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eGigabyte September, 2001

Melvyn L. Sterling, MD, FACP
Governor, Southern California Region II

Governor's Column

This issue of eGigabyte is the first that will be sent exclusively by email and posted to the Chapter website. This will allow us to offer timely and useful (and perhaps, in happier times, even entertaining) information directed to the interests and needs of internists at all stages of our careers.
Do not miss the description of our upcoming October 13 -14 Regional Scientific Meeting just a few paragraphs down.

Terrorism, the Internist and the ACP-ASIM

We are all saddened by the September 11th attack on New York and Washington that took our nation by surprise. We sympathize with the many colleagues, patients and fellow citizens whose lives have been struck by the horror of these events.

Thousands of Americans have volunteered time and money to help the victims and their families in this hour of need.

Now we must go forward, but which way should we go? What must we do to minimize the likelihood of another such tragedy?

One can cast many stones at our intelligence and defense agencies but I am not sure that is fair or reasonable.

It reminds me of the biblical admonition, "let he who is without sin among you cast the first stone".

The sin that we physicians may be vulnerable to is lack of preparation for another terrorist attack, one that employs a biological agent rather than an airplane or a bomb.

Our Board of Governors has previously heard testimony that it is not a question of "if" there will be a bioterrorist attack, rather the question is when and which agent will be used.

The College recognizes the importance of educating our members on the issues involved but that is only the first link in the chain of response. The next link is a more robust public health system. A stronger and more visible public health system is a vital component of our defense in the case of a biological attack.

Models of such attacks assume that anthrax or smallpox or ??? will go unrecognized by our primary care physicians and therefore delay identification, treatment and/or quarantine.

It is my hope that we will be sensitized to the necessity of reporting unusual clusters of cases - or atypical presentations of "viral syndromes" - to our public health authorities. Such reports are the vital, initial step in detection of such an attack.

You will note the comment by our editors that we have invited the health officers of Orange, Riverside and San Bernardino Counties to contribute to this newsletter. The article in today's eGigabyte is not about bioterrorism, it was written before September 11th and was planned to arrive in your office at about the same time as your flu vaccine. Future articles will address bioterrorism but in the meantime you can begin with our ACP-ASIM introduction at http://www.acponline.org/bioterro/medicalaspects.htm.

October Scientific Program

Our clinically focused, practical ACP-ASIM Region II Scientific Meeting will feature nationally recognized experts in diabetes, cardiovascular disease, nephrology and rheumatology.

Federal, state and local government officials and our own leadership will discuss the impact of government on the practice of internal medicine. The meeting will be in the Hilton Hotel in Costa Mesa on October 13 and 14, 2001.

In addition to state-of-the-art updates in cardiology, diabetology nephrology, and rheumatology, there will be hands-on workshops in office evaluation of peripheral vascular disease and joint aspiration and injection.

In a departure from the usual format of our CME meetings, we will also learn what a State Senator and a Congresswoman see in the health care - government interface in the near future.

Both the President-Elect of the ACP-ASIM and the Vice-President for Government Affairs will present the perspective of the National office. The Chair of our California ACP-ASIM Health and Public Policy Committee, Jeremiah Tilles will be the moderator of a panel discussion of government and health care.

All this - and "The Future of Medicine" by the extraordinarily talented (and entertaining) Faith Fitzgerald.

Does this sound like a commercial for the October Meeting? OK, but it really is a wonderful program. In addition to what I have described above, there will be a discussion of the nuts and bolts of practice organization by Maher Roman, MD, FACP, MBA and a panel on career planning as well as a workshop on advancement to Fellowship by Sarah Walker (bring your cv).

Ovarian Cancer

Our State ACP-ASIM was asked by Health and Education Communication Consultants (HECC) to participate in a public information program on ovarian cancer. We had an extensive discussion about the pro's and cons of participating in this effort. The downside was the risk of increasing public fears of this very serious malignancy. The upside was the opportunity to provide an objective analysis of available screening and treatment and have that perspective presented by the communication specialists of HECC. I will keep you posted.

Update on Medicare Documentation Guidelines

The Centers for Medicare and Medicaid Services (CMS), (when it was the HCFA), contracted with a company called Aspen to create a set of "Clinical Examples" that would show what proper documentation for various levels of service were (i.e., 99212, 99213, 99214…). An AMA committee that I work with reviewed these "Examples" - after several specialty societies (both internal medicine and surgical specialties) reviewed them. The committee found that the examples presented by Aspen described documentation suitable for a level 4 exam and coded it as a level 3! Many felt that the documentation presented as appropriate for level 3 was actually suitable for a level 5. The Aspen approach was rejected by our ACP-ASIM and the AMA.

We are waiting to see what happens next and are still waiting for HCFA's promise (the promise was made while it was still HCFA), to test the review plan that we have developed here in California; a system that is based on peer review of contested charges.

Currently our judgment may be overruled by employees of the fiscal intermediary that have no particular expertise or experience in the area of medicine that is in question. Indeed, they may not even be physicians!

More Medicare News

The Health Care Financing Administration has changed its name to the Centers for Medicare and Medicaid Services. Wonder why? Perhaps Tommy Thompson was on the level when he said, in a speech to the AMA in June, he is going to "really change the way his agency does things". We shall see.

Medicare Education and Regulatory Fairness Act (MERFA)
This Medicare reform bill, originally proposed by AMA and vigorously supported by ACP-ASIM, will probably be incorporated into another bill, probably the one proposed by Representatives Nancy Johnson and Pete Stark. The bill addresses the need to get honest and reliable answers from Medicare fiscal intermediaries, places limits on the egregious practice of extrapolation that often extorts huge sums of money from physicians based on the unilateral opinion of the carrier, as well as addressing educational issues in the Medicare program.

It is interesting that Pete Stark, originally an opponent of MERFA, has left the Dark Side to join in restoring some semblance of fairness and due process to the physicians that care for the elderly.

And still more on Medicare

Have you ever gotten a notice from HCFA (now CMS) that you provided a service that was "unnecessary" - you must refund the money? Or, the laboratory test that you ordered was not medically indicated and the lab wants you to pay for it? Well, never again! CMS has published an "Advance Beneficiary Notice" (ABN) so that our attempts to satisfy their previously ill-defined criteria for an ABN are no longer necessary. Download the forms (General ABN, Laboratory ABN) or get them from their website if you prefer - http://www.hcfa.gov/medicare/bni/cmsr131g.doc for the "General ABN" and http://www.hcfa.gov/medicare/bni/cmsr131l.doc for the "Laboratory ABN".

I would be interested in reader's comments as we use these forms.

The editors of eGigabyte have invited the Health Officers of our three county ACP-ASIM Region to contribute to our periodical. We thought you might find this historical review written by Dr. Gary Feldman, Riverside County Health Officer interesting.
Arthur D. Silk MD FACP
Gary M. Stewart MD FACP

The Influenza Pandemic, 1918

Gary Feldman, MD.

I want to tell the story of the plague of 1918, the great Influenza pandemic. A pandemic is an epidemic so widespread as to affect all parts of the globe. This is a story that is relevant today and still has much to teach us about the extent of our ignorance about communicable disease and our vulnerability to emerging infections and to bioterrorism. This material is drawn from an excellent book called "Flu" by Gina Kolata, Touchstone Books, 1999, which lays out the history of the epidemic as well as the ongoing and unfinished search for the actual virus that claimed so many lives. The book has a lot to say also about our capacity for panic and the potential price we may pay for our historical forgetfulness.

Some claimed plague germs were put into aspirin tablets by the Germans at the Bayer factory; some said they were spread by a German ship that crept into Boston Harbor; maybe it was brought by an U-boat; no, the Germans released the germs at theaters and Liberty Bond rallies. This kind of talk was not such a stretch. You need to remember that the world was at war in 1918; the talk in the US was of trench warfare and mustard gas.

Soon the plague was everywhere and no one was safe. It preyed on the young and healthy. You might notice a dull headache and your eyes might burn. Your muscles ache. You start to shiver and no amount of blankets can keep you warm. Your sleep is ruined by delirious nightmares as your fever rises. Your face turns a dark brown purple and your feet turn black. You cough up blood as you gasp frantically for breath. Blood tinged saliva bubbles out your mouth and you die - by drowning actually - as your lungs fill with a reddish fluid.

They called the plague of 1918 Influenza, but it was nothing like any influenza before or since. It took off in September of that year and when it was over, half a million Americans lay dead. It spread to the remotest parts of the globe. Entire Eskimo villages disappeared; 20% of Western Samoans perished. And wherever it struck, it killed the healthy young adults preferentially, and, to a lesser extent, infants and the elderly. Worldwide, it killed more people in less than a year than any other illness in the history of the world over a similar time span.

Nowadays when we think of plagues, we think of AIDS, Hepatitis C, Ebola, even the Black Plague maybe, but Influenza rarely makes the list. It just seems like a winter nuisance and besides we have a vaccine, don't we? Even the name speaks of winter; it probably comes from the Italian - Influenza di freddo - influence of the cold. Others believe that it derives from astrology - Influenza di stelle.

But flu is mostly unavoidable unless we are lucky with the annual vaccine. We know more about how not to get AIDS than we know about how to avoid the flu.

The flu of 1918 was surely unavoidable. How many became ill? - more than 25% of the US population and world population. Because it attacked healthy adults, more than 40% of servicemen were stricken. And worldwide, estimates range from between 20 million and 100 million dead. The true number can never be known since many of the countries most devastated did not keep mortality statistics, nor was there a completely agreed upon case definition. But even at the low estimate, it killed more people in a year than the entire history of the AIDS epidemic, twice as many as the combat deaths of WWI and well more than the combat deaths of WWII. It was 25 times more lethal than ordinary Influenza. It was so lethal that the average lifespan in the US fell by 12 years in 1918, falling to 39 years from 51 years in 1917, due to the half a million US deaths.

If such a plague came today it would kill over 1.5 million in the US and from 80 - 400 million worldwide. For the US, this is more than the combined annual death toll from heart disease, stroke, cancer, chronic lung disease, AIDS and Alzheimer's disease combined. And for the world, it was more than all those diseases plus the deaths from malaria and tuberculosis.

One cannot begin to imagine the horror of the epidemic. For example, in the week ending October 5th, 1918, 2600 hundred died in Philadelphia alone and the following week 4,500. Hundreds of thousands were ill. Sick people arrived at teeming hospitals in pushcarts, horse carts and limousines. Public health nurses worked in scenes that looked like the plague years of the 14th century - as they went out, they were mobbed by hundreds of dying patients. Undertakers were overwhelmed and the dead remained in houses and streets for days. Bodies were stacked 3 and 4 deep in the city morgue. And there was widespread price gouging by undertakers and cemeteries.

Public Health officials tried to stem the disease but to no avail. A typical order read like this one from Tucson -

"no person shall appear in any street, park, or place where any business is transacted,… without wearing a mask consisting of at least four thicknesses of butter cloth or at least seven thicknesses of ordinary gauze, covering both the nose and the mouth"

We couldn't do much better today. Remember that by 1918 viruses had already been discovered by indirect means, although no one had ever seen one - the electron microscope was far into the future. Vaccination was understood on an empiric basis but almost nothing useful was known about the immune system. This was wartime and the flu was seriously eroding the military capabilities of the combatants in WWI. So some of the best civilian and military minds went to work on Influenza. Some doctors thought that they had isolated a bacterium associated with the illness, but the reports were eventually disproved. Crude extracts of infected patients serum was tried as a vaccine. The arms swelled up horribly with a reaction, but those patients also died. No one had the ability to identify the Influenza virus or to design an effective vaccine.

It was also noticed that in 1918 millions of pigs came down with a flu-like illness, and thousands died almost overnight. Entire farms in the Midwest were decimated. One pig inspector, a Mr. Koen, proposed the pig as the source of the epidemic since many farm families came down with similar symptoms. In fact, it was Koen who coined the term "swine influenza." At the time no one took him seriously and the animal industry, for obvious reasons, did everything they could do to discredit him.

Modern researchers tried to revisit this idea. The short version is that, despite all kinds of experiments including dripping infected pig mucus into human nostrils, no one was able to prove that pigs were the source of the pandemic. Ultimately, it was shown that the viruses that cause swine flu and the human flu of the pandemic were not the same, despite the fact that survivors of the pandemic had cross-reacting antibodies to the swine virus.

All this took a long time to work out. The issue was still up in the air when there was a scare in 1976 that the pandemic might be returning. This concern about swine flu led to the rapid development and roll out of the "swine flu" vaccine that year - which is, in itself, a fascinating story mixing health and politics in a potent fear driven frenzy. In February of 1976, a previously healthy young private died at Fort Dix of Influenza after a 2 day illness. There had been a flu-like illness going around at the Fort but the doctors thought it was Adenovirus. When the throat swabs from ill soldiers showed Influenza, there was great concern, especially when the strain could not be identified. The CDC finally identified the virus as swine flu. This was very frightening since there had been no previous fully documented human cases of swine flu, nor had the soldiers had any plausible contact with pigs. The CDC was at a crossroads. Downplay the situation and risk a swine flu pandemic, or gear up for a massive vaccination campaign and risk being the biggest boy to ever cry wolf in public health history. They ultimately recommended to President Ford that the vaccination program go forward. Ford faced the same political dilemma and agreed to go forward at a cost of $135 Million to vaccinate every man, woman and child in the United States for a disease that no one could prove was a real threat. In retrospect, it was the wrong decision. The swine flu never spread beyond Fort Dix and flu vaccination was discredited for years because of what turned out to be a false association with Guillan-Barre disease.

Even today we know a lot, but not enough to stop an influenza pandemic, because we have no idea what made this virus different from the run-of-the-mill Influenza that we experience annually these days. As it happens, all tissue saved from the epidemic has been lost or so badly preserved that we have no credible RNA from the virus to work with. Searchers have unearthed bodies of victims from the frozen tundra looking for the virus, but (maybe fortunately) no viable specimens have ever been found. It is terrifying to think what might have happened if the virus was viable in such specimens and was unleashed back into an unsuspecting world. Other researchers, using PCR technology, are trying to reconstruct the genome of the 1918 virus from incomplete RNA fragments that have been isolated from old preserved infected tissues, but so far without complete success.

Today we know quite a bit more about how to deal with the bacterial super-infection that often complicates the flu and how to support very ill patients. Unfortunately, we have very little excess capacity in the medical care system in the US and there is no excess capacity in the developing world to deal with anything like the 1918 pandemic. We don't even have enough capacity to handle a slightly more intense flu season than average. Here in Riverside County, there are not enough ER physicians, intensive care beds, nurses or even oxygen tanks to handle a heavier than average flu season.

It is true that we have antiviral medications today that somewhat ameliorate the symptoms of the flu, but do not eliminate them. Of course, we have no idea if they would be effective against the 1918 strain. And besides, we couldn't manufacture and distribute them fast enough to make a dent in this country, let alone throughout the world.

Vaccination won't work either. Because the Influenza virus mutates so rapidly, no vaccine is useful for more than a couple of years. So every year the CDC lives in fear that the next flu epidemic will be the big one. The viral scientists try to guess the pattern of genetic and geographical drift of the various Influenza strains that are circulating to predict what should go into the next year's vaccine. They are often right, but not always. Then the vaccine manufactures try to grow the tissue cultures to harvest vaccine in time for the next season, and sometimes that doesn't work either. Under the best of circumstances, we make only the smallest fraction of the doses necessary to protect everyone from a minor flu epidemic and it is hopeless to imagine that we could gear up in time to have an effect on next pandemic in this country, let alone the world. And, because of the swine flu debacle of 1976, it would take quite a bit to convince anyone to attempt a full scale effort to vaccinate the entire population, even if it were feasible. In short, we are no less at the mercy of the next pandemic than we were in 1918.

Everything said about and Influenza pandemic could apply to any number of viral plagues, whether they emerge out of the natural world or are inflicted upon us in an act of bioterrorism. At this point, our only hope is to build and maintain enough of a public health infrastructure to give us early warning by means of international surveillance and to maintain enough research and medical capability in the hopes that we can somewhat stem the tide.

Taking the long view, the issue is not whether the next pandemic will come, but when.

Gary Feldman MD

What else will Gigabyte bring you?

  • Medicare bytes (as above).
  • Other information concerning the business and government/regulatory issues that we have to deal with, no matter what our mode of practice.
  • Updates from our Associate's Councils and comments, letters and articles from students at UCI and Loma Linda.From time to time we may incorporate items derived from other organizations that impact us and our practice.
  • And a note from Region III: Dr Herbst has organized a Scientific program for the Spring of 2002 "The Role of the Community Physician in Chemical and Biologic Disasters". It will be held March 1-3, 2001 at Indian Wells. The point of contact is Susan Chadwell at 619-543-2210.

And, if you will write to us, we will share your joys, problems and solutions to the many challenges that make internal medicine so interesting.

Mel Sterling

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