Ken’s Take on the World

Healthcare: Commodity or Essential Right

The recently, spectacularly, failed American Healthcare Act (AHCA), once again, brought to the forefront the debate on whether healthcare access should be considered a commodity, much like an automobile, subject to the whims of a free market and made available to those who can afford it or, rather, that healthcare is an essential right of all Americans that must be guaranteed by government.  Democrats appear united behind the concept that healthcare access is crucial to society and must be available to every US citizen regardless of their economic status.  As the debate over the AHCA progressed, it became obvious that Republicans are divided over this central question.  Polling shows that overwhelming majorities of Americans believe every citizen should have access to high-quality, affordable, healthcare.  In this, it appears the GOP is at odds with the majority of Americans.


This week, President Trump signaled the AHCA is not actually dead and that his campaign pledge to repeal and replace the Patient Protection and Affordable Care Act, also known simply as the Affordable Care Act (ACA) or, “Obamacare” continues onward.  The problem with this position is that the President has not articulated what this would look like.  Even with Republican majorities in both chambers of Congress, and without input from Democrats, a coherent plan that would meet the President’s promises of providing affordable health insurance to even more Americans, and at lower costs than the ACA, was not presented.  Competing factions within the Republican Congress ensured that no bill put forth would garner a majority of votes or even entice moderate Democrats to join in support.  Party leadership attempted to rush the bill through the House even prior to scoring by the nonpartisan Congressional Budget Office (CBO) which ultimately decided that, although ten-year cost projections would reduce the budget, the result would be more people without health insurance than prior to enactment of the ACA.


After the AHCA was pulled prior to a vote, the President commented, “Who would have known that healthcare would be so complicated?”  What?!?!  Besides anyone who has ever studied this topic?  This point underlies a central problem within the Trump Administration.  There is a serious lack of competent Administration leadership that might be able to shepherd complicated proposals through a Congress that is itself lacking in effective leadership that is committed to promoting and implementing legislation that will serve to actually benefit the American people.  Basically, Republicans have demonstrated that, since at least 2010, they lack the ability, or desire, to govern in the best interests of the people.


The failure of the AHCA effectively leaves the Republican leadership in Congress with two choices.  They can continue in their efforts to undermine the ACA which will lead to its eventual collapse, or, they can work with Democrats to strengthen the law which is what a majority of Americans currently favor.  It should be noted that the ACA has been effective and would continue to remain viable for at least the next decade but for efforts of the Republican Party over the past seven years.  Elected Republicans, and right-wing talking heads on radio and television, have spent the last seven years misleading the American public.  This has resulted in ballot box gains, however, it has not actually helped the American people.  While the ACA did not seriously further the debate on whether healthcare was an essential right versus a commodity available to the highest bidder, it did suggest that access to insurance to provide for healthcare expenses was a necessary thing that should be promoted by government.  In contrast, the debate among Republicans since 2009 has brought into the open the role of government in healthcare access at all levels.  It should be noted that prior to 2010, there was no question that government should ensure the availability of some access to healthcare for all Americans.  In 1986, President Ronald Reagan signed the bipartisan Emergency Medical Treatment and Active Labor Act (EMTALA) into law.  Likewise, COBRA was enacted under the Reagan Administration which provided individuals with a continuity of health insurance coverage.


The most recent debate between Republicans over the AHCA has placed a focus on whether government has any role in determining access to health insurance or healthcare itself.  This debate also served to highlight a disconnect between elected Republicans in Congress and their constituents.  Had the AHCA passed, the harms would have been felt significantly more among rural voters who overwhelmingly voted Republican over the past several election cycles.  The more extreme members of the GOP who make-up the Libertarian-wing (aka the Freedom Caucus formerly known as the Tea Party caucus) believe healthcare should be left to the winds of a completely free market.  Health insurers should be let alone to serve only the customers they desire and to charge whatever rates the free market might bear.  Let the buyer beware lest they procure a policy only to find out it lacks the protections necessary when they are needed, or worse, they are dis-enrolled when they become ill or seriously injured.  Somewhat more moderate Republicans seek to provide competition among insurers by removing obstacles to the sale of health insurance policies across state lines.  Theoretically, this appears to be reasonable, however, there are a significant number of realities that make this an unattractive proposal.  The biggest one is that insurance companies establish provider networks where they operate.  Healthcare providers are not likely to want to participate in a network that is out-of-state, perhaps in a different time zone, when they need to have their billing issues resolved or if they need to seek authorization for patient care.  This is inefficient and costly.  Another major issue affecting consumers is relating to the need to, perhaps, sue an insurance company for denial of a claim.  Consumers would be subjected to the laws of a particular state which might be much more favorable to the insurance company in a classic David and Goliath tale.


I doubt there is anyone who disagrees with the idea that society functions better when people are healthier.  Employee productivity is increased, chronic healthcare expenditures are decreased, and individual satisfaction is improved.  The United States outspends every other developed nation on healthcare but has significantly lower health outcomes on almost every measure.  Civilized societies throughout the world recognize this.  In promoting the well-being of their respective nations, leaders have already debated whether healthcare should be construed as a basic right to be assured by government.  It has been unanimously affirmed by economically- advanced societies that some level of healthcare must be provided for each person as by doing so it benefits every person.  The United States continues to be an outlier.  If, by independent measures, it was demonstrated that our status as an outlier made the health of our nation’s citizens better it would make perfect sense to continue our current system of healthcare delivery.  Unfortunately, this is not the case on ANY measure of national health.  Republicans continue to refuse to acknowledge this and continue to permit healthcare to consume ever-larger amounts of spending and an ever-growing share of our gross domestic product (GDP).


It is obvious the Republican Party is incapable, or unwilling to, of addressing this.  We, the people, must continue to demand healthcare access for all.  GOP-led efforts to undo the most significant healthcare reform in a generation is harmful to patients, providers, and insurers.  These efforts undermine the healthcare infrastructure and will lead to a significant collapse that would cause all of us to suffer.  If we recognize that a healthy citizenry makes for a more robust society, we must not maintain the idea of healthcare as a commodity to be enjoyed only by those who can afford it.  Essential healthcare must be available for all people.  This must be ensured by government.

I live only 2 hours from the Ebola hospital in Dallas. Here’s what I’m doing to protect my family.

I live only 2 hours from the Ebola hospital in Dallas. Here’s what I’m doing to protect my family..

Thanks, Jennifer Raff, for this snag!!  Knowledge is power!!

Preparing the Central Sterile Processing Department for Ebola

Ebola electron photograph Photo MD Health

The Ebola virus is something that has been on the mind of virtually every American these days.  In addition to becoming a formal public health concern within the past month and a half, it has managed to become a political issue.  The fact this has become a political issue is disappointing and a topic for a different post.  This post is to inform readers of preparations that must be made to protect healthcare providers from the very real possibility of providing medical care to a patient who presents with symptoms that are consistent with the Ebola virus.

Hospitals in the United States have already provided care for at least seven individuals who have become infected with Ebola virus.  This includes two missionary medical aid workers who contracted the virus while working with Africa, a man from Liberia who arrived in the Dallas Texas area, two nurses who cared for the Texas patient, and a cameraman for a media outlet that was covering the epidemic in west Africa.  The infections involving the two nurses who provided care for Thomas Duncan, the Texas patient, are troubling and put on display flaws with the Centers for Disease Control and Prevention (CDC) response to the currently unfolding public health situation.  While I have great respect and admiration for the CDC, and especially the work of Dr. Anthony Fauci who I personally admire a great deal, I am disappointed with their response to the current situation unfolding in the US with regards to Ebola.  Dr. Fauci has been the single beacon of confidence in the current conversation on this major public health concern.

It is important to note that not a single healthcare worker involved in the treatment of the two missionary workers contracted Ebola during their care of these patients.  It is also wise to note that no healthcare worker who provided care to Mr. Duncan during his initial visit to Dallas Presbyterian Hospital nor the Emergency Medical Technicians (EMT’s) who transported Mr. Duncan to the hospital a couple of days later have contracted the virus.  None of Mr. Duncan’s personal contacts on the area in which he was staying prior to his admission to the hospital were infected either.  These bits of news should provide some reassurance to an American public that seems to thrive on fear and conspiracy.

This brings us to the two nurses who, apparently, provided care to Mr. Duncan after he was admitted into the hospital.  By all accounts, these two nurses, as well as other nurses, technicians and physicians who cared for him until his demise in the hospital from multiple-organ failure, were wearing at least the level of personal protective equipment (PPE) that had been recommended by the CDC.  Guidance on donning (putting on) and doffing (removal) of PPE has been made available on the CDC website here:  I have found this document to be flawed in regards to the acceptable level of PPE required for the safe and effective care of a patient in the most contagious stages of Ebola virus infection and, in particular, with the sequence for removal of PPE in any case.  However, until now, this is what healthcare workers have had for a resource.  In defense of the CDC, they have stated that the PPE guidelines provided are the minimum levels of protection for healthcare workers caring for a patient with confirmed or suspected Ebola virus infection.  This is not very reassuring.

Donning PPE

It is believed that the two nurses that have become infected with Ebola following the care of their patient may have inadvertently contaminated themselves during removal of their contaminated PPE.  This, in itself, is a tragedy.  It is likely that additional healthcare workers caring for Ebola patients using the same measures could become infected based on the selection of PPE and if they are removing their PPE using the steps outlined by the CDC.

Part of the rationale behind the CDC’s guidance is an awareness that very few American hospitals currently have the capacity to provide enhanced forms of PPE for significant numbers of their healthcare providers.  Full protective suits and gear are limited and stockpiled in small quantities for acute, transient, emergencies and quantities necessary to provide extended care for a patient requiring such gear is not on hand in most facilities.  I have learned this at my own facility as I began researching to prepare a policy for, specifically, Central Sterile Processing Department (CSPD) staff members who will be on the front lines of cleaning, decontaminating, disinfecting and sterilizing items used in the care of a patient with Ebola.

To date, no patient hospitalized for treatment of Ebola in the United States has required surgical intervention in the course of their treatment or recovery.  This is great news, because there is currently no guidance from the CDC on how to handle surgical intervention on such a patient.  The American College of Surgeons has issued guidance on surgical intervention for a patient with Ebola virus infection here:  This is a good resource for Operating Room (OR) team members including surgeons, nurses, anesthesia providers and surgical technologists.  It does not, however, address the concerns related to the reprocessing of items used in surgical procedures for these patients.  In my contacts with other CSPD managers, including at US hospitals that have treated patients with Ebola, there are no policies in place and the comments are that they are, essentially, relying on current CDC guidance if necessary.

Below is the first draft of a policy specifically addressing the needs of CSPD staff members who will bear the responsibility of cleaning, decontaminating, disinfecting, and sterilizing items used in the care of a patient with Ebola virus infection.  I am also attaching two of the appendices that address donning and doffing of PPE.  Perhaps someone at the CDC might incorporate these into a poster format!

While the vast majority of US hospitals are currently unprepared to handle an onslaught of Ebola cases, I have extreme confidence that most hospitals can safely and effectively care for a patient infected with the Ebola virus if they are given the proper resources and training.  It is critical to tamp down the hysteria and fear surrounding Ebola and base our actions on a scientific understanding and using evidence-based measures for providing care that is safe and effective for both our patients and our healthcare workers.

The Policy:

Handling and Processing of Items Exposed, or Potentially Exposed, to Ebola or Other Hemorrhagic Fever Patients


To provide guidance and direction for Central Sterile Processing personnel on the handling of instruments and durable medical equipment (DME) exposed, or potentially exposed, to the blood or other body fluids of a confirmed, or suspected, patient with Ebola, other hemorrhagic fever viruses.


XXXXXXXXXXX serves as the primary quarantine facility for travelers arriving through Detroit Metropolitan Airport.  The possibility exists for a disembarking passenger to present to airport officials with symptoms that may be consistent with suspected infection with Ebola, or other hemorrhagic fever, viruses.

To ensure that all proper infection control practices are implemented in order to protect staff members, patients, visitors and others who may be exposed to surgical instrumentation or durable medical equipment (DME) that has been used on a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.


All Central Sterile Processing personnel must follow specific guidelines when handling surgical instrumentation and durable medical equipment (DME) that has been exposed, or potentially exposed, to the blood, or other bodily fluids, of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.


It is the responsibility of the attending physician to notify the Infection Control (IC) Director, or her/his designee, anytime a patient presents with symptoms consistent with exposure to, or infection with, Ebola, or other hemorrhagic fever, viruses.

The Infection Control (IC) Director, or her/his designee will notify, in addition to other appropriate Managers, the Manager of the Central Sterile Processing Department (CSPD), that a patient with confirmed, or suspected, Ebola, or other hemorrhagic fever, viruses has been admitted to the facility.

The Manager of the Central Sterile Processing Department (CSPD), or her/his designee, will work with other appropriate Managers to ensure that items necessary for the cleaning, decontamination, disinfection and/or sterilization of items used in the care of patients with confirmed, or suspected, Ebola, or other hemorrhagic fever, viruses are readily available for staff members within CSPD.  (See Appendix A)

The Manager of the Central Sterile Processing Department (CSPD) will ensure that appropriate education and training has been conducted for all staff members responsible for the cleaning, decontamination, processing, disinfection and/or sterilization of surgical instrumentation, or durable medical equipment (DME), used on a patient with confirmed, or suspected, Ebola, or other hemorrhagic fever, viruses.

The Manager of the Central Sterile Processing Department (CSPD) will maintain documentation of the qualifications of CSPD staff members with regard to the cleaning, decontamination, processing, disinfection and/or sterilization of surgical instrumentation, or durable medical equipment (DME), used on a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.  The Manager of CSPD, or her/his designee, will be responsible for conducting annual in-service education and training for addressing Ebola, or other hemorrhagic fever, viruses.

The Nurse Manager, or her/his designee, of a unit providing care for a patient with a confirmed, or suspected, diagnosis of infection with Ebola, or other hemorrhagic fever, viruses will immediately notify the Central Sterile Processing Department (CSPD) Manager, or her/his designee, when an item used in the care of the patient is to be transported for processing by the CSPD.

Items transported to the Central Sterile Processing Department (CSPD) must be contained within a sealed, impervious, barrier.  Small items should be transported within an enclosed, or covered cart and not carried by hand.  Durable medical equipment (DME) should be contained within a large plastic bag, or similar impervious containment device, and transported on a cart that is also covered, where possible. Isolation carts, crash carts and other wheeled carts or equipment that have been used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses are to be covered with a large plastic bag, or similar impervious containment device, for transportation to the decontamination area.  Fluids are to be contained within sealed suction canisters.  Linen and trash must be contained within autoclaveable, leak resistant bags.  These bags must then be contained in impervious bags for transport to the CSPD.  Items that cannot be autoclaved must be segregated and discarded in red biohazard containers that are leak-proof and puncture-proof.

Items transported from a patient care area to the decontamination area must be constantly attended.  Items are not to be placed on an elevator or left in hallways awaiting transportation.  Contaminated items are not to be transported through the pneumatic tube system.  The person delivering the item(s) to the decontamination area must immediately notify the Sterile Processing Technician on duty that an item has been delivered to the decontamination area.  The Sterile Processing Technician on duty must immediately notify the Central Sterile Processing Department (CSPD) Supervisor on duty or on call.  The CSPD Supervisor will designate qualified individuals to perform the cleaning and decontamination of items associated with the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.  The CSPD Supervisor will directly supervise the cleaning and decontamination of such items.

The Central Sterile Processing Department (CSPD) Supervisor will ensure the decontamination area is prepared and appropriately stocked for the decontamination process.  (See Appendix B)

Central Sterile Processing Department (CSPD) staff members assigned to the cleaning and decontamination of items used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses are to wear specific personal protective equipment (PPE). (See Appendix D)  CSPD staff members are to work in pairs as assigned by the CSPD Supervisor.  One staff member is designated as the “Primary” Technician and the other is designated as the “Secondary” Technician.  Both staff members shall wear the specific personal protective equipment (PPE) required for this process.  All other staff members are to be removed from the decontamination area for the duration of the cleaning and decontamination process of items associated with the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.

The cleaning and decontamination process for surgical instrumentation used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses is consistent with established cleaning and decontamination processes recommended by the Association for the Advancement of Medical Instrumentation (AAMI), the Association of Professionals in Infection Control (APIC) and the Association of Perioperative Registered Nurses (AORN) regarding the cleaning and decontamination of any surgical instrumentation.  In all cases, manufacturer instructions for use (IFU’s) must be followed consistently.  NOTE:  Surgical instrumentation that cannot be processed using immersion, automated cleaning processes, ultrasonic cleaning, or high-temperature sterilization methods should not generally be used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses.

The Primary Technician will be responsible for performing all tasks associated with the cleaning, decontamination and disinfection of surgical instrumentation and durable medical equipment (DME) associated with a patient with confirmed, or suspected, Ebola, or other hemorrhagic fever, viruses.  The Secondary Technician will be responsible for ensuring no other personnel enter the decontamination area during this process, as well as directly observing the Primary Technician to identify any compromise in the personal protective equipment (PPE) and ensuring that the process for removal of PPE by the Primary Technician is performed properly.

Durable medical equipment (DME) used in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses is to be cleaned using an appropriate, hospital-grade, disinfectant that is capable of inactivating non-enveloped viruses.  Adherence to wet times is to be strictly enforced.  Wheeled equipment, including IV poles, crash carts, isolation carts, stretchers, wheelchairs, etc are to have all surfaces, including wheels, wiped down with approved, hospital-grade disinfectants that are capable of inactivating non-enveloped viruses.

Donning Specialized PPE:

Appendix D—Donning of personal protective equipment (PPE) for the cleaning, decontamination, disinfection and sterilization of items involved in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses


The employees who are assigned as “Primary” or “Secondary” Technician will be identically attired for the duration of the cleaning and decontamination process.

  1. The employees will don disposable scrub tops and pants.
  1. The employees will remove all jewelry including earrings, bracelets, necklaces, finger

            rings, and wristwatches.

  1. The employees will apply standard shoe covers over shoes.
  1. The employees will wear a hair cover and a surgical mask (if they will be wearing a

completely enclosed hood) or N95 high-filtration disposable respirator mask.

  1. The employees will don a pair of surgical-grade gloves ensuring adequate fit.
  1. The employees will don a Tyvek® biohazard suit hood. Ensure flaps of hood are

fully extended down the front and the back.  NOTE:  This is for a suit with a

separate hood/face-shield.  Attire must comply with ASTM: F1671.

  1. The employees will don a Tyvek® biohazard suit with attached booties. If the suit

does not have attached booties (one-piece), the employees will need to don water-

proof, disposable, knee-high booties.  The employees will ensure that the hood

flaps are completely contained within the suit.  Attire must comply with ASTM: F1671.

  1. The employees will use Duct tape to completely seal the sleeve to the inner gloves

making sure to leave a one (1) inch flap of tape for removal after the cleaning and

decontamination process.  Duct tape will also be used to seal knee-high booties if

these are worn leaving a one (1) inch flap of tape for removal.

  1. The employees will use Duct tape to completely seal the collar of the suit and the

body of the suit making sure to leave a one (1) inch flap of tape for removal after

the cleaning and decontamination process.  NOTE:  This is for a suit with a separate


  1. The employees will use Duct tape to completely seal the zippers of the Tyvek® suit

making sure to leave a one (1) inch flap of tape for removal after the cleaning and

decontamination process.

  1. If the Tyvek® suit does not have an enclosed hood with face-shield, the employees

will don fully-enclosed goggles that secure with an elastic band AND a full face-shield.

  1. The employees will don a second pair of gloves that must be at least surgical-grade or


  1. The employees will use Duct tape to completely seal the outer glove and sleeve

making sure to leave a one (1) inch flap for removal after the cleaning and

decontamination process.

  1. The Central Sterile Processing Department (CSPD) Supervisor will verify that all

steps of the PPE donning process have been followed before permitting the

Technicians to enter the decontamination area.  This includes ensuring all areas

have been taped/sealed properly.

Removal of PPE:

Appendix E—Doffing (Removal of) personal protective equipment (PPE) used in the cleaning, decontamination, disinfection and/or sterilization of items involved in the care of a patient with confirmed, or suspected, infection with Ebola, or other hemorrhagic fever, viruses

The employees who are assigned as “Primary” or “Secondary” Technician will be identically attired for the duration of the cleaning and decontamination process.  Personal protective equipment (PPE) is to be removed in a specific order in order to reduce the risk of inadvertent contamination of self during the removal of this gear.  The Central Sterile Processing Department (CSPD) Supervisor will directly observe the removal of PPE to ensure there are no breaks in technique.

  1. Verify the decontamination area has been properly cleaned and all items exposed,

or potentially exposed, to any contamination resulting from the cleaning and

decontamination process have been correctly disposed of.

  1. Position waste hamper with empty, autoclaveable, waste bag near tarpaulin that

has been positioned on the floor near the entry vestibule.

  1. Step onto tarpaulin to be sprayed off with approved, hospital-grade, disinfectant

ensuring that all surfaces of the PPE has been wetted.

  1. After the established wet-time criteria has been met, PPE may be removed in the

following order:

  1. Face-shield (if worn) is removed by grasping strap at back of head and pulling

up and over the head.  NOTE:  Applies if a separate hood/face-shield was not

worn.  Discard in waste hamper.

  1. Goggles (if worn) are removed by grasping strap at back of head and pulling

up and over the head.  NOTE:  Applies if a separate hood/face-shield was not

worn.  Discard in waste hamper.

  1. Remove each strip of Duct tape by pulling on tab left during donning of PPE.

Exercise care to not tear Tyvek® suit material.  Roll tape between hands into

a ball and discard into waste hamper.

  1. Remove booties (if used) and discard in waste hamper.
  2. Unzip Tyvek® suit exercising care to not let gloves touch scrubs.
  3. Remove outer gloves and discard in waste hamper.
  4. Remove Duct tape from inner glove/sleeve by pulling on tab left during

donning of PPE.

  1. One-piece suit—Grasp back of hood and pull back and downwards rolling

suit down back and arms ensuring outside of suit does not come into

contact with skin or scrubs.  Carefully step out of suit and off tarpaulin onto

clean floor.  Carefully roll suit up, ensuring suit does not come into contact with

skin or scrubs, and discard into waste hamper.

  1. Two-piece suit—Grasp suit at shoulders and pull back and downwards rolling

suit down back and arms ensuring outside of suit does not come into contact

with skin or scrubs.  Remove hood by grasping material of hood and pulling up

and over the head, ensuring outside of hood does not come into contact with

skin or scrubs, and discard in waste hamper.  Carefully step out of suit and off

tarpaulin onto clean floor.  Carefully roll suit up, ensuring suit does not come

into contact with skin or scrubs, and discard in waste hamper.

  1. Remove first inner glove by grasping palm of second glove and pulling downward

and off hand and discard in waste hamper.

  1. Remove second inner glove by sliding finger under cuff and rolling glove down

and off fingers and discard in waste hamper.

  1. The Primary and Secondary Technician will each don a pair of gloves then an impervious

gown and a pair of outer gloves to roll up and discard the tarpaulin, secure the waste

hamper and place hamper on autoclave cart.  The waste hamper is to be

decontaminated as other pieces of equipment.  These items will then be removed as

described above and discarded in a regular waste hamper along with shoe covers,

hair covers, masks, and disposable scrub tops and pants.  Clean scrub tops and pants will

be immediately available in the vestibule to change into.

  1. Remove mask by untying strings, or by grasping band, and pulling up and over

head and away from face.

  1. Remove hair cover by grasping top and pulling up and over head.
  2. Remove shoe covers by grasping shoe cover at heel and pulling down and

toward toes.

  1. Remove first glove by grasping palm of second glove and pulling downward

and off hand.

  1. Remove second glove by sliding finger under cuff and rolling glove down and

off fingers.

  1. The Primary and Secondary Technician will be escorted to an area where they are to

perform hand-washing and be permitted the opportunity to shower.

The Supreme Court Ruling on Hobby Lobby, et al., and Implications for PrEP

This past Monday’s decision by the US Supreme Court regarding Hobby Lobby, et al., has been widely misinterpreted as both a sweeping victory for Christian businesses and a slap at the Obama Administration and the Affordable Care Act, as well as, a total annihilation of reproductive rights and reproductive healthcare in the United States.  Both of these extremes are flawed and completely miss the mark.


While I do believe the opinion, penned by Associate Justice Samuel Alito, is flawed, it was not a broad sweeping opinion and it attempted to narrowly relate to the facts presented in the case.  The ruling’s major flaws include its attempt to insert the Supreme Court into the role of determining, what is a legitimate religious liberty and, recognizing a corporate entity as having the legitimacy of personhood.  Other flaws associated with the ruling are more covert and may not be recognized for a period of time.


While many have been quick to claim the Justices voting in favor of the Hobby Lobby decision acted out of a political, or ideological, motivation, they miss the fact that the government failed to provide enough proof for the Court to rule otherwise.  The attorneys representing Hobby Lobby, Conestoga, etc., brought a case that expressed their clients’ opposition to four specific types of contraceptives that, to one extent or another, prevent the implantation of a fertilized egg into the wall of the uterus.  These drugs, referred to by Hobby Lobby, et al., attorneys as abortifacients, prevent the fertilized egg from implanting into the uterine wall.   They did not present evidence opposing forms of contraception that prevented the fertilization of the egg claiming only that their clients believed, as a matter of religious teaching that life begins at fertilization.  The government failed to counter these claims with satisfactory evidence otherwise including any rationale that may exist, demonstrating improved safety, cost-efficiency, or beneficence for women.   


The Court did not address, nor did the Hobby Lobby group claim, more invasive forms of contraception, including vasectomy or tubal ligation, violated their sincerely held religious beliefs.  Nor did the Court address forms of contraception that prevent the fertilization of an egg.  This is what narrows this particular ruling.  One flaw in narrowing the ruling is that the Court failed to recognize medical and scientific consensus that life can only be recognized as beginning when the egg implants into the wall of the uterus and begins to divide.  The Court relied on the Religious Freedom and Restoration Act (RFRA) to determine that the owner of a business does not sever their religious faith simply by entering into a contractual structure as in incorporating a business. 


It should be noted that an egg that does not implant in the uterine wall, but rather begins to divide anywhere else is referred to as ectopic and may often require the surgical excision of a dividing embryo.  This condition, an ectopic pregnancy, and the consequent surgical intervention associated with terminating this pregnancy would appear to also violate the religious beliefs of the Hobby Lobby participants in this case.  This demonstrates the convoluted rational the Court used in reaching its 5 to 4 decision.


While the ruling did note that future court cases seeking religious exemptions for vaccinations and blood transfusions may result in a different opinion than what was rendered here, it is important for those of us concerned about reproductive health, that there are implications for pre-exposure prophylaxis (PrEP) to be discussed.


Because the Court did not address other forms of contraception, including vasectomy and tubal ligation, they also did not, more broadly address other forms of reproductive healthcare including vaccination against the Human Papiloma Virus (HPV), post-exposure prophylaxis (PEP), or PrEP.  It is reasonable to anticipate that another corporate entity may elect to seek exemptions from requirements for other forms of reproductive healthcare.  For example, an employer may suggest that sex outside of traditional marriage between a man and a woman violates their sincerely held religious beliefs, therefore requiring them to provide insurance coverage for PrEP or PEP is a Constitutional violation of their religious liberties.  Notwithstanding the fact that there are male/female married couples that currently use PrEP as a part of their reproductive health, the Court’s failure to recognize legitimate scientific and medical consensus in the Hobby Lobby case should give us a reason to be concerned about how the current Court might rule when faced with such a case.


The Court erred in attempting to determine what constitutes a legitimate, and sincerely held, religious belief deserving of Constitutional protection which is troubling.  The US Constitution ensures that each of us, as individuals has a right to believe as we so choose.  The Supreme Court has now made itself the arbiter of what religious beliefs can be imposed by employers on employees which should be a concern for each of us.

Defunding “Obamacare?!”

Among a string of poor public policy positions advocated by members of the Republican Party, the recent decision to attach an amendment to a Continuing Resolution (CR) that would fund the government but withdraw all funding for various components of the Affordable Care Act (ACA) is among the dumbest.  There are several reasons for arriving at this conclusion.  The most dangerous is that it will potentially lead to a partial shutdown of government which affects every single American.


First, the amendment that was attached to the Continuing Resolution striking funding for the ACA is purely a political gimmick designed to appease a small, extremely regressive, faction of the Republican base.  It is highly unlikely this amendment will be attached to a Senate resolution for a floor vote.  If it is offered as an amendment, it will likely not be approved.  This means the Bill goes into a Conference Committee.  This will put the House of Representatives into a showdown with the Senate and pushes us closer to a deadline which will result in the stoppage of essential government services.  Think Social Security checks, Military paychecks, the Centers for Disease Control and Prevention (CDC) which is gearing up for flu season!


For the sake of argument, let us say that the amendment does become a part of the final Bill that is presented to the President.  It is extremely likely the President the President would return the Bill to Congress with a bright VETO stamp across the top.  Republicans do not have the votes to overturn a veto and would be left holding the bag on a smelly collection of dog excrement when the deadline for government operational funding passes.  American citizens do not like when there is no one answering the telephone at the Social Security Office!  I personally would be quite pissed off if I found that our Military service members were not getting paid!!


Let’s enter the world of a Republican wet dream for a moment.  The amendment that defunds the ACA is passed through both chambers of Congress and the President accidentally signs this wrong-headed piece of legislative bovine-manure.  The Republican Party collectively orgasms all over themselves and claims they have achieved a monumental victory!  Orthopedic surgeons in the Beltway will be extremely happy for with all of the folks patting themselves on the back there are sure to be a few Rotator Cuff tears to deal with.


What happens next?


This amendment does not repeal the Affordable Care Act.  It does not block the implementation of any of the rules and regulations promulgated by the ACA.  It only does one thing.  It eliminates funding for any of the provisions of the Affordable Care Act.  So, what?


Hospitals have begun to implement Electronic Health Records (EHR’s) using money provided under the ACA.  Study after study has demonstrated that EHR’s reduce medical errors and have the potential to reduce costs.  The ACA requires that hospitals and physicians adopt the EHR as part of a goal to improve patient safety.  Doctors and hospitals are now left solely on the hook for the expense of this technology.  Failure to comply will result in a loss of eligibility for Medicare and Medicaid reimbursement.  The hospital I work at receives more than 40% of its reimbursement from these two programs.  Fortunately, we have already completed adoption of an EHR system.  I do not know about all of our affiliate physician groups and individual practice physicians, however.  If our surgeons cannot operate on Medicare patients, a huge piece of our revenue stream disappears.  Hospitals generally operate on extremely thin operating margins (gross revenue over expenses), typically 1 to 3%.  Many hospitals have a much higher percentage of Medicare and/or Medicaid patients and would be impacted even more by a loss of access to these revenue streams.  Loss of Medicare funding will mean the demise of a number of independent hospitals and loss of funding for EHR technology will mean that most independent practice physicians and many physician groups will cease to exist.


States are required to begin enrolling individuals in Health Insurance Exchanges (HIE’s) beginning on October 1.  Funding to set up these exchanges was allocated through provisions of the Affordable Care Act.  In a number of Republican-led states, the legislature and executive refused to participate in an HIE.  In these states, the Federal government is operating the exchange.  The money to administer these programs is eliminated as a result of the defunding amendment.  Insurance companies are participating in these exchanges anticipating a new influx of customers seeking health insurance.  From a business standpoint, health insurance companies know that having a broad base of customers allows them to spread risk among a broad base of payers.  This means that insurance rates can be maintained at an affordable rate for all consumers.  In a number of states that have already started operating these exchanges, insurance rates, including premiums and deductibles have been lower than suggested by certain folks on the right of the political spectrum.  Many of the folks enrolling are doing so in anticipation of subsidies available as part of the ACA.  Those subsidies are gone as a result of the amendment.


Under the Affordable Care Act, which, by the way, remains the law, insurance companies cannot deny coverage or charge exaggerated rates to individuals based on health status.  With the defunding amendment, Health Insurance Exchanges have been hobbled and not able to reach out to customers.  Since they will not be able to obtain, potentially 30 million additional customers, insurance companies will be forced to drastically raise the cost of premiums for all of their customers.  Except for the wealthiest among us, individuals will find they are unable to afford monthly premiums and will be forced to drop their coverage.  Businesses will find it increasingly difficult to afford the cost of health insurance for their employees and will begin to drop insurance coverage.  Instead of stable, affordable premiums, I would anticipate much more expensive premiums.  The result, millions more uninsured Americans!


This wrong-headed amendment to defund the Affordable Care Act would be dangerous for patient safety, health insurance companies, hospitals, doctors, taxpayers, and businesses.  The proponents of this legislation have failed to grasp the tremendous negative consequences of such a thing happening.


I am absolutely certain the Republican leadership in Congress is fully aware that they are playing political gimmickry with this amendment to defund the Affordable Care Act.  They know, completely, that this amendment will not make it to the President’s desk.  Speaker-of-the-House John Boehner knows this as does every member of the US Senate.  The absolute worst possible outcome for Speaker Boehner, and every Republican member of Congress would be for this to land on the President’s desk as part of a Continuing Resolution and actually be approved by President Obama.  The resulting collapse of the Affordable Care Act will lead to a collapse of the health insurance industry, hospitals and physician practices, and culminate in the establishment of a universal, single-payer healthcare system in the United States.  Speaker Boehner would be credited, single-handedly, with bringing Socialized medicine to the United States of America!

Thoughts on World AIDS Day

December 1, 2012 marked another World AIDS Day.  Once again, I had the opportunity to participate in events over the past week relating to WAD.  Each year, I pause to remember those I have known who have lost their valiant battles with this disease.  Since 2002, World AIDS Day has had a special significance as in January of 2002, I tested positive and was diagnosed with AIDS.  I am one of the fortunate ones.  I have a loving and supportive family and wonderful group of friends.  I am also a beneficiary of the tremendous scientific advancements that have served to save and extend my life.

Ken WAD 2012aThis year, I attended the International AIDS Conference in Washington DC.  I met many incredible people who are true leaders and advocates in the fight against HIV and AIDS.  This year was the first IAC to be held in the United States since 1990!  The event was remarkable because it was the first time a person who has been cured of HIV was introduced.  The event also highlighted other great strides that give hope and promise that HIV will become a chronic, manageable condition instead of the virtual death sentence that was the case in the first 10 to 15 years of the epidemic.  Also, evidence was presented about the benefits of pre-exposure prophylaxis (PrEP) and that people with suppressed HIV viral loads have a greatly reduced risk of transmitting the virus.

In contrast to all of the hopeful information that was shared at the IAC, some troubling issues were raised.  One person is infected with HIV in the US every nine-and-a-half minutes.  One-in-five people, or 20% of those infected, are unaware of their HIV status.  Among Americans who are diagnosed with HIV only one-quarter have their viral load suppressed.  The AIDS Drug Assistance Program (ADAP) still has people on waiting lists for financial support for HIV medications.  A number of states have reduced an individual’s income level required to be eligible for ADAP support.  Criminalization and stigma continue to have a negative impact on HIV testing and prevention efforts.

Secretary of State, Hillary Clinton, has stated a goal of achieving zero new HIV infections by 2015.  In order for these goals to be realized there must be improvements made to the issues identified above.  We currently have the tools necessary to eliminate new infections and we need to generate the interest in implementing proven strategies to make this happen.

This brings me to this year’s WAD events that I participated in.  This year I noticed that at various events, a minority of participants were actually HIV positive.  A similar, relatively small, number were gay men.  Considering the impact that HIV has among men who have sex with men, I was disappointed.  If we are going to reduce the rates of HIV infection in this population to be consistent with the goals of Secretary Clinton, a significant ramp-up of education and prevention efforts will have to occur in order for this to happen.

I know this will require folks, like me, who have been living with HIV, to stand up and speak out.  It requires people to have personal courage and a desire to erase the stigma associated with HIV.  It will require people to get tested for HIV and to be adherent to medications that will suppress the virus.  It will require pharmaceutical companies and the government to ensure that these medications are made available to everyone who needs them and that they will be affordable.  It will require the repeal of criminal statutes that penalize those who are known to be infected with HIV.  It will require a commitment from policy-makers, patients, people who are at high-risk for HIV infection, educators, activists, healthcare workers and business leaders to make this happen.

In the 1980’s, as this new epidemic was unfolding, it was activists who demanded changes to the status quo.  The time has come for these activists, along with a new generation of activists and allies, to come together and demand the changes necessary to make HIV and AIDS a thing that is discussed in history textbooks.  It can happen.  It must happen.  HIV will lose.  But, only if we, as a nation, come together and commit to an end of AIDS!

My Story—World AIDS Day Version
November 26, 2012, 8:35 am
Filed under: Health and Medicine

I left for the Navy 20 days after my High School graduation.  Being only 17, my folks had to sign the forms to let me enlist.  I had an agreement with the Navy to become a Hospitalcorpsman (HM), a Navy medic.  While I knew that I liked guys, I somehow did not quite grasp the fact that I was gay quite yet.  After Basic Training I entered Hospitalcorps A School and graduated near the top of my class.  During my HM schooling, I learned of some advanced programs that were available upon completion of the A school.  I selected Surgical Technology thinking that you could not do surgery on a ship and that I would have a land-based assignment and be able to finish college while still enlisted in the Navy.  I would soon discover there are ships on which you can do surgery.

In 1986, while stationed aboard the USS Saipan, a helicopter/amphibious assault ship, the US military began mandatory HIV testing for all active duty military personnel.  HIV testing of all military recruits and US-based military personnel had actually begun in 1985.  The test was actually used as a proxy to identify gay military personnel.  Remember, in the early ‘80’s, it was gay men in New York and San Francisco that were being decimated by this new syndrome.  I was tested, although I was not really worried even though by this point I had realized that I was gay, because I had never been to San Francisco (ever) or New York (except as a kid).  I was one of a few of us HM’s on the ship who then tested over 850 sailors and 2,500 Marines for HIV over the course of a week.  Back then it was a blood draw.  We didn’t even wear gloves until the lab tech told us we were idiots because Hepatitis B could be contracted through the skin!!  One of the tests came back positive.  A young man who served as a cook on the Admiral’s Staff.  He was escorted off the ship and I never had a chance to meet with him or find out what he was told.

After getting kicked out of the Navy during a witch-hunt for gay men on my ship, I came home and started working as a Surgical Technologist.  My taxpayer-funded education did pay off!!  This was in mid-1987 and Universal Precautions (now called Standard Precautions) was just being rolled out.  A vaccine for Hepatitis B was also being introduced.  I received the first of the series and then a few weeks later suffered a scalpel injury in the OR and contracted Hep B from the patient.  Throughout the late-‘80’s and into the mid-‘90’s, when other co-workers did not want to work with a patient who was known, or thought, to be gay, or have HIV/AIDS, I would always step in and offer to care for the patient.  I told a surgeon off in the mid-‘90’s for being an idiot for requiring all of his patients to be tested for HIV before he would do surgery on them.

Because of my experience getting kicked out of the Navy, I became an anti-discrimination advocate when I came home.  I served as a volunteer switchboard operator at our local community center, Affirmations.  I also became Chairperson of the Detroit Area Gay/Lesbian Council’s (DAG/LC) Anti-Violence Task Force that was being created to address a spate of anti-gay hate crimes that were occurring in the metropolitan-Detroit area.  I became the Gay/Lesbian Liaison to the Michigan ACLU and also served on some other boards of gay/lesbian organizations.  When DADT was first proposed, I did a fair amount of public speaking in opposition to this so-called compromise.  I also became involved with protests that were taking place against the first Cracker Barrel restaurant in Michigan!  I actually organized the first sit-in protest one Sunday morning at the restaurant in Bellville, Michigan!  It was pretty successful and the Manager was kind enough to inform us when they were going to have to call the Police!  Fun times!!

In 1988, I met my life partner, Michael, and we opened a gay and lesbian bookstore/ coffeehouse, Just 4 Us, in Ferndale, Michigan in 1997.  Michael had become the Director of the metro-Detroit PrideFest in 1990 and also established the Michigan International Lesbian and Gay Film Festival, and the Lesbian and Gay ComedyFest.  In 1998, stress from the business and from my regular job as well as personal issues between us, led to our breakup.  Because of our responsibilities to the business, we had to remain cordial and professional, and we have become the best of friends even after we sold the business in 2002!  Today we are roommates (along with his life partner, Scott).

My first HIV test after the Navy was in 1990 and I tested each year for several years.  In 1997, I decided I would test every other year and tested negative in January 1997 and, again, in 1999.  In January of 2002, I realized I had not tested in 2001 and went in for a test at the testing site.  Throughout the Fall of 2001, I had been sick a few times which was unusual and in January of 2002 when I went in to be tested I was sick with a troublesome cold/bronchitis once again.  I tested on Saturday, January 20, 2002 and planned to go back in a week to get my test results.  In the meantime, I showed up for work on the 25th and my co-workers looked at me, popped me into a wheelchair and dropped me off in the ER!  One convenient thing about working in a hospital!  At this time, I was working as an Educator and teaching the Surgical Technology Program that we had started in January of 1999 with William Beaumont Hospital and Oakland Community College.  I had a very handsome, young, internal medicine physician assigned to my case and after eliciting my history (namely, I was gay), he ordered appropriate bloodwork.  Because I was waiting for my HIV test results and to avoid the snooping eyes of any unscrupulous colleagues, the blood tests he ordered were surrogates.  Namely, he ordered basic lab work and CD4 profiles.  I had 10 fewer CD4’s than my age at the time!  In addition, my Hepatitis markers indicated that I would not be able to scrub into surgical cases anymore.  That was kind of a crushing blow for me.  25 CD4’s I could live with, but not being able to do what I really enjoyed and was pretty good at was tough to take.

I was let go from my position at the hospital in July of 2002, and while I am certain it was because of my HIV status, I was not out about this except to my family and friends.  Of course they said it was because I couldn’t scrub in surgery anymore, however, no surgical technology program in the country actually requires this of their instructor’s.  In fact, the Surgical Technology Program Director at Macomb Community College hired me as an Adjunct Faculty member in the following semester!  It took a little while, but one of my professional contacts also recruited me to work for her firm which contracted with hospitals to manage Sterile Processing Departments and a couple of years later I was recruited by the Henry Ford Health System to run the Sterile Processing Department at their flagship facility!  I now work as a Supervisor of the Sterile Processing Department for Oakwood Hospital and Medical Center, and spend a fair amount of time in the OR, although, I still cannot scrub in.  I also still teach Surgical Technology at Oakland Community College and Macomb Community College.  After OCC severed their ties with the hospital, their new Surgical Technology Program Director has brought me back on board!

One of the topics that I cover in my courses, and that I have presented for other instructors, is on bloodborne pathogens.  I have discussed my Hepatitis status with all of these students as part of the lecture.  For my core students, however, I have not discussed my HIV status, although I do present HIV in its history and its current impact on healthcare practice.  For other students, I do not have an issue with it, however, with my core students, I do this presentation very early in the program and I have these students for two full semesters and so I do not want my status to overshadow the rest of the material I need to present throughout the program.  This past August, when the Dearborn Police Department made that traffic stop involving an HIV+ individual, I learned about it, first from Robert, and second, from Aaron!  I then read Todd’s piece in The American Independent, watched the video, and called the Police Chief.  I told him in our meeting that as someone who is poz, I found the officer’s comments to be ignorant and unacceptable.  I was subsequently interviewed by Todd for a follow up piece.  Chief Haddad and I have some tentative training set up for early next year.  I was also interviewed for a new magazine called, “X Press” regarding the rate of HIV infections and the importance of prevention.  That is my first real public “outing” of my status.  Oh yeah, and I did a photo for “A Day With HIV.”

It is only about a year-and-a-half since I became acquainted with Poziam and through it, Robert B!  It is really only since then that I have decided to become more open about my status.  For me, I do not feel a need to “come out” to someone, but, if anyone asks, I will tell them.  When I “came out” as gay, it was basically when I was interviewed regarding my experiences and opposition to DADT in 1993 and people saw the news coverage.  I had written letters to the editor of our main papers in the area about gay and lesbian issues since I had been kicked out of the Navy and so some people “knew.”  Likewise, I have written letters to the editor about HIV education and prevention as well as posts on FB and Twitter that would lead some people to “know” that I am HIV+.