But first, an anesthesiologist — Dr.Ìý — put her under by placing a mask over her face.

“Now I’m breathing for her with this mask,” he said. “And I’m delivering sevoflurane to her through this breathing circuit.”

Ìýis one of the most commonly used anesthesiology gases. The other big one is. There are others too, like nitrous oxide, commonly known as laughing gas.

Whichever gas a patient gets is inhaled, but only about 5% is metabolized. The rest is exhaled. And to make sure the gas doesn’t knock out anyone else in the operating room, it’s sucked into a ventilation system.

And then? It’s vented up and out through the roof, to mingle with other greenhouse gases.

The two frequently used gases are fairly similar medically; sevoflurane needs to be more carefully monitored and meted outÌýin some patients, but that’s not difficult, Chesebro said.

Generally, unless there’s a reason in a particular case to use one over the other, anesthesiologists simply tend to pick one of the two gases and stick with it. Few understand that

And that bothered Chesebro. He grew up on a ranch in Montana that focused on sustainability.

“Part of growing up on a ranch is taking care of the land and being a good steward,” he said.

Now he lives in the city with his three kidsÌýand has gradually started to worry about their environmental future.

“When I look around and I see the stewardship on display today, it’s discouraging,” he said.

“I got depressed for a while, and so I hit the pause button on myself and said, ‘Well, what’s the very best that I can do?'”

He spent hours of his own time researching anesthesiology gases. And he learned desflurane is 20 times more powerful than sevoflurane in trapping heat in the Earth’s atmosphere. , whereasÌýsevoflurane breaks down in just one year.

Opening a big, black notebook filled with diagrams and tiny writing, he showed how he computed the amount of each gas the doctors in his group practice used. Then he shared their carbon footprint with them.

“All I’m doing is showing them their data,” Chesebro said. “It’s not really combative. It’s demonstrative.”

One of the doctors he shared his analysis with was Dr. Michael Hartmeyer, who works at theÌýÌýwith Chesebro.

“I wish I had known earlier,” Hartmeyer said. “I would have changed my practice a long time ago.”

Hartmeyer said he was stunned when Chesebro explained that his use of desflurane was the greenhouse-gas equivalent of Ìýfor the duration of each surgical procedure. It’s “only”Ìý if he uses sevoflurane.ÌýHartmeyer noted that outside the operating room he drives a Prius, a hybrid electric car.

“You try to be good,” he said. “You take shorter showers or [don’t] leave lights on, or whatever else. But you know there’s always more that we could probably do. But this was, far and away, a relatively easy thing that I could do that made a huge impact.”

The anesthesiology carts that get brought into operating theaters tend to have a row of gases to choose from. Hartmeyer was able to switch pretty much overnight.

Other anesthesiologists made the switch, too. And it didn’t hurt that sevoflurane is considerably cheaper.

Hartmeyer’s change saved his hospital $13,000 a year.

When Chesebro shared his findings with the anesthesia departments at all eightÌý in Oregon, they prioritized the use of sevoflurane. They now save about $500,000 a year.

Providence’sÌýchief executive, , said the hospital system didn’t change its use of the gas because of the money. It changed because the Ìýnow says climate change is theÌýÌý— and because of Chesebro.

Vance said Chesebro teared up in front of 2,000 people when talking about the gas, his children and theÌý character created by .

“Unless someone like you cares a whole awful lot, nothing’s going to get better — it’s not,” said Vance, quoting the book “The Lorax.”

, an associate professor of anesthesiology atÌý, called Chesebro’s efforts remarkable and important.

She said several hospitals around the country have tried to make this shift, but with mixed results. Some just gave anesthesiologists the information and not much changed. Other hospitals took desflurane away, but that left many anesthesiologists feeling disrespected and angry.

Chesebro succeeded, she said, because he chose to persuade his colleagues — using data. He showed doctors their choice of gas plotted against their greenhouse impact. And it helped that he showed them over and over, so doctors could compare their progress to their peers.

“Providing ongoing reports to providers is the best way for this movement to catch on and grow,” she said. It can reinforce over time, she added, not just what their carbon footprint is, but also what progress they’re making.

Sherman said efforts such as Chesebro’s are sorely needed because the U.S. health sector is responsible for about .

“We clinicians are very much focused on taking care of the patient in front of us,” she said. “We tend to not think about what’s happening to the community health, public health — because we’re so focused on the patient in front of us.”

In an emailed statement, one of the largest manufacturers of both the anesthesia gases — — said it’s important to provide a range of options for patients. The company also said inhaled anesthetics have a climate impact of 0.01% of fossil fuels.

“The overall impact of anesthetic agents on global warming is low, relative to other societal contributors, especially when you consider the critical role these products have in performing safe surgical procedures,” the statement reads.

It’s a fair point, Chesebro said, but he has a counterargument.

“Well, if it’s there, it’s bad. And if I can reduce my life’s footprint by a factor of six … why wouldn’t you do it?'”

The surgery Chesebro was involved in that morning at Providence was a success. Chesebro estimates that by using sevoflurane on his patient, the amount of greenhouse gases produced was the same as in a 40-mile drive across the Portland region. If he’d used desflurane instead, he said, it would have been like driving the more than 1,200 miles from Seattle to San Diego.

Now Chesebro’s hospital bosses are hoping other doctors will follow his lead, research their own pet peeve and maybe solve a problem no one’s thinking about.

This story is part of a partnership that includesÌý,Ìýand Kaiser Health News.

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Investigadores hallaron que los pacientes de raza negra analizados en el tuvieron un 40% menos de chances de recibir medicamentos para el dolor que los blancos no hispanos.

, jefe de los programas de servicios médicos de emergencia en la Oregon Health and Science University y el Oregon Institute of Technology, dirigió la investigación, que en un simposio en Orlando, Florida

Para el trabajo, los investigadores recibieron fondos del departamento de Servicios Médicos de Emergencia de Oregon y la Oficina de Salud Rural del estado.

Los investigadores dicen que la discriminación abierta por parte de paramédicos es algo raro, e ilegal. Agregan que es posible que haya una suerte de prejuicio inconsciente.

Hace unos años, era una de las pocas mujeres técnicas de emergencias médicas de raza negra que trabajaban en el condado de Lenawee, en Michigan. Dijo que, en base a su experiencia, los hallazgos del estudio son ciertos.

Recordó una llamada en particular: el paciente se había caído y sentía dolor. Cuando los paramédicos llegaron a la casa, Gregory vio que el paciente era de raza negra. Y ahí fue cuando escuchó la queja de uno de sus colegas.

“Creo que fue algo como: ‘Oh, Dios mío. Aquí vamos de nuevo ‘”, dijo Gregory. Le preocupaba, entonces, como ahora, que, porque el paciente era de raza negra, su colega asumiera que estaba simulando el dolor para que le dieran medicamentos.

“Estoy absolutamente segura que fue inconsciente”, agregó Gregory, quien ahora vive y trabaja en Portland, Oregon, donde fundó una organización sin fines de lucro para crear conciencia sobre las disparidades raciales en la atención médica. “En ese momento, recuerdo que me sentí estresada y pensé: “Ahora voy a tener que pelear con mi colega por más analgésicos”.

El sesgo inconsciente puede ser sutil, pero, como muestra este nuevo informe, puede ser uno de los factores detrás de las vinculadas a la raza que se registran en los Estados Unidos.

El estudio examinó 104,000 historias clínicas de pacientes que fueron traslados en ambulancia o atendidos por paramédicos de 2015 a 2017. Encontró que los pacientes de minorías tenían menos probabilidades de recibir morfina y otros medicamentos para el dolor en comparación con los pacientes blancos no hispanos, independientemente de los factores socioeconómicos, como si tenían o no seguro médico.

Durante un cambio de turno en la sede de en Portland, los técnicos de emergencias médicas y los paramédicos discutieron el problema con un reportero mientras preparaban sus equipos.

Jennifer Sanders, quien ha sido paramédica durante 30 años, insistió en que la raza del paciente no impacta en su trabajo. “Nunca he tratado a nadie de manera diferente”, aseguró.

La mayoría de los trabajadores de emergencia entrevistados, entre ellos Jason Dahlke, dijeron que la raza no afecta el tratamiento que brindan. Pero Dahlke también dijo que él y algunos de sus compañeros de trabajo están pensando profundamente en el prejuicio inconsciente.

“Históricamente, es la forma en que este país ha sido”, dijo Dahlke. “Al principio teníamos esclavitud, después segregación… te puedes perder en una gran escala macro, pero sí. Está allí”.

Cuando se le preguntó por dónde creía que se podía deslizar el prejuicio inconsciente, Dahlke habló sobre un paciente que acababa de tratar.

El hombre era de raza negra y tenía alrededor de 60 años. Dahlke es blanco y tiene unos 30. El paciente tiene diabetes y llamó al 911 desde su casa, quejándose de dolor extremo en sus manos y pies.

Cuando Dahlke llegó a la casa del paciente, siguió el procedimiento estándar y le hizo una prueba de glucosa en sangre. Los resultados mostraron que el nivel de azúcar del hombre era bajo.

“Así que mi decisión fue tratar el azúcar en la sangre primero. Asegurarte que el número suba”, dijo Dahlke.

Le dio glucosa al paciente, pero no medicina para el dolor.

Dahlke dijo que no abordó el dolor del hombre en este caso porque cuando lo estabilizó, había llegado al hospital, donde el paciente ya era responsabilidad del personal de la sala de emergencias.

“Cuando las personas están gravemente enfermas o lesionadas, los medicamentos para el dolor son importantes”, dijo Dahlke. “Pero no es lo primero que nos va a preocupar. Vamos a preocuparnos por las amenazas a la vida. No necesariamente va a morir de dolor, y vamos a hacer lo que satisfaga la necesidad en el momento de llevarlo a la ambulancia y al hospital y a un nivel más alto de atención”.

Dahlke dijo que no está seguro si, si el paciente hubiera sido blanco no hispano, le habría administrado analgésicos, aunque no lo cree.

“¿Es algo en lo que pienso cuando me encuentro con un paciente que no se parece a mí? No sé si eso cambia mi forma de tratarlo”, dijo.

Cuando se le preguntó si las disparidades en el tratamiento a veces se debían a que las personas blancas (no hispanas) tenían más probabilidades de pedir más medicamentos, Dahlke sonrió.

“Me pregunto, si en este estudio hablamos de personas de color a las que se les niega o no se les dan medicamentos narcóticos tanto como a los blancos (no hispanos), tal vez estamos tratando demasiado a los blancos (no hispanos) con medicamentos narcóticos”.

La investigación ha encontrado que los afroamericanos son más propensos a , y eso también podría desempeñar un papel en la disminución de la atención. Tal desconfianza es comprensible y se remonta a generaciones, dijo Gregory.

“¿Cómo puede una persona de color no faltarle el respeto a un sistema que está constantemente estudiando y hablando sobre estas disparidades, pero no hace nada para solucionarlo?”, se preguntó.

Gregory escribió a los Centros para el Control y Prevención de Enfermedades (CDC) en 2015, pidiéndole que declarara al racismo como una amenaza para la salud pública.

Las declaraciones de crisis anteriores, como las que centran la atención en problemas como el tabaquismo o el VIH, han tenido resultados significativos, destacó Gregory.

Pero los CDC le dijeron a Gregory, en una , que, si bien apoyan las políticas del gobierno para combatir la discriminación racial y , “el racismo y la discriminación racial en la salud es un problema social y de salud pública, que requiere una estrategia social de base amplia para desmantelar efectivamente el racismo y sus impactos negativos en los Estados Unidos”.

Kennel dijo que los falsos estereotipos sobre las diferencias en la fisiología basadas en la raza que se remontan a la esclavitud también desempeñan un papel en las disparidades en la atención médica. Por ejemplo, a pesar de la falta de apoyo científico, algunos profesionales de salud todavía piensan que la sangre de los afroamericanos se coagula más rápido, dijo Kennel, citando realizado con estudiantes de medicina en la Universidad de Virginia.

También se les preguntó a los estudiantes si pensaban que los afroamericanos tenían menos receptores del dolor que los blancos. “Un porcentaje incómodamente grande de estudiantes de medicina dijo: ‘Sí, eso es cierto'”, agregó Kennel.

Además de eso, dijo, los técnicos y los paramédicos a menudo trabajan en situaciones de presión temporal, donde se limitan a información clínica ambigua y recursos escasos. “En estas situaciones, es mucho más probable que los proveedores tomen decisiones (basadas) en estereotipos”, dijo.

Las . Los blancos no hispanos tienden a recibir mejor atención y experimentan mejores resultados, ya sea que estén en el consultorio de un médico o en la sala de emergencias. Pero antes del estudio de Kennel, nadie sabía si lo mismo sucedía en la parte trasera de una ambulancia.

Y casi no llegaron a saberlo, porque la investigación requirió que las compañías de ambulancia divulgaran datos altamente confidenciales.

“Estábamos preparados para no lucir tan bien”, dijo Robert McDonald, gerente de operaciones de American Medical Response (AMR), en Portland. AMR es una de las organizaciones de ambulancias más grandes del país y compartió sus datos de más de 100,000 pacientes con Kennel.

Algunas personas atribuyen las disparidades que encontró a las diferencias en la demografía y en si se tiene o no seguro de salud, pero Kennel dijo que controló esas variables.

Entonces, ahora que AMR conoce las disparidades en su atención, ¿qué puede hacer la compañía?

“Mi opinión es que probablemente vamos a impartir cierta educación y entrenamiento a nuestra gente que sale a las calles”, dijo McDonald.

Además, dijo, AMR va a contratar más personas de color.

“Queremos ver más grupos étnicos representados en emergencias, que históricamente ha sido una fuerza de trabajo blanca dominada por hombres”, agregó.

Las políticas de AMR también deben cambiar, expresó McDonald. La compañía ha comprado un software que permitirá a los pacientes leer los formularios de permisos médicos en 17 idiomas. Y la firma está planificando un esfuerzo para llegar a las comunidades de color para explicar el papel de los trabajadores de emergencias.

Esta historia es parte de una asociación que incluye a , y Kaiser Health News.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Specifically, the scientists found that black patients in were 40 percent less likely to get pain medication than their white peers.

, head of emergency medical services programs at Oregon Health and Science University and the Oregon Institute of Technology, led the research, which was in December at the Institute for Healthcare Improvement Scientific Symposium in Orlando, Fla.

The researchers received a grant to produce the internal report for the Oregon Emergency Medical Services department and the Oregon Office of Rural Health.

Outright discrimination by paramedics is rare, the researchers say, and illegal; in these cases, unconscious bias may be at work.

A few years ago, was one of a very few black female emergency medical technicians working in Lenawee County, Mich. She said the study’s findings ring true based on her experience.

She remembered one particular call — the patient was down and in pain. As the EMTs arrived at the scene, Gregory could see the patient was black. And that’s when one of her colleagues groaned.

“I think it was something like: ‘Oh, my God. Here we go again,'” Gregory said. She worried — then, as now — that because the patient was black, her colleague assumed he was acting out to get pain medication.

“I am absolutely sure this was unconscious,” added Gregory, who now lives and works in Portland, Ore., where she founded a nonprofit to spread awareness about racial disparities in health care. “At the time, I remember, it increased my stress as we rode up on this person. Because I thought, ‘Now am I going to have to fight my colleague for more pain medication, should that arise?'”

Unconscious bias can be subtle — but, as this new report shows, it may be one of the factors behind race-linked seen across the U.S.

The study looked at 104,000 medical charts of ambulance patients from 2015 to 2017. It found that minority patients were less likely to receive morphine and other pain medication compared with white patients — regardless of socioeconomic factors, such as health insurance status.

During a shift change at headquarters in Portland,Ìý EMTs and paramedics discussed the issue with a reporter as they got their rigs ready for the next shift.

Jennifer Sanders, who has been a paramedic for 30 years, was adamant that her work is not affected by race.

“I’ve never treated anybody different — regardless,” said Sanders.

Most of the emergency responders interviewed, including Jason Dahlke, said race doesn’t affect the treatment they give. But Dahlke also said he and some of his co-workers are thinking deeply about unconscious bias.

“Historically it’s the way this country has been,” Dahlke said. “In the beginning, we had slavery and Jim Crow and redlining — and all of that stuff you can get lost in on a large, macro scale. Yeah. It’s there.”

Asked where he thinks unconscious bias could slip in, Dahlke talked about a patient he just treated.

The man was black and around 60 years old. Dahlke is white and in his 30s. The patient has diabetes and called 911 from home, complaining of extreme pain in his hands and feet.

When Dahlke arrived at the patient’s house, he followed standard procedure and gave the patient a blood glucose test. The results showed that the man’s blood sugar level was low.

“So it’s my decision to treat this blood sugar first. Make sure that number comes up,” Dahlke said.

He gave the patient glucose — but no pain medicine.

Dahlke said he did not address the man’s pain in this case because by the time he had stabilized the patient they had arrived at the hospital — where it was the responsibility of the emergency department staff to take over.

“When people are acutely sick or injured, pain medication is important,” Dahlke said. “But it’s not the first thing we’re going to worry about. We’re going to worry about life threats. You’re not necessarily going to die from pain, and we’re going to do what satisfies the need in the moment to get you into the ambulance and to the hospital and to a higher level of care.”

Dahlke said he is not sure whether, if the patient had been white, he would have administered pain medicine, though he doesn’t think so.

“Is it something that I think about when I come across a patient that does not look like me? I don’t know that it changes my treatment,” he said

Asked whether treatment disparities might sometimes be a result of white people being more likely to ask for more medications, Dahlke smiled.

“I wonder that — if, in this study, if we’re talking about people of color being denied or not given narcotic medicines as much as white people, then maybe we’re overtreating white people with narcotic medicines.”

Research has found African-Americans more likely to be , and that might play a role in diminished care, too. Such distrust is understandable and goes back generations, said Gregory.

“How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” she asked.

Gregory wrote an to the Centers for Disease Control and Prevention in 2015, asking it to declare racism a threat to public health.

Past declarations of crisis — such as those focusing attention on problems such as smoking or HIV — have had significant results, Gregory noted.

But the CDC told Gregory, in its , that while it supports government policies to combat racial discrimination and , “racism and racial discrimination in health is a societal issue as well as a public health one, and one that requires a broad-based societal strategy to effectively dismantle racism and its negative impacts in the U.S.”

Kennel said false stereotypes about race-based differences in physiology that date to slavery also play a role in health care disparities. For example, despite a lack of any supporting science, some medical professionals still think the blood of African-Americans coagulates faster, Kennel said, citing a of medical students at the University of Virginia.

Another question in the survey asked the students whether they thought African-Americans have fewer pain receptors than whites. “An uncomfortably large percentage of medical students said, ‘Yes, that’s true,'” said Kennel.

On top of that, he said, EMTs and paramedics often work in time-pressured situations, where they are limited to ambiguous clinical information and scarce resources. “In these situations, providers are much more likely to default to making decisions [based] on stereotypes,” he said.

Disparities in health care are . Whites tend to get better care and experience better outcomes, whether they’re in a doctor’s office or the ER. But before Kennel’s study, nobody knew whether the same was true in the back of an ambulance.

And they nearly didn’t get to know, because the research required ambulance companies to release highly sensitive data.

“We were prepared to maybe not look that great,” said Robert McDonald, the operations manager at American Medical Response in Portland. AMR is one of the nation’s largest ambulance organizations, and it shared its data from more than 100,000 charts with Kennel.

Some people chalk up the disparities he found to differences in demography and health insurance status, but Kennel said he controlled for those variables.

So now that AMR knows about disparities in its care, what can the company do?

“My feeling is we’re probably going to put some education and training out to our folks in the field,” McDonald said.

In addition, he said, AMR is going to hire more people of color.

“We want to see more ethnicities represented in EMS — which has historically been a white, male-dominated workforce,” McDonald said.

AMR’s policies must change, too, he added. The company has purchased software that will enable patients to read medical permission forms in any of 17 different languages. And the firm is planning an outreach effort to communities of color to explain the role of EMS workers.

This story is part of a partnership that includesÌý,Ìýand Kaiser Health News.

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¿Cómo están respondiendo los funcionarios de salud pública?

En el condado de Clackamas, en el noroeste de Oregon, han decidido preguntarles a las personas a las que se les diagnostica una ETS cuáles son o fueron sus parejas sexuales, y buscarlas.

Ese trabajo recae en dos mujeres: la enfermera registrada Mary Horman y la especialista en intervención de enfermedades Liz Baca. La mayor parte de la tarea la realizan por teléfono, informándoles a las personas que su pareja sexual (no les dicen el nombre) ha sido diagnosticada con gonorrea, VIH, clamidia o sífilis.

Es una conversación difícil. Y a muchos no se los puede contactar por teléfono. Entonces, una vez a la semana, Horman y Baca se suben a un automóvil y comienzan golpear puertas.

“A veces puede ser aterrador”, dijo Baca, “especialmente en las zonas rurales donde realmente confías en el GPS para llegar a destino, y en ocasiones hay caminos que te llevan… a ninguna parte”. Hasta ahora nunca se han perdido.

Muchos residentes en las afueras del condado poseen armas de fuego, agregó Baca, y se sienten cómodos mostrándolas, si sienten que necesitan proteger sus propiedades.

“Siempre trato que me vean bien y de no parecer temerosa”, dijo. Su objetivo es acercarse con la mayor calidez posible, diciendo: “’Vengo con una enfermera’ o ‘Me llamo Liz y trabajo para el condado de Clackamas'”.

Las mujeres viajan juntas y nunca entran a una casa, explicó Baca. Y siempre llevan un teléfono celular para mantener informada a la oficina central sobre su paradero.

En la tarde que las entrevisté, Horman y Baca ya habían sido desafiadas por un perro y tuvieron que irse del parque de casas rodantes con las manos vacías. Tenían la dirección correcta, pero no sabían a qué puerta tocar. Y no podían simplemente preguntar, porque los vecinos pueden adivinar por qué el departamento de salud está rastreando a alguien, y eso sería una violación de la privacidad médica.

Luego llamaron a un trabajador de 64 años, al que identificamos solo como Larry por las mismas razones de privacidad. Acordó hablar con ellas, con la esperanza de advertir a otras personas sobre los .

Baca y Horman le explicaron cómo algunas enfermedades, como la sífilis, son , lo que significa que tan pronto como lo diagnosticaron a Larry, el médico tuvo que informar al condado, y por eso ellas estaban allí.

Larry les dijo que ya había recibido penicilina por vía intravenosa y que estaba sanando bien.

La conversación se hizo más dura cuando Baca trató de comprender el alcance de la infección de Larry mostrándole imágenes gráficas de llagas y erupciones.

“Entonces, otro síntoma de la sífilis secundaria es la pérdida de cabello”, le explicó. “¿Recuerdas alguno de estos síntomas? ”

“Sí”, respondió Larry, sonriendo. “Y he tenido llagas en estos 10 años”.

Eso significa que Larry vivió con sífilis por al menos una década, sin saberlo.

Muchas personas que tienen sífilis son asintomáticas, lo que significa que portan la bacteria, pero no muestran síntomas obvios. Y eso hace que la infección sea más difícil de combatir.

Además, el hecho que la enfermedad fue por un tiempo, hace que algunos médicos más jóvenes no reconozcan fácilmente los síntomas.

Larry dijo que solía tener relaciones sexuales con múltiples parejas que contactaba a través de Craigslist, pero no recuerda ningún nombre.

Después de 10 años, ya es demasiado tarde para rastrear a esas personas, dijo Baca, abatida. Aun así, siente que hablar con Larry no fue una pérdida de tiempo.

“Al estar en la calle, te encuentras con la gente y logras tener esa intervención de salud pública que es crucial”, dijo.

David Harvey, director ejecutivo de la National Coalition of STD Directors, coincidió en que los esfuerzos de los trabajadores de campo como Baca y Horman son vitales.

“Los especialistas en intervención de enfermedades están haciendo un trabajo heroico”, dijo. “Están ayudando a las personas a navegar el sistema y a recibir atención”.

Harvey agregó que, veinte años atrás, había hasta 4.000 especialistas en intervención de enfermedades como Baca en el país. Ahora, debido a los costos de salud pública, el número ha bajado a aproximadamente 1.400.

Baca dijo que continuará el trabajo, priorizando las poblaciones de alto riesgo, como los hombres que tienen relaciones sexuales con hombres y las mujeres embarazadas.

La doctora Sarah Present, oficial de salud pública del condado de Clackamas, dijo que la sífilis en los recién nacidos puede causar complicaciones neurológicas graves e incluso la muerte.

“Tenemos varios casos de sífilis congénita en nuestro condado este año”, señaló Presente, “algo inaudito hace una década”.

En parte debido a ese aumento de la , Clackamas ahora dedica más recursos a rastrear agresivamente a las parejas, y a alentarlas a que se realicen la prueba, dijo Present, incluso si esas notificaciones pueden llevar a conflictos familiares.

“Hacemos todo lo posible para que la [persona diagnosticada en primer lugar] hable con sus parejas por nosotros”, dijo Present. “No queremos ser los malos”. Sin embargo, podemos ser un aliado para las personas que tienen las infecciones y ayudarlas a encontrar la mejor manera de controlar la propagación de la enfermedad”.

Un a principios de este verano muestra que las tasas de sífilis han aumentado 1,300 % en ocho años, en parte debido a que las cifras solían ser muy pequeñas.

Y Clackamas no es un caso atípico. Un nuevo informe de los Centros para el Control y Prevención de Enfermedades (CDC) encontró que, en los últimos años y a nivel nacional, y los casos de sífilis en un 76%.

El , director del Centro Nacional de Enfermedades de Transmisión Sexual de los CDC, dijo que la nación está retrocediendo.

“Los sistemas que previenen la diseminación de estas enfermedades están quebrándose”, agregó.

Los científicos dicen que hay muchas razones para que los casos se disparen a nivel nacional, desde el aumento de las bacterias resistentes a los antibióticos, hasta la facilidad de tener sexo casi de manera anónima en una era de aplicaciones de citas en celulares.

Los departamentos de salud pública en los Estados Unidos tienen un . En su esfuerzo por prevenir la propagación de enfermedades, se les permite inspeccionar, tratar y poner en cuarentena a cualquier persona, incluso sin su consentimiento. Ese poder se origina en la ley inglesa, que considera que los derechos de un individuo pueden limitarse en nombre del bien común.

El ejemplo más famoso es el de la cocinera Mary Allon, de Long Island, Nueva York, a la que se la conoció como . Allon era portadora asintomática y transmisora ​de la fiebre tifoidea a principios del siglo XX, y funcionarios de salud estatales la mantuvieron aislada, a la fuerza, por años.

Nadie aboga ahora por medidas tan draconianas, especialmente para las enfermedades de transmisión sexual. Pero los departamentos de salud pública pueden ejercer un poder significativo sobre ciertas enfermedades infecciosas (como la a los medicamentos) que son más ampliamente contagiosas porque se trasmiten por el aire.

El condado de Clackamas y los otros dos condados que conforman el área metropolitana de Portland han recibido subsidios estatales y federales importantes para ayudar a pagar el trabajo de alcance comunitario extra de salud pública.

Están tomando varias medidas para detener la transmisión de infecciones sexuales, como el fortalecimiento de las actividades de prevención, la mejora de las pruebas de detección, la evaluación de poblaciones de alto riesgo y la educación del público. Los condados también intentan apoyar mejor a las personas cuyos resultados dan positivos.

Cuando Baca y Horman visitaron a Larry en el porche de su casa, el hombre se dio cuenta que estaba muy enfermo y comenzó a tomarse la infección muy en serio, “iba a ser una cuestión de vida o muerte”.

Baca y Horman reconocen que la oportunidad de salvar vidas es la razón por la cual hacen este trabajo, aunque a veces es incómodo, reconocieron ambas mientras volvían al auto, listas para visitar al próximo paciente.

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So how are public health officials responding?

In northwest Oregon’s Clackamas County, health officials have decided to ask anyone who comes in with an STD who their sexual partners are — and then track those partners down.

That job falls to two women: registered nurse Mary Horman and disease intervention specialist Liz Baca. They do most of the work over the phone, telling people they’ve had a partner (no name is revealed) who has tested positive for gonorrhea, HIV, chlamydia or syphilis.

It’s a difficult conversation. And many people can’t be reached via phone. So about once a week, Horman and Baca jump into a car and start knocking on doors.

“It can definitely be scary at times,” Baca said, “especially those rural areas where you’re really relying on the GPS to get you there, and sometimes there are roads that lead you to nowhere.” So far, they haven’t gotten lost.

Plenty of residents in the county’s outskirts own firearms, Baca said, and are comfortable displaying them if they feel they need to protect their property.

“I always try to make myself visible and not be fidgety,” she said. Her goal is to approach with as much warmth as possible, saying, “‘I have a nurse with me.’ Or, ‘My name is Liz, and I work for Clackamas County.'”

The women travel as a pair and never enter a home, she said. And they always carry a cellphone to keep the home office informed of their whereabouts.

On the afternoon I caught up with them, Horman and Baca already had been challenged by a dog and had to leave a trailer park empty-handed. They had the right location, but didn’t know which door to knock on. And they couldn’t just ask around, because neighbors might guess why the health department is tracking someone down, and that would be a breach of medical privacy.

They next called on a 64-year-old laborer, whom we’re identifying only as Larry for those same privacy reasons. He agreed to talk with them, in hopes of warning other people about the substantialÌý.

Baca and Horman explained how some diseases, like syphilis, are “” — meaning that as soon as Larry was diagnosed, the doctor had to inform the county, which is why they were at his door.

Larry told them he’s already had penicillin delivered intravenously and is healing fine.

The conversation got tougher as Baca tried to understand the extent of Larry’s infection by showing him graphic pictures of sores and rashes.

“So, another symptom of secondary syphilis is the loss of hair,” she explained. “So, you suddenly lose some hair. You’re thinking, ‘What’s going on?’ In a couple of weeks, it resolves. And you’re still infected. So do you recall any of these symptoms?”

“I do,” Larry said, smiling. “And I would probably say that the lesion, I think you called it, I think occurred — it was probably about 10 years ago.”

That means Larry was living with syphilis for at least a decade — without knowing it.

Many people who have syphilis are asymptomatic — meaning they are carriers of the bacteria but show no obvious symptoms. And that makes the infection tougher to fight.

Also, the fact that the disease was, for a time,ÌýÌýin much of the United States,Ìýmeans some younger doctors don’t readily recognize the symptoms and signs.

Larry said that he used to have sex with multiple partners he found on Craigslist, but he can’t remember any names.

After such a long time, it’s too late to track down those people, Baca recalled, crestfallen. Still, she insisted, her time wasn’t wasted.

“Being out in the field, you find individuals and you get that public health intervention that is crucial,” she said.

David Harvey, the executive director of the National Coalition of STD Directors, echoed that the efforts of fieldworkers like Baca and Horman are vital.

“Disease intervention specialists are doing heroic work,” he said. “They’re helping to navigate and get people into care.”

Twenty years ago, Harvey said, there were as many as 4,000 disease intervention specialists like Baca in the U.S. Now, because of public health costs, the number is down to about 1,400.

Baca said she’ll continue the work, prioritizing high-risk populations — like men who have sex with men and pregnant women.

The public health officer for Clackamas County, Dr. Sarah Present, saidÌýÌýcan cause serious neurological complications and even death.

“We have now multiple cases of congenital syphilis in our county — just in this year,” Present noted, “whereas that had been fairly unheard of for at least the last decade, if not more.”

Partly because of that surge in syphilis among babies, Clackamas now dedicates more resources to aggressively tracking down partners and encouraging testing, Present said — even if those notifications might lead to family strife.

“We do our absolute best to have the [first person diagnosed] talk to their partners for us,” said Present. “We don’t want to have to be the bad guys. However, we can be a partner for people who have the infections — and help them figure out the best way to control the spread of the disease further.”

AÌýÌýreleased by Clackamas County earlier this summer shows rates of syphilis have increased 1,300 percent over eight years — in part, because the numbers involved used to be so small.

“Within the last year, we have seen our numbers dramatically increase to the point I’m quite concerned about it,” Present said.

And Clackamas is no outlier. A new report from the Centers for Disease Control and Prevention found that over the past several years, the number of gonorrhea cases has increasedÌý, and syphilis cases are up 76 percent.

The director of the CDC’s national center for STDs,Ìý, said the nation is sliding backward.

“It is evident the systems that identify, treat and ultimately prevent STDs are strained to the near-breaking point,” he said.

Scientists say there are many reasons for the national increase — from the rise in antibiotic-resistant bacteria, to the ease of finding anonymous sex in an era of cellphone hook-up apps.

Public health departments in the United StatesÌýhaveÌý. In their effort to prevent the spread of disease, they are allowed to inspect, treat and quarantine anyone — even without consent. That power originates in English common law, which finds the rights of an individual can be limited for the common good.

The most famous example is perhaps the Long Island, N.Y.,Ìýcook, Mary Mallon, better known as “.” She was an asymptomatic carrier — and transmitter — of typhoid in the early 1900s, and was forcibly isolated for years by New York public health officials.

Nobody’s advocating such draconian measures now, especially for sexually transmitted diseases. But public health departments can exercise significant power over certain infectious diseases (such asÌý) that are more broadly contagious because they are airborne.

Clackamas County and the two other counties that make up the Portland metro area have received substantial state and federal grantsÌýto help pay for extra public health outreach.

They are taking several steps to stop the transmission of STDs — like strengthening prevention activities, enhancing screening, testing high-risk populations and educating the public. The counties also try to better support people who test positive; expand investigations; and unite community leaders on this important issue.

As Baca and Horman visited with Larry on his front porch, the man thought back to when he first realized he was very sick. Once he found out why his health was failing, he said, he started to take the infection seriously. “Because, really truly, for me,” he said, “it was going to be a matter of life and death.”

Getting the chance to save lives is why Baca and Horman do this work, they said, even if it’s uncomfortable sometimes.

A few minutes later, the women climbed back into the car they’d left parked in a spot where getting away would be easy — just in case Larry wasn’t so accommodating. They checked their map and the next name on their list.

“There are those areas where you’re entering a property and there’s no one in sight,” Baca said, “and dogs can be scary. You have to run very fast if you see them.”

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But some health organizations are now asking much more general questions: Do you have trouble paying your bills? Do you feel safe at home? Do you have enough to eat? Research shows these factors can be as important to health as exercise habits or whether you get enough sleep.

Research has begun to show that a person’s to her health as her genetic code.

That’s why Shannon McGrath was asked to fill in a “” this spring when she turned up for her first obstetrics appointment at Kaiser Permanente in Portland, Ore. She was 36 weeks pregnant. (Kaiser Health News is not affiliated with Kaiser Permanente.)

“When I got pregnant I was homeless,” she said. “I didn’t have a lot of structure. And so it was hard to make an appointment. I had struggles with child care for my other kids; transportation; financial struggles.”

“I find it incredibly helpful because it can be very hard to find out,” said Lambert, who is McGrath’s OB-GYN and works at Kaiser Permanente Northwest. “Having it coded right there — we have this problem list that jumps up — really can give you a much better understanding as to what the patient’s going through.”

Federal officials introduced new medical codes for the social determinants of health a few years ago, saidÌý, director of the Office of Minority Health at the Centers for Medicare & Medicaid Services.

“More providers are beginning to recognize the impact that the social determinants have on their patients,” she said.

Nicole Friedman, a regional manager at Kaiser Permanente Northwest, agreed. But she goes one step further.

She hopes giving doctors more information about the home life of each patient will push health care in a new direction — away from more high-priced treatments and toward providing the basics that protect a person’s health.

“My personal belief is that putting more money into health care is a moral sin,” she said. “We need to take money out of health care and put it into other social inputs, like housing and food and transportation.”

Linking health organizations like KP with nonprofit social services such as the Oregon Food Bank will help governments and medical providers see where their money can make the biggest difference, Friedman said.

For example, spending more on affordable housing for homeless people can also have health benefits — in turn, saving the government money down the line.Ìýin emergency room utilization.

McGrath was initially skeptical when doctors offered to help her with things like rent and transportation.

“I didn’t want someone to see my situation and have it raise alarms,” she said.

But ultimately she was glad to have shared that information.

“I’m able to look at life and not feel overwhelmed or burdened,” she said, “or like I’ve got the whole world on my shoulders.”

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Not in the first years, said a online in the New England Journal of Medicine.

The study found ER use among Medicaid patients in Oregon stayed high even two years after people gained coverage, and even as more patients visited doctors’ offices, too.

All eyes have been on Oregon to answer this question because eight years ago, Oregon tried an experiment. It wanted to expand Medicaid, but it didn’t have the money to cover every eligible resident.

It wouldn’t be ethical to leave some people without coverage just to be a “.” But, since the state was doing it, it offered an invaluable chance to study the differences between people who have Medicaid and people who don’t.

It was the first randomized study on the impacts of health insurance, and it’s one of the largest, surveying 25,000 people.

The first findings reported earlier were that MedicaidÌýÌýin many ways: it improved people’s financial security; they went to the doctor when they were sick and it reduced rates of depression.

“These are all things that are really important benefits of Medicaid expansion,” said Wright.

But another earlier study found Medicaid enrolleesÌýÌýby 40 percent over the first 15 months.

“That was a surprise to a lot of folks,” said Wright.

It was widely believed that having insurance would encourage people to get primary care in doctors’ offices or clinics, instead of waiting until they’re really sick and heading to the ER, where care is most expensive.

After that study, experts scrambled to explain what was happening. Some thought it was pent-up demand from a group that hadn’t seen a doctor in years because they didn’t have insurance.

Others thought people just hadn’t had time to establish a relationship with a primary care doctor. And that when they did, emergency department use would drop.

But now, after looking at two years of data, that’s not what this latest study found, said Wright, who is one of the researchers.

“There was no sign that this ED use went down. So this idea of pent-up demand sort of fading away, at least in the first couple of years, it didn’t happen.”

Quite the opposite.

“If your hope is that in the short term, the first couple of years, you’re going to see savings that come out of reduced ED use from Medicaid expansion alone. I don’t think I’d be super optimistic about that. I think that it is going to cost money in the short term,” he said.

Wright said there maybe savings in other areas, like an increased use of preventive services that could stave off problems that would become more expensive later.

And, Leslie Clement, with the Oregon Health Authority, said during the past two years, Oregon has seen avoidable emergency room use drop by 4 percent.

She said, that’s because the state is coordinating care better, by doing things like helping people get to their doctors’ appointments and take their medication.

“It is not just a ‘open up coverage and let people used health care services as they have done historically,’ ” she said. “But it’s reforming that system.”

The Oregon study can’t tease out much more information because the experiment had to stop when the state expanded Medicaid fully under the Affordable Care Act.

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Five more states could come into that last category this fall, as voters decide whether to legalize it in California, Nevada, Maine, Massachusetts and Arizona.

It was only six years ago that Arizona approved marijuana for medicinal use, and that’s a stark contrast to Oregon, where medicinal marijuana was legal for almost two decades before smoking pot for fun became OK last year.

Opposition to recreational use in Arizona has been organized and vocal. A group that includes two county attorneys sued, unsuccessfully, to get it off the ballot.

And then there are people like Debbie Moak, 59, who said she put her son in drug rehab when he was 20.Ìý“A lot of these kids who are going to be impacted the most by this, they won’t be voting in this election,” said Moak, who lives outside of Phoenix. “This is where we need to be the adult in the room and protect the kids.”

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“My leg started bothering me. First it was my knees.” She ignored the pain, and thinks now it was it the sciatic nerve acting up, all along. “I just tried to deal with it,” Keene says.

But eventually, she went to a doctor who prescribed Vicodin and muscle relaxants. – more than 900,000 people. The state currently leads the nation in nonmedical use of opioids. And about a third of the hospitalizations related to drug abuse in Oregon are because of opioids.

Keene says the drugs helped her, but only to a degree.

“My body was saying, ‘Well, if I take another one, maybe it’ll work.’ So, I mean, that’s just human nature. Especially when you’re in the kind of pain I was in. You get to the point after months and months of pain where you’re begging for anything – anything — to relieve the pain,” she says.

In the end, Keene says, she became addicted. Her doctor ended up cutting off her supply of pills.

“I got very upset. I said, ‘What do you mean? You gave them to me. Why’d you give them to me and then tell me that I couldn’t have them?’ I was begging,” she says.

Then Keene went to the , a pain management center in Portland.

“There should be an array of things for people to choose from,” Eisen says, “whether it be chiropractic care, or naturopathic care, or acupuncture, nutrition, massage. TryÌýthose things — and if they don’t work, you use opioids as a last resort.”

Oregon wants more patients to take this approach. , coordinator of the Oregon Pain Management Commission, says Medicaid’s traditional way of dealing with back pain involved advising bed rest and prescribing painkillers.

“The only thing that might have been covered in the past was narcotics,” Taray says. “But treatments such as acupuncture, chiropractor, massage therapy, physical therapy and rehab would never have been covered.”

But starting in January 2016, the state will fund many of these back-pain treatments for patients who get their health care via Oregon’s version of Medicaid — the . While the treatments may cost more than a course of pain pills, the hope is that money will be saved by reducing the number of people who become addicted to opioids or abuse them. And pills as some people assume.

“Research is out there that suggests that with back conditions we’re spending a lot of money on health care treatments and services that aren’t improving outcomes,” Taray says.

Oregon also has not found overwhelming evidence that acupuncture, yoga or spinal manipulation work better than other options. But, as Taray points out, these alternatives don’t involve drugs.

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When Congress debated the Affordable Care Act in 2009, the legislation originally included a provision that would have allowed Medicare to reimburse doctors when they meet with patients to talk about end-of-life care.

But then Sarah Palin argued that such payments would lead to care being withheld from the elderly and disabled. Her comment ignited a firestorm among conservatives and helped fuel the opposition to the legislation.

Her assertions greatly distressedÌýDr. Pamelyn Close, a palliative care specialist in Los Angeles.

“It did terrible damage to the concept of having this conversation,” she said.

Amid the ensuing political uproar, Congress deleted the provision. And the lack of payments and concerns about the controversy further discouraged doctors from initiating these talks, according to Close.

“We just are not having these conversations often enough and soon enough,” Close said. “Loved ones who are trying to do always the right thing, end up being weighed with tremendous guilt and tremendous uncertainty without having had that conversation.”

“By paying doctors for these conversations, what we’re doing is opening the door to directive counseling and coercion,” said Catherine Glenn Foster, an attorney with the group. Foster says her organization supports end-of-life counseling and planning, but not in a doctor’s office.

“A doctor is not really the person you’d want to be having it with – particularly not a general practitioner who would not be able to advise on the nuances of end-of-life care in the first place,” she says.

But patients seem to want these talks. A 2012 study by the California HealthCare Foundation found thatÌýÌýof Californians would like to have an end-of-life conversation with their physician, but fewer than one in 10 has done so.

Many doctors who initiate the discussions often do so on their own dime. More often, they don’t have them at all, saidÌý, an internist with Cedars-Sinai Medical Center in Los Angeles.

“When a doctor has patients scheduled every 15 minutes, it’s difficult to have a face-to-face conversation about values and goals related to the end of life, which is one of the most sensitive topics that you can possibly discuss with a patient,” Stone said.

, an internist with the Center for Ethics in Health Care at the Oregon Health and Science University in Portland, says the informality with which such conversations are held now means that family members may not be included. Having the discussion as part of a formal doctor’s appointment can change that, she said.

“What it does is, it gives this really important conversation dignity and standing,” she said.

In Oregon, doctors have been squeezing end-of-life discussions into regular medical appointments for decades, under less-than-ideal circumstances. Over the last five years a quarter of a million Oregonians filed their wishes with a state registry. They use what’s known as a , which stands for Physician Orders for Life Sustaining Treatment. A version of it has been adopted by some other states, including New York and West Virginia.

Jo Ann Farwell, a retired Portland social worker who was recently diagnosed with a brain tumor, completed the form after talking to her doctor.

“I had surgery and had a prognosis of four to six months to live,” she said, after she was diagnosed with a brain tumor.

She did it, she said, to make sure her last hours are as comfortable as possible.

“I wouldn’t want to be on tube-feeding,” she said. “I wouldn’t want to be resuscitated, or have mechanical ventilation, because that would probably prolong my dying, rather than giving me quality of life.”

In the 1990s, health care workers all over Oregon recognized that the wishes of patients weren’t being consistently followed. So the health care establishment worked with the state and with ethicists to prioritize end-of-life talks; the result was the POLST form.

, a Democrat from Portland, has introduced the Medicare reimbursement legislation every session since 2009. Until now, he says, the federal government hasn’t placed any value on helping people prepare for death, and he finds that ironic.

“The Medicare program will pay for literally thousands of medical procedures, many of them very expensive and complex, even if the person is at the latest stage of life and it may not do any good,” Blumenauer says.

From a purely financial point of view, the change could save money. But Blumenauer says that’s not what’s driving him.

“I don’t care what people decide,” he says. “If they want to die in an ICU with tubes up their nose, that’s their choice. What we want is that people know what their choices are.”

Farwell, the brain tumor patient, well remembers when her sister was dying from cancer.

“She never talked about death or dying,” Farwell said, “never talked about what she wanted at the end. It was very, very difficult for me to try to plan and give her care.”

Farwell wants her sons to be in a better position when it comes to carrying out her wishes.

The federal government is now accepting public comment on the Medicare reimbursement proposal. It’s expected to make a decision in November.

This story is part of a partnership that includes KPCC, Oregon Public Broadcasting, NPR andÌý.

KHN’s coverage of aging and long term care issues is supported in part by a grant from .

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