Back in 2013, ProPublica detailed what seemed a stunning development in the pharmaceutical industry’s drive to win the prescription pads of the nation’s doctors: In just four years, one doctor had earned $1 million giving promotional talks and consulting for drug companies; 21 others had made more than $500,000.
Six years later — despite often damning scrutiny from prosecutors and academics — such high earnings have become commonplace.
More than 2,500 physicians have received at least half a million dollars apiece from drugmakers and medical device companies in the past five years alone, a new ProPublica analysis of payment data shows. And that doesn’t include money for research or royalties from inventions.
More than 700 of those doctors received at least $1 million.
“Holy smokes,” said Dr. Walid Gellad, an associate professor of medicine and health policy at the University of Pittsburgh, where he leads the Center for Pharmaceutical Policy and Prescribing. It is “quite striking” how much money doctors were earning from “other activities aside from patient care,” he said.
Some academics and physicians predicted that the exposure might cause companies to rethink making payments and doctors to rethink taking them. A flurry of studies matched the payment data with doctors’ prescribing choices and found links between the payments and the products doctors chose.
But ProPublica’s new analysis shows that the public reporting has not dampened the enthusiasm of the drug and medical device industry for having doctors deliver paid dinner talks and sponsored speeches or paying them to consult on products.
In fact, there has been almost no change in how much the industry is spending. Each year from 2014 to 2018, drug and medical device companies spent between $2.1 billion and $2.2 billion paying doctors for speaking and consulting, as well as on meals, travel and gifts for them. (These figures do not include research spending, but they do include royalties.)
Roughly the same number of doctors — more than 600,000 — received payments in any given year.
That consistency, some academics say, is conspicuous.
“It makes me wonder whether patients are using this information or whether physicians are even aware this information is out there,” said Dr. Joseph Ross, a professor of medicine and public health at Yale who has studied pharmaceutical marketing. “It’s almost like it’s not happening.”
Holly Campbell, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, defended company payments to doctors. “It is not necessarily a negative that the numbers have remained generally flat over the past five years,” she wrote in an email. “That statistic appears to be consistent with companies’ belief that their interactions with physicians have been and remain legitimate, even when subjected to sunshine.”
ProPublica updated Dollars for Docs with the latest data from the federal government on all payments.
Among their findings:
Consistency Breeds Familiarity
Over the course of five years, 1 million doctors, dentists, optometrists, chiropractors and podiatrists received at least one payment, most often a meal, from a company. Of those practitioners, more than 323,000 received at least one payment every year. About 240,000 received a payment in only one year. And the rest received payments in more than one year but in fewer than five.
For context, there are about 1.1 million doctors in the United States.
Dr. Aaron P. Mitchell, a medical oncologist and health services researcher at Memorial Sloan Kettering Cancer Center, said his research has shown that when doctors interact more consistently with a drug company they are more likely to prescribe that company’s cancer drug. The drug industry, Mitchell said, “knows that they need to cultivate relationships over more time, so that’s what they’re really trying to do. It’s not just one drug meal. It’s consistency.”
Some Drugs Are Promoted Heavily Year After Year
Of the top 20 drugs with the most annual spending on doctors from 2014 to 2018, six made the list in each of the years: Invokana to treat type 2 diabetes, the blood thinners Xarelto and Eliquis, the antipsychotic Latuda, the immunosuppressive drug Humira and the multiple sclerosis drug Aubagio. Another three drugs were on the list for four years: Victoza to treat type 2 diabetes, psoriasis treatment Otezla and the cholesterol-lowering drug Repatha. (Research funding and royalties are not included.)
Xarelto topped the list in spending for four years, totaling more than $123 million in payments from 2014 to 2018. In March, its makers, Johnson & Johnson and Bayer AG, agreed to pay $775 million to settle about 25,000 lawsuits claiming that the companies had failed to warn patients that Xarelto could cause fatal bleeding.
In statements, J&J and Bayer have said that the allegations lacked merit and that Xarelto is safe and effective. They noted that six cases that went to trial were decided in their favor.
Many drugs on the list are in categories where there is fierce competition. For example, seven of the top 20 in 2018 treat diabetes. And in most of the drug classes on the list, “there are more than one available drug — sometimes all with the same mechanism of action — indicated for the same condition selling for very high prices,” Dr. Aaron Kesselheim, a professor of medicine at Harvard Medical School, said in an email.
According to GoodRx, a drug discount website, the average cash price of a month’s supply of diabetes drugs Invokana, Jardiance and Farxiga is more than $600.
“Promotional spending is a major way that manufacturers in these situations distinguish themselves from each other — not by conducting comparative studies or by engaging in substantial price reductions,” Kesselheim said.
ProPublica and a number of researchers have examined the types of drugs that prompt the highest payments. Ross, of Yale, and a colleague published an analysis in the British Medical Journal in 2017 that found that the “top promoted drugs were less likely than top selling and top prescribed drugs to be effective, safe, affordable, novel, and represent a genuine advance in treating a disease.”
“Our findings suggest that pharmaceutical promotion should be met with healthy skepticism,” the analysis concludes.
Prosecutors Say the Payments by Some Drug Companies Are Kickbacks, Despite the Transparency of Open Payments
There is a perception among many physicians, including some in academia, that drug company payments are fairly benign — a moonlighting gig that educates other doctors about important medications. But since ProPublica began looking at physician payments, one drugmaker after another has paid tens, or even hundreds, of millions of dollars to resolve allegations of improper, or illegal, marketing tactics.
In fact, drug company whistleblowers and federal prosecutors have said explicitly that in some cases the payments were actually bribes and kickbacks. And this behavior has continued despite tools like Dollars for Docs.
Here are some recent examples:
Spending: In 2014, the payment data shows, Insys Therapeutics spent $7.5 million promoting Subsys, a fentanyl spray for advanced cancer pain, making it one of the drugs with the most spending that year. Through 2018, the company’s total spending on the drug had reached $17.6 million.
Prosecutors say: Insys paid doctors to speak about Subsys to other physicians during “educational lunches and dinners,” according to a Justice Department press release, from August 2012 to June 2015. The meals “were actually used as a vehicle to pay bribes and kickbacks to targeted practitioners in exchange for increased Subsys prescriptions to patients and for increased dosage of those prescriptions.”
Penalty: This June, Insys agreed to plead guilty to five counts of mail fraud, pay a $2 million fine and forfeit $28 million. It also agreed to pay $195 million to settle a separate whistleblower case. At least eight company executives have now been convicted of crimes relating to the illegal marketing of the drug. Insys has said it completely restructured its operations, hired new leaders and has filed for bankruptcy protection.
Spending: From 2014 to 2018, Avanir spent nearly $22 million on its drug Nuedexta, which treats pseudobulbar affect, or uncontrollable laughing or crying.
Prosecutors say: An Avanir employee reported that one doctor at a long-term care facility, who was also a paid speaker for Nuedexta, put “entire units” of patients on Nuedexta. Another doctor at the facility, which had a number of dementia patients, routinely stopped the Nuedexta, only to have the first doctor restart it, according to a Department of Justice press release.
Penalty: In September, the company agreed to pay more than $108 million to resolve criminal and civil allegations that it paid kickbacks to doctors and marketed the drug for unapproved uses, including behaviors associated with dementia. In a statement, Avanir said it fully cooperated with investigators “and engaged in extensive remedial measures. The individuals listed in the resolution agreements are no longer Avanir employees.”
Though relationships between drug companies and doctors continue, seemingly with little change, Kesselheim, of Harvard, said that the transparency “helps bring into light an area of the field that was in the shadows.
“Now we need to figure out what to do with this.”
Republished with permission under license from ProPublica.
By April Thames, University of Southern California
Negative social attitudes, such as racism and discrimination, damage the health of those who are targeted by triggering a cascade of aberrant biological responses, including abnormal gene activity. It is not surprising that reports documenting lifespan and causes of mortality have demonstrated a clear pattern: African Americans die sooner and bear a heavier burden of many diseases, including hypertension, heart disease, dementia and late-stage breast cancer.
Scientists have searched for genetic causes to health disparities between blacks and whites but have had limited success. The strongest evidence to date points to social-environmental factors such as poverty, health care inequities and racism.
Our society is plagued by racism and racial inequality which is not fully recognized by all, according to a recent study showing that many Americans overestimate our progress in fixing racial inequality. On the other hand, more Americans (65%) are aware that it has become more common for people to express racist or racially insensitive views, according to a U.S. survey.
Racism is not merely negative attitudes or treatment from one person to another. Racism has deep historical roots in American society, sustained through institutional policies and practices, whereby people of color are routinely and systematically treated differently than whites.
As an African American/white individual, I often experienced comments growing up like “You don’t sound black,” and “What are you?” that made me cringe. In college, I became intrigued by the field of psychology as it was a field that explained how prejudices, stereotyping and racism arise. My research as a clinical psychologist at USC is focused on understanding how societal factors interact with biology to create disparities in health outcomes. A recent study I co-authored showed that racism promotes genes that turn on inflammation, one of the major drivers of disease.
Less overt, but entrenched
Although racism may be less overt today than during the early 20th century, government policies and norms, unfair treatment by social institutions, stereotypes and discriminatory behaviors are sobering reminders that racism is still alive – and contribute to earlier deaths in addition to poorer quality of life.
For example, blacks are more likely than whites to receive drug testing when prescribed long-term opiates even though whites show higher rates of overdose. African Americans have shouldered the burden of racism for decades, creating a level of mistrust for societal systems, be it health care or law enforcement.
Terms such as “driving while black” illustrate how racism and discrimination have been deeply embedded in African American cultural experience. Just imagine trying to buy a home and being turned down because of your race. This is too common of an experience for African Americans. Nearly half (45%) reported experiencing discrimination when trying to find a home and in receiving health care, according to a Robert Wood Johnson survey that was developed by the Harvard T.H. Chan School of Public Health, Robert Wood Johnson Foundation and National Public Radio.
From macro to micro, the effect is widespread
Until recently, we scientists did not know the mechanism linking racism to health. The new study from my lab here at USC and colleagues at UCLA shows that the function of genes may explain this relationship. As it turns out, our study showed that genes that promote inflammation are expressed more often in blacks than in whites. We believe that exposure to racism is why.
We previously showed how activating racism, such as asking people to write down their race before taking an exam, in the form of stereotyping impairs brain functions such as learning and memory and problem-solving in African Americans. This may partly explain the higher rates of dementia in African Americans compared to whites.
Researchers have well documented that chronic stress alters the function of brain regions, such as the hippocampus, that are targeted in brain diseases such as Alzheimer’s disease. This work has been expanded through the field of social genomics, largely pioneered by my colleague Steve Cole at UCLA. A relatively new field called social genomics demonstrates how the function of genes – termed gene expression – is influenced by social conditions.
Genes are programmed to turn off and on in a certain manner. But those patterns of activity can shift depending on environmental exposures.
Certain marginalized groups demonstrate abnormal patterns of gene activity in genes responsible for innate immunity. Innate immunity is how the body fights off and responds to foreign pathogens. Dr. Cole named this pattern/sequence of gene activity the Conserved Transcriptional Response to Adversity. It refers to the how genes controlling innate immunity behave under positive or negative environmental conditions.
When environmental stresses like socioeconomic disadvantage or racism trigger the sympathetic nervous system, which controls our fight-or-flight responses, the behavior of our genes is altered. This leads to complex biochemical events that turn on genes, which may result in poor health outcomes.
The Conserved Transcriptional Response to Adversity profile is characterized by increased activity of genes that play a role in inflammation, and decreased activity of genes involved in protecting the body from viruses.
We found that blacks and whites differed in the pattern of which pro-inflammatory and stress signaling genes were turned on. Our findings are particularly important because chronic inflammation ages the body and causes organ damage.
As my colleagues and I pulled this study together, we took into consideration the health disparities such as socioeconomic status, social stress, and health care access. For example, we recruited African Americans and whites with similar socioeconomic status. We also examined racial differences in reports of other types of stress events. Both groups reported similar levels of social stress.
For this particular study, none of these traditional factors explained why African Americans had greater expression in pro-inflammatory genes than whites. However, we found that experiences with racism and discrimination accounted for more than 50% of the black/white difference in the activity of genes that increase inflammation.
So what do these results mean for future health? I believe racism and discrimination should be treated as a health risk factor – just like smoking. It is toxic to health by damaging the natural defenses our bodies use to fight off infection and disease. Interventions tailored toward reducing racism-associated stress may mitigate some of its adverse effects on health. As a society we cannot afford to perpetuate health inequities by undermining or disguising the biological impact of racism.
The government’s hefty arsenal of surveillance tools just welcomed a powerful new member. Rather than monitoring an external device—a bug or a smartphone—or even the exterior features of your face, the new tech aims straight for your heart. Literally.
First reported by MIT Technology Review, the US Pentagon is developing an infrared laser that captures a person’s unique “cardiac signature” from as far as 200 meters—the length of just over two football fields—away, as long as you’re still. According to Steward Remaly of the Pentagon’s Combating Terrorism Technical Support Office (CTTSO), even longer ranges may be possible with higher intensity lasers.
Although chilling, the tech builds on previous ideas.
Contact infrared sensors have long been used to monitor a person’s pulse, in a clinical setting or when traversing high altitudes. Here, the devices shoot infrared light into a finger and measure how much blood flow alters the refraction. Unlike this classic setup, the Pentagon’s new tech—dubbed Jetson—uses laser doppler vibrometry that detects minute movements on the skin caused by heartbeat.
Currently under development by Ideal Innovations, Inc., a veteran-owned biometrics, forensics, and scientific company based in Arlington, Virginia, the goal of Jetson is to positively identify an individual within five seconds using a “heartprint.”
“Existing long-range biometric methods that rely on facial recognition suffer from acquiring enough pixels at a distance to use the face matching algorithms and require high performance optics to acquire visual signatures at significant distances,” explained the CTTSO. “The Jetson effort…is a ruggedized biometric system that will capture cardiac signatures to aid in the positive identification of an individual” from a distance with little lag time.
Jetson is just the latest attempt at surveillance from a distance. Rather than old-school technologies such as fingerprinting or retinal scans, this new generation of surveillance technologies uses biometrics to monitor your every move—be it face, speech, heartbeat, or even brain activity—from a distance.
The tech may sound extreme, but Jetson is using the same playbook as biometrics for security. And to project where surveillance is going, it pays to look at biometrics research as the canary in the coal mine. Using your finger or face to unlock your phone is just the convenient side of things—what makes your biometric signature secure as a passcode is also what makes you identifiable as an individual.
Facial recognition technology is no doubt the current crown prince of surveillance technologies. China readily adopted the tech as part of their Social Credit System, which monitors a civilian’s every move in public to generate a numerical score for compliance. Even here in the US facial recognition is welcomed by law enforcement. Amazon’s Rekognition system, for example, is reportedly “supercharging” police efforts in Oregon and other police departments, despite pressure from civil liberties groups, lawmakers, and even its own shareholders.
Surveillance loves facial recognition because the tech is relatively mature and can be done from a distance. And no doubt, there is value for the technology in long-range counterterrorism. For example, the technology can be used to remotely confirm the identity of a suspect—say, an ISIS leader—and in turn allow a state to authorize an attack.
The problem? Facial recognition software is far from perfect. A study by the ACLU using Rekognition found that the system incorrectly matched 28 members of Congress to mug shots, with the majority being African-American. Technological hiccups aside, a face is relatively easy to disguise. The perfect surveillance system needs to be efficient, effective, and low-error. In other words, it needs something more concrete, immutable, and physiological to target.
That’s where cardiac signatures come in.
Beat of the Heart
To Dr. Wenyao Xu at the State University of New York, the heart is a much better surveillance target than facial recognition. “Compared with face, cardiac biometrics are more stable and can reach more than 98 percent accuracy,” he said.
Back in 2017, his team developed a non-contact, remote biometrics device that uses dimensions of the heart as a person’s identifier for security. His system distills the geometry of a person’s heart—measured by refracting sound waves with Doppler radars—to identify the particular shape and size that characterizes an individual. But because it relies on sound waves, the system could only function up to 30 meters away—a fraction of the Pentagon’s ideal distance.
Other cardiac signatures have also been used for security. The Toronto company Nymi, for example, developed a wearable wristband that uses an employee’s electrocardiogram (ECG), which is also uniquely tailored to each individual, as an access passcode for an enterprise’s secure database.
Jetson extends this approach by co-opting an off-the-shelf device that normally measures vibrations from structures at a distance. The device further utilizes a gimbal to hold its laser beam steady, allowing it to keep its measurements on target. According to MIT Technology Review, the current system takes roughly 30 seconds to generate a good return signal, and it’s only effective if the target is staying put—either standing or sitting.
Despite these caveats, Remaly said that Jetson works with an admirable 95 percent accuracy if the conditions are optimal. In practice, though, this means Jetson isn’t accurate enough to be reliable on its own. If adopted into surveillance tech, it would likely work alongside other measures, such as facial recognition or gait analysis, as secondary confirmation.
In addition, unlike faces and fingerprints, cardiac signatures aren’t exactly standard collection data. For the technology to truly impact surveillance, the government needs to build a new database from scratch. However, the team argues, when deployed over a period of time—sufficient to capture the heartprint of an individual seen doing something they shouldn’t, for example—it may still be used to positively identify a person, even if his or her actual identity remains mysterious. What’s more, clothing isn’t a deterrent since the tech blasts right through.
Military use aside, the Pentagon foresees the technology trickling down into the cultural mainstream. A doctor could remotely monitor his patient’s cardiac rhythms, for example, without having to rely on electrical wires. Nevertheless, like technologies using echolocation to track an elderly person’s gait for falls, it’s an open question if the benefits warrant the invasion of privacy.
Monitoring the heart may be just the first step in a new age of long-distance biometrics surveillance.
Speech is another identifier under attack. According to the CTTSO, the already-completed project Beetlejuice uses a beam-forming microphone array to monitor an individual’s speech, in addition to performing speaker tagging, tracking, and locating. The tech relies on deep neural networks to reduce noise and allow near real-time situational awareness of incoming signals, filtering speaker, messages, languages, and location, the report stated.
“The capabilities will be integrated into a lightweight platform in support of operators on the move and handle a variety of noisy audio media…This unique combination will improve performance in both noise reduction, source location, and human language technologies,” the team explained.
Going even further, Xu and others are working on “brainprints” for security measures. Unlike facial or cardiac fingerprints, the brain offers an “inexhaustible” source of secure passwords based on its response to various stimuli, explained Xu.
Using EEG, which picks up neural electrical activity from electrodes placed on the scalp, the team can extract automatic and unconscious activation patterns as a “brain password” unique to a particular individual. Of course, so far there isn’t a way to remotely monitor someone’s brain activity or construct a database of initial readings. And unlike a face or retina, a brainprint changes when an individual is faced with another stimulus.
Nevertheless, a snapshot of brain activity perhaps most uniquely represents you, as an individual, and technological challenges haven’t exactly been a deterrent to agencies that stand most to gain (hydrogen bombs, anyone?).
If history’s any indication, security measures based on biometrics are ripe for hacking and tracking. Now, thanks to Jetson, smearing paint on your face or wearing thick jackets will no longer circumvent surveillance monitoring. San Francisco and Somerville, Massachusetts both recently blanket-banned facial recognition software in protection of civil rights, with New York likely to follow in narrower domains. It’s worth keeping an eye on what comes next.
More than five years after Flint’s water crisis first hit the news, the city has successfully lowered the lead levels in its water.
The most recently available testing, from the second half of 2018, puts the lead in Flint’s water at 4 parts per billion. That’s well below the level, 15 ppb, that the federal government currently regards as dangerous for public health.
If more than 10% of samples exceed 15 parts per billion of lead, the rule states that the water system must take steps to control pipe corrosion – the main source of lead in residential tap water – as well as to inform the public and the U.S. Environmental Protection Agency.
Water systems, especially in rural areas, can report much higher levels than the EPA cutoff. In 2017, for example, an elementary school in Tulare County, California, home to agricultural laborers, reported lead levels of 4,600 ppb. The school distributed bottled water to its students and replaced its well. The same year, a senior living center in Stroudsburg, Pennsylvania, had lead levels of 3,428 ppb. Such drinking water is truly poisonous, especially for children.
Large urban water systems tend to have lower contaminant levels than systems in rural areas, including for lead, because they have expert staff to run facilities. But when contamination occurs in urban systems, it affects more people. Flint’s water system serves 71,500 people and its woes drew the attention of the Obama administration. In 2004, when Washington, D.C. had similar lead levels, Congress intervened to demand a rapid fix.
Right now, Newark, New Jersey – an area that I have studied for more than 10 years – is in the hot seat for lead, but has not drawn similar attention. In June the city reported to the EPA lead samples more than 2.5 times higher than that of Flint at the peak of the crisis, the highest level in a two-year running problem.
The Pequannock facility, one of Newark’s two water treatment plants and the source of the issue, distributes water to the city and several surrounding communities. The Newark Water Department serves a total of more than 290,000 people.
Of cities with more than 100,000 in population reporting issues since the beginning of 2017, nearest in rank to Newark in terms of levels of lead is Pittsburgh; then Trenton, New Jersey; Fort Wayne, Indiana; Suez Water, headquartered in Hackensack, New Jersey, serving multiple communities; Portland, Oregon; Providence, Rhode Island; and Green Bay, Wisconsin.
Most cities reporting issues are in New England and the Middle Atlantic States, where older housing is more likely to have lead pipes that run from the water main into the home.
Shining a light on the problem: Missing data
What’s more, an undetermined number of water systems with lead problems in their water do not report heightened lead levels to the federal government, in violation of the law.
The report says that the number of water systems that do not report their problems at all is understated – in some cases badly so. Flint itself initially failed to report its elevated lead levels to the EPA. The congressional report, compiled by the Government Accountability Office, found a host of problems on this score, concluding that “data available from the EPA likely understate the number of sample results, violations and enforcement actions.”
As of December 2016, the end date of the GAO investigation, only about 47% of states had reported as required on their corrosion control methods, the primary way a lead problem is addressed.
The report recommended that the EPA require states to report data for small water systems, those most likely to fail to report, but the EPA folded this initiative into a revision of the Lead and Copper Rule that has not happened.
Without better data collection on lead contamination, Americans will never know how bad the problem really is in their communities.
SHILOH, Ill. — After a health insurance change forced Bernard Macon to cut ties with his black doctor, he struggled to find another African American physician online. Then, he realized two health advocates were hiding in plain sight.
At a nearby drugstore here in the suburbs outside of St. Louis, a pair of pharmacists became the unexpected allies of Macon and his wife, Brandy. Much like the Macons, the pharmacists were energetic young parents who were married — and unapologetically black.
Vincent and Lekeisha Williams, owners of LV Health and Wellness Pharmacy, didn’t hesitate to help when Brandy had a hard time getting the medicine she needed before and after sinus surgery last year. The Williamses made calls when Brandy, a physician assistant who has worked in the medical field for 15 years, didn’t feel heard by her doctor’s office.
“They completely went above and beyond,” said Bernard Macon, 36, a computer programmer and father of two. “They turned what could have been a bad experience into a good experience.”
Now more than ever, the Macons are betting on black medical professionals to give their family better care. The Macon children see a black pediatrician. A black dentist takes care of their teeth. Brandy Macon relies on a black gynecologist. And now the two black pharmacists fill the gap for Bernard Macon while he searches for a primary care doctor in his network, giving him trusted confidants that chain pharmacies likely wouldn’t.
Black Americans continue to face persistent health care disparities. Compared with their white counterparts, black men and women are more likely to die of heart disease, stroke, cancer, asthma, influenza, pneumonia, diabetes and AIDS, according to the Office of Minority Health.
But medical providers who give patients culturally competent care — the act of acknowledging a patient’s heritage, beliefs and values during treatment — often see improved patient outcomes, according to multiple studies. Part of it is trust and understanding, and part of it can be more nuanced knowledge of the medical conditions that may be more prevalent in those populations.
For patients, finding a way to identify with their pharmacist can pay off big time. Cutting pills in half, skipping doses or not taking medication altogether can be damaging to one’s health — even deadly. And many patients see their pharmacists monthly, far more often than annual visits to their medical doctors, creating more opportunities for supportive care.
That’s why some black pharmacists are finding ways to connect with customers in and outside of their stores. Inspirational music, counseling, accessibility and transparency have turned some minority-owned pharmacies into hubs for culturally competent care.
“We understand the community because we are a part of the community,” Lekeisha Williams said. “We are visible in our area doing outreach, attending events and promoting health and wellness.”
To be sure, such care is not just relevant to African Americans. But mistrust of the medical profession is especially a hurdle to overcome when treating black Americans.
Many are still shaken by the history of Henrietta Lacks, whose cells were used in research worldwide without her family’s knowledge; the Tuskegee Project, which failed to treat black men with syphilis; and other projects that used African Americans unethically for research.
Filling More Than Prescriptions
At black-owned Premier Pharmacy and Wellness Center near Grier Heights, a historically black neighborhood in Charlotte, N.C., the playlist is almost as important as the acute care clinic attached to the drugstore. Owner Martez Prince watches his customers shimmy down the aisles as they make their way through the store listening to Jay-Z, Beyoncé, Kirk Franklin, Whitney Houston and other black artists. Prince said the music helps him in his goal of making health care more accessible and providing medical advice patients can trust.
In rural Georgia, Teresa Mitchell, a black woman with 25 years of pharmacy experience, connects her customers with home health aides, shows them how to access insurance services online and even makes house calls. Her Total Care Pharmacy is the only health care provider in Baconton, where roughly half the town’s 900 residents are black.
“We do more than just dispense,” Mitchell said.
Iradean Bradley, 72, became a customer soon after Total Care Pharmacy opened in 2016. She struggled to pick up prescriptions before Mitchell came to town.
“It was so hectic because I didn’t have transportation of my own,” Bradley said. “It’s so convenient for us older people, who have to pay someone to go out of town and get our medicine.”
Lakesha M. Butler, president of the National Pharmaceutical Association, advocates for such culturally competent care through the professional organization representing minorities in the pharmacy industry and studies it in her academic work at the Edwardsville campus of Southern Illinois University. She also feels its impact directly, she said, when she sees patients at clinics two days a week in St. Charles, Mo., and East St. Louis, Ill.
“It’s just amazing to me when I’m practicing in a clinic setting and an African American patient sees me,” Butler said. “It’s a pure joy that comes over their face, a sigh of relief. It’s like ‘OK, I’m glad that you’re here because I can be honest with you and I know you will be honest with me.’”
She often finds herself educating her black patients about diabetes, high blood pressure, high cholesterol and other common conditions.
“Unfortunately, there’s still a lack of knowledge in those areas,” Butler said. “That’s why those conditions can be so prevalent.”
Avoiding Medical Microaggressions
For Macon, his experiences with medical professionals of backgrounds different from his own left him repeatedly disappointed and hesitant to open up.
After his wife had a miscarriage, Macon said, the couple didn’t receive the compassion they longed for while grieving the loss. A few years later, a bad experience with their children’s pediatrician when their oldest child had a painful ear infection sparked a move to a different provider.
“My daughter needed attention right away, but we couldn’t get through to anybody,” Macon recalled. “That’s when my wife said, ‘We aren’t doing this anymore!’”
Today, Macon’s idea of good health care isn’t colorblind. If a doctor can’t provide empathetic and expert treatment, he’s ready to move, even if a replacement is hard to find.
Kimberly Wilson, 31, will soon launch an app for consumers like Macon who are seeking culturally competent care. Therapists, doulas, dentists, specialists and even pharmacists of color will be invited to list their services on HUED. Beta testing is expected to start this summer in New York City and Washington, D.C., and the app will be free for consumers.
“Black Americans are more conscious of their health from a lot of different perspectives,” Wilson said. “We’ve begun to put ourselves forward.”
But even after the introduction of HUED, such health care could be hard to find. While about 13% of the U.S. population is black, only about 6% of the country’s doctors and surgeons are black, according to Data USA. Black pharmacists make up about 7% of the professionals in their field, and, though the demand is high, black students accounted for about 9% of all students enrolled in pharmacy school in 2018.
For Macon, though, the Williamses’ LV Health and Wellness Pharmacy in Shiloh provides some of the support he has been seeking.
“I still remember the very first day I went there. It was almost like a barbershop feel,” Macon said, likening it to the community hubs where customers can chitchat about sports, family and faith while getting their hair cut. “I could relate to who was behind the counter.”
I was hospitalized recently for three weeks. I was rushed by ambulance to the emergency room, transferred to another hospital for surgery where I spent the majority of my recovery in the intensive care unit (ICU).
Although a hospital is within an insurance provider’s network, the doctors providing care may not be. For insurance purposes, those physicians might be considered “out-of-network” providers, and the insurance company may not cover any of the treatment costs. This from what I understand is a fairly common practice. When this happens, the patient even when covered by insurance has to cover the majority of the medical cost.
Article By Michelle Andrews
Elham Mirshafiei was at the library cramming for final exams during her senior year at California State University-Long Beach when she grew nauseated and started vomiting. After the 10th episode in an hour, a friend took her to the nearest emergency room. Diagnosis: an intestinal bug and severe dehydration. In a few hours, she was home again, with instructions to eat a bland diet and drink plenty of fluids.
That was in 2010. But the $4,000 bill for the brief emergency department visit at an out-of-network hospital has trailed her ever since. Mirshafiei, 31, has a good job now as a licensed insurance adviser in Palo Alto, Calif. But money is still tight and her priority is paying off her $67,000 student loan debt rather than that old hospital bill.
Once or twice a year she gets a letter from a collection agency. She ignores them, and, so far, the consequences have been manageable. “It’s not like electricity that gets cut off if you don’t pay it,” she said.
Mirshafiei has plenty of company. At least 43 million other Americans have overdue medical bills on their credit reports, a federal Consumer Financial Protection Bureau report on medical debt found in 2014. And 59% of people contacted by a debt collector say the exchange was over medical bills, the most common type of contact stemming from an overdue bill, according to the CFPB.
This month, the CFPB proposed a rule to frame what debt collectors are allowed to do when pursuing many types of overdue bills, including medical debt.
Federal law already prohibits debt collectors from harassing consumers or contacting them before 8 a.m. or after 9 p.m., among other things. But the law, which was passed in 1977, didn’t anticipate emails and text messages. The CFPB’s proposal clarifies how debt collectors can use these communication tools. And it would allow consumers to opt out of being contacted this way.
The rule also specifies that debt collectors can make no more than seven telephone calls weekly over a specific debt.
But some consumer advocates panned the effort. “This really doesn’t go far enough to protect consumers and make sure that consumers are not abused or harassed or subject to unfair collection practices in debt collection,” said April Kuehnhoff, an attorney at the National Consumer Law Center who specializes in debt collection.
For instance, the center wants a limit of just three telephone attempts each week on a debt. The seven-call limit could be particularly tough on people with medical debt, Kuehnhoff said. They may accumulate bills from several providers for a single medical event — hospital, doctors, a lab and a nursing home, for example — and all could be in collections separately, potentially resulting in dozens of calls each week.
Debt collectors aren’t necessarily in favor of the seven-call cap either, but for different reasons. They say that limiting the number of calls could lead to more litigation or adverse credit reporting rather than working out a payment plan. Overall, the proposed rule seemed to strike a good balance between collection industry and consumer concerns, said Leah Dempsey, vice president and senior counsel for federal affairs at ACA International, a trade group representing 2,500 debt collectors, asset buyers and related professions.
The general consensus is that people should pay their debts. But taking responsibility for medical debt isn’t always as straightforward as paying off a large-screen TV that someone put on a credit card. Did health insurance pay the correct amount? Was the person screened for eligibility for Medicaid, charity care or financial assistance?
“The actual debt collector problem is often about the lack of accountability that providers have for the people that they pass their debt along to,” said Leonardo Cuello, director of health policy at the National Health Law Program.
When a debt collector calls, consumers who are confused about the bill should ask, in writing and generally within 30 days, that the debt be validated. Debts are often bundled and sold multiple times to different collectors, which means errors may be introduced along the way. “There are no magic words; you don’t need to cite the statute,” said Justin J. Lowe, legal director at Health Law Advocates, a nonprofit law firm in Boston that helps people with low incomes who are having trouble accessing or paying for medical care.
At that point, the collection agency has to stop activities until it proves what the consumer owes. The proposed CFPB rule would spell out verification information that must be provided along with instructions for consumers about how to dispute the debt.
The proposal would also address other practices, including the collection of so-called zombie debt. That refers to a bill that has passed a time limit — or statute of limitations — for bringing legal action, often between three and six years, depending on the state. In many states, if a collector sues someone for such a time-barred debt, consumers can raise the issue in court in their defense. If a judge agrees, the case could be dismissed.
Consumer advocates have long wanted debt collectors to be prohibited from trying to collect zombie debt. After several years, it can be difficult for patients to remember whether a bill has been paid or to locate records, they argue.
The proposed CFPB rule would prohibit debt collectors from suing or threatening to sue consumers for zombie debt, but only if the collectors knew or should have known that the statute of limitations had expired. That puts the onus on the consumer to prove what was in the debt collector’s mind rather than merely showing that too much time had passed to collect.
It’s unclear how the proposed changes announced by the CFPB might affect Mirshafiei’s situation. The statute of limitations in California on written contracts is four years.
One thing someone in Mirshafiei’s situation should be aware of is that making a payment could reset the statute of limitations, Lowe said. The debt collector could argue that by making a payment the person is affirming that he or she owes the debt.
Because of her damaged credit, Mirshafiei needed a relative to co-sign for student loans for graduate school. She worries that if she tries to buy a house, she’ll have trouble getting approved.
“I just hope that in the next chapter of my life I don’t have to be denied things because of this stain on my record,” she said.
As the federal government moves ahead with the rule to address various types of debt collection activities, legislators in a few states have introduced bills that specifically target medical debt. Their efforts often focus on improving access to financial assistance for medical care and limiting predatory debt collection tactics.
Last month, Washington Gov. Jay Inslee signed a law that reduces the maximum interest rate on medical debt prior to a court judgment from 12% to 9%. It also prohibits sending a medical debt to collections until 120 days after the patient is sent the initial bill and requires collection agencies to provide itemized statements to patients for medical and hospital debts and to notify them of their possible eligibility for charity care.
In Oregon, a bill sponsored by Rep. Andrea Salinas would require nonprofit hospitals and affiliated clinics to provide care free of charge to families with incomes up to 200% of the federal poverty level (about $43,000 for a family of three) and charge a sliding scale for families earning up to 400% of the poverty level (about $85,000 for a three-person family).
Like the Washington law, the Oregon bill places limits on the interest charged for medical debt. It also requires health care facilities to screen patients for eligibility for financial assistance and insurance.
The bill passed the House earlier this month. Some hospitals already have strong financial assistance policies, but the playing field needs leveling, said Salinas. “We really need hospitals to be a part of the solution to prevent consumers from going into bankruptcy over medical debt.”
Republish with permission under license from Kaiser Health News a national health policy news service.
Christopher Duntsch’s surgical outcomes were so outlandishly poor that Texas prosecuted him for harming patients. Why did it take so long for the systems that are supposed to police problem doctors to stop him from operating?
The pain from the pinched nerve in the back of Jeff Glidewell’s neck had become unbearable.
Every time he’d turn his head a certain way, or drive over bumps in the road, he felt as if jolts of electricity were running through his body. Glidewell, now 54, had been living on disability because of an accident a decade earlier. As the pain grew worse, it became clear his only choice was neurosurgery. He searched Google to find a doctor near his home in suburban Dallas who would accept his Medicare Advantage insurance.
That’s how he came across Dr. Christopher Duntsch in the spring of 2013.
Duntsch seemed impressive, at least on the surface. His CV boasted that he’d earned an M.D. and a Ph.D. from a top spinal surgery program. Glidewell found four- and five-star reviews of Duntsch on Healthgrades and more praise seemingly from patients on Duntsch’s Facebook page. On a link for something called “Best Docs Network,” Glidewell found a slickly produced video showing Duntsch in his white coat, talking to a happy patient and wearing a surgical mask in an operating room.
There was no way Glidewell could have known from Duntsch’s carefully curated internet presence or from any other information then publicly available that to be Duntsch’s patient was to be in mortal danger.
In the roughly two years that Duntsch — a blue-eyed, smooth-talking former college football player — had practiced medicine in Dallas, he had operated on 37 patients. Almost all, 33 to be exact, had been injured during or after these procedures, suffering almost unheard-of complications. Some had permanent nerve damage. Several woke up from surgery unable to move from the neck down or feel one side of their bodies. Two died in the hospital, including a 55-year-old schoolteacher undergoing what was supposed to be a straightforward day surgery.
Multiple layers of safeguards are supposed to protect patients from doctors who are incompetent or dangerous, or to provide them with redress if they are harmed. Duntsch illustrates how easily these defenses can fail, even in egregious cases.
At least two facilities that quietly dumped Duntsch failed to report him to a database run by the U.S. Department of Health and Human Services that’s supposed to act as a clearinghouse for information on problem practitioners, warning potential employers about their histories.
“It seems to be the custom and practice,” said Kay Van Wey, a Dallas plaintiff’s attorney who came to represent 14 of Duntsch’s patients. “Kick the can down the road and protect yourself first, and protect the doctor second and make it be somebody else’s problem.”
It took more than six months and multiple catastrophic surgeries before anyone reported Duntsch to the state medical board, which can suspend or revoke a doctor’s license. Then it took almost another year for the board to investigate, with Duntsch operating all the while.
When Duntsch’s patients tried to sue him for malpractice, many found it almost impossible to find attorneys. Since Texas enacted tort reform in 2003, reducing the amount of damages plaintiffs could win, the number of malpractice payouts per year has dropped by more than half.
Duntsch’s attorney did not allow him to be interviewed for this story. Representatives from one hospital where he worked also would not respond to questions. Two more facilities said they could not comment on Duntsch because their management has changed since he was there, and a fourth has closed.
In the end, it fell to the criminal justice system, not the medical system, to wring out a measure of accountability for Duntsch’s malpractice.
The case was covered intensely by local and state media outlets. D Magazine, Dallas’ monthly glossy, published a cover story in 2016 with the headline “Dr. Death”; the nickname stuck.
Last year, Duntsch was convicted and sentenced to life in prison, becoming the first doctor in the nation to meet such a fate for his practice of medicine.
“The medical community system has a problem,” Assistant District Attorney Stephanie Martin said in a press conference after the verdict. “But we were able to solve it in the criminal courthouse.”
Glidewell was the last patient Duntsch operated on before being stripped of his license to practice medicine.
According to doctors who reviewed the case, Duntsch mistook part of his neck muscle for a tumor and abandoned the operation midway through — after cutting into Glidewell’s vocal cords, puncturing an artery, slicing a hole in his esophagus, stuffing a sponge into the wound and then sewing Glidewell up, sponge and all.
Glidewell spent four days in intensive care and endured months of rehabilitation for the wound to his esophagus. To this day, he can only eat food in small bites and has nerve damage. “He still has numbness in his hand and in his arm,” said his wife, Robin. “He basically can’t really feel things when he’s holding them in his fingers.”
Neither Glidewell, nor the prosecutors, nor even Duntsch’s own attorneys said they thought his outlandish case had been a wake-up call for the system that polices doctors, however.
“Nothing has changed from when I picked Duntsch to do my surgery,” Glidewell said. “The public is still limited to the research they can do on a doctor.”
For Duntsch, the path into medicine was unconventional and, perhaps, a reflection of his tendency to fixate on unlikely goals.
The first of these had been college football. Duntsch’s father had been a gridiron standout in Montana and Duntsch, though not a particularly talented athlete, was determined to follow in those footsteps. He trained hour after hour on his own and played linebacker on his high school team in Memphis, Tennessee. Classmates remember him as a turbine of sheer determination.
“He had his goal, his sight on a goal and whatever it took to get there,” said one classmate, who did not want to be named. “He wanted to go to college and play, and I can recall he was like 180 pounds and said, ‘I need to get to 220’ in order to be a linebacker at Colorado or Colorado State.”
He did get a football scholarship, but it was to Millsaps College in Mississippi. He yearned to transfer and play linebacker for a Division I team. He set his sights on the Colorado State Rams his sophomore year and made it as one of the few walk-on players. Chris Dozois, a fellow linebacker with the Rams, recalled Duntsch struggling, even with basic drills, but begging to run them over and over.
“He’d be, ‘Coach, I promise I can get this, let me do it again.’ He’d go through; he’d screw it up again,” Dozois said. “I gathered very quickly that everything that he had accomplished in sports had come with the sweat equity. When people said, ‘You weren’t going to be good enough,’ he outworked that and he made it happen.”
Homesick, Duntsch left Colorado after a year and transferred again to what was then Memphis State University, now the University of Memphis. He had hoped to play football, but he tearfully told Dozois his multiple transfers had taken away his eligibility.
It was then, Dozois recalled, that Duntsch set his sights on his next goal: to be a doctor. And not just any doctor — a neurosurgeon, operating on injured backs and necks.
After getting his undergraduate degree in 1995, Duntsch enrolled at the University of Tennessee at Memphis College of Medicine, in an ambitious program to earn both an M.D. and a Ph.D.
As part of the program, he worked in a research lab, studying the origins of brain cancer and the various uses of stem cells. For a time, after he earned his dual degrees in 2001 and 2002, it seemed he might make a career in biotechnology rather than treating patients.
As he did his surgical residency, Duntsch teamed up with two Russian scientists, recruited by the University of Tennessee, to explore the commercial potential of stem cells to revitalize ailing backs. They patented technology to obtain and grow disk stem cells, and in 2008, they launched a company, DiscGenics, to develop and sell such products. Two of Duntsch’s supervisors from the university were among the first investors.
While Duntsch appeared to be thriving during these years, more unsavory aspects of his life simmered below the surface.
In sworn testimony from 2014, an ex-girlfriend of one of his closest friends described a drug-fueled, all-night birthday celebration for Duntsch about midway through his residency. Revelers drank and used cocaine and pills, she said. At dawn, Duntsch slipped on his white coat and headed for rounds at the hospital.
“Most people, when they go binge all night long, they don’t function the next day to go to work,” she said in her deposition. “After you’ve spent a night using cocaine, most people become paranoid and want to stay in the house. He was totally fine going to work.”
One of the early investors in DiscGenics, Rand Page, said he was initially impressed with how Duntsch presented himself and the company, but as time passed, Page became wary of his new business partner.
“We would meet in the mornings, and he would be mixing a vodka orange juice to start off the day,” Page said. Once, he stopped by Duntsch’s house to pick up some paperwork. He opened a desk drawer to find a mirror with cocaine and a rolled-up dollar bill sitting on top of it.
Ultimately, Duntsch was forced out of DiscGenics and his partners and investors sued him over money and stock. (Representatives of DiscGenics declined to be interviewed for this story.)
The University of Tennessee said it could not comment on Duntsch, citing the confidentiality and privacy of medical students’ records, but Dr. Frederick Boop, chief of neurosurgery at the hospital where Duntsch did his residency, appears to have known about Duntsch’s substance abuse.
In a 2012 phone call recorded by a Texas doctor who contacted Boop because he was alarmed by Duntsch’s surgical errors, Boop acknowledged that an anonymous woman had filed a complaint against Duntsch, saying he was using drugs before seeing patients.
In the phone conversation, Boop said university officials had asked Duntsch to take a drug test, but he had avoided it, disappearing for several days. When he returned, he was sent to a program for impaired physicians and closely supervised for the remainder of his surgical training, Boop told the Texas doctor. (An attorney for the University of Tennessee said Boop would not respond to questions for this story.)
It’s not clear how much training Duntsch actually received, however.
After his arrest, the Dallas district attorney’s office subpoenaed every hospital on Duntsch’s CV for records of his surgeries, including those during his residency and subsequent one-year fellowship.
According to the Accreditation Council for Graduate Medical Education, a neurosurgery resident does about 1,000 operations during training. But according to records gathered by the DA, by the time Duntsch finished his residency and fellowship, he had operated fewer than 100 times.
Despite what Duntsch had told friends when he headed off to medical school, Page said Duntsch had staked his fortune on being a businessman, not a doctor.
“I don’t think his plan was ever to become a surgeon,” he said. When Duntsch was kicked out of DiscGenics, “I think the decision was made for him that he was going to have to enter into the medical community to support himself.”
Duntsch’s first job as a practicing physician was at the Minimally Invasive Spine Institute in the affluent Dallas suburb of Plano, which hired him in the summer of 2011, when he also received privileges to operate at Baylor Regional Medical Center.
The hospital welcomed Duntsch with a $600,000 advance. While no one from the practice agreed to be interviewed, they sent an email describing the recommendations they had gotten from Duntsch’s supervisors at the University of Tennessee medical school in Memphis.
“We were told Duntsch was one of the best and smartest neurosurgeons they ever trained, as they went on at length about his strengths,” they said in the email. “When asked about Dr. Duntsch’s weaknesses or areas for improvement, the supervising physician communicated that the only weakness Duntsch had was that he took on too many tasks for one person.”
In 2010, Boop faxed a recommendation for Duntsch to Baylor-Plano, checking off “good” or “excellent” in boxes asking about his skills and noting, “Chris is extremely bright and possibly the hardest working person I have ever met.” Another supervisor, Dr. Jon Robertson, who was an old family friend of the Duntsches and an investor in DiscGenics, noted on his recommendation that Duntsch had an “excellent work ethic.” (A University of Tennessee attorney said Robertson could not respond to questions.)
A vascular surgeon who operated at Baylor-Plano, Dr. Randall Kirby, said he met Duntsch soon after he started and found him to be an arrogant know-it-all.
“I would see him maybe once a week at the scrub sinks or in the doctor’s lounge,” Kirby said. “He is among giants up there, and he was trying to tell me over and over again how most of the spine surgery here in Dallas was being done inappropriately and that he was going to clean this town up.”
Duntsch lasted only a few months at the spine institute, not because his patients had complications, but because of a falling out with the other doctors over whether he was fulfilling his obligations.
One weekend in September 2011, Kirby said, Duntsch was supposed to be taking care of a patient. He went to Las Vegas instead. One of the partners, Dr. Michael Rimlawi, “was notified by the administration that the patient wasn’t getting rounded on, and Dr. Rimlawi then dismissed Dr. Duntsch after that,” Kirby said. (Rimlawi declined to comment for this story.)
Nonetheless, Duntsch still had privileges at Baylor-Plano, and on Dec. 30, 2011, he operated on a man named Lee Passmore.
At the time, Passmore was an investigator in the Collin County Medical Examiner’s office, just north of Dallas. He had undergone successful back surgery once before, but the pain had returned. Passmore’s pain specialist told him he didn’t have a back surgeon to whom he routinely referred patients, but that he’d gone to lunch recently with one who “seemed like a guy that knew what he was talking about,” Passmore recalled in court testimony.
Vascular surgeon Mark Hoyle assisted with the operation. In later testimony, he said he watched in alarm as Duntsch began to cut out a ligament around the spinal cord not typically disturbed in such procedures. Passmore started bleeding profusely, so much so that the operating field was submerged in a lake of red. Duntsch not only misplaced hardware in Passmore’s spine, but he stripped the screw so it could not be moved, Hoyle testified. At one point, Hoyle said, he either grabbed Duntsch’s scalpel or blocked the incision — he could not remember which — to keep Duntsch from continuing the procedure. Then Hoyle said he left the operating room and vowed never to work with Duntsch again. (In response to a request for comment, Hoyle sent a note saying he was through talking about Duntsch.)
Passmore did not respond to requests for comment for this story. Passmore has testified that he lives with chronic pain and has trouble walking as a result of Duntsch’s errors.
The next patient Duntsch operated on was Barry Morguloff.
Morguloff ran a pool service company. He had worn out his back working in his father’s import business, helping to unload trucks. “It took a toll on my back even with back supports and exercise and a strong core,” Morguloff said. His pain returned after an earlier back surgery, but the surgeon recommended exercise and weight loss, not another procedure.
A pain specialist gave Morguloff Duntsch’s card.
“Everything that I read when we first got his card — outstanding reviews, people loved him. I read everything I could about this guy,” Morguloff said. He set up an appointment and found himself impressed by Duntsch’s easy confidence.
“Phenomenal, great guy, loved him,” Morguloff recalled. Most importantly, he added, “I was in pain and somebody, a neurosurgeon, said, ‘I can fix you.’”
His surgery, an anterior lumbar spinal fusion, took place on Jan. 11, 2012. At the request of a head-and-neck surgeon also on the case, the vascular surgeon assisting Duntsch was Kirby. Kirby said it should have been a routine case.
“In the spectrum of what a neurosurgeon does for a living, doing an anterior lumbar fusion procedure’s probably the easiest thing that they do on a daily basis,” he said.
But Duntsch quickly got into trouble. Instead of using a scalpel, he tried to pull Morguloff’s problem disk out with a grabbing instrument that could damage the spine. Kirby said he argued with Duntsch, even offering to take over, but Duntsch insisted he knew what he was doing. Kirby left the room.
Morguloff awoke in excruciating pain.
His previous surgeon testified at Duntsch’s trial that the procedure had left bone fragments in Morguloff’s spinal canal. The surgeon said he repaired what damage he could, but Morguloff still walks with a cane. As scar tissue builds up, his pain will worsen and his range of motion will decrease. One day, he will likely be in a wheelchair.
“As time goes on, the scar tissue and everything builds up, and I lose more and more function of that left side,” he said. “I do my best to stay active. But some days I just can’t get moving. The pain is continuous.”
Soon after the Morguloff surgery, Duntsch took on a patient who was also an old friend.
Jerry Summers had played football with Duntsch in high school and helped with logistics at the research lab during his residency. When Duntsch took the job in Dallas, he asked Summers to move with him and help set up his practice. They lived in a downtown luxury high-rise while Duntsch shopped for a house.
In a deposition he gave later to the district attorney, Summers said he asked Duntsch to operate on him because he had chronic pain from a high school football injury that had gotten worse after a car accident. After the February 2012 surgery, however, Summers couldn’t move from the neck down.
According to doctors who later reviewed the case, Duntsch had damaged Summers’ vertebral artery, causing it to bleed almost uncontrollably. To stop the bleeding, Duntsch packed the space with so much anticoagulant that it squeezed Summers’ spine.
For days after the operation, Summers lay in the ICU, descending into a deep depression. “Jerry was calm with Chris,” said Jennifer Miller, then Summers’ girlfriend, “but all Jerry would say to me is: ‘I want to die. Kill me. Kill me. I want to die.’”
One morning, Summers began screaming and told several nurses that he and Duntsch had stayed up the night before the surgery doing eight-balls of cocaine. In truth, the night before the surgery Summers and Miller had dinner at a local restaurant and watched the University of Memphis basketball team play Southern Mississippi on the bar TV.
In his 2017 deposition, Summers acknowledged he made up the pre-surgery cocaine binge because he felt Duntsch had abandoned him, as both his surgeon and his friend.
“I was just really mad and hollering and wanting him to be there,” Summers said. “And so I made a statement that was not something that was necessarily true. … The statement was only made so that he might hear it and go, ‘Let me get my ass down there.’”
Baylor officials took Summers’ accusation seriously and ordered Duntsch to take a drug test. As at the University of Tennessee, he stalled at first, telling administrators he got lost on the way to the lab. He passed a separate psychological evaluation and, after three weeks, was allowed to operate again, but he was told to stick to relatively minor procedures.
His first patient after his return was elementary school teacher Kellie Martin, who had a compressed nerve from falling off a ladder as she fetched Christmas decorations from her attic. During the surgery, records show, Martin’s blood pressure inexplicably plummeted.
As she regained consciousness after the surgery, the nurses tending to Martin testified that she began to slap and claw at her legs, which had turned a splotchy, mottled color. She became so agitated the staff had to sedate her. She never reawakened. An autopsy would later find that Duntsch had cut a major vessel in her spinal cord, and within hours, Martin bled to death.
Baylor-Plano again ordered Duntsch to take a drug test. The first screening came back diluted with tap water, but a second, taken a few days later, came up clean. Hospital administrators also organized a comprehensive review of Duntsch’s cases, after which they determined that his days at the facility were over.
But — importantly — they did not fire him outright. Instead, he resigned, leaving on April 20, 2012, with a lawyer-negotiated letter saying, “All areas of concern with regard to Christopher D. Duntsch have been closed. As of this date, there have been no summary or administrative restrictions or suspension of Duntsch’s medical staff membership or clinical privileges during the time he has practiced at Baylor Regional Medical Center at Plano.”
Since Duntsch’s departure was technically voluntary and his leave had been for less than 31 days, Baylor-Plano was under no obligation to report him to the National Practitioner Data Bank.
The databank, which was established in 1990, tracks malpractice payouts and adverse actions taken against doctors, such as being fired, barred from Medicare, handed a long suspension, or having a license suspended or revoked.
The information isn’t available to the public or other doctors, but hospital administrators have access to the databank and are supposed to use it to make sure problem doctors can’t shed their pasts by moving from state to state or hospital to hospital. Robert Oshel, a patient safety advocate and former associate director of the databank, says that hospitals are required to check all applicants for clinical privileges and once every two years for everyone who has clinical privileges.
Many hospitals, however, hesitate to submit reports to the databank, worrying that doing so may hurt doctors’ job prospects or even prompt lawsuits.
“What happens sometimes is that doctors are allowed to resign in lieu of discipline so that the hospital can protect its perceived legal liability from the doctor,” said Van Wey, the Dallas trial lawyer. “If Dr. Duntsch was unable to get privileges at other hospitals, theoretically Dr. Duntsch could have sued Baylor and said: ‘Look, I could be making $2 million a year here. … You owe me $2 million for the rest of my life.’”
According to a report by Public Citizen, a consumer watchdog group, about half the hospitals in the country had never reported a doctor to the databank by 2009. A more recent analysis didn’t find much change, said Dr. Sid Wolfe, a founder of Public Citizen’s Health Research Group.
Despite his string of problems at Baylor-Plano, Duntsch also wasn’t reported to the Texas Medical Board, the state’s main purveyor of doctor discipline. Such boards often move slowly, but if hospital officials submit material they’ve gathered to justify letting a doctor go, boards can act to protect patients from imminent harm.
“Had Baylor’s action been reported appropriately, I would anticipate the board would have met within days to have an immediate suspension,” said Dr. Allan Shulkin, a Dallas pulmonologist who was on the medical board in 2012.
The board would still have conducted an investigation, but Duntsch would not have been allowed to operate while it was going on, Shulkin said. He was visibly angered by Baylor-Plano’s failure to report. “What’s the worst that can happen, a lawsuit?” he said. “Come on. These are people dying, and we’re stopping because you’re afraid of a lawsuit?”
Two years after Duntsch left Baylor-Plano, the hospital’s decision not to report its review of his work or its results prompted an investigation by state health authorities. The hospital was hit with a violation and fined $100,000 in December 2014, but a year later, the citation and penalty were withdrawn. The Texas Health and Human Services Commission would not explain why, saying the records were confidential.
Hospital officials declined to be interviewed for this story, submitting a written statement instead.
“Our primary concern, as always, is with patients,” it said. “Out of respect for the patients and families involved, and the privileged nature of a number of details, we must continue to limit our comments. There is nothing more important to us than serving our community through high-quality, trusted healthcare.”
Duntsch’s next stop was Dallas Medical Center, which sits outside Dallas’ northern edge in the city of Farmers Branch. Baylor-Plano officials might have thought any future employer would contact them before hiring him and they could share information confidentially, but Dallas Medical Center granted Duntsch temporary privileges while its reference checks were still going on.
On July 24, 2012, Duntsch operated on Floella Brown, 64, a banker about to retire after a long career. She had come to Duntsch for cervical spine surgery to ease her worsening neck and shoulder pain.
About a half hour into Brown’s surgery, Duntsch started to complain that he was having trouble seeing her spine.
“He was saying: ‘There’s so much blood I can’t see. I can’t see this,’” said Kyle Kissinger, an operating room nurse. He kept telling the scrub tech “’suck more, suck more. Get that blood out of there. I can’t see.’ That’s really concerning to me because, not only that he can’t do it correctly when he can’t see that but, why is it still bleeding?”
Brown bled so much that blood was saturating the blue draping around her body and dripping onto the floor. The nursing staff put down towels to soak it up.
After the operation, Brown woke up and seemed fine, but early the next morning she lost consciousness. Pressure was building inside her brain for reasons that were unclear at the time.
That same morning — with Brown still in the ICU — Duntsch took another patient into surgery.
The patient’s name was Mary Efurd. She was an active 71-year-old who’d sought Duntsch’s help because back pain was keeping her off her treadmill.
Duntsch arrived at the hospital about 45 minutes after Efurd’s surgery had been set to start, Kissinger said. He spotted a hole in Duntsch’s scrubs. “It’s on the butt cheek of his scrubs. He didn’t wear underwear. That’s why it really shined down to me,” Kissinger said. The nurse realized he’d seen that hole for three straight days — Duntsch apparently hadn’t changed his scrubs all week. Kissinger also noticed that Duntsch had pinpoint pupils and hardly seemed to blink.
When Duntsch arrived, the staff told him that Brown, his patient from the day before, was in critical condition.
Soon after beginning Efurd’s surgery, Duntsch turned to Kissinger and told him to let the front desk know he would be performing a procedure on Brown called a craniotomy, cutting a hole in her skull to relieve the pressure in her brain. Problem was, Dallas Medical Center did not perform those, or even have the proper equipment to do them.
As he operated on Efurd, Duntsch quarreled first with Kissinger and later with his supervisors, insisting on a craniotomy for Brown, according to court testimony. All the while, the operating room staff questioned whether Duntsch was putting hardware into Efurd in the right places and noticed he kept drilling and removing screws.
In the end, Duntsch did not perform a craniotomy on Brown. She was moved to another hospital but never regained consciousness. In court, her family said they withdrew life support a few days later. A neurosurgeon hired to review her case would later determine that Duntsch had both pierced and blocked her vertebral artery with a misplaced screw. The review also found that Duntsch misdiagnosed the source of her pain and was operating in the wrong place.
The day after her surgery, Efurd awoke in agony. She couldn’t turn over or wiggle her toes. Hospital administrators called Dr. Robert Henderson, a Dallas spine surgeon, to try to repair the damage.
Shortly after he arrived at the hospital, Henderson pulled up Efurd’s post-operative X-rays. When he saw them, he said, “I’m really thinking that some kind of travesty occurred.” That impression only grew when Henderson reopened Efurd’s freshly made incisions the next day. “It was as if he knew everything to do,” Henderson said of Duntsch, “and then he’d done virtually everything wrong.”
There were three holes poked into Efurd’s spinal column where Duntsch had tried and failed to insert screws. One screw was jabbed directly into her spinal canal. That same screw had also skewered the nerves that control one leg and the bladder. Henderson cleaned out bone fragments. Then he discovered that one of Efurd’s nerve roots — the bundle of nerves coming out of the spine — was completely gone. For some inexplicable reason, Duntsch had amputated it.
The operation was so botched, Henderson recalled thinking Duntsch had to be an impostor passing himself off as a surgeon. Even after Henderson’s repairs, Efurd never regained her mobility and now uses a wheelchair. (In an email, Efurd said that discussing what happened to her again would take a toll on her health.)
By the end of the week, hospitals administrators told Duntsch he would no longer operate at Dallas Medical Center. But, as had happened at Baylor-Plano, Duntsch was allowed to resign and the hospital didn’t notify the National Practitioner Data Bank. Dallas Medical Center officials said the hospital had different managers when Duntsch worked there and that current administrators could not comment on his work or the circumstances under which he left.
Duntsch would continue to operate. In fact, his career in Dallas was only about half over.
After Duntsch’s disastrous run at Dallas Medical Center, he was finally reported to the state medical board. The first report came from Shulkin, the Dallas physician who served on the board, who had been told of the surgeries on Efurd and Brown. Other doctors started complaining, too.
“Once I heard about those cases, I called the medical board,” said Kirby, the vascular surgeon who had been present for Morguloff’s surgery. “I said: ‘Listen, we’ve had egregious results at Baylor-Plano. He was not reported to the databank. We’ve had egregious results at Dallas Medical Center. He’s got to be stopped.’”
After being called in to help Efurd, Henderson, too, made it his personal mission to stop Duntsch from operating. He called Boop at the University of Tennessee to ask about Duntsch’s training and spoke to officials at Baylor-Plano hospital. He also called the state medical board.
When a couple of months passed and they didn’t hear about more bad outcomes, Henderson and Kirby said they assumed perhaps Duntsch’s mistakes had finally caught up with him.
Then, in December 2012, Kirby was asked to help Jacqueline Troy, a patient suffering from a severe infection. (The Troy family would not comment for this story.) Troy was being transferred to a Dallas hospital from a surgery center in the suburb of Frisco. She’d had neck surgery, but the surgeon had cut her vocal cords and one of her arteries. When Kirby learned the details, he asked the doctor who referred the case to him about the surgeon: “Is it a guy named Christopher Duntsch?”
Duntsch had managed to get a job at Legacy Surgery Center, an outpatient clinic. (The ownership of the clinic has changed and the new owners declined to comment for this story.)
Soon after Troy’s surgery, Duntsch was finally reported to the National Practitioner Data Bank, though not by any of his previous employers. A report dated Jan. 15, 2013, obtained by an attorney representing one of Duntsch’s patients, shows that Methodist Hospital in the Dallas suburb of McKinney had reported Duntsch after denying him privileges six months earlier. Their rejection was based on Duntsch’s “substandard or inadequate care” at Baylor-Plano. (Methodist McKinney declined to comment for this story.)
But even after the report to the databank, Kirby was stunned to discover another hospital had given privileges to Duntsch. In May 2013, he was invited to a “Meet Our New Specialist” dinner thrown by University General hospital at a Dallas restaurant. The event was to celebrate the arrival of a new neurosurgeon: Christopher Duntsch.
“I called down there and raised holy hell,” Kirby said.
University General, formerly known as South Hampton Community Hospital, had a troubled history: two bankruptcies and a former CEO sentenced to prison for health care fraud. Purchased for $30 million in 2012 by a Houston-based company, University General was one of only three hospitals serving Dallas’ southern half, an area that spans 200 square miles and includes more than 560,000 people. The surrounding community was hoping for a turnaround.
The hospital is now closed, and its administrators from that time did not respond to questions about why they hired Duntsch.
It likely came down to simple economics. According to the health care analysis firm Merritt Hawkins, the average neurosurgeon is worth $2.4 million a year in revenue to a hospital.
“That’s a dream for a hospital administrator,” Kirby said.
It’s also a virtual employment guarantee for a doctor with Duntsch’s credentials, Dallas neurosurgeon Dr. Martin Lazar said.
“I don’t think it’s because of our charm,” Lazar added dryly. “We are like a cash cow.”
It was at University General that Glidewell had his neck surgery, knowing none of Duntsch’s by then two-year history of botching operations.
Glidewell’s back problems had begun almost a decade earlier, in 2004, when he broke his back in two places in a motorcycle accident. After a year of rehab, he tried to go back to his job working on air conditioning systems but lasted only months before the pain stopped him. He left his first meeting with Duntsch elated and filled with hope.
“I was actually so happy with the way it went that I called my wife and my mother and said, ‘I think I found somebody on my insurance that’s gonna fix my neck,’” he said.
The day of the surgery began ominously. That morning, “We pulled out of the driveway, and soon as we started going forward down the street, a black cat ran across the front of the car,” Glidewell said. “I said, ‘Oh, Lord, this is not good.’ We turned the corner, and when we got on the first county road, and another one. Turning into the hospital, another one.”
Three black cats on the way to the hospital. “I said, ‘We need to just turn around and go home.’”
Once at the hospital, Glidewell and his wife waited. And waited. Three hours late, they said, Duntsch finally arrived in a cab. “He had on jeans that were frayed at the bottom,” Glidewell said. “He didn’t look like he was ready for a surgery.”
Reluctantly, Glidewell went ahead. But hours later, Duntsch came out and told Glidewell’s wife that he had found a tumor in Glidewell’s neck and aborted the procedure.
“I was devastated, crying,” Robin Glidewell recalled. She went to see her husband in the recovery room. “Immediately, Jeff was: ‘Where is the doctor? I can’t move my arm or my leg.’ He was having trouble even talking and said, ‘Something’s wrong, something’s wrong.’”
There was no tumor, but Duntsch had made a series of errors after mistaking a portion of Glidewell’s neck muscle for a growth, according to a review of the case.
The owner of University General heard about what happened to Glidewell and called Kirby to try to mitigate the damage.
“I, with reluctance, went down there and met the Glidewell family and took care of him,” Kirby said. Glidewell was spiking fevers and was transferred to another hospital for care. He would remain there for months.
“This was not an operation that was performed,” Kirby said. “This was attempted murder.”
By the time Duntsch operated on Glidewell, the state medical board had been investigating him for about 10 months.
Frustrated by the board’s inaction, Henderson had called the lead investigator six months earlier to beg for faster intervention. In a recording Henderson made of the call, he says, “This is a bad, bad guy, and he needs to be put on the fast track if there’s such a thing.” She tells him she wishes they could suspend his license while they investigate, but the board’s attorneys wouldn’t go for that.
Kirby sent the board a five-page letter on June 23, 2013, spurred by what had happened to Glidewell. “Let me be blunt,” it said. “Christopher Duntsch, Texas Medical Board license number N8183, is an impaired physician, a sociopath, and must be stopped from practicing medicine.” Robin Glidewell also sent a letter, describing what happened to her husband.
By then, Brett Shipp, a reporter from Dallas’ ABC affiliate, had gotten tips about the board’s slow-moving investigation of Duntsch from a friend of one of Duntsch’s patients and a plaintiff’s attorney. “Very shortly after I contacted them,” Shipp said, “they suspended his license.”
On June 26, Duntsch was ordered to stop operating. The head of the medical board at the time, San Angelo family physician Dr. Irvin Zeitler, said the investigation took a while because “it’s not uncommon for there to be complications in neurosurgery.”
It also struck the board as highly improbable that a surgeon fresh out of training could be so lacking in surgical skill.
“So none of us rushed to judgment,” Zeitler said. “That’s not fair, and in the long run, it can come back to be incorrect. To suspend a physician’s license, there has to be a pattern of patient injury. So that was, ultimately that’s what happened. But it took until June of 2013 to get that established.”
Even after the board acted, those most involved in trying to keep Duntsch from operating were afraid it would not be the end of his career.
“I was terrified of that term, ‘suspended,’” Henderson said. “I mean, that indicates that he might get it back at some point in time, and I was already aware of the fact of how glib Dr. Duntsch was, and how disarming he was, and how friendly and intelligent he appeared whenever he introduced himself to people that he wanted to impress. I was concerned that he would do the same thing in getting his license back whether it was six months later, a year later, two years later.”
Kirby, Henderson and another doctor decided to contact the district attorney, convinced that Duntsch’s malpractice was so egregious it was criminal. They met with an assistant DA but got little traction.
On Dec. 6, 2013, the medical board permanently revoked Duntsch’s license.
He left Texas, moving in with his parents in Colorado and filing for bankruptcy, claiming debts of around $1 million. His life seemed to go into a free fall. In January 2014, he was pulled over by police in southern Denver around 3:30 a.m. Officers said he was driving on the left side of the road with two flat tires. When he opened the window, they smelled the sour tang of alcohol and spotted an empty bottle of Mike’s Hard Lemonade on the floor of the car. A full one was sitting in the console. After a breath test, Duntsch was arrested for DUI and sent to a detox facility.
Even though he was living in Colorado, he continued to return to Dallas to see his two sons. His older son had been born back when he at Baylor-Plano. His girlfriend, Wendy Young, had a second son in September of 2014.
The following spring, in March, police were called to a bank in Northeast Dallas after passers-by noticed a man with blood on his hands and face beating on the doors. It was Duntsch, babbling about his family being in danger. He was wearing the shirt of his black scrubs. It was covered in blood. Officers took him to a nearby psychiatric hospital.
In April, Duntsch went to a Dallas Walmart because his father had wired him money. According to a police report, he filled a shopping cart with $887 worth of merchandise, including watches, sunglasses, silk neckties, computer equipment, a walkie-talkie and bottle of Drakkar Noir cologne. He put them in bags he swiped from a register. He then then picked out a pair of trousers and put them on in a dressing room. He put his own pants into the cart and rolled the cart out the front door without paying for the pants he was wearing. Moments later, he was arrested for shoplifting.
By then, reporters were following every twist in the Duntsch saga. In May 2015, the Texas Observer published an article with the headline, “‘Sociopath’ Surgeon Duntsch Arrested for Shoplifting Pants.” In the comment section underneath the article, Duntsch responded with a series of diatribes against everyone he thought had conspired against him. His cybermanifesto ran to more than 80 pages when printed out.
In one comment directed at Kirby, he wrote, “You use the word without explanation impaired physician and sociopath. Since I am going to sue you or [sic] libel and slander of a criminal nature, this might be a good point to defend this comment.” He called Morguloff’s surgery “a perfect success.”
Kirby took the comments to the district attorney’s office. By then, a judge who knew Glidewell had also brought the case to the DA’s attention.
Prosecutors began discussing the case anew and one assistant district attorney, Michelle Shughart, found it particularly interesting. In 13 years with the Dallas DA’s office, she’d prosecuted drug dealers, robbers, but never a doctor. “I went and started doing my own research,” she said. “I just ended up taking over the case.”
One of the biggest challenges was that there hadn’t been a case like it before.
“We did a lot of research to see if we found find anyone else who had done any cases like this, any other doctors who had been prosecuted for what they had actually done during the surgery,” Shughart said. “We couldn’t find anyone.”
As she and other prosecutors contacted every person Duntsch had ever operated on or their survivors, they struggled to figure what crimes he could be charged with. They settled on five counts of aggravated assault arising from his treatment of four patients, including Brown and Glidewell, and one count of injury to an elderly person, because Efurd was over 65.
In Texas, this charge carried a potential life sentence, but prosecutors had to race to file the case.
“We had about four months left before we were going to run out on the statute of limitations” on Efurd’s case, Shughart said. “I spent those four months just digging as hard as I possibly could, trying to gather as much information as I could. And by the time we got down to that July, I had overwhelming evidence to indict him.”
Duntsch was taken into custody on July 21, 2015.
For some of his patients, the criminal case offered a last chance at justice they couldn’t get through the civil courts.
Since Texas capped damages in medical malpractice lawsuits, limiting the amount plaintiffs can be awarded for pain and suffering in most cases to $250,000, the number of suits filed and amounts paid out have plummeted.
The suits that go forward often ride on economic damages, such as lost earning power, which the law does not limit in non-death cases. But many of Duntsch’s patients were disabled when they came to him, or older, or had lower incomes. Some had pain that was hard to economically quantify. Despite having clear-cut claims and serious, irreversible injuries, three patients I talked to said me they had trouble finding attorneys to take their cases.
“It is not worth an attorney’s time and energy to take on a malpractice case in the state of Texas,” Morguloff said.
Ultimately, at least 19 of Duntsch’s patients or their survivors obtained settlements, but 14 of them were represented by Van Wey, who said she’s taken them on more out of a sense of outrage than out of any financial upside.
Morguloff was told no so often, he was surprised when attorney Mike Lyons finally took his case. He received a confidential settlement but said, “It wasn’t much.” He took more solace from the criminal case.
“To get this guy off the streets so nobody else got hurt again was important,” he said. “The public needed to know that there was a monster out there.”
Duntsch’s trial began on Feb. 2, 2017, and focused on the charge related to Efurd, injuring an elderly person.
She testified, but first, to show that her botched surgery was part of pattern, prosecutors — over objections from Duntsch’s attorneys — put a long line of his other patients and their relatives on the stand.
“You had people in walkers. You had people on crutches. You had people that could barely move. You had people that had lost loved ones,” Robbie McClung, Duntsch’s lead defense attorney, said. “You had all sorts of things that had gone wrong. Before we even get to Mary Efurd, you can see that it’s just … it’s going downhill. I mean, it’s going downhill fast.”
Duntsch held up remarkably well, seeming calm in the certainty that he really was a good surgeon.
“I always thought when I looked at him, even when he was in his jail clothes, he exuded a confidence,” Richard Franklin, another member of the defense team, said. “And I could certainly understand why patients would trust him.”
Then Lazar and other experts walked the jury through a litany of Duntsch’s surgical missteps. Duntsch’s attorneys noticed a change come over him. He deflated before their eyes.
“I think that he thought he was doing pretty good,” Franklin said. “Really and truly, in his own mind. Until he actually heard from those experts up there.”
A key prosecution witness was Kimberly Morgan, who had been Duntsch’s surgical assistant from August 2011 through March 2012 and was also his ex-girlfriend. Morgan described Duntsch’s mercurial nature, vacillating from being kind and caring to patients to being angry and confrontational behind closed doors.
The prosecutors had Morgan read parts of an email Duntsch had sent to her in the early morning hours of Dec. 11, 2011, three weeks before he operated on Passmore at Baylor-Plano, the first of his surgical disasters.
The subject line of the email was “Occam’s Razor.” Occam’s razor is the idea that the simplest explanation for anything is most likely the right one. The email rambled on for five profanity-laced pages, but Morgan delivered the most startling passage.
“Unfortunately, you cannot understand that I am building an empire and I am so far outside the box that the Earth is small and the sun is bright,” Duntsch had written. “I am ready to leave the love and kindness and goodness and patience that I mix with everything else that I am and become a cold blooded killer.”
It took the jurors just hours to find Duntsch guilty of knowingly injuring Efurd. He was sentenced to life in prison. He’s currently incarcerated in Huntsville, about an hour outside Houston. On Sept. 18, his attorney filed an appeal in a Dallas court, arguing that the testimony on cases other than Efurd’s and the email read by Morgan unfairly influenced the jury.
In February, I visited Summers, Duntsch’s old football buddy-turned-patient, in his small apartment in downtown Memphis.
He remains in much the same condition as he awoke in after Duntsch operated on him, unable to move from the neck down. He requires 24-hour caregivers and sat, tipped back, in his power wheelchair, as I talked to him about Duntsch.
Summers seemed resigned to his injuries, to his friend’s role in them and to the systemic weaknesses that allow problem doctors to keep practicing. He said he tries not to think about Dallas anymore.
I asked him why he’d trusted Duntsch to be his doctor. He couldn’t say. He looked out the window.
He knew his friend could barely drive a car without getting lost, he said. He just assumed he had been better trained for neurosurgery.
Republished with permission under license from ProPublica a Pulitzer Prize-winning investigative newsroom.
California teenager Jahi McMath, who suffered catastrophic brain injury as a result of a routine tonsil surgery, died on June 22, 2018.
Her death came after four years of her family fighting in court to continue her care in California. Eventually, they moved her to a facility in New Jersey, a state that accommodates religious views that don’t recognize brain death.
Much of the popular discussion in the case centered on the family’s refusal to accept the diagnosis of brain death. However, as a philosopher who writes on bioethics and race, I believe an underappreciated aspect of the discussion was the role of race – both in how the medical personnel dealt with the family and how the family interpreted their interactions with the medical establishment.
The surgery and outcome
On Dec. 9, 2013, the 13-year-old McMath entered Children’s Hospital and Research Center in Oakland, California, for what should have been a routine tonsillectomy. The young girl was, according to her mother’s account, frightened that something would go wrong. Her mother reassured McMath that she would be okay.
McMath’s post-surgical complications began about an hour after her surgery. A nurse provided a bin to catch the blood that McMath had begun spitting up. Although the nurses indicated to the family that some post-surgical bleeding was normal, two hours later, McMath’s blood filled two plastic bins and the bandages packing her nose were saturated with blood. Her hospital gown was also covered in blood.
According to the family, four and a half hours passed before a physician saw her, despite the family’s repeated pleas for intervention. The hospital has maintained that they can not discuss Jahi’s case in detail because of privacy laws. Bleeding complications, though rare, can occur after tonsillectomy because tonsils are near arteries.
As a result of the immense blood loss, McMath’s heart stopped and her brain was deprived of oxygen. Three days later, on Dec. 12, 2013, the medical staff at Children’s Hospital declared McMath brain dead. Hospital personnel encouraged the family to withdraw life support and donate her organs.
McMath’s family refused to accept the diagnosis, and a court battle to keep McMath on life support ensued.
A judge in California initially ruled that McMath could remain on life support until Jan. 7, 2014. However, the Alameda County coroner issued a death certificate anyway.
Philosopher Jeffrey P. Bishop, who holds the chair of health care ethics at Saint Louis University, writing in Harvard Divinity School bulletin noted the ethical oddities of the case. In California, once two physicians confirm brain death, the patient is legally dead. The body is then technically released to the coroner before being released to the family so that they can make arrangements. In the case of McMath, she was still in the hospital and on a ventilator when these procedures kicked in.
From the beginning, the case was tangled up with all sorts of questions regarding the nature and diagnosis of brain death. Although there are long-established criteria, how brain death is determined in practice can vary. These differences in practices can contribute to confusion, particularly among the lay public, about brain death.
Her family rejected the brain death diagnosis alleging the hospital had a conflict of interest and simply wanted McMath’s organs.
Revisiting a history of medical racism
Rather than dismiss the family’s concerns as paranoid or ignorant, it is important to understand the historical realities faced by black patients in their encounters with the U.S. medical system.
There is a long historical record of using African-Americans for medical experimentation. For example, medical experimentation performed by J. Marion Sims, “the father of modern gynecology,” highlights the medical establishment’s disregard for black people.
Sims, who began conducting his gynecological experiments in the 1840s, is credited with developing a surgical procedure to repair vesicovaginal fistula, a hole that develops between the vaginal wall and the bladder, resulting in incontinence. However, Sims achieved his success by experimenting on enslaved women, often without anesthesia.
Sims wasn’t the only one. During the 19th century, medical schools used both enslaved and free black people, often without their consent, to teach their white medical students anatomy, disease progression and diagnosis. This practice continued after slavery.
Additionally, the graves of African-Americans were robbed and their bodies disinterred so that medical students could use black bodies as cadavers. Aware of these practices, African-American communities were deeply suspicious of local medical schools and unsure whether the medical personnel were actually “treating” them or merely “experimenting” on them.
Few examples of the abuse of African-Americans in medical experimentation loom larger than the Tuskegee syphilis experiment – a 40-year-long study of disease progression of syphilis in 600 men in the Tuskegee, Alabama, area that began in 1932. The study was sponsored by the U.S. Public Health Service.
None of the 399 men who had syphilis were ever told of their diagnosis. Nor were these men or their partners treated with penicillin once penicillin became the standard treatment for syphilis in 1945. In 1997, President Bill Clinton issued a formal apology on behalf of the U.S. government to the eight remaining survivors of the Tuskegee experiment.
One presidential apology, however, could not erase the sense of mistrust that many African-Americans feel toward health care institutions.
And the medical injustice continues: There are wide gaps in outcomes between whites and African-Americans in a variety of diseases. For example, the American Cancer Society reports that, of all the racial and ethnic groups in the U.S., African-Americans, are more likely to die from most cancers.
Lower quality of care?
African-Americans also report lower quality of health care and greater dissatisfaction with the care they receive. In addtion, they are significantly more likely to report experiencing racial discrimination and negative attitudes by health care personnel than non-Hispanic whites.
Medical mistrust and the resulting dissatisfaction have been connected to patient anxiety, as well as lower engagement in health care decision-making between patient and provider.
“No one was listening to us, and I can’t prove it, but I really feel in my heart: if Jahi was a little white girl, I feel we would have gotten a little more help and attention.”
Sadly, Winkfield is not alone in her suspicions.
It is possible that the ultimate outcome might still have been tragic. Even with the most attentive care, McMath might have died. However, the family feeling that the medical team did not do all that they could have done for their loved one, and that this, for them, was a function of race, needlessly inflicted additional injury.
Living in West Virginia, perhaps the nation’s poorest state, I have also seen the benefits of the ACA’s Medicaid expansion since 2014.
To understand how the ACHA’s proposed changes to Medicaid would affect people and our health care system, let’s look more closely at the program.
What is Medicaid?
Created in 1965, Medicaid today provides health care services for 75 million Americans. It is jointly administered by the federal government and the states. The federal government pays at least 50 percent of the costs of the program. For particularly poor states, the federal government’s contribution can exceed 75 percent.
Medicaid helps many Americans who are generally not considered “needy.” For example, the Katie Beckett program provides support to families with children with significant disabilities without regard to parental income.
However, the American Health Care Act goes further. Specifically, it alters the funding mechanism for the entire Medicaid program. Instead, it provides a set amount of funding per individual enrolled in Medicaid. In doing so, it ends the federal government’s open-ended commitment to providing health care to America’s neediest populations.
What would be the effects of dismantling Medicaid?
Both the American Health Care Act and the Trump budget would be challenging for the program. In combination, I believe they would be truly devastating.
The cuts would force millions of Americans into uninsurance. Confronted with medical needs, these Americans will be forced to choose between food and shelter and medical treatment for themselves and their families. They would also force millions of Americans into medical bankruptcy, similar to the situation prior to the ACA.
The cuts would also affect the broader American health care system. They would create incredible burdens on American hospitals and other safety net providers. Many of them are already operating on very thin margins.
Onesimus (fl. 1706 – 1717), was a slave and medical pioneer. Few details are known about the birth of Onesimus, but it is assumed he was born in Africa, in the late seventeenth century, although the precise date and place of his birth are unknown, before eventually landing in Boston.
Onesimus first appears in the historical record in the diary of Cotton Mather, a prominent New England theologian and minister of Boston’s Old North Church. Reverend Mather notes in a diary entry for 13 December 1706 that members of his congregation purchased for him “a very likely Slave; a young Man who is a Negro of a promising aspect of temper” (Mather, vol. 1, 579). Mather named him Onesimus, after a biblical slave who escaped from his master, an early Christian named Philemon.
When asked if he’d ever had smallpox, Onesimus answered “Yes and No,” explaining that he had been inoculated with a small amount of smallpox, which had left him immune to the disease. Fascinated, Mather asked for details, which Onesimus provided, and showed him his scar.
Onesimus told Mather about the centuries old tradition of inoculation practiced in Africa. By extracting the material from an infected person and scratching it into the skin of an uninfected person, you could deliberately introduce smallpox to the healthy individual making them immune.
Onesimus was one of about a thousand persons of African descent living in the Massachusetts colony in the early 1700s, one-third of them in Boston. Many were indentured servants with rights comparable to those of white servants, though an increasing number of blacks–and blacks only–were classified as chattel and bound as slaves for life.
Excited, he investigated among other Africans in Boston and realized that it was a widespread practice; indeed, a slave could be expected to fetch a higher price with a scar on his arm, indicating that he was immune.
Mather's writings suggest that, more than most of his contemporaries, he admired Africans, but he also accepted slavery, and had raised no objections when his congregation presented him with a young slave in 1706.
What Onesimus thought of Mather’s opinions the historical record does not say, nor do we know much about his family life other than that he was married and had a son, Onesimulus, who died in 1714. Two years later Onesimus gave the clearest indication of his attitude toward his bondage by attempting to purchase his release from Mather. To do so, he gave his master money toward the purchase of another black youth, Obadiah, to serve in his place.
Mather probably welcomed the suggestion, since he reports in his diary for 31 August 1716 that Onesimus “proves wicked, and grows useless, Froward [ungovernable] and Immorigerous [rebellious].” Around that time Mather signed a document releasing Onesimus from his service “that he may Enjoy and Employ his whole Time for his own purposes and as he pleases” (Mather, vol. 2, 363). However, the document makes clear that Onesimus’s freedom was conditional on performing chores for the Mather family when needed, including shoveling snow, piling firewood, fetching water, and carrying corn to the mill. This contingent freedom was also dependent upon his returning a sum of five pounds allegedly stolen from Mather.
Little is known of Onesimus after he purchased his freedom, but in 1721 Cotton Mather used information he had learned five years earlier from his former slave to combat a devastating smallpox epidemic that was then sweeping Boston.
Considered extremely dangerous at the time, Cotton Mather convinced Dr. Zabdiel Boylston to experiment with the procedure when a smallpox epidemic hit Boston in 1721 and over 240 people were inoculated. Opposed politically, religiously and medically in the United States and abroad, public reaction to the experiment put Mather and Boylston’s lives in danger despite records indicating that only 2% of patients requesting inoculation died compared to the 15% of people not inoculated who contracted smallpox. Boylston successfully variolate 300 patients with only six of them dying. By contrast, 1,000 of the 6,000 people who acquired smallpox naturally died during the same period.
In a 1716 letter to the Royal Society of London, Mather proposed “ye Method of Inoculation” as the best means of curing smallpox and noted that he had learned of this process from “my Negro-Man Onesimus, who is a pretty Intelligent Fellow” (Winslow, 33). Onesimus explained that he had
undergone an Operation, which had given him something of ye Small-Pox, and would forever preserve him from it, adding, That it was often used among [Africans] and whoever had ye Courage to use it, was forever free from ye Fear of the Contagion. He described ye Operation to me, and showed me in his Arm ye Scar.” (Winslow, 33)
Reports of similar practices in Turkey further persuaded Mather to mount a public inoculation campaign. Most white doctors rejected this process of deliberately infecting a person with smallpox–now called variolation–in part because of their misgivings about African medical knowledge. Public and medical opinion in Boston was strongly against both Mather and Dr. Zabdiel Boylston, the only doctor in town willing to perform inoculations; one opponent even threw a grenade into Mather’s home. A survey of the nearly six thousand people who contracted smallpox between 1721 and 1723 found, however, that Onesimus, Mather, and Boylston had been right. Only 2 percent of the six hundred Bostonians inoculated against smallpox died, while 14 percent of those who caught the disease but were not inoculated succumbed to the illness. Boylston traveled to London in 1724. There he published his results and was elected to the Royal Society in 1726.
Onesimus’ traditional African practice was used to inoculate American soldiers during the Revolutionary War and introduced the concept of inoculation to the United States and variolation remained the most effective means of treating the disease until the development of vaccination by Edward Jenner in 1796.
It is unclear when or how Onesimus died, but his legacy is unambiguous. His knowledge of variolation gives the lie to one justification for enslaving Africans, namely, white Europeans’ alleged superiority in medicine, science, and technology. This bias made the smallpox epidemic of 1721 more deadly than it need have been. Bostonians and other Americans nonetheless adopted the African practice of inoculation in future smallpox outbreaks.
Herbert, Eugenia W. “Smallpox Inoculation in Africa.” Journal of African History 16 (1975).
Mather, Cotton. Diary (1912).
Silverman, Kenneth. The Life and Times of Cotton Mather (1984).
Winslow, Ola. A Destroying Angel: The Conquest of Smallpox in Colonial Boston (1974).