive branch adviser who apparently provides input about health insurance, yet who does not seem to understand what health insurance is.

Aetna CEO Wrongly States Canada Has a De Facto National Health Service in Which the Government Owns and Runs Hospitals and Physicians' Practices

This example is of a top corporate health care executive, not a politician or government adviser.  As reported by Lee Fang writing in the Intercept on September 20, 2017:

[Aetna CEO Mark Bertolini] asked the room of investors and analysts to 'name a country that has single payer.'

When several participants named Canada, Bertolini disputed the answer and claimed that Canada has a 'government-run health care system. They’re not single payer, they’re single everything.'


The suggestion, however, that Canada has a completely government-run health care system under which all medical professionals 'work for the government' is false. In Canada, medical claims for virtually all non-dental health care are paid by the government, but doctors and hospitals work in the private sector.

'Doctors in Canada are not employed by the government. They are self-employed, they are independent business people,' said Karen Palmer, an adjunct professor at Simon Fraser University. 'The system is publicly funded but privately delivered.'

Bertolini appeared to be confusing single payer with a single-provider system, such as the National Health Service in the United Kingdom, under which doctors and providers work directly for a government entity.

Bertolini is the CEO of a huge for-profit health care insurance company, so one would think we might know the difference between national health insurance and a national health system.  The example of Canada is a one often used by those who promote "single-payer" health insurance in the US, an idea which Mr Bertolini opposes.  So one would think we would be familiar with the Canadian example. 


It would be too much to expect that health care policy debates would be rigorously evidence-based.  However, lately they seem to include loudly expressed views devoid of facts or rationality.  We have proposed that this is the result of "managerialism."  We have discussed this doctrine, promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy. 

However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives that often put short-term revenue ahead of the health of patients and the population.)  And in the latest health care reform debate, some of the politicians and political appointees who are the de facto managers of health policy have disdained the advice of health care professionals and health policy experts.  (And above we presented an example of a true managerialist corporate health care executive who also - to put it bluntly - did not seem to know what he was talking about in a discussion of various country's health insurance systems.)

Ignorance and falsehood in the health care debate could also be part of a broader trend toward anti-intelletualism or what has recently been termed "The Death of Expertise" (see this New York Times review of a book with that title.)  Managerialism could be part of that trend.  And the extreme relativism of post-modernism, which we also discussed in the context of the current debate on health care reform, could be another.  

Facts, however, are stubborn things.  Evidence is evidence, no matter what politicians or corporate executives it might offend.  Basing legislation on the sorts of alternative thinking displayed in the cases above could lead to real life, or life and death consequences for the sick, injured and vulnerable.  True health care reform requires clear thinking and the input of people who actually know something about health care.

Sunday, September 17, 2017

"The Censorship That It is" - Now Threatens US Government Health Agencies (DHHS, CMS, CDC)

On Health Care Renewal we discus the dark side of health care, particularly of the leadership and governance of health care, that has enabled health care dysfunction.  Our discussions are based on publicly available information, often produced by dogged health care journalism.

Uur work has become more difficult as journalism is challenged by economic circumstances.  Yet now there are worse threats.  Despite First Amendment protections of freedom of speech and the press, journalism is now under fire from the highest reaches of US government.

Information Blockade at the Department of Health and Human Services

Two recent articles in the Columbia Review of Journalism pointed to specific problems  The first, "Under Trump, Health Reporters Confront an Information Blockade," September 7, 2017, focused on decreasing transparency at the US Department of Health and Human Services (DHHS), and its Center for Medicare and Medicaid Services (CMS).  It provided numerous examples of officials failing to respond to apparently straightforward requests for legitimate health care information.  For example,
Washington Post healthcare reporter Paige Winfield Cunningham recently raised a few serious questions about how the Trump administration planned to manage Obamacare’s fall enrollment season. 'The six-week sign-up period will be the first handled exclusively by an administration that’s hostile to the Affordable Care Act,' Cunningham wrote, 'and one that hoped by now to see Congress pass legislation unraveling much of the law.'

Any reporter might have asked the questions Cunningham put to the Department of Health and Human Services, some of which she published in her daily Health 202 column:

Will the government contact current enrollees to alert them that sign-ups will last just 45 days, about half as long as in the past three years? Will HHS run call centers for consumers who need help as they look for plans? Will the computer system be adjusted to accommodate a possible crush of shoppers given the shorter sign-up period? And how will automatic enrollment be handled?

HHS offered no answers, although a spokesperson for the department’s communications staff did provide Cunningham with a statement: 'As open enrollment approaches, we are evaluating how best to serve the American people who access coverage on' Even that statement did not stand for long, reported Cunningham:

An hour later, the spokeswoman, Jane Norris, requested that the statement be withdrawn, saying that she did not have permission to release it. When I asked her again for detailed answers, neither she nor anyone else at HHS responded further.

'Nobody at HHS ever reaches out to me,' Cunningham told CJR during an interview.


Matt Wynn, data reporter for MedPage Today, went public with his troubles prying loose the data underlying a series of maps CMS sent out this summer. One map published in early June identified counties without insurers selling policies on this fall, and a news release announced at least 35,000 active Exchange participants live in counties projected to be without coverage in 2018.' Wynn asked CMS to see the numbers supporting those conclusions.

I shot an email to the media relations office in the department, asking for the data behind the map.

About an hour later I got a response. No further information would be shared at this time, wrote Shelby Venson-Smith, a public affairs specialist. Adding insult to injury, the non-response was not to be used as a direct quote, the email said.

However, while DHHS and CMS officials resisted responding to uncomplicated requests for information,

they seem to have plenty to say in their news releases and email blasts, which disparage the health law and sound more like campaign propaganda and GOP talking points than routine communications from a federal agency. The Obama administration was not shy about using the same PR tools to boost the ACA. But messages from HHS now feel substantively different, perhaps because they are aimed at denigrating a law they have a legal responsibility to administer.
Thus officials at DHHS seem to now be more interested in following the party line of the current administration than in providing basic information to the public.

Many other health care journalists experienced similar problems, including Charles Ornstein from ProPublica, Dan Diamond of Politico, Harris Meyer of Modern Healthcare, and Noam Levy of the Los Angeles Times.

Trudy Lieberman, the author of the CJR article, wrote,

HHS and CMS are powerful agencies that could decide the future of critical programs like Medicaid and Medicare, the Obamacare insurance marketplaces, and whether or not hospitals are considered safe. But when agency press officials avoid interviews and refuse to answer questions, it’s hard to present their positions fairly and understand whose side they are on. Government agencies are supposed to be objective about industry practices under their jurisdiction. But if reporters cannot get honest information about the industries they regulate, where can they go?
Kathryn Foxhall, who "works with the Society of Professional Journalists on freedom of information issues," put it this way,
I don't see the administration ever stopping what they are doing, unless we as journalists pull out all stops and call it the censorship that it is.

Public Health Without Public Information?

Worse, one week later, CJR published another article  on the US Centers for Disease Control (CDC).  The CDC is the lead US public health agency.

Axios published text from a late August email by a CDC public affairs officer that directs staff to route any correspondence with journalists—'everything from formal interview requests to the most basic of data requests'—through the communication office at its Atlanta headquarters:

'The message—sent by public affairs officer Jeffrey Lancashire and dated Aug. 31—instructs all CDC employees not to speak to reporters, ‘even for a simple data-related question’… Lancashire did not respond to requests for comment about the policy. But I’d love to know what harm was being done by CDC employees answering ‘the most basic of data requests.’'
Thus CDC officials now seem to want to substitute public relations for straightforward information provision.  Given that the mission of CDC is public health, this seems to be an example of mission-hostile management, a concept we have used most often to refer to the management of private health care organizations, not US government agencies.  Charles Ornstein of ProPublica commented

This is genuinely disturbing. The idea that someone at CDC headquarters needs to sign off on responses to basic data requests shows a level of media control beyond which I have ever seen. What’s next?

Felice Freyer of the Boston Globe tweeted

CDC is employed by taxpayers. Why shouldn't its work be readily shared with them?
At Health Care Renewal, we have often discussed the anechoic effect, a taboo against public discussion of many aspects of health care dysfunction, particularly those that might discomfit people who are personally profiting from the current system.  In particular, the currently dysfunctional health care system has made the leaders of big health organizations, particularly for-profit corporations,  hugely wealthy.  Furthermore, big health care organizations have been eager to develop financial relationships with health care professionals, academics, leaders of non-profit organizations and NGOs, etc, leading to a web of conflicts of interest draped over health care.  Who wants to speak out when doing so may offend not only distant CEOs, but also one's colleagues, bosses, friends, relatives etc who may have financial ties to those CEOs' corporations?  Furthermore, who wants to speak out when large corporations command huge marketing and public relations operations that can be used to drown out unwanted ideas, and legal departments ready to threaten litigation?

Now government health care officials seem to be enlarging their own public relations efforts while shutting off access of honest information.  This will only make open discussion of the true causes of health care dysfunction more difficult. 

Even more chilling is the threat that health care officials now may be attempting actual censorship.  We have depended on health care journalists to root out bad behaviors that lead to health care dysfunction, and by doing break taboos about discussion such behaviors.  Up to now we have assumed at least that government would not make it harder for journalists to do their job, protected by the Bill of Rights protections of free speech and a free press.  But now the current administration seems to be taking the side of censorship.

From Censoship to Incitement of Violence?

Even worse, some worry that the regime's hostility to journalists  threatens their actual harm.  In early September, the New York Times reported on comments by the United Nations High Commissioner for Human Rights, who

was reacting to Mr. Trump’s recent comments at a rally in Phoenix during which he spoke of 'crooked media deceptions' in reports of the violent clashes at a white nationalist rally in Charlottesville, Va., that resulted in the death of a counterprotester.

In Phoenix, the president’s words also appeared to whip up audience hostility toward journalists.

The failing @nytimes writes false story after false story about me. They don't even call to verify the facts of a story. A Fake News Joke! — Donald J. Trump (@realDonaldTrump) June 28, 2017

'It’s really quite amazing when you think that freedom of the press, not only a cornerstone of the Constitution but very much something the United States defended over the years, is now itself under attack from the president himself,' [UN official] Mr. al-Hussein said. 'It’s a stunning turnaround.'


'To call these news organizations fake does tremendous damage,' Mr. al-Hussein added. 'I believe it could amount to incitement. At an enormous rally, referring to journalists as very, very bad people — you don’t have to stretch the imagination to see then what could happen to journalists.'

Ominously, the response from the White House included more unsubstantiated charges of "false narratives," and threatened media tha fails to be responsible as judged by the regime, never mind the First Amendment and its promise of free speech and a free press. 

the White House press secretary, Sarah Huckabee Sanders, said in an emailed statement, 'We believe in free press and think it is an important part of our democracy, but the press also has a big responsibility to the American people to be truthful. Their job is to report the news, not create it.

'Is it not ‘dangerous’ for the media,' she continued, 'to create false narratives and overzealous attacks against the president that the American people chose to be their leader? The president is focused on growing our economy, creating jobs, securing our border and protecting Americans. Since those are also the priorities of most Americans, hopefully the media will make covering them theirs.'

Strong, even overzealous verbal and written attacks on politicians, the president included, have been essential parts of American democracy since the Bill of Rights was ratified.  The First Amendment shows that our political system values such boisterous discourse.  The White House press secretary thus threatened not only the press but the fundamental US system of government.  

Strategic Hostility

Finally, there is an argument that the regime's attacks on the media may not be just reckless, but  strategic and calculated.  The UN Special Rapporteur on the promotion and protection of the right of freedom of opinion and expression, Prof David Kaye of University of California - Irvine School of Law, wrote,

The President’s attacks may be reckless – who knows whether someone in his audience will take the President’s word as license to take action against enemies of the American people? – but they are not without purpose. They have concrete aims: to intimidate reporters into certain kinds of coverage, or clarify for his favored outlets what coverage he desires, or plant the seeds of doubt about news stories (such as the Russia investigation led by Robert Mueller).


However, when we tie together the jeremiads and rhetoric with what the Trump administration is doing in other governing spaces, the practice of attacking the press becomes clearer as policy than solely reckless rant.

First, the attack on the press is not merely rhetorical; it is increasingly reflected in policy.


Second, Trump’s incendiary statements work in tandem with a pattern of lying and disinformation, both aiming to limit the accessibility of truthful information


Third, the administration operates as if it has something to hide.
Who knows what they might be hiding.  But there certainly have been plenty of accusations of  severe conflicts of interest and corruption affecting the Trump presidency?


Up to last year, I was cautiously optimistic that the anechoic effect was starting to erode, enabling the health care discussion to begin to encompass the deeper causes of health care dysfunction.  Since November, however, we seem to be going backward.  What little openness and transparency that were developing are at risk of sinking under a new tide of propaganda and censorship.  My concerns have primarily been about health care and health care dysfunction, but the larger trends threaten our whole society and the ability of the US to maintain itself as a republic.  Ben Franklin's warning becomes more acute.  What we have is only 

A republic if you can keep it. 

That will now take some work.  

Thursday, September 07, 2017

The Shame of US Health Care Dysfunction: Hookworm Returns to Alabama

An article just published online(1), and reported so far in only one major media outlet (the Guardian, based in the UK) showed how hookworm, now considered a disease of poor, third world countries, has returned to the American south.  This in a country which spends more per capita on health care than any other supposedly developed country.

Background - the Supposed Eradication of Hookworm

A 2009 article in Health Affairs documented the supposed elimination of common diseases once found in US.(2)  The background of the article included:

In 1916 a new textbook appeared on the 'endemic diseases of the southern states.' With chapters on malaria, pellagra, and intestinal worms, the book’s authors identified the region as particularly, and peculiarly, diseased. Absent was the dominant southern disease of the nineteenth century: yellow fever. Although yellow fever had traveled hand in hand with the import trade of southern cities, the twentieth-century triad of pellagra, malaria, and hookworm was inextricably linked with the rural poverty engendered by cotton culture and the tenant labor system that evolved to replace slavery after the Civil War. The rural farm worker had little money or access to health care, ate a poor diet, and lived in a subtropical landscape that was host to parasitic worms and mosquitoes. In 1916 the South’s endemic diseases appeared to be thoroughly entrenched. Later, in the depths of the Great Depression, these diseases continued to plague southerners. Yet by 1950 southerners were almost free of them all.

The article noted that hookworm in particular was associated with the South:

Hookworm disease was once associated so much with the South that when a baseball commentator referred to southern players as coming from the 'Hookworm Belt' in 1947, the phrase needed no explanation. The hookworm is a tiny parasite that latches onto the wall of the small intestine, secretes an anticoagulant to promote bleeding, and feeds on the host’s blood. About 110 worms can consume a teaspoon of blood a day. A well-fed host with adequate iron intake can usually replace the lost iron and plasma proteins of a mild infection, but a malnourished person harboring sizable numbers of parasites will become anemic and protein deficient. In children the disease stunted physical and cognitive development. It made them weak, apathetic, and perpetually tired.

In the beginning of the 20th century, the Rockefeller Foundation launched a campaign that probably began the apparent eradication of hookworm.

In 1902, however, Charles Stiles, a medical zoologist, recognized in southerners the same symptoms he had seen among European hookworm victims. Once he started looking, he found a startling prevalence of the disease. He convinced representatives of the Rockefeller Foundation to take up the cause of hookworm eradication, and in 1909 the philanthropy launched an all-out assault on the disease. Their initial surveys found 43 percent of those surveyed to be infected with hookworm; in some areas the percentage rose into the 90s.

The Rockefeller campaign stressed education, treatment, and the assumption by local and state boards of health of the responsibility to carry on what the foundation had begun. With a million dollars in their coffers, the Rockefeller men spread across the South, offering lantern shows about the hookworm, testing and treating individuals, and pushing the construction of sanitary privies. Surveys of rural schools and churches found that 80 percent lacked any sort of privy; private homes were even less likely to have sanitary facilities. Children of all classes went barefoot in the summer, often not wearing shoes until they were teenagers. By 1914, when Rockefeller ended its U.S. campaign, the prevalence of infection had been cut to 39 percent, but the message of hookworm and its implications was now well known throughout the South. The campaign also energized southern public health, leaving a legacy of empowered institutions on the state and local levels.
For more on the history of the Rockefeller Foundation campaign, look here.  I hope the Foundation will not mind me using a picture of a hookworm treatment clinic from 1923.

Hookworm persisted for a surprisingly long time after these initial eradication efforts, although it seemed to be nearly gone by the 1980s.  The article noted that

Even in the 1960s there was persistent infection in coastal South Carolina (3 percent) and eastern Kentucky (14 percent). One source reported that hookworm prevalence in southern Georgia went from 60 percent in 1910 to 13 percent in 1964 and to 6 percent in 1970.

So the disease prevalence fell from over 40% in the early 20th century to a few percent by the 1980s.  One particular mechanism for the decrease was basically better plumbing.

Concerns about typhoid, which was frequently fatal, drove the cities to put in sewers and running water, and fears that the privies of the poor would infect the affluent meant that even the poorer sections of towns had sanitary waste disposal throughout much of South in the 1920s. Slowly the expectation grew that the sanitary privy was essential for adequate housing. In North Carolina in the 1940s, the state board of health required them by law.

So the problem appeared to be solved.  I learned about hookworm in a course in tropical diseases in medical school in the 1970s.  At the time, since I was not planning to go into global health, the knowledge did not seem very relevent.  I suspect that such courses were no longer very prevalent in medical school.

That was then.  This is now.

Hookworm Returns to the Impoverished US South

The new article by McKenna et al noted that hookworm is still very common globally.  In addition, it noted that the conditions are again ripe for the return of hookworm, and presumably other ailments now considered irrelevant to developed countries, to parts of the US.  In particular, the advances in plumbing so important to the eradication of hookworm are no longer so much in evidence.

According to the Alabama Center for Rural Enterprise (ACRE), an organization that addresses poverty and economic development in one of the poorest areas of the nation, there continues to be residences without adequate sanitation systems, increasing exposure to open sewage near dwellings. The “Black-Belt” soil native to this area is composed of a firm sedimentary limestone bed overlain with a layer of dark, rich soils, which requires expensive septic systems for proper waste disposal. In Lowndes County, Alabama, where the per capita income is $18,046, and 31.4% of the population lives below the poverty line, sanitation systems are unaffordable. For rural, impoverished individuals, the main form of waste removal involves use of 'straight piping,' a method involving a series of ditches or crudely constructed piping systems to guide human waste away from the residence. Most pipes never reach more than 10 meters in length, and during rainstorms or flooding, the residents report visible stool entering their homes (reported by ACRE, unpublished data).

The investigators therefore performed an epidemiological study in Lowndes County.  There sample size was small.  However, their findings were striking.  More than one-third (34.%) of subjects tested positive for necator americanus, the American hookworm.  This is close to the prevalence reported back in the early twentieth century.

The Guardian article provided vivid anecdotal evidence about the state of public health in rural Alabama that likely contributed to this result.  The reporter's tour of Lowndes county revealed vividly inadequate sewage systems.  He documented that in Alabama, "public health" was ostensibly insured by making it a criminal offense for people to have inadequate sewage systems.

people were afraid to report the problems, given the spate of criminal prosecutions that were launched by Alabama state between 2002 and 2008 against residents who were open-piping sewage from their homes, unable to afford proper treatment systems. One grandmother was jailed over a weekend for failing to buy a septic tank that cost more than her entire annual income.

'People are scared. They don’t like to speak out as they’re worried the health department will come round and cause trouble,' [community activist Aaron] Thigpen said.

Apparently the state government does not see that it has any resonsibility to provide adequate sewer systems, or provide any help to people to improve sanitation, even those clearly unable to affort it on their own.  Consider, for example, the plight of Ruby Rudolf

Rudolph, now 66, does have her own septic tank at the back of her house, which she shows us in the sweltering 41C (105F) heat. But it doesn’t function properly and when it rains the tank spills over, spreading raw waste all over the yard. 'That’s better than when it flushes back into the house, and I’ve had that too,' she said.

She’s been told a replacement system would cost her at least $12,000, which is beyond her means. She runs through her finances: she gets up at 4am every day to do an early shift at a Mapco convenience store, which brings in less than $1,200 a month. From that amount she has to pay $611 for her mortgage and there’s the electricity bill that can be more than $300 a month when it’s hot and the air conditioning is busy. There’s not a lot left to put toward a new tank.

Left entirely unsaid in the scholarly article or the Guardian story is the likelihood that any residents of these rural Alabama counties have access to any other ways to mitigate the hookworm problem.  Left also unsaid is whether they have access to health care professionals who could test them or treat them for hookworm.


As we have noted endlessly, the US spends more per capita on health care than any other developed country.  US politicians used to make the claim that the country has the best health care system in the world, often to ward off any attempts at true health care reform.  However, US rankings on various measures - some of which may be disputed - of health care processes and outcomes have been decidedly mediocre.  (See for example the latest Commonwealth Fund study here.)

The new study of hookworm prevalence was not based on a big, systematic, or geographically diverse sample.  However it is striking, and dismaying that a disease once thought to be eradicated is again alive and well in the poorer parts of a very rich country. 

Note that while the eradication of hookworm was partially attributed to the energizing of public health in the south, currently public health officials seem to think their job is to arrest poor people who cannot afford adequate sanitation.  The government does not seem to think it has a responsibility to assure working sewers or other forms of basic sanitation.  There also seems to be a governmental abandonment of public health focused on reaching individuals who might most be at risk of disease.

Meanwhile, the country, as we have said before, has seen the diversion of tremendous amounts of health care and public health dollars into the pockets of health care managers, their cronies, health care management and administration in general, and in some cases investors.  This appears in turn to be a consequence of deregulating the system, allowing concentration of power,  allowing the commercialization of various kinds of health care organizations (insurance, hospitals, medical practices, etc), and of turning health care leadership over to managers trained in business schools (managerialism) with no appreciation of health care professionals' values, and with perverse incentives focused on increasing their organizations' revenue and hence their personal enrichment.  We can spend untold sums on new treatments with dubious margins of benefits vs harms, but not on basic public health or access to primary care. 

And hookworm is back. 

Shame on us. 


1.  McKenna ML, McAtee S, Bryan PE et al.  Human intestinal parasite burden and poor sanitation in rural Alabama.  Am J Trop Med Hygeine 2017;

2.  Humphreys M. How four once common diseases were eliminated from the American south.  Health Aff 2009; 28: 1734-1744.  Link here