Does the BCG Vaccine Offer Any Protection Against Coronavirus Disease 2019?

Mueez Rehman¹

Akshay Sood MD, MPH^2,3

¹University of New Mexico Main Campus, Albuquerque, NM, USA

²Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM USA

³Black Lung Program, Miners’ Colfax Medical Center, Raton, NM, USA

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus-2 (SARS-COV2), shares features with diseases caused by other coronaviruses such as influenza, the Severe Acute Respiratory Syndrome (SARS) outbreak of 2003, and the Middle East Respiratory syndrome (MERS) outbreak of 2012. COVID-19 has been a challenging and devastating pandemic, resulting in death rates of more than 1%, testing nations both rich and poor, and outlining the importance of strong public health programs. Social distancing, masking and hand washing have become the new norm. Healthcare professionals are on the front lines, risking their lives. Those with pre-existing health conditions or older individuals face a significant risk for complications.

As scientists race to understand this deadly virus and find a cure to protect millions, an unlikely ally may come in a vaccine created over 100 years ago. The Bacillus Calmette-Guérin or BCG vaccine was created in 1921 to protect against tuberculosis (TB). At the time, tuberculosis was widespread, and the BCG vaccine was quickly implemented globally. However, as tuberculosis rates declined, developed countries such as the United States and many European countries discontinued widespread BCG administration. This change in vaccination policy was due to the supply of the vaccine and concerns for its efficacy. On the other hand, countries such as India, Pakistan, Indonesia, Vietnam, Russia, Ethiopia, and many others have continued widespread administration of the BCG vaccine. Many of these countries still have high rates of tuberculosis infections, as well as a large percentage of their population live in poverty (1). When COVID-19 started to emerge as a pandemic, global leaders and public health officials feared this pandemic would have catastrophic effects on these countries, overwhelming their healthcare systems, and killing millions. Interestingly, the opposite outcome was observed as these countries reported low rates of COVID-19. Instead, Europe became the world’s first epicenter outside of mainland China, followed by the United States, both of which reported large infection rates and death tolls due to COVID-19. The hardest hit countries had a similarity in that, they did not require widespread neonatal BCG vaccination. Ultimately, it is possible that the key difference between rates of COVID-19 infections in nations lies in neonatal BCG immunization rates amongst the populations. However, these conclusions are subject to confounding variables, such as the strength of the public health programs, and testing and reporting rates for COVID-19. An interesting outlier is Iran, which implemented a nationwide BCG vaccination program late in 1984, for children less than 6 years of age, using the Pasteur strain (2). With the high rates of COVID-19 cases in Iran, further research needs to examine this outlier, to see if there is any association with the type of vaccine used, administration at a later age, or the fact that currently middle-aged and elderly Iranians are not universally vaccinated.

Another interesting observation comes from the COVID-19 racial/ethnic distribution in the United States. The Centers for Disease Control and Prevention (CDC) released the race/ethnicity data for 580 lab-confirmed COVID-19, hospitalized patients on April 8, 2020 (3). In this data, African Americans constituted 33% of patients (when compared to 18% in the catchment populations) while Asians constituted 5.5% of the patients (proportion of Asians in the catchment population was not described). In certain states, Asian American populations showed higher disease and death rates for COVID-19, when compared to the general population (4). Interpretation of this data is, however, subject to confounding variables. The racial category for the Asian population is reported differently throughout the nation. Many states have differing definitions for the Asian race, certain states fail to divide the Asian population into different subgroups, and others combine Asian populations with ‘other’ racial groups (5). Furthermore, because the US does not have a widespread COVID-19 testing program, certain communities lack access to tests, and disparities for groups may be hidden. Once comprehensive data is available, it would be interesting to examine if the Asian subgroups consisting of individuals who received the BCG vaccine from a BCG administering country, before immigrating to the US show better outcomes against COVID-19, when compared to other Asian American subgroups.

The BCG vaccine was created by Albert Calmette and Camille Guérin against a live attenuated strain of Mycobacterium bovis, a mycobacterium that is similar to the one that causes tuberculosis. The vaccine creates both specific immunity to that mycobacterium, as well as nonspecific immunity against other pathogens that cause respiratory tract infections. In a study conducted on mice, researchers found that when subjecting mice to infectious viruses such as the A0 and A2 influenza viruses, herpes simplex virus, as well as other highly infectious viruses, mice inoculated with BCG were found to exhibit a significantly higher resistance to these infections compared to control mice (6). An explanation for this finding may lie in the fact that the BCG vaccine results in innate immune memory in the host. This trained immunity works by reprogramming a host’s bone marrow hematopoietic stem cells and multipotent progenitors through epigenetic/metabolic changes, resulting in greater variability of the differentiated innate immune cells response following a pathogen (7). Ultimately, this may result in the host’s immune system being able to successfully fight off large numbers of respiratory tract infections, including possibly SARS-CoV-2.

The World Health Organization (WHO) stands firm on the stance that there is no scientific evidence as to whether the BCG vaccine actually protects against COVID-19. Furthermore, WHO mentions that BCG vaccination is particularly important for children in countries with high prevalence of tuberculosis, and if local supplies are diverted, these children will face an increase in disease and death from tuberculosis (8).

As more scientific research is being conducted, the preliminary findings may indicate BCG as a potential safeguard against COVID-19. This may be explained through the lower rates of infection in countries with widespread neonatal BCG vaccination policies. Furthermore, immigrants who come from BCG administering countries may also have this advantage against COVID-19. Currently, the US Government is working to release a racial/ethnic breakdown of COVID-19 cases. As more data is published on race and ethnicities, it will be useful to examine if fewer COVID-19 cases and deaths occur amongst immigrant populations from BCG-administering parent countries, after adjusting for confounders.

References

1. Zwerling A, Behr MA, Verma A, et al. The BCG World Atlas: A Database of Global BCG Vaccination Policies and Practices. PLoS Med. 2011 Mar;8(3):e1001012. [CrossRef] [PubMed]
2. Fallah F, Nasiri MJ, Pormohammad A. Bacillus Calmette-Guerin (BCG) vaccine in Iran. J Clin Tuberc Other Mycobact Dis. 2018;11:22. [CrossRef] [PubMed]
3. Garg S, Kim L, Whitaker M, et al. Hospitalization rates and characteristics of patients hospitalized with laboratory-confirmed coronavirus disease 2019 - COVID-NET, 14 States, March 1-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69.458-64. [CrossRef] [PubMed]
4. NYC Health. Age-adjusted rates of lab confirmed COVID-19 non-hospitalized cases, estimated non-fatal hospitalized cases, and patients known to have died 100,000 by race/ethnicity group as of April 16, 2020. Available at https://www1.nyc.gov/assets/doh/downloads/pdf/imm/covid-19-deaths-race-ethnicity-04162020-1.pdf; Printed April 16, 2020. Accessed May 1, 2020.
5. Growing Data Underscore that Communities of Color are Being Harder Hit by COVID-19 | The Henry J. Kaiser Family Foundation. https://www.kff.org/coronavirus-policy-watch/growing-data-underscore-communities-color-harder-hit-covid-19/?utm_source=sfmc&utm_medium=email&utm_campaign=covidexternal&utm_content=newsletter. Accessed April 24, 2020.
6. Floc’h F, Werner GH. Increased resistance to virus infections of mice inoculated with BCG (Bacillus calmette-guérin). Ann Immunol (Paris). 1976;127(2):173-86. [PubMed]
7. Gursel M, Gursel I. Is global BCG vaccination coverage relevant to the progression of SARS-CoV-2 Pandemic? Allergy. 2020 Apr 27. [CrossRef] [PubMed]
8. World Health Organization. Bacille Calmette-Guérin (BCG) vaccination and COVID-19. https://www.who.int/news-room/commentaries/detail/bacille-calmette-guérin-(bcg)-vaccination-and-covid-19. Accessed April 14, 2020.

Cite as: Rehman M, Sood A. Does the BCG vaccine offer any protection against coronavirus disease 2019? Southwest J Pulm Crit Care. 2020;20(5):170-2. doi: https://doi.org/10.13175/swjpcc035-20 PDF 

2020 International Year of the Nurse and Midwife and International Nurses’ Day

Carol M. Baldwin, PhD, RN, CHTP, CT, AHN-BC, FAAN

Edson College of Nursing & Health Innovation

Arizona State University

Phoenix, AZ USA

Barbara M. Dossey, PhD, RN, AHN-BC, FAAN, HWNC-BC

Nightingale Initiative for Global Health (NIGH)

Washington, DC USA

The World Health Organization (WHO) designated 2020 as the International Year of the Nurse and Midwife to acknowledge the contributions of nurses and midwives in promoting the health and welfare of populations across the globe. This recognition is in concert with the 200^th anniversary of the birth of Florence Nightingale. Although nurses and midwives make up over half the world’s health care workforce, the WHO estimates that 2020 will see a shortage of 9 million nurses (1,2). International Nurses’ Week begins May 6^th and culminates on May 12^th, International Nurses Day, the anniversary of Nightingale’s birth with hopes of bringing greater re, cognition nurses play in local to global health.

Defying expected Victorian norms for women born to well-connected, affluent British families in the middle of the nineteenth century, Florence Nightingale chose the art and science of nursing over marriage. “Nightingale” is synonymous with the foundation of professional nursing, as well as her dedicated service as a manager and trainer of nurses during the Crimean War.

Florence Nightingale’s influence, however, encompasses so much more than establishing nursing education. Military and field medicine, epidemiology, early prefabricated hospitals, hospital supervision, community and public health, health policy, establishment of nursing schools and infirmaries, early pioneering in the concept of medical tourism, as well as social reform for women and all sections of society have benefitted from her groundbreaking achievements. Her work continues. The Nightingale Initiative for Global Health (NIGH), for example, fosters Nightingale’s activities grounded in social and environmental justice, preventive medicine, and holistic health from the local to global levels (3,4).

A keen observer of conditions that lead to poor health, Nightingale wrote extensively regarding sanitary reform. Her Notes on Nursing emphasized frequent handwashing that presaged the hygiene required during the current Covid-19 pandemic (5). Nightingale was the first woman admitted to the London Statistical Society (5). She became a member of the American Statistical Association (6). She was the first nurse to conduct and use research. Nightingale showed that physical and social factors influenced health, and that quality of care can be improved through careful data collection, visual displays that used her original “Polar-Area Diagram,” critical thinking, and practice based on evidence (7).

Florence Nightingale’s legacy endures in the face of the Covid-19 pandemic. It was announced on 24 March 2020 that the new “Nightingale Hospital” would be set up at the ExCel conference centre in East London to provide support for up to 4,000 patients with Covid-19 (8). On 3 April 2020, within two weeks of the announcement, the NHS Nightingale Hospital was officially opened by HRH Prince Charles as a coronavirus field hospital. In his remarks, Prince Charles stated, “Florence Nightingale, the lady with the lamp, brought hope and healing to thousands in their darkest hour. In this dark time this place will be a shining light” (9).

The Southwest Journal of Pulmonary and Critical Care congratulates and values the many legatees of Florence Nightingale in this 2020 International Year of the Nurse--the nurses and midwives across the globe for their unwavering dedication to education, research, practice and policy, as well as our valued interprofessional collaborations in promoting health and preventing disease.

References 

1. World Health Organization. Year of the Nurse and the Midwife 2020. Accessed 1 May 2020 from https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020
2. Jakel P. WHO’s International Year of the Nurse and Midwife. Accessed 1 May 2020 from https://www.oncnursingnews.com/publications/oncology-nurse/2020/april-2020/2020-whos-international-year-of-the-nurse-and-the-midwife
3. Beck DM, Dossey BM. In Nightingale's footsteps - individual to global: From nurse coaches to environmental and civil society activists. Creative Nursing: A Journal of Values, Issues, Experience and Collaboration, 2019;25(3):1-6.
4. Dossey BM, Rosa WE, Beck DM. Nursing and the sustainable development goals: From Nightingale to now. American Journal of Nursing, 2019;119(5):40-45. 
5. Bates, R. Florence Nightingale: A pioneer of handwashing and hygiene for health. Accessed 3 May 2020 from https://theconversation.com/florence-nightingale-a-pioneer-of-hand-washing-and-hygiene-for-health-134270
6. Columbia Mailman School of Public Health, Healthcare Policy. Florence Nightingale was an epidemiologist too. Accessed 4 May 2020 from https://www.mailman.columbia.edu/public-health-now/news/florence-nightingale-was-epidemiologist-too
7. Baldwin CM, Schultz AA, Barrere CC. (2016) ‘Evidence-based practice’, in Dossey BM & Keegan L., Holistic nursing: A handbook for practice. Burlington, MA: Jones & Bartlett, p. 639.
8. NHS England Website. Accessed 1 May 2020 from New NHS Nightingale Hospital To Fight Coronavirus
9. Evening Standard. NHS Nightingale officially opened by Prince Charles as coronavirus field hospital becomes world’s largest critical care unit. Accessed 2 May 2020 from https://www.standard.co.uk/news/health/nhs-nightingale-coronavirus-field-hospital-open-prince-charles-a4405796.html

2020 Año Internacional de la Enfermera y Partera y el Día Internacional de la Enfermera

Carol M. Baldwin, PhD, RN, CHTP, CT, AHN-BC, FAAN

Edson College of Nursing & Health Innovation

Arizona State University

Phoenix, AZ USA

Barbara M. Dossey, PhD, RN, AHN-BC, FAAN, HWNC-BC

Nightingale Initiative for Global Health (NIGH)

Washington, DC USA

La Organización Mundial de la Salud (OMS) designó 2020 como el Año Internacional de la Enfermera y la Partera para reconocer las contribuciones de las enfermeras y parteras en la promoción de la salud y el bienestar de las poblaciones de todo el mundo. Este reconocimiento está en concierto con el bicentenario del nacimiento de Florence Nightingale. Si bien las enfermeras y las parteras representan más de la mitad de la fuerza laboral mundial de atención de la salud, la OMS estima que en 2020 habrá una escasez de 9 millones de enfermeras (1,2). La Semana Internacional de Enfermeras comienza el 6 de mayo y culmina el 12 de mayo, Día Internacional de las Enfermeras, el aniversario del nacimiento de Nightingale con la esperanza de brindar un mayor reconocimiento a las enfermeras en la salud local y mundial.

Desafiando las normas victorianas esperadas para las mujeres nacidas de familias británicas acomodadas y bien conectadas a mediados del siglo XIX, Florence Nightingale eligió el arte y la ciencia de la enfermería en lugar del matrimonio. "Nightingale" es sinónimo de la base de la enfermería profesional, así como su servicio dedicado como gerente y formadora de enfermeras durante la Guerra de Crimea.

La influencia de Florence Nightingale, sin embargo, abarca mucho más que establecer una educación en enfermería. Medicina militar y de campo, epidemiología, hospitales prefabricados tempranos, supervisión hospitalaria, salud comunitaria y pública, política de salud, establecimiento de escuelas de enfermería y enfermerías, pioneros tempranos en el concepto de turismo médico, así como reforma social para las mujeres y todos los sectores de la sociedad se han beneficiado de sus logros innovadores. Su trabajo continúa. La Nightingale Initiative for Global Health (NIGH), por ejemplo, fomenta las actividades de Nightingale basadas en la justicia social y ambiental, la medicina preventiva y la salud holística desde el nivel local hasta el global (3,4).

Un observador entusiasta de las condiciones que conducen a la mala salud, Nightingale escribió ampliamente sobre la reforma sanitaria. Sus Notas sobre Enfermería enfatizaban el lavado frecuente de manos que presagiaba la higiene requerida durante la actual pandemia de Covid-19 (5). Nightingale fue la primera mujer admitida en la Sociedad Estadística de Londres (5). Se convirtió en miembro de la Asociación Americana de Estadística (6). Fue la primera enfermera para realizar y utilizar investigaciones. Nightingale demostró que los factores físicos y sociales influyeron en la salud, y que la calidad de la atención se puede mejorar mediante una cuidadosa recolección de datos, exhibiciones visuales que utilizaron su "diagrama de área polar" original, pensamiento crítico y práctica basada en evidencia (7).

El legado de Florence Nightingale perdura ante la pandemia de Covid-19. Se anunció el 24 de marzo de 2020 que el nuevo "Hospital Nightingale" se establecería en el centro de conferencias ExCel en el este de Londres para brindar apoyo a hasta 4,000 pacientes con Covid-19 (8). El 3 de abril de 2020, dentro de las dos semanas posteriores al anuncio, El “NHS Nightingale Hospital” fue inaugurado oficialmente por el Príncipe Carlos como un hospital de campaña de coronavirus. En sus comentarios, el Príncipe Carlos declaró: “Florence Nightingale, la dama de la lámpara, trajo esperanza y sanación a miles en su hora más oscura. En este tiempo oscuro este lugar será una luz brillante” (9).

The Southwest Journal of Pulmonary and Critical Care felicita y valora a los muchos legatarios de Florence Nightingale en este Año Internacional de la Enfermera 2020: las enfermeras y parteras de todo el mundo por su inquebrantable dedicación a la educación, la investigación, la práctica y la política, así como a nuestras valiosas colaboraciones interprofesionales en la promoción de la salud y la prevención de enfermedades.

Referencias

1. World Health Organization. Year of the Nurse and the Midwife 2020. Accessed 1 May 2020 from https://www.who.int/news-room/campaigns/year-of-the-nurse-and-the-midwife-2020
2. Jakel P. WHO’s International Year of the Nurse and Midwife. Accessed 1 May 2020 from https://www.oncnursingnews.com/publications/oncology-nurse/2020/april-2020/2020-whos-international-year-of-the-nurse-and-the-midwife
3. Beck DM, Dossey BM. In Nightingale's footsteps - individual to global: From nurse coaches to environmental and civil society activists. Creative Nursing: A Journal of Values, Issues, Experience and Collaboration, 2019;25(3):1-6.
4. Dossey BM, Rosa WE, Beck DM. Nursing and the sustainable development goals: From Nightingale to now. American Journal of Nursing, 2019;119(5):40-45. 
5. Bates, R. Florence Nightingale: A pioneer of handwashing and hygiene for health. Accessed 3 May 2020 from https://theconversation.com/florence-nightingale-a-pioneer-of-hand-washing-and-hygiene-for-health-134270
6. Columbia Mailman School of Public Health, Healthcare Policy. Florence Nightingale was an epidemiologist too. Accessed 4 May 2020 from https://www.mailman.columbia.edu/public-health-now/news/florence-nightingale-was-epidemiologist-too
7. Baldwin CM, Schultz AA, Barrere CC. (2016) ‘Evidence-based practice’, in Dossey BM & Keegan L., Holistic nursing: A handbook for practice. Burlington, MA: Jones & Bartlett, p. 639.
8. NHS England Website. Accessed 1 May 2020 from New NHS Nightingale Hospital To Fight Coronavirus
9. Evening Standard. NHS Nightingale officially opened by Prince Charles as coronavirus field hospital becomes world’s largest critical care unit. Accessed 2 May 2020 from https://www.standard.co.uk/news/health/nhs-nightingale-coronavirus-field-hospital-open-prince-charles-a4405796.html

Cite as: Baldwin CM, Dossey BM. 2020 international year of the nurse and midwife and international nurses’ day. Southwest J Pulm Crit Care. 2020;20(5):165-9. doi: https://doi.org/10.13175/swjpcc034-20 PDF

Who Should be Leading Healthcare for the COVID-19 Pandemic?

The recent COVID-19 pandemic brought to mind the Oscar Wilde quote, “An expert is an ordinary man away from home giving advice” (1). COVID-19 advice has flooded my inbox and dominated news coverage on television, in print and electronically. Everyone from the President to the hospital secretary seems to think they are qualified to offer advice on COVID-19 prevention and care. I admit to not being an expert on COVID-19 because I am not a virologist. However, despite retiring from the ICU in 2011, I think I know quite a bit about caring for sick patients with pneumonia having done it for over 30 years. For my part, and for many of my colleagues, the non-solicited, non-expert advice offered from these sources should be returned and the sender instructed to place it in that recess of the body most protected from sunlight.

The US government has not provided outstanding leadership during this pandemic. The President and CDC were both initially slow to respond and sometimes issued confusing or contradictory statements (2,3). Occasionally they were just wrong. The news media contributed to the confusion by reporting what was at times nonsense. All would be better off if we followed the guidance of someone like the NIH’s Dr. Tony Fauci who has said the right things while walking a political tightrope of gently contradicting the President.

Most hospitals have not done much better than the White House. I am overwhelmed with advice and sometimes pronouncements that claim to be evidence- or CDC-based. Sometimes they are-sometimes not. These are usually from a non- or minimally qualified administrator lacking medical expertise. We now hear reports that administrators are trying to direct health care providers not to wear personal protective equipment (PPE, masks, goggles, booties, etc.) in hallways or forbidding physicians and nurses from bringing their own PPE from home (4,5).

The hospitals give a variety of reasons for their actions, from conservation of PPE to the belief that it scares patients. Conservation of PPE is good idea. However, having someone change their mask every time they see a potential or a confirmed COVID-19 means using lots of masks while wearing one mask all day would help to conserve. Scaring patients is not good but unnecessarily exposing healthcare providers is worse. In Italy and Spain healthcare workers make up a disproportionately high number of cases (6-7). It is now thought that the hospital may be a primary source of infection and that the lack of doctors and nurses is impairing healthcare (6-8). Patients should be frightened and even more so when someone enters their room without a mask.

Although dealing with this crisis is the first priority, we need to ask ourselves at some point how could the US be so unprepared. We saw what a surge in ICU patients could do with the H1N1 influenza pandemic of 2009 leaving ICU beds and ventilators in short supply (9). In the 11 years since that time, the country did little to nothing. Where are the ventilators, the PPE and the medical personnel we now need?

Healthcare planning and emergency preparation have been done by non-medical people who now must take responsibility for our lack of preparedness. Those same people are now trying to direct care. They should back away and let those best able to deal with the present catastrophe provide the care. In the future we should ask what role they should play in planning for a National healthcare emergency. Will those planning be more concerned about allocating monies for future healthcare emergencies or another purpose? Perhaps we should have the planning done by those more knowledgeable and more concerned for the American people.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Guernsey L. Suddenly, everybody's an expert. NY Times. February 3, 2020. Available at: https://www.nytimes.com/2000/02/03/technology/suddenly-everybody-s-an-expert.html (accessed 3/27/20).
2. Edwards HS.  The Trump administration fumbled its initial response to coronavirus. Is there enough time to fix it? Time. March 19,2020. Available at: https://time.com/5805683/trump-administration-coronavirus/ (accessed 3/27/20).
3. Chen C, Allen M, Churchill L. Internal emails show how chaos at the CDC slowed the early response to coronavirus. ProPublica. March 26, 2020. Available at: https://www.propublica.org/article/internal-emails-show-how-chaos-at-the-cdc-slowed-the-early-response-to-coronavirus (accessed 3/27/20).
4. Ault A. Amid PPE shortage, clinicians face harassment, firing for self-care. Medscape. March 26, 2020. Available at: https://www.medscape.com/viewarticle/927590?nlid=134683_5461&src=wnl_dne_200327_mscpedit&uac=9273DT&impID=2325986&faf=1#vp_3 (accessed 3/27/20).
5. Whitman E. 'Taking masks off our faces': how Arizona hospitals are rationing protective gear. Available at: https://www.phoenixnewtimes.com/news/arizona-hospitals-rationing-masks-protective-gear-banner-11459400 (accessed 3/27/20).
6. Van Beusekom M. Doctors: COVID-19 pushing Italian ICUs toward collapse. Center for Infectious Disease Research and Policy, March 16, 2020. Available at: http://www.cidrap.umn.edu/news-perspective/2020/03/doctors-covid-19-pushing-italian-icus-toward-collapse (accessed 3/27/20).
7. Jones S. Spain: doctors struggle to cope as 514 die from coronavirus in a day. The Guardian. Available at: https://www.theguardian.com/world/2020/mar/24/spain-doctors-lack-protection-coronavirus-covid-19 (accessed 3/27/20).
8. Begley S. A plea from doctors in Italy: To avoid Covid-19 disaster, treat more patients at home. Stat. March 22, 2020. Available at: https://www.statnews.com/2020/03/21/coronavirus-plea-from-italy-treat-patients-at-home/ (accessed 3/27/20).
9. Levey NN, Christensen K, Phillips AM. A disaster foretold: Shortages of ventilators and other medical supplies have long been warned about. LA Times. March 20, 2020. Available at: https://www.latimes.com/politics/story/2020-03-20/disaster-foretold-shortages-ventilators-medical-supplies-warned-about (accessed 3/27/20).

Cite as: Robbins RA. Who should be leading healthcare for the COVID-19 pandemic? Southwest J Pulm Crit Care. 2020;20(3):103-4. doi: https://doi.org/10.13175/swjpcc021-20 PDF 

Why Complexity Persists in Medicine

This month’s Medical Image of the Month is a cartoon illustrating the complexity of medical billing (1). It illustrates that there are many people involved in the billing process who add nothing medically. However, they do add work, chaos and cost to both the provider and the patient. These along with other administrative costs are likely responsible for the largest portion of increasing healthcare expenses (2). Healthcare costs have far outpaced inflation and inflation adjusted reimbursement to providers has decreased (3,4). Costs of healthcare have become an increasing issue in political campaigns for both National parties. So why is no one doing anything about the issue? The truth is that some are benefitting from the complexity and have a financial incentive to maintain the status quo by opposing change.

The Centers for Medicare and Medicaid Services (CMS) and state Medicaids need to accept some of the responsibility for these cost increases. There has been a public sentiment doctors are overpaid, so actions taken by CMS and other government agencies have made physicians an easy target for policies that have led to instability in compensation. The declining income of private practice has led many physicians to flee to employed models (4). Not only has CMS contributed to driving physicians from self-employment by underpaying independent physicians but they have over compensated physician employed by hospitals. CMS estimates that it is now paying about $75 to $85 more on average for the same clinic visit in hospital outpatient settings compared to physician offices (5). Not surprisingly, these and other compensation disproportions have led to higher healthcare spending (6).

So, why does CMS rob the independent physicians to pay the hospitals and large healthcare organizations? An answer might be found in the recent actions regarding site-neutral payments. Many hospitals have bought physician and walk-in clinics to take advantage of the increased compensation from CMS and other insurance carriers. When the Trump administration proposed a “site-neutral” policy where payment would be lowered to hospitals and other healthcare organizations employing physicians, the American Hospital Association (AHA) and Association of American Medical Colleges (AAMC) sued (7). Government agencies are reluctant to challenge hospital, insurance or pharmaceutical companies and their lobbyists who are powerful and well-funded. This gives the appearance that it is much easier to be tough on independent physicians who are poorly organized, politically weak and not likely to sue.

Political tactics have been taken by the pharmaceutical companies who persuaded Congress not to allow US agencies such as CMS and the Department of Veterans Affairs to negotiate drug prices. It was in 2003, under then President George W. Bush, that Congress added a Part D benefit, through which CMS pays for seniors’ prescription drugs. The enactment followed a controversial House roll call vote, which was held open for several hours as House leaders maneuvered to secure enough votes for passage. One bargaining chip to attract votes from “market-oriented” Congressmen was the so-called “noninterference clause” which banned negotiations between CMS and pharmaceutical companies on drug prices and prevented the government from developing its own formulary or pricing structure. In other words, US Government agencies are forced to pay whatever prices the manufacturers set (8).

Sadly, our professional societies have also contributed to rising healthcare costs. An example is the Joint Commission which was formed in 1951 by merging the Hospital Standardization Program with similar programs run by the American College of Physicians, the American Hospital Association (AHA), the American Medical Association, and the Canadian Medical Association. However, the Joint Commission has become dominated the American Hospital Association which has continually pushed a hospital administrative agenda (9). Standards leading to or encouraging administrative efficiency appear nonexistent. Even our own professional societies have fixated on programs such as Choosing Wisely which emphasizes physicians not performing unnecessary testing or procedures. Although this is important for our patients, it is has not, nor is likely to, make any difference in healthcare costs.

All this is occurring at a time when the hospital-private practice physician partnership has largely dissolved. Hospitals want employed physicians because of the financial benefits of higher reimbursement but also because physicians as employees are much easier to control. As hospitals hire their own physicians, often in open competition with private practice physicians on their staff, the hospitals and private practice physicians are no longer partners but adversarial competitors. It is naïve to believe that hospitals will not take advantage of their position of power to eliminate the private practice competition or make changes to a system such as the complex reimbursement system which has benefited them so greatly. Even something so basic as stating the cost of a procedure has been vigorously opposed by the AHA (10). Similarly, the pharmaceutical industry has opposed transparency or government negotiation on drug prices (11). And why should the any of these healthcare administrators, pharmaceutical companies or insurance companies agree to any change? They are growing rich at the American public’s expense.

Rather than throwing up our hands in disgust or going to our windows, opening them and sticking our heads out to yell – “I'm as mad as hell and I'm not gonna take this anymore!” it is time to do something. However, as physicians we need to realize that we are weak and need help. First, we need to elect political candidates at all levels of government not based on their political affiliation but on their willingness to take action to curb healthcare costs. Second, if the politicians do not take action, we need to hold them accountable by voting for someone else. Third, we should lobby through our professional societies that administrative change needs to happen. If the societies will, we either need to serve in a society leadership role or change the leadership. Fourth, we need to oppose actions to further intrude into or control the practice of medicine at the local hospital level. For example, physician leaders are often chosen by the hospital administration not for their abilities by their amenability to a hospital administration’s agenda. As physicians we have let healthcare become controlled by greedy businessmen and correcting their intrusion into medical practice will be difficult. However, we should maintain hope, the alternative simply costs too much.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Umar A, Robbins RA. Medical image of the month: complexity of healthcare payment. Southwest J Pulm Crit Care. 2020;20(2):59. [CrossRef]
2. Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85. [CrossRef]
3. Kacik A. Rising prices drive estimated 6% medical cost inflation in 2020. Modern Healthcare. June 20, 2019. Available at: https://www.modernhealthcare.com/providers/rising-prices-drive-estimated-6-medical-cost-inflation-2020 (accessed 1/30/20).
4. Morris SS, Lusby H. The physician compensation bubble is looming. American Association of Physician Leadership. January 16, 2019. Available at: https://www.physicianleaders.org/news/physician-compensation-bubble-looming (accessed 1/30/20).
5. Dickson V. CMS slashes clinic visit payments, expands 340B cuts. Modern Healthcare. November 2, 2018. Available at: https://www.modernhealthcare.com/article/20181102/NEWS/181109978 (accessed 1/30/20).
6. Baker LC, Bundorf MK, Kessler DP. Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff (Millwood). 2014 May;33(5):756-63. [CrossRef] [PubMed]
7. Terry K. Court overturns CMS' site-neutral payment policy; doc groups upset. Medscape Medical News. September 19, 2019. Available at: https://www.medscape.com/viewarticle/918744?nlid=131645_5401&src=wnl_dne_190920_mscpedit&uac=9273DT&impID=2101100&faf=1#vp_2 (accessed 1/31/20).
8. Lee TL,  Gluck AR, Curfman GD. The politics of Medicare and drug-price negotiation (updated). Health Affairs Blog. September 19, 2016. Available at: https://www.healthaffairs.org/do/10.1377/hblog20160919.056632/full/ (accessed 1/31/20).
9. Gaul GM. Accreditors blamed for overlooking problems. Washington Post. 2005. Available at: https://www.washingtonpost.com/wp-dyn/content/article/2005/07/24/AR2005072401023.html (accessed 2/1/20).
10. Evans M. Hospitals turn to courts as lobbying fails to block price-transparency proposal. The Wall Street Journal. December 5, 2019. Available at: https://www.wsj.com/articles/hospitals-turn-to-courts-as-lobbying-fails-to-block-price-transparency-proposal-11575551412 (accessed 2/1/20).
11. Parramore LS. Prescription drug costs in Americans are sky-high. And yes, Big Pharma greed is to blame. NBC News. January 2, 2020. Available at: https://www.nbcnews.com/think/opinion/prescription-drug-costs-americans-are-sky-high-yes-big-pharma-ncna1109076 (accessed 2/1/20).

Cite as: Robbins RA. Why complexity persists in medicine. Southwest J Pulm Crit Care. 2020;20(2):60-2. doi: https://doi.org/10.13175/swjpcc006-20 PDF 

Fatiga de enfermeras, el sueño y la salud, y garantizar la seguridad del paciente y del publico: Unir dos idiomas

Carol M. Baldwin, PhD, RN, AHN-BC, FAAN

Edson College of Nursing & Health Innovation, PAHO/WHO Collaborating Centre to Advance the Policy on Research for Health, Arizona State University, Phoenix, AZ

Stuart F. Quan, MD, FAASM

Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Asthma and Airways Research Center, University of Arizona, Tucson, AZ

Editor's Note: The following editorial is in both Spanish and English with the Spanish first. It refers to the article published in Spanish "Declaración de posición: Reducir la fatiga asociada con la deficiencia de sueño y las horas de trabajo en enfermeras". There is a link in the article to the original English version published in Nursing Oulook in 2017.

“Ahora ... tráeme ese horizonte” - Capitán Jack Sparrow

Estas palabras, pronunciadas por Capitán Jack Sparrow al final de Piratas del Caribe, presagian un nuevo comienzo, una aventura, un potencial en expansión. Así, también, con el Southwest Journal of Pulmonary and Critical Care. La revista está ampliando sus horizontes con la publicación de artículos de investigación y comentarios en español para desarrollar relaciones con investigadores de pulmón, cuidados críticos y sueño en todo el continente americano. Esta primera publicación en español, “Declaración de posición: reducir la fatiga asociada con la deficiencia de sueño y las horas de trabajo en enfermeras,” por Caruso y sus colegas, es una reimpresión traducida por los Centros para el Control y la Prevención de Enfermedades del Instituto Nacional de Seguridad y Salud Ocupacional (CDC NIOSH). Si bien el contenido es específico para las enfermeras, las implicaciones para la fatiga y la deficiencia del sueño son relevantes para otros proveedores de servicios de salud, personal de primera respuesta y profesiones y organizaciones adicionales que requieren turnos y horarios extendidos en todo el mundo. Dada la epidemia mundial de deficiencia de sueño, que es especialmente generalizada en las sociedades modernas, este documento debería ser un ejemplo para otras profesiones de la salud. (1) Se puede acceder a la versión en inglés de esta Declaración de posición en la cita a continuación. (2) La versión en español publicada en esta revista será la primera incursión en una "conversación" con nuestros colegas de habla hispana. Ahora ... ¡tráeme ese nuevo horizonte SWJPCC!

Referencias

1. Chattu VK, Sakhamuri SM, Kumar R, Spence DW, BaHammam AS, Pandi-Perumal SR. Insufficient Sleep Syndrome: Is it time to classify it as a major noncommunicable disease? Sleep Sci. 2018 Mar-Apr;11(2):56-64.
2. Caruso CC, Baldwin CM, Berger A, Chasens ER, Landis C, Redeker NS, et al. (2017). Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses. Nurs Outlook 2017;65:766-768.

Carol M. Baldwin y Stuart F. Quan desean reconocer a Gerardo (Jerry) González, Oficina de Relaciones con los Medios, Universidad Estatal de Arizona por su cuidadosa revisión y comentarios para la versión en español de este editorial.

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Nurse Fatigue, Sleep, and Health, and Ensuring Patient and Public Safety: Bringing Two Languages Together

Carol M. Baldwin, PhD, RN, AHN-BC, FAAN

Edson College of Nursing & Health Innovation, PAHO/WHO Collaborating Centre to Advance the Policy on Research for Health, Arizona State University, Phoenix, AZ

Stuart F. Quan, MD, FAASM

Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; Asthma and Airways Research Center, University of Arizona, Tucson, AZ

“Now... bring me that horizon” – Captain Jack Sparrow

These words, uttered by Captain Jack Sparrow at the close of Pirates of the Caribbean, presage a new beginning, an adventure, expanding potential. So, too, with the Southwest Journal of Pulmonary and Critical Care (SWJPCC). The journal is broadening its horizons with the publication of Spanish-language research and commentary articles to grow relationships with pulmonary, critical care and sleep researchers throughout the Americas. This first Spanish-language publication, “Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses,” by Caruso and colleagues is a reprint translated by the Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (CDC NIOSH). While the content is specific to nurses, the implications for fatigue and sleep deficiency are relevant to other health providers, first responders, professions and organizations that require shift work and extended shift hours across the globe. Given the worldwide epidemic of sleep deficiency, which is especially pervasive in modern societies, this document should be an exemplar for other health professions. (1) The English version of this Position Statement can be accessed at the citation below. (2) The Spanish version published in this journal will be the first foray into a ‘parley’ with our Spanish-speaking colleagues. Now... bring me that new SWJPCC horizon!

References

1. Chattu VK, Sakhamuri SM, Kumar R, Spence DW, BaHammam AS, Pandi-Perumal SR. Insufficient Sleep Syndrome: Is it time to classify it as a major noncommunicable disease? Sleep Sci. 2018 Mar-Apr;11(2):56-64.
2. Caruso CC, Baldwin CM, Berger A, Chasens ER, Landis C, Redeker NS, et al. (2017). Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses. Nurs Outlook 2017;65:766-768.

Carol M. Baldwin and Stuart F. Quan wish to respectfully acknowledge Gerardo (Jerry) Gonzalez, Office of Media Relations, Arizona State University for his careful review and comments for the Spanish-language version of this editorial.

Cite as: Baldwin CM, Quan SF. Fatiga de enfermeras, el sueño y la salud, y garantizar la seguridad del paciente y del publico: unir dos idiomas. Southwest J Pulm Crit Care. 2019;19:175-6. doi: https://doi.org/10.13175/swjpcc076-19 PDF