A Discourse on the Current Prominence and Prevalence of Medical Malpractice
Julia Rodriguez
Jorge Zamora-Quezada: A Case Study
Nikolas Montaquila
The Lethal void
Emelie Nguyen
Medical Malpractice in Developing Countries: a Case Study of Mexico
Emily Mrakovcic
Failure to Diagnose HIV: A Multidimensional Case of Medical Malpractice
Chilsea Wang
My Personal Experience with Antimicrobial Resistance
Joshua Kalfus
Rhode Island’s Approach Toward the Overdose Crisis: Harm Reduction Centers
Nelsa Tiemtoré
Unmasking the Savior Syndrome: HBO’s Documentary Sheds Light on Medical Malpractice
Ruviha Homma
‘First, Do No Harm’: Doctors Who Spread COVID-19 Misinformation Put Patients’ Lives At Risk
Julia Rodriguez
Medical Malpractice from a Legal Perspective
Emily Mrakovcic
Communication and Linguistic Inequality in the Healthcare System
Ruviha Homma
The Disproportionate Burden of Healthcare-Associated Infections in LMIC
Alison Lu
Opioid Use Disorders and The Rise In Infectious Diseases
EDITOR’S NOTE
Dear Reader,
Welcome, or welcome back, to our newly found community! We are beyond proud to present the second issue to the first year of our publication, the Infectious Disease Society (IDS) Magazine. As we parade through the logistics of starting a publication from the ground up, we are led by a source of light; that source being the unwavering passion and academic curiosity of our team to dive deeper into the topic of infectious diseases, of the interface between communicable disease and its corresponding societal structures.
As we reflect on the impact we want our magazine to leave on the scientific community of Brown, we would like to hone in on the holistic dimensions of health and disease, drawing and analyzing often overlooked connections. That being said, we present to you “Malpractice or Ignorance: A Discourse on the Current Prominence and Prevalence of Medical Malpractice”,
an issue dedicated to exploring medical malpractice, communicable disease, and resultant intersections with clinical enterprises, global health, health policy, and health disparities. What is the nature of the spread of hospital-acquired diseases? How is stigma and inequality transmitted through medical practice? How is the paralegal system involved in our healthcare system? As you flip through the pages of this magazine, we invite you to join us in this flow of inquiry through medical malpractice.
With the presentation of our second issue, we would like to give thanks to everyone that has made this possible. As such, we want to begin by acknowledging the hard work of the IDS Magazine team–our writers, editors, design editors, and communications chair–who collectively worked together to make the production of this magazine feasible. This magazine would also not be possible without the help of the IDS Executive Board and larger IDS community. We would like to conclude with the hope that this magazine will serve to not only promote discussion, but build a community of individuals passionate about infectious diseases beyond its current and future pages.
With kind regards,
Sean Park and Alvaro Uribe Editors-in-Chief
Our Staff:
Writers
Julia Rodriguez
Emily Mrakovcic
Ruviha Homma
Nelsa Tiemtoré
Emelie Nguyen
Editors
Annie Smith
Dylan Lai
Lisa Miyazaki
Vanessa Vu
Design Editors
Katharine Knowles
Kiara Anderson
Communications Chair
Shrey Mehta
s MAGAZINE
“In selling as in medicine, prescription before diagnosis is malpractice”
–Tony Alessandra, Author
“I thought there should in truth be heavy damages for malpractice on human souls.”
–Owen Wister, American Writer and Historian
Jorge Zamora-Quezada:
A Case Study
Written By:
Julia Rodriguez
On May 11, 2018, Dr. Jorge Zamora-Quezada from a small city in South Texas was arrested for health care fraud, conspiracy to commit money laundering, and conspiracy to commit health care fraud (Perez, 2018a). He was denied bond and was considered a flight risk (CBS 4 News, 2018), possibly due to his proximity to the Texas-Mexico border and the fact that he possessed properties and bank accounts in Mexico. His wife was also charged for conspiracy to commit money laundering, conspiracy to commit health care fraud, health care fraud, and conspiracy to obstruct justice (KRGV News, 2018; Perez, 2018c). His wife allegedly ordered employees to alter billing and medical record information in response to Zamora-Quezada’s practice being investigated by federal authorities (Gonzalez, 2018). Interestingly, she was also not given bail under the premise that she too, was a flight risk (Gonzalez, 2018). Felix Ramos, Zamora-Quezada’s financial manager, and Estelle Santos Natera, Zamora-Quezada’s billing supervisor, were also caught in the crossfire and charged with conspiracy to commit money laundering, conspiracy to commit health care fraud, health care fraud, and conspiracy to obstruct justice (Perez, 2018c). However, as the doctor who orchestrated the scheme, falsely diagnosed patients,
and administered dangerous treatments, Zamora-Quezada is the focal point of the case. Born in Guadalajara, Mexico, Zamora-Quezada moved to Dallas in 1984 (Perez, 2018a). He graduated from the University of Guadalajara and obtained a masters of public health from Harvard School of Public Health (Perez, 2018a; Texas Medical Board, n.d.). At the time of his arrest, Zamora-Quezada had been practicing in the Rio Grande Valley for 19 years (Perez, 2018a).
The high-profile case unfolded over the course of 2 years until 2020, when he was convicted of “one count of conspiracy to commit health care fraud, seven counts of health care fraud, and one count of conspiracy to obstruct justice” and found guilty in his involve-
ments in his patients’ medical records to justify the expensive therapies and hid records of patients visiting other doctors for second opinions (Horton, 2018). He purchased various properties in Mexico, Colorado, California, and Texas, under the premise that he was renting these properties out to justify his high income (Christensen et al., 2018). He even owned a Maserati and a private plane with his initials on them, along with other luxury items (Christensen et al., 2018).
“I had heard about medical malpractice cases and health fraud schemes on the news, but after seeing the Zamora-Quezada case in my community, I realized medical malpractice effects extend beyond the walls of the exam room.”
ment of a health care fraud scheme of $325 million dollars (U.S. Department of Justice Office of Public Affairs, 2020). Deemed “one of the worst medical fraudsters” by U.S. Attorney Ryan K. Patrick of the Southern District of Texas (U.S. Department of Justice Office of Public Affairs, 2020), Zamora-Quezada diagnosed patients with lifelong diseases that they did not have, such as rheumatoid arthritis, and prescribed caustic drugs and treatments, such as chemotherapy, that were not needed in order to gain more money (Puente, 2022). He wrote false state-
Zamora-Quezada had a history of lawsuits and investigations against him before his arrest in 2018, which can make one wonder why he was not caught sooner. Over the course of the 2000s, Zamora-Quezada was sued by former patients who were allegedly falsely diagnosed with rheumatoid arthritis(Perez, 2018b). In 2005, Zamora-Quezada was sued for sexual discrimination, sexual harassment, and a hostile work environment by four female plaintiffs and lost the case (Alaniz v. Zamora-Quezada, 2005; Perez, 2018a). The plaintiffs claimed he excessively hugged and touched them, tried to kiss them, and even asked to pay for a nose job for one of his employees (Alaniz v. Zamora-Quezada, 2005). He was publicly reprimanded in 2009 by the Texas Medical Board for prescribing improper drugs and billing for unneeded treatment (Texas Medical Board, 2009). According to a news release by the Texas Medical Board, he was ordered to “have an independent audit of his billing practices,” complete education for billing, coding, and recordkeeping, pay a $30,000 fine, and have his business monitored (Texas
Medical Board, 2009). A lawsuit was filed against him in August of 2016 by Amalia Mendoza, a former patient to whom Zamora-Quezada administered rheumatoid arthritis treatments while she had chronic renal failure and kidney dialysis (Perez, 2018a; Zamora-Quezada v. Mendoza, 2018). Mendoza claimed Zamora-Quezada’s prescription of methotrexate caused her to experience “ulcers in her esophagus and mouth and a “life threatening low blood count of white blood cells” (Perez, 2018a). To support her case, she submitted a report from James M. Wheeler, M.D. (Zamora-Quezada v. Mendoza, 2018). Zamora-Quezada objected to the report, claiming Dr. Wheeler was not a credible expert on the matter because Dr. Wheeler was a reproductive endocrinologist and OB/GYN and not a rheumatologist, and filed a motion to dismiss the case (Zamora-Quezada v. Mendoza, 2018). Mendoza submitted another expert report, to which Zamora-Quezada objected again and filed another motion to dismiss. The motion to dismiss was denied and his objections were unsuccessful (Zamora-Quezada v. Mendoza, 2018). Instead of improving his practice and behavior, Zamora-Quezada was determined to make sure no one and no lawsuit could deter his money making scheme.
Somehow, Zamora-Quezada kept up this business for almost 20 years –starting in 2000, until he was stopped in 2018 (Puente, 2022). At the end, up to 10,000 people in the Rio Grande Valley, San Antonio, and other places were estimated to be affected, including children, disabled people, the undocumented, and the elderly (Estrada, 2018; Horton, 2018; Puente, 2022; Perez, 2018b). The reach case was so extensive that the FBI set up a hotline and email for his victims to contact: ZamoraPatient@fbi.gov (Perez, 2018b).
It was quite the bombshell – a doctor, who is by nature supposed to be generous and helpful towards the community, engaging in, as said by Inspector General for the U.S. Department of Health and Human Services CJ Porter, “unthinkably callous and cruel criminal conduct, committed for the sheer sake of greed” (U.S. Department of Justice Office of Public Affairs, 2020). Although Zamora-Quezada’s properties in Mexico, Colorado, and Texas were seized (Puente, 2022), he did not have to give up all of his property. According to tax records, Zamora-Quezada still has a property under his name in a prestigious Mission neighborhood, valued at $754,202 (Hidalgo CAD, n.d.). The property is listed as a homestead despite the fact that he is incarcerated (Hidalgo CAD, n.d.). The building where he practiced medicine is also still under his family trust. Shockingly, his license to practice medicine was merely suspended at the time of his conviction; his license was finally canceled due to non-payment, not even because of his conviction.
I had heard about medical malpractice cases and health fraud schemes on the news, but after seeing the Zamora-Quezada case in my community, I realized medical malpractice effects extend beyond the walls of the exam room. Zamora-Quezada’s scheme took down his employees and even his wife, and impacted not just his former patients, but also his other family, friends, and employees who were unaware of the scheme. How can patients, family, friends, and staff accept that severe medical malpractice occurred for decades, right in front of their faces? The impacts of the scheme extend even further, across counties. The trust of an entire community, which spans across the Rio Grande Valley (Cameron, Hidalgo, Starr, and Willacy counties), was degraded, with thousands of communi-
ty members left in the wake of Zamora-Quezada’s malpractice. Even worse, Zamora-Quezada took advantage of the community’s already fragile health – the Rio Grande Valley is a medically underserved area and suffers disproportionately from diabetes (South Texas College, 2023), with almost 30% of its people living in poverty (U.S. Census Bureau, n.d.). Zamora-Quezada’s malpractice made patients worse off in their health and finances, as he prescribed expensive, unnecessary treatments and ordered excessive diagnostic tests, just so he could gain more money off the misfortunes of struggling lower income community members. Zamora-Quezada’s scheme left the community even more skeptical of the few healthcare options available. Although others in the United States may have forgotten about the buzzing news story in 2018, the Zamora-Quezada case will be remembered by many in the Rio Grande Valley, and its social effects of mistrust in the health care system will ripple for years to come. The Zamora-Quezada case should teach us not only about the grave legal and medical consequences of medical malpractice driven by greed, but also about the reach of its social consequences.
Edited By:
The Lethal Void
Written By:
Nikolas Montaquila
Bacterial infections have been battling humanity for a very long time - so long ago in fact, that these battles may predate the species of human that populates Earth today. Fossil evidence suggests that the Australopithecus africanus in modern day South Africa was losing the battle against the bacterium Brucella up to 2.8 million years ago (D’Anastasio et al, 2009). The battle against bacteria has waged on since, and while today’s Homo sapiens are certainly better equipped to battle these microscopic predators than hominids 3 million years ago, the fight is still far from fair. Nearly an epoch later, humanity continues to struggle with chronic infection, necrosis, septicemia, and other symptomatic manifestations of bacterial infections.
Antimicrobial resistant (AMR) bacteria have become a formidable foe for those practicing modern medicine. Names like MRSA (Methicillin-resistant Staphylococcus aureus), VRE (vancomycin-resistant Enterococcus), and MDR-TB (multi-drug-resistant tuberculosis) have come to strike fear in the hearts of both physicians and patients. Yet these are merely a few names on an ever-growing list of AMR bacteria. Infectious diseases have disproportionately impacted the most medically fragile, having become the second highest cause of death amongst cancer patients (Nanayakkara et al, 2021). More than just a cause of concern for oncologists, bacterial infections have come to make up a large proportion of all AMR infections. In 2019, AMR was present amongst 2.8 million infections in the United States. Of these 2.8 million infections, AMR bacteria took the lives of 35,000
Americans (CDC, 2019). In the same year, AMR bacteria infected nearly 5 million people around the world (Antibiotic Resistance Collaborators, 2019) with low-and middle-income countries bearing a disproportionate burden of disease as a result of poor awareness and surveillance, among other factors (Sharma et al, 2022). Of the nearly 5 million infected, AMR bacteria took the lives of 1.27 million people (Antibiotic Resistance Collaborators, 2019), leading the World Health Organization to list AMR as one of the top ten global health threats facing humanity (WHO, 2021).
In response to these 2019 findings, dozens of infectious disease experts from around the world came together to publish an alarming assertion in the Lancet: AMR has become the leading cause of death globally (Antibiotic Resistance Collaborators, 2019). Edging out conditions known to terrorize vulnerable populations, namely HIV/AIDs and malaria, these experts concluded that AMR infections present an acute threat to human health. The United Nations predicts that the number of fatalities at the hands of AMR infections could reach 10 million people globally by 2050 (WHO, 2019).
When considering the vast progress made in modern medicine over the last century, it becomes questionable how humanity has been put in such a precarious situation. Infectious diseases no longer have the prominence of being the main threat to American public health, but not so long ago this was quite different. At the turn of the 20th century, pneumonia and tuberculosis were the leading cause of mortality in the United States (CDC, 1999). Following the introduction of antibiotics, like penicillin, into everyday clinical care in the mid-1900s, infectious disease mortality decreased markedly. Ninety-nine years later, the main causes of death amongst Americans have shifted toward noncommunicable diseases, namely heart disease and cancer (CDC, 1999).
Flemming’s discovery of penicillin in 1928 helped trigger this epidemiological shift, but the largest progress in the battle against bacteria unfolded over the next five decades. Perhaps a ‘golden age’ of antimicrobial discovery, 27 registered classes of antibiotics were brought to market in the 50 years following Flemming’s sentinel discovery (Silver, 2011). While the first cases of MRSA were recorded in the 1960s, the discovery of vancomycin appeared to quell any concerns about widespread AMR (Ventola, 2015). Researchers struggled to culture resistance toward vancomycin in the laboratory, manifesting hopes that antibiotic resistance toward the medication would never develop in clinical settings. Yet, in 1979 the first case of vancomycin resistant staphylococcus was documented, dashing the hopes of an AMR-proof medication.
This increase in AMR has several causes, including: overuse, improper prescribing practices, and the use of antibiotics in agriculture (Ventola, 2015). These flawed practices have contributed to much of the AMR toward antibiotics we see today, but these negative effects lagged in their proliferation into the clinical setting. In spite of these flawed practices having gone on for decades, novel drug discovery was able to stave off concerns of widespread AMR infections throughout the 1960s and 80s (Ventola, 2015). The end of antibiotic discovery’s ‘golden age’ marked the beginning of AMR infections’ ascension toward an acute medical threat. Aside from the discovery of Teixobactin in 2015, there have been no novel classes of antibiotics brought to market in the last three decades (Silver, 2011). The stagnation of antibiotic discovery has many complex causes, yet many center on the economic incentives surrounding the research and development (R&D) needed to steward antibiotics through the approvals process, and ultimately, their use and accessibility in the clinical market.
Infectious Disease Society Magazine
It costs approximately 1.7 billion dollars to bring an antibiotic to market, a process with a measly 5% success rate during R&D (Plackett, 2020). Approved antibiotics generate a maximum of 46 million dollars per year (Plackett, 2020), making antibiotics overall a poor source of income and investment for big pharma corporations. Considering that oncological medications are three times more profitable than antibiotics, and musculoskeletal condition medications are 11 times more profitable (Plackett, 2020), it becomes clear why pharmaceutical companies have abandoned this avenue of drug discovery. Subsequently, the average share price for companies developing drugs to fight infectious diseases have fallen by 71% since 2018 (Plackett, 2020).
There are two areas which must be addressed in order to close this deadly void in antibiotic discovery: the first by way of policy and the second through technological advancements. Policy actions largely center on a ‘push and pull’ strategy, combining the power of public funds with economic incentives for pharmaceutical companies to spur the development of new antibiotics (Årdal et al, 2019). Using the United States as an example, there have been many ‘push’ initiatives from the National Institute of Allergy and Infectious Diseases which have lessened the economic peril of the antibiotic discovery process; complimented by ‘pull’ initiatives, like efforts to increase the reimbursement rate for new antibiotics to ensure that these newly discovered antibiotic compounds are taken through the approvals process and brought to market. To make the complex process of antibiotic discovery less burdensome, several recent technological advances have taken place. In 2010, researchers at Northeastern University described a novel method known as iChip. This new technology allowed in situ bacteria cultivation, greatly expanding the number of bacteria that are culturable when compared to traditional laboratory methods (Nichols et al, 2010). Just
several years ago, researchers at the Massachusetts Institute of Technology demonstrated that artificial intelligence (AI) can be utilized to identify bacteria growths with possible antibiotic properties based on molecular structure (Stokes et al, 2020).
While AMR bacterial infections are becoming an increasing threat to human health, increased investment and incentivisation of technological advancement has the potential to spur production of new antibacterial medications. AI guided antibiotic discovery and iChip represent two successful examples of what can be accomplished when combating the acute threat posed by AMR, ultimately leading to the discovery of two novel antibiotics: Halicin (Stokes et al, 2020) and Teixobactin (Lodhi et al, 2018), respectively. With proper investment of resources, today’s technology has the capacity to fill the deadly void in antibiotic drug discovery and can provide new and improved weapons to once again tilt the battle against bacteria in humans’ favor.
References:
D’Anastasio, R., Zipfel, B., Moggi-Cecchi, J., Stanyon, R., & Capasso, L. (2009). Possible Brucellosis in an Early Hominin Skeleton from Sterkfontein, South Africa. PLoS ONE, 4(7), e6439. https://doi.org/10.1371/ journal.pone.0006439
Nanayakkara, A. K., Boucher, H. W., Fowler, V. G., Jezek, A., Outterson, K., & Greenberg, D. E. (2021). Antibiotic resistance in the patient with cancer: Escalating challenges and paths forward. CA: A Cancer Journal for Clinicians, 71(6), 488–504. https://doi. org/10.3322/caac.21697
CDC. (2019). Antibiotic resistance threats in the United States, 2019. ANTIBIOTIC RESISTANCE THREATS in the UNITED STATES. https://doi.org/10.15620/ cdc:82532
Sharma, A., Singh, A., Dar, M. A., Kaur, R. J., Charan, J., Iskandar, K., Haque, M., Murti, K., Ravichandiran, V., & Dhingra, S. (2022). Menace of antimicrobial resistance in LMICs: Current surveillance practices and control measures to tackle hostility. Journal of Infection and Public Health, 15(2), 172–181. https://doi. org/10.1016/j.jiph.2021.12.008
Antibiotic Resistance Collaborators. (2022). Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. The Lancet, 399(10325), 629–655. https://doi.org/10.1016/S0140-6736(21)02724-0
WHO. (2021, November 17). Antimicrobial resistance. Who.int; World Health Organization: WHO. https:// www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
WHO. (2019, April 29). New report calls for urgent action to avert antimicrobial resistance crisis. Www.who. int. https://www.who.int/news/item/29-04-2019-newreport-calls-for-urgent-action-to-avert-antimicrobialresistance-crisis
CDC. (1999). Achievements in public health, 19001999: control of infectious diseases. Centers for Disease Control and Prevention MMWR. https://www. cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm
Silver L. L. (2011). Challenges of antibacterial discovery. Clinical microbiology reviews, 24(1), 71–109. https://doi.org/10.1128/CMR.00030-10
Ventola C. L. (2015). The antibiotic resistance crisis: part 1: causes and threats. P & T : a peer-reviewed journal for formulary management, 40(4), 277–283.
Årdal, C., Balasegaram, M., Laxminarayan, R., McAdams, D., Outterson, K., Rex, J. H., & Sumpradit, N. (2019). Antibiotic development — economic, regulatory and societal challenges. Nature Reviews Microbiology, 18, 267–274. https://doi.org/10.1038/s41579-019-02933
Nichols, D., Cahoon, N., Trakhtenberg, E. M., Pham, L., Mehta, A., Belanger, A., Kanigan, T., Lewis, K., & Epstein, S. S. (2010). Use of ichip for high-throughput in situ cultivation of “uncultivable” microbial species. Applied and environmental microbiology, 76(8), 2445–2450. https://doi.org/10.1128/AEM.01754-09
Stokes, J. M., Yang, K., Swanson, K., Jin, W., Cubillos-Ruiz, A., Donghia, N. M., MacNair, C. R., French, S., Carfrae, L. A., Bloom-Ackermann, Z., Tran, V. M., Chiappino-Pepe, A., Badran, A. H., Andrews, I. W., Chory, E. J., Church, G. M., Brown, E. D., Jaakkola, T. S., Barzilay, R., & Collins, J. J. (2020). A Deep Learning Approach to Antibiotic Discovery. Cell, 180(4), 688–702.e13. https://doi.org/10.1016/j.cell.2020.01.021
Lodhi, A. F., Zhang, Y., Adil, M., & Deng, Y. (2018). Antibiotic discovery: Combining isolation chip (iChip) technology and co-culture technique. Applied Microbiology and Biotechnology, 102(17), 7333–7341. https:// doi.org/10.1007/s00253-018-9193-0
“In the pursuit of global health equity, confronting medical malpractice is as important as tackling infectious diseases or improving access to essential medicines, as it directly influences health outcomes and public trust in healthcare systems.” –Unknown
“Without regulations and standardizations, medical tourism has the potential to be a hub of medical malpractices in which unqualified healthcare professionals treat naïve patients.”
–Dr. Prem Jagyasi, Medical Tourism Magazine
Malpractice or Ignorance: A Discourse on the Current Prominence and Prevalence of
Medical Malpractice in Developing Countries:
A Case Study of Mexico
Written By:
Emelie Nguyen
When thinking of medical malpractice, people often think of the complicated litigation that comes with breaking the rules. However, does this remain the case for countries that lack strict regulations and courts? Developing countries may not have the luxury of worrying about medical malpractice. There are a multitude of reasons for this: health insurance is less common, resources and infrastructure can be limited, physicians are scarce, etc. To counteract these disparities, Mexico established the National Commission for Medical Arbitration (Conamed) in 1996. Its aim was to tackle a range of
civil code jurisdiction, characterized by a codified legal framework that encompasses a wide range of laws, including those pertaining to personal injury.2
Unlike common law jurisdictions like the United States, where legal outcomes are heavily influenced by case law and judicial precedents, Mexico relies on its Federal Civil Code and corresponding state codes to address personal injuries through “extra-contractual liability.” Despite the broad scope of these codes, only a small fraction of their sections deal directly with tort law, leaving significant aspects of personal injury law underdeveloped. Legal expert Jorge Vargas points out that Mexican legislation has not adequately evolved to address the complexities of modern personal injury cases, which leaves courts with considerable discretion but little guidance
“Mexico’s medical malpractice system exemplifies a promising alternative for developing countries grappling with the challenge of regulation and litigation.”
healthcare-related issues from facility quality to medical malpractice.1 Conamed represents an innovative model in addressing medical malpractice disputes, offering a compelling blueprint for developing countries in search of efficient and fair alternatives to the cumbersome traditional litigation process.
Mexico’s legal system operates as a
on key legal concepts, such as fault, negligence, or causation. Additionally, the method for calculating compensatory damages in Mexico, based on a workers’ compensation formula from the Federal Labor Act, tends to limit the potential compensation for injured plaintiffs, thus discouraging them from pursuing legal action. This, coupled with a cultural aversion to litigation and a general distrust of the judiciary,
leads many people to settle disputes informally, further detracting from the development of a robust personal injury legal framework in Mexico.
An alternative emerged in 1996, when then-President Ernesto Zedillo declared that a new national arbitration agency would be formed within Mexico’s Ministry of Health: la Comisión Nacional de Arbitraje Médico, or Conamed. Conamed was designed as a more accessible, efficient, and cost-effective alternative to civil courts, tailored specifically to handle disputes over medical care between patients and providers. It can resolve cases at three stages: intervention, conciliation, or arbitration.
Initially, about 73% of cases find resolution within two days through a
rapid, somewhat informal intervention stage. This phase facilitates open communication between the patient and provider, occasionally with input from Conamed’s specialized consultants, offering an appealing option for individuals in developing countries seeking to avoid the complexities of adversarial litigation.
If this initial intervention step fails to resolve the dispute, the process advances to conciliation, where Conamed’s experts screen complaints, focusing on genuine cases of medical malpractice. This second stage involves a comprehensive medical review by Conamed’s experts alongside the treating physicians. The aim of the conciliation phase is to reach an amicable agreement, with over half of the cases
typically resolved within three to six months. If the dispute remains unresolved, parties may choose to exit the Conamed process and pursue legal action, or proceed to the final stage, arbitration.
Arbitration requires a formal agreement that prevents the parties involved from pursuing court proceedings. Arbitrators, independent professionals in medicine or law, are supported by Conamed, which selects expert consultants relevant to each case. During this stage, arbitrators may award compensation for malpractice, typically based on a workers’ compensation formula, with awards generally lower than those ordered by courts. While Conamed’s arbitration cannot impose sanctions on physicians or award “moral dam-
References:
LaFee, S., & Buschman, H. (2017, April 25). Novel Phage Therapy Saves Patient with Multidrug-Resistant Bacterial Infection. UC San Diego Today. Retrieved November 10, 2023, from https://today.ucsd.edu/ story/novel_phage_therapy_saves_patient_with_multidrug_resistant_bacterial_infect
Barron, M. (2022, August 31). Phage Therapy: Past, Present and Future. American Society for Microbiology. Retrieved November 10, 2023, from https://asm. org/Articles/2022/August/Phage-Therapy-Past,-Present-and-Future#:~:text=Bacteriophages%2C%20 or%20phages%2C%20are%20viruses,are%20thousands%20of%20different%20types
Anomaly J. (2020). The Future of Phage: Ethical Challenges of Using Phage Therapy to Treat Bacterial Infections. Public health ethics, 13(1), 82–88. https:// doi.org/10.1093/phe/phaa003
ages,” it effectively spares participants the costs and complexities of litigation, relying on its esteemed standing within both the medical and legal communities in Mexico to facilitate fair outcomes.
It seems that Conamed has been well-received by the general population. Conamed received “good” or “excellent” ratings by 97% of the roughly 5500 patients and providers anonymously surveyed. Mexico’s medical malpractice system exemplifies a promising alternative for developing countries grappling with the challenge of regulation and litigation. By mitigating key barriers and streamlining the resolution process, similar systems can significantly improve access to justice for malpractice victims, fostering equitable outcomes and instilling trust in the healthcare system.
Edited By:
Malpractice or Ignorance: A Discourse on the Current Prominence and
Unmasking the Savior Syndrome:
HBO’s Documentary Sheds Light on Medical Malpractice
Written By:
Nelsa Tiemtoré
Released on HBO Max in 2023, Savior Complex is a true crime documentary that illustrates how Renee Bach, an untrained American, provided improper medical treatment to nearly a thousand Ugandan children through her faith-based nonprofit, Serving His Children. In the nonprofit’s four years of operation (2011-2015), 105 of the 940 children they treated died. In the first year alone, 20% of the children taken in by the organization died, which is particularly high for an international aid group. Even more concerning? A third of these deaths occurred within the first 48 hours that they were admitted to Bach’s critical care center.
The story of Serving His Children is a classic example of medical malpractice on the African continent. Many NGOs flock to Africa, driven by saviorism, to “help” its citizens through a variety of aid efforts. While there are often good intentions behind these efforts and some of these efforts
may actually be beneficial, not all of these agendas are always carried out in a legal or safe manner. For example, Renee Bach claimed that at 19, God called her to move to Jinja, Uganda in order to start a nonprofit; Bach made this decision despite never having lived in Uganda previously or even having left the United States. Lacking a college education and any formal medical or nutritional training, a young Bach created her organization to help combat malnutrition. At first, her main priority was feeding the children of Jinja. However, after some time, Bach decided to create a critical care center for malnourished kids to temporarily stay until they reached a target healthy weight. The critical care center then expanded,
containing multiple beds, employing 3 Ugandan nurses, and creating a stock room filled with medical supplies such as over-the-counter medicines, oxygen tanks, IV catheters, and health monitoring equipment.
A major issue presented itself when children arriving at the critical care center were found to be suffering from not only malnutrition, but also from serious illnesses such as tuberculosis, pneumonia, internal parasites, and stage 4 HIV. Instead of being referred to hospitals for care, Bach set out to treat these children herself. She went as far as to complete a number of procedures such as blood transfusions and IV on the children, sometimes without a certified nurse present, blindly using information from Google to guide her diagnoses.
Jackie Kramlich, a licensed nurse
from North Dakota, recalled her time with Serving His Children as being quite concerning. In 2011, she planned to volunteer with the nonprofit organization for a year, but quit four months into her new position as she felt Bach took too much liberty treating the children and acted almost as if it was a
color) due to a belief of containing a certain amount of knowledge that can be applicable to solving solutions worldwide. In the same way that White imperialists justified colonizing the African continent by claiming that they were ‘civilizing’ the indigenous peoples of Africa, many saviorists today
“Bach allowed medical malpractice to proliferate in many facets: she not only ran a critical care center where improper treatment was given, but also practiced severe negligence and delayed/improper diagnoses.”
game. Kramlich even went as far as to send a letter to Serving His Childrens’ board of directors in the United States. Bach allowed medical malpractice to proliferate in many facets: she not only ran a critical care center where improper treatment was given, but also practiced severe negligence and delayed/improper diagnoses. However, it would not be until 2015 that Kramlich would have the courage to file a case with the Ugandan police. Once the case was filed, families of children who had died in Bach’s care also came forward calling for justice. While the case of Serving His Children is horrifying, this is not the first time in history that such a thing has occurred. Africa has often been the western world’s playground for experimental health efforts, such as the French’s health campaigns in Central Africa since colonial times. These dangerous practices have resulted in growing medical distrust on the African continent.
In its essence, white saviorism is rooted in colonialism and is a result of westerners (often caucasian) feeling a responsibility to ‘rescue’ marginalized communities (often communities of
take over areas of Africa and disrupt the community in inappropriate ways under the guise of ‘helping.’ Saviorism often undermines indigenous African knowledge systems, prioritizing white supremacy and western knowledge systems. Studies have also shown that saviorism is actually detrimental to health outcomes as it fails to address the systemic and historical issues that harm the health of people of color. Luckily, there has been pushback by organizations, like No White Saviors, who are trying to hold nonprofits providing international aid in Africa accountable. This pushback is necessary for allowing Africans to exercise agency in the protection of both their homelands and themselves.
Reflecting upon the medical malpractice monstrosities carried out under Serving His Children, it is important to examine not only global health impacts, but also societal ones. Medical malpractice backed by a savior complex not only leads to increased deaths, but also further adds to the foundation of systemic issues that have been perpetuated for centuries. It is important that this toxic foundation be remedi-
References:
Aizenman, Nurith et al. ‘’American With No Medical Training Ran Center For Malnourished Ugandan Kids. 105 Died.’’ NPR: Goats and Soda, 9 Aug. 2019, www.npr.org/sections/goatsandsoda/2019/08/09/749005287/american-with-no-medicaltraining-ran-center-for-malnourished-ugandan-kids105-d.
Berman, Judy. ‘’Savior Complex Review.’’ Time, 2023, time.com/6317172/savior-complex-review/.
Fleisher, Chris. ‘’The long shadow of colonial medicine.” American Economic Association. https://www.aeaweb.org/research/africa-colonial-health-campaign-impact
Silver, Mark. ‘’How NPR Covered the Missionary Who Ran a Center for Malnourished Kids Where 105 Died.’’ NPR: Goats and Soda, 26 Sept. 2023, www.npr.org/ sections/goatsandsoda/2023/09/26/1200688372/ how-npr-covered-the-missionary-who-ran-a-centerfor-malnourished-kids-where-105-.
Murphy, Colleen et al. ‘’White Savior Complex.’’ Health. com, www.health.com/mind-body/health-diversity-inclusion/white-savior-complex
ated by empowering Africans, rather than acting on a false and harmful urge to ‘save’ them.
antibiotic treatments and stop super-bacteria dead in their tracks. They are also a reminder that even most basic life forms hold power beyond our imagination.
Edited By:
Failure to Diagnose HIV:
A Multidimensional Case of Medical Malpractice
Written By:
Emily Mrakovcic
When individuals seek medical attention, they often grapple with fear and uncertainty, emotions universally shared among patients. In the face of a new diagnosis, the approach taken by healthcare providers plays a pivotal role in shaping patient outcomes. Compassionate and attentive care not only offers reassurance but also facilitates prompt and effective medical treatment. Conversely, lapses in judgment or oversight can have severe repercussions for patients. Nowhere is this more evident than in cases involving the diagnosis and management of HIV. Failure to promptly initiate appropriate treatment following a diagnosis leads to both an increase in viral load and perpetuates the risk of viral transmission to others. Medical negligence in HIV care thus poses a dual threat: compromising individual health and endangering the community to virus contraction.
were recorded in the cities of Gujrat, Sargodha, and Larkana. Particularly alarming was the situation in the Jalalpur Jattan village Gujrat, where 36% of individuals at an HIV screening camp tested positive, yet transmission continued unabated without intervention for another decade. Furthermore, access to and utilization of antiretroviral therapy (ART) remained unavailable and underutilized (Ejaz et
harm reduction programs were non-existent, and a lack of awareness about HIV transmission prevailed, particularly in rural areas. This multifaceted crisis underscores a crucial realization drawn from Pakistan’s epidemics: medical malpractice and public health shortcomings often intertwine, compounding the challenges in combating infectious diseases.
In the case of Pakistan, as well as
“Particularly alarming was the situation in the Jalalpur Jattan village Gujrat, where 36% of individuals at an HIV screening camp tested positive, yet transmission continued unabated without intervention for another decade.”
al., 2024). Interviews conducted in the affected village revealed a grave lack of awareness among residents, with just over a third recognizing both sexual contact and blood transfusion as routes of HIV transmission. This points not only to a failure on the part of medical professionals to provide adequate care but also to a broader public health failure in educating vulnerable populations about the primary modes of HIV transmission.
Pakistan, one of the many nations battling a severe HIV epidemic, has unfortunately witnessed instances of medical malpractice within its healthcare system. As of 2022, the country ranks as the second largest in Asia in terms of HIV cases (Rangwala et al., 2022). Disturbingly, outbreaks attributed to medical negligence have been notably high (Davlidova, 2019). In 2019, large-scale outbreaks
In April 2019, Larkana faced an HIV outbreak that revealed a grim reality. With high transmission rates, the Larkana police took action and registered several cases of medical negligence against 24 privately practicing doctors. However, the issues ran deeper than simple individual shortcomings in healthcare delivery. Beyond the evident medical malpractice, it was discovered that condom usage was shockingly low,
many other countries worldwide, including the United States, numerous pressing health issues are worsened by the coupling of medical malpractice and public health failures. When both medicine and public health are not executed correctly, the consequences can be dire, affecting the lives of many individuals. In Pakistan, medical malpractice hindered the care of those living with HIV and also perpetuated the spread of the virus by failing to adequately address the needs of infected individuals. Meanwhile, public health measures, including harm reduction strategies, education initiatives, and sexual health resources, fell short in adequately informing communities and providing essential resources to mitigate infection rates. When either sector fails, whether due to medical malpractice or public health deficiencies, the overall state of health and well-being
deteriorates. This interconnectedness emphasizes the importance of addressing both components of healthcare to effectively combat pressing health challenges.
In Pakistan, one proposed solution to combat medical malpractice and enhance public health outcomes revolves around government intervention within the healthcare system itself to raise awareness for HIV (Salman et al., 2022). This strategy could be executed by leveraging the existing infrastructure to raise awareness about HIV, such as by encouraging healthcare workers to disseminate vital information. Additionally, efforts should be made to identify and remove unqualified providers who are not equipped to effectively manage HIV cases. By addressing these issues from an internal standpoint, Pakistan can tackle the root causes of medical malpractice. Furthermore, augmenting this solution with additional measures can significantly amplify its effectiveness. Expanding into the realm of public health, the Pakistani government could implement initiatives aimed at increasing awareness in rural areas and improving the accessibility of HIV treatment and testing kits. If medical malpractice and public health are both addressed, these complementary solutions can reinforce one another, resulting in a more comprehensive approach to strengthening population health.
To effectively address the intertwined challenges of medical malpractice and public health failures, a multidisciplinary approach is essential. These issues are interconnected, representing
two sides of the same coin, and both demand urgent and meticulous attention. The transmission of HIV within communities underscores the dual nature of these challenges. Firstly, it highlights the importance of adequate medical care in preventing the spread of the virus. Secondly, it emphasizes the critical role of community resources and outreach programs in prevention efforts. While medical malpractice undoubtedly poses a clear and immediate threat, it’s essential to recognize that health outcomes are influenced by factors beyond medical treatment alone. Public health, often less visible but equally significant, constitutes the other determinants of health within communities. While these factors may not be at the forefront of our daily lives, they have profound influence on our well-being. As such, solutions aimed at addressing medical malpractice must also incorporate public health initiatives. By acknowledging the multifaceted nature of these issues and embracing a holistic approach, we can
References:
Davlidova, S., Abidi, S.H., Ali, S. (2019). Healthcare malpractice and continuing HIV outbreaks in Pakistan. BMJ Global Health, 4(6).
Ejaz, U., Ahmad, F., Burki, R.K., Shahbaz, U. (2024). HIV in Pakistan: Understanding Challenges and Implementing Strategies for Prevention. Asia Pacific Journal of Public Health.
Rangwala, H.S., Anwar, Z., Ovais, M.H., Fatima, H., Siddiq, M.A. (2022). Rising HIV cases in Pakistan: Start of a pandemic?. Jinnah Sindh Medical University.
Salman, Y., Shaeen, S.K., Butt, M.S. (2022). HIV in Pakistan: Challenges, efforts and recommendations. Annals of Medicine & Surgery, 84( ).
strive towards comprehensive solutions that address the root causes of health disparities and promote the well-being of all individuals.
Malpractice or Ignorance: A Discourse on the Current Prominence and Prevalence
My Personal Experience with Antimicrobial Resistance
Written By:
Chilsea Wang
My dad called me at 4 a.m.
Fumbling for my phone,
I tiptoed out of my room, wincing in apology to my still-sleeping roommate. The quiet peace of the early morning was cut short by the news rushing down the phone line: my grandfather, not yet in his seventies, had just died.
A lung transplant surgery cut a giant hole in Grandpa’s chest. In keeping with best practice for transplant care, his immune system was suppressed so his new lungs could integrate without being rejected as foreign biomatter. Though this is a life-saving operation, it creates the opportunity for an antimicrobial-resistant (AMR) infection to slip in. Despite intensive treatment, his upper respiratory tract collapsed inwards, ceding space to bacteria that resisted every available antibiotic the hospital had to offer.
My family wasn’t the only one particularly plagued by these tiny living specks — a systematic analysis published in the Lancet found that AMR infections were a direct cause of 1.27 million deaths in 2019, and a secondary or associated cause in an additional 3.68 million deaths.
Let’s make a distinction here: antibiotics are great! They help get rid of painful infections that impede our bodies’ function. However, populations of bacteria mutate and evolve over quite short periods of time – each time bacteria double, there is an opportunity for a lucky few from
the population to acquire increased resistance to their environment. Improper antibiotic usage, such as incorrect dosing or irregular timing, allows these adaptations to be retained and passed down into new generations of “super-bacteria”.
In hospital statistics, antibiotic resistance manifests itself as longer recovery times, less open hospital beds, and decreased surgical success rates. For my family, it was months spent by the bedside of a man made ever weaker by successive infections, almost unrecognizable as he was overtaken by the entropy of these tiny cells. X-rays showed the delicate tissue in Grandpa’s lungs being damaged irreversibly – I wonder if he felt the machinery of his life breaking, ceding back into the background chaos of the universe.
My grandpa, who had been someone who could hike a three-hour trail and not break a sweat, became so weak that he had to be on a ventilator at all times. We had plans to go fishing next to the Heilongjiang River when I graduated from high school. Instead, I found myself describing the California sky to him over FaceTime, his eyes no longer able to focus on a tiny phone screen.
This is not just a personal grief; it is also a global issue. Per the aforementioned Lancet article, antimicrobial resistance is responsible for the loss of 192,000 million disability-adjusted life years, or DALYs, around the world². Each DALY represents a year where someone experiences pain that significantly impacts their ability to function. This could mean a grandpa who cannot hike, a mother who cannot work, a farmer who cannot till his fields, or a
chef who cannot turn on the stove and cook.
If medicine aims to preserve human connections that matter and allow human stories to continue to grow, then addressing this problem of antimicrobial resistant bacteria is crucial. The big question is, how?
The Center of Disease Control (CDC) has outlined three major steps towards tackling antimicrobial resistance –
1. preventing infections in the first place
2. improving antibiotics use to prevent resistance
3. stopping the spread of resistant bacteria
In service of improving antibiotics use, the CDC also identifies four settings that are key to addressing antimicrobial resistance –
1. Healthcare providers’ offices
2. The vet
3. Within households
4. Feed troughs of livestock and poultry producers
In each of these four settings, the advice is similar: it’s strongly advised to cut back antibiotics prescription and use, treating it as a last resort. The easiest way to prevent antimicrobial resistance is to make sure that bacteria do not have time to evolve an evolutionary response, and are wiped out quickly and cleanly when antibiotics are truly needed.
This article is dedicated to the loving memory of my maternal grandfather, Ziqun Rong. May he rest in peace.
References:
Centers for Disease Control and Prevention. (2021, December 14). Actions to fight antibiotic resistance. Centers for Disease Control and Prevention. Retrieved May 2, 2022, from https://www.cdc.gov/drugresistance/actions-to-fight.html
Lobanovska, Mariya, and Giulia Pilla. “Penicillin’s Discovery and Antibiotic Resistance: Lessons for the Future?.” The Yale journal of biology and medicine vol. 90,1 135-145. 29 Mar. 2017
Lung Transplant. American Lung Association. (n.d.). Retrieved May 2, 2022, from https://www.lung.org/ lung-health-diseases/lung-procedures-and-tests/ lung-transplant
Murray, C. J. L., Ikuta, K. S., Sharara, F., Swetschinski, L., Robles Aguilar, G., Gray, A., Han, C., Bisignano, C., Rao, P., Wool, E., Johnson, S. C., Browne, A. J., Chipeta, M. G., Fell, F., Hackett, S., Haines-Woodhouse, G., Kashef Hamadani, B. H., Kumaran, E. A., McManigal, B., … Naghavi, M. (2022). Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. The Lancet, 399(10325), 629–655. https://doi. org/10.1016/s0140-6736(21)02724-0
“I think we are faced in medicine with the reality that we have to be willing to talk about our failures and think hard about them, even despite the malpractice system. I mean, there are things that we can do to make that system better.”
–Atul Gawande, American Surgeon and Writer
“As a nurse, I was the patient’s advocate. As a medical malpractice attorney, I am still the patient’s advocate but in a different arena and profession.”
–Susan A. Capra, Lawyer
“First, Do No Harm”:
Doctors Who Spread COVID-19 Misinformation
Put Patients’ Lives
At Risk
Written By:
Ruviha Homma
Various false claims were spread during the COVID-19 pandemic, including that masks are unnecessary, COVID-19 vaccines are dangerous, and non-FDA-approved therapies should be used. One would expect this spewing of false information surrounding COVID-19 to come from a person with no medical background. However, these exact false narratives were publicly spread and endorsed by America’s Frontline Doctors, an organization that describes itself as a “non-partisan” group of medical professionals (Bergengruen, 2021).
Defined as “information that is false, inaccurate, or misleading accord-
users (Gisondi et al., 2022). This has facilitated the spread of misinformation by various organizations and individuals, such as former president Donald Trump, one of the largest drivers of COVID-19 misinformation in the media (Evanega et al., 2020). Even more concerning, however, is the role certain physicians have played in spreading these false claims.
A recent study found general themes among COVID-19 misinformation spread by physicians on social media platforms. These common narratives include disputing the effectiveness of vaccines and masks, promoting medical treatments with a lack of federal approval, and several other conspiracy theories (Sule et al., 2023). Even beyond the scope of social media, some high-profile physicians have spread COVID-19 misinformation. Take Dr. Joseph Ladapo, Florida’s
“Spreading false narratives about COVID-19, risking the health of their patients; This goes against the very core values of being a doctor, of doing no harm and promoting the health of all.”
ing to the best available evidence at the time,” misinformation has been a crucial issue since the start of the COVID-19 pandemic (U.S. Department of Health and Human Services, n.d.). The rise of social media has allowed for information on COVID-19, often not checked for accuracy, to be propagated and spread rapidly by
current surgeon general, for instance. Since his appointment as the state’s surgeon general in 2021, he has made a barrage of false claims. Dr. Ladapo affirmed that healthy children should not receive COVID-19 vaccines and that such vaccines should stop being used, given debunked claims of certain contaminants integrating into human DNA (Mandavilli, 2024). While health
experts and federal agencies continuously disprove these narratives spread by certain physicians, it may not be enough to prevent the public from believing them.
These false claims spread by physicians have significant public health risks. Since 2020, the COVID-19 pandemic has resulted in 1,186,671 deaths in the United States alone (Centers for Disease Control and Prevention, 2024). Of these deaths, it is estimated that nearly 234,000 — close to 25% of all deaths — could have been prevented with vaccinations (Amin et al., 2022). Misinformation plays a role in these preventable deaths, as exposure to misinformation can increase vaccine hesitancy and reduce behavioral intention to become vaccinated (Lee et al., 2022). Thus, physicians who have spread misinformation on COVID-19 and vaccines have contributed to these preventable deaths.
To address this form of medical malpractice, individuals and organizations have attempted to hold physicians accountable for their actions. For instance, some state medical boards have revoked the licenses of physicians who have spread misinformation. In 2021, the Oregon Medical Board revoked the license of a doctor who disregarded COVID-19 mask mandates at the time and falsely claimed that masks cause carbon dioxide poisoning (AP, 2021). Patients have also pursued malpractice lawsuits against certain physicians and organizations, including America’s
Frontline Doctors, for spreading misinformation and prescribing unproven treatments, which have resulted in deaths (Bergengruen, 2023). In addition, legislation has been proposed and implemented in select states to discipline doctors for spreading misinformation, such as a law in California that penalizes doctors for spreading COVID-19 misinformation (Pierson, 2023). However, this law was eventually blocked by a judge due to lawsuits challenging it on the grounds of free speech (Pierson, 2023). Despite these efforts by certain medical boards, states, and individuals to curb the speech of these physicians, other states have instead attempted to protect their voices. Around a dozen states have implemented legislation to limit the authority of medical boards when disciplining physicians for spreading misinformation (Weiner, 2023).
With this myriad of conflicting actions and policies among medical boards and states, it is clear that pass-
ing regulations to limit COVID-19 misinformation spread by physicians is not a straightforward, non-partisan process. Given that the First Amendment of the U.S. Constitution guaranteeing the right to free speech is so intertwined with this topic, holding physicians accountable for the information they spread becomes even more difficult and politicized (Sage & Yang, 2022). Although it is important that people have a right to free speech, the act of spreading COVID-19 misinformation can be deadly and has implications for population health. It is not simply a matter of “free speech” when lives are at risk.
All of this isn’t to say that the entire medical profession is in the wrong. In fact, individuals trust in physicians. Many people are confident that physicians are credible, reliable sources of health information, and, in most cases, they are. Yet, some physicians are undoubtedly spreading false narratives about COVID-19, risking the health of their patients. This goes against
the very core values of being a doctor, of doing no harm and promoting the health of all. For this reason, physicians should be disciplined for spreading misinformation.
Even beyond the COVID-19 pandemic, as more infectious diseases are expected to emerge in the next century, it is imperative to continue to grapple with this issue. States and medical boards must enforce regulations to combat health misinformation, ensuring that all physicians and other medical professionals are rightfully held accountable for their speech and actions.
Edited By:
Annie Smith
Malpractice or Ignorance: A Discourse on the Current
Medical Malpractice:
A Legal Perspective
Written By:
Julia Rodriguez
Law and regulations play a role in every aspect of our lives.
From the food we eat, the roads we drive on, the products we use, to the buildings we inhabit, regulations safeguard our well-being. Similarly, in the realm of healthcare, laws and regulations serve to uphold honesty, safety, and professionalism in the practice and delivery of medical services. Law affects how doctors practice, in both clinical and administrative senses, but many medical students receive limited education on health law and its significance.. It has been documented that many medical students learn about health law through the “hidden curriculum”-- an implicit influence stemming from the learning environment, social norms, and unspoken beliefs. This lack of formal education on health law and policy leads to misconceptions and negative attitudes towards legal matters among medical students and for experienced physicians to teach students to consider medical malpractice in their clinical decisions (Arbel et al., 2024). More often than not, medical students are generally taught to avoid getting involved in the legal field by trying to prevent malpractice, which reinforces negative attitudes towards the legal system (Arbel et al., 2024).
past two decades that highlights a prevailing negative sentiment towards the legal field within Brown’s own medical school (Kelly & Miller, 2009). Based on a study conducted at Brown University in 2006, Brown medical school students believed that the medical malpractice system needed reform and that doctors were frequently subjected to unwarranted malpractice lawsuits (Kelly & Miller, 2009). Notably, these perceptions remained throughout the students’ four years at the medical school, underscoring the lack of education on health law and a failure to address negative beliefs (Kelly & Miller, 2009). Since this study was conducted almost twenty years ago, I investigated Brown Medical School’s curriculum offerings to assess any potential changes in curricula over the years. Regrettably, it appears that the Brown Warren Alpert Medical School does not include health law or billing systems in their Doctor of Medicine (MD) curriculum,
negative perceptions, there remains a lack of courses within the MD program that focus on the legal aspects of medical practice (Shah, 2008; Arbel et al., 2024). A representative from the legal community advocates for changes in this approach, recognizing the potential benefits of integrating legal education into the medical school curriculum
“Although research indicates that educating medical students over health law can mitigate negative perceptions, there remains a lack of courses within the MD program that focus on the legal aspects of medical practice.”
In fact, there is evidence from the
not even as electives. However, their Master of Science in Population Medicine (ScM) program includes courses that teach the critical aspects of health systems. These courses cover “healthcare financing, health disparities, social determinants of health, patient safety, quality improvement, and medical-legal partnerships.” Although research indicates that educating medical students over health law can mitigate
I recently interviewed a medical malpractice defense attorney based in Texas. She emphasized the critical need for medical students to receive education on health law and the intricacies of the billing system in the United States. When asked about the inclusion of medical malpractice and legal risks in the medical school curriculum, she stated , “Absolutely, for both the doctor and patient’s sake. Schools should not be graduating doctors who are ignorant about laws that govern their practices.” According to her, comprehensive education on billing systems is especially important, as miseducation regarding billing is often to blame for financial recoupments. She highlighted the complexity of billing processes, noting that billing “is complicated and doctors may have employees with just a high school diploma handling millions of dollars of accounts receivables. Billing under federal and state plans (i.e., Medicare, Medicaid, and Tricare) carries the potential for civil and criminal penalties. There seems to be a lack of education among physicians about those payment systems, particularly with regard to the doctor’s responsibilities in billing and the legal and financial implications of fraudulent or excessive billing.” She explained how billing systems, especial-
ly for Medicare and Medicaid patients, can influence the way doctors practice medicine in the field. For instance, doctors are required to document certain information in a patient’s medical chart to justify a CPT code used in the billing process. This requirement influences the questions asked, exams performed, and diagnostic tests or imaging studies ordered. Ignorance of billing systems can result in grave consequences for doctors getting into major trouble with the federal government by way of recoupment of fees, sometimes amounting to millions of dollars, for unnecessary medical treatment due to insufficient documentation. In severe cases, doctors may face criminal proceedings for fraud. The attorney further emphasized the risk associated with delegating billing responsibilities to untrained staff, which may lead to coding errors and other or other billing inaccuracies. In cases where fraud is suspected, the federal government will audit the doctor’s practice. If fraud is confirmed, even if unintentional, the federal government has the authority to seize assets from the doctor to recoup the money. In essence, the attorney’s insights emphasize the indispensable nature of comprehensive education on health law and billing systems for medical students. Such education not only protects doctors from legal issues but also ensures ethical medical practices for patients.
In certain states, tort reform specific to medical malpractice cases has been implemented. Texas, for example, placed a cap on non-economic damages. This has resulted in a notable reduction in the number of case filings post-reform. Conversely, in states like Rhode Island where there are no damage caps, plaintiffs can potentially receive unlimited compensation (Goguen, n.d.). It is important to note that experienced physicians who mentor medical students may harbor outdated perceptions of over-suing,
imparting these opinions onto their students. Therefore, it is imperative for medical students to be aware of the reforms enacted to mitigate unnecessary lawsuits against doctors. This awareness not only serves to dispel negative attitudes, but also fosters a deeper understanding of how such reforms influence medical practice. By understanding the impact of these reforms, medical students can navigate the legal landscape more effectively, ensuring both sound patient care and professional integrity.
Doctors hold the power to enact changes in their clinical practice aimed at reducing the likelihood of malpractice occurrences. One critical aspect is doctors explaining “in layman terms the side effects, complications, and instructions to their patients.” Failure to do so can lead to confusion and poor health outcomes, particularly in cases involving language barriers or when doctors lack cultural competency. Recognizing the significance of cultural competence in healthcare delivery, Brown Medical School has taken steps to equip its students with the necessary skills. This includes incorporating language courses (e.g., medical Portuguese, Spanish, and Chinese) and culturally sensitive training courses. By prioritizing such education, medical students are better prepared to communicate effectively with diverse patient populations and ultimately improve health outcomes.
For individuals interested in health and law, but lacking a strong STEM background, there are definitely opportunities in the field. Contrary to popular belief, one does not need medical or nursing education or training to succeed as a medical malpractice lawyer. According to the attorney, “You will be trying cases to community members who are not trained medical professionals so it is important to learn the medicine and be able to communicate
References:
Arbel, E., Reese, A., Oh, K., & Mishra, A. (2024). Medical Law and Medical School Curricula: A Systematic Review. Cureus, 16(2), e54377. https://doi.org/10.7759/ cureus.54377
Goguen, D. (n.d.). Rhode Island Medical Malpractice Laws. www.nolo.com. https://www.nolo.com/legal-encyclopedia/rhode-island-medical-malpractice-laws. html
Kelly, E. T., & Miller, E. A. (2009). Perceptions of medical malpractice and medical malpractice reform among first- and fourth-year medical students. Health policy (Amsterdam, Netherlands), 91(1), 71–78. https:// doi.org/10.1016/j.healthpol.2008.11.005
Shah, N. D. (2008). The Teaching of Law in Medical Education. AMA Journal of Ethics, 10(5), 332–337. https://doi.org/10.1001/virtualmentor.2008.10.5.oped1-0805
your defense in a manner in which a non-trained person can understand. I have seen former nurses and doctors who later become lawyers get bogged down in technicalities that may matter in medicine but do not matter in a trial.” For her, the most rewarding aspect of being a medical malpractice attorney is continually learning about diverse medical disciplines. Crafting a persuasive narrative that explains the sequence of events in a manner understandable to the jury requires creativity. This entails weaving together medical record excerpts and visuals and employing storytelling techniques to construct a compelling argument to the jury. Her most valuable advice? Approach the case from a perspective grounded in common sense: “a lawyer will likely not outsmart a physician in the medicine, but a good lawyer will make common sense points that a jury will understand, but that the opposing physician expert never saw coming on cross examination.”
Edited By:
Malpractice or Ignorance: A Discourse on the Current Prominence and Prevalence
Rhode Island’s Approach Toward the Overdose Crisis:
Harm Reduction Centers
Written By:
Joshua Kalfus
Drug-induced overdose deaths and the transmission of chronic illnesses have significantly impacted the United States. Over the course of a year, ending in April 2021, more than 100,000 lives were lost to substance-related overdose. While we do not yet have a complete census of drug overdose prevalence for Rhode Island in 2021, it has been predicted that there was an 8% increase in drug overdose deaths from the previous year; that translates to more than 400 deaths by drug overdose amongst Rhode Island residents in the last year alone. Listening to the March 2022 recorded meeting of Governor McKee’s Overdose Prevention and Intervention Task Force, it was evident that the attendees were passionate and working towards improving the safety and welfare of
organization’s aim to improve access to safe drug consumption by way of Harm Reduction Centers (elsewhere referred to as “safe consumption sites”) and the introduction of vending machines that offer a range of supplies, including naloxone and condoms. As members from the local community joined the virtual meeting, discussions of the drug overdose epidemic came to a momentary pause for a moment of silence in recognition of the neighbors, friends, families, and loved ones who have succumbed to the consequent fatalities of Rhode Island’s substance use struggles.
Currently, many policymakers in opposition to safe-consumption sites argue their largest hesitation toward implementation comes from the lack of prevention of drug use; they question how the nation will overcome substance use and abuse if establishments are being created to allow persons with Substance Use Disorder a controlled
“If successful, these centers could be tailored to the local community, providing support and resources dependent on prevalent issues at a more intimate level than before. ”
Rhode Islanders, both through safe access to and proper disposal of sterile drug-use equipment. Katie Howe, Chair of Rhode Island’s Harm Reduction Workgroup, discussed the
environment to continue using. The larger issue facing our nation is not the use of drugs themselves, but rather the all too familiar consequences of overdose and transmission of HIV/Hep C via non-sterile syringes. Overdose
deaths can be mitigated if the proper personnel and resources are available. Harm Reduction Centers attempt to meet this need by creating a safe space for individuals with Substance Use Disorder to use drugs whilst having access to the necessary equipment in the event of life-threatening complications.
The goal of the Governor’s Overdose Task Force is to advocate for and implement harm reduction strategies aimed at reducing overdose deaths and HIV/Hep C transmission, aided by the establishment of Harm Reduction Centers. Through a set of practical strategies, these centers work toward the Task Force’s overarching goals through the safe collection of sterile needles, provision of safe paraphernalia such as sterile injection equipment, and distribution of naloxone to drug users. Case manager Katelyn Case’s
PowerPoint highlighted that 81% of all sterile needles distributed amongst the substance-using Rhode Island population were returned in the 2021 cycle as a part of the state’s “needle exchange” program. This program not only helps prevent the spread of the aforementioned diseases, but also aids in the maintenance of clean streets throughout the areas where the program is active including Providence, Pawtucket, and surrounding towns.
As the quality of the program improves, the Task Force seeks to expand the centers throughout Rhode Island. With the help of the Rhode Island Department of Health, licensure applications have become available to open additional Harm Reduction Centers. Upon questions from the public, it was noted that the application is intended for organizations that have the capabil-
ities to establish governance oversight in conjunction with strict maintenance of the center. If successful, these centers could be tailored to the local community, providing support and resources dependent on prevalent issues at a more intimate level than before. Similarly, the structure and function of additional centers will create the capacity to add vending machines, indoors and outside, allowing for 24-hour access to safe and sterile supplies. By increasing the accessibility and attraction of such initiatives, the vending machines are intended to attract a younger audience of drug users who may be hesitant to interact with providers at the centers.
The legislation to implement Harm Reduction Centers currently does not have funding attached to the proposal; this may prompt opponents of the action to argue against further advancement based on a lack of initial and continued funding to maintain the functionality of such centers and machines. Additionally, the ethics of safe drug use is a controversial topic for many policymakers. Providing a safe space and equipment to inject, snort, and smoke pre-obtained drugs is beneficial in reducing harm but may seem counterproductive for those wishing to ban drugs altogether. Nonetheless, as they stand, Harm Reduction Centers help maintain safe streets and citizens, regardless of views on drug use. Finally, there is a matter of autonomy and anonymity involved with the use of centers and vending machines. To utilize the vending machines, users must be members of the center’s program in which a unique code is provided. While this helps to cap the number of weekly purchases made through the vending machines, users may be weary of obtaining an identification code. To mitigate this hesitancy, the Task Force has planned to provide unique codes without requiring identifiable information; hence, anonymity is maintained while providing users the autonomy to
References:
Centers for Disease Control and Prevention. (2021, November 17). Drug overdose deaths in the U.S. top 100,000 annually. Centers for Disease Control and Prevention. Retrieved May 2, 2022, from https:// www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm
Rhode Island Department of Health: Drug Overdose Surveillance Data Hub. (n.d.). Retrieved May 2, 2022, from https://ridoh-drug-overdose-surveillance-fatalities-rihealth.hub.arcgis.com/
Joseph, R., Kofman, A., Larney, S., & Fitzgerald, P. (2014, July). Hepatitis C Prevention and Needle Exchange Programs in Rhode Island: ENCORE . Rhode Island Medical Society. Retrieved April 24, 2022, from http://rimed.org/rimedicaljournal/2014/07/2014-07-31-hepc-joseph.pdf
Rhode Island Department of State. (n.d.). Harm Reduction Centers (216-RICR-40-10-25). Rhode Island Department of State. Retrieved May 2, 2022, from https://rules.sos.ri.gov/regulations/part/216-40-10-25
Weidele, H., Howe, K., Case, K., Samuels, E., Conkey, L., Dean, S., & Roy, C. (2022, March). Prevent Overdose RI. Retrieved April 2022, from https://preventoverdoseri.org/presentation-archive/
purchase enough supplies to enhance safety and reduce harm from drug use.
While February 2022 brought legislation toward the implementation of Harm Reduction Centers to reality, community support is needed to establish and maintain these safe-consumption sites; thus, widespread implementation is not likely to occur for at least another six months. As substance abuse continues to impact all states throughout the nation, Harm Reduction Centers pose a potentially viable solution toward combating drug-related overdoses. Tracking the rate of adverse effects of substance use in Rhode Island will be necessary in identifying whether HRCs are successful in helping mitigate drug-related overdose deaths and similar transmission of diseases caused by non-sterile injection equipment.
“Medical malpractice not only inflicts harm on individual patients but also deepens the divide between privileged and marginalized groups, perpetuating disparities in health outcomes and access to justice.” –Unknown
“The medical community’s refusal to acknowledge the pain and suffering of Black patients led to the under-treatment of their conditions.”
–Harriet A. Washington, Author
Malpractice or Ignorance: A Discourse
Communication And Linguistic Inequality In The Healthcare System
Written By:
Emily Mrakovcic
Communication plays a central role in all elements of life, whether it be during a job, sports event, lecture, or simple interaction. Healthcare is one such element, universally experienced, that not only benefits from good communication, but demands it. Communication plays a central role in the healthcare decision-making process, as it influences subsequent health interventions and health behaviors (Ashton et al., 2003).
Even as the United States healthcare system continues to improve in addressing and lessening disparities propagated by the provision of variable care, it is important to remain vigilant of differences in health outcomes that arise due to communication-related problems. Most doctors strive to keep their clinical work free of bias, but, time and time again, social psychology research has found that bias can occur without intention or recognition (Ashton et al., 2003). With communication being such an instinctual part of the human experience, differences in the provision of healthcare may occur without doctors or patients even being aware.
Ethnic groups have preferred styles of communication that may alter how information is perceived or provided and how thoughts are expressed. While people from individualistic cultures may be more direct, assertive, and expressive, people from collectivist cultures tend to be indirect, deferential to authority, and accommodating (Ashton et al., 2003).
How, may you ask, does this affect healthcare? Patients who are spoken to, rather than talked with, may experience less effective interactions with
tor-patient communication have historically received little attention as a potential cause of health disparities (Ashton et al., 2003). This is highly problematic, as low health literacy patients, if not communicated with and informed properly, face increased rates of hospitalization, emergency service use, poor health status, and mortality (Murugesu et al., 2022). Patients with limited English proficiency are among some of the most vulnerable populations in healthcare, as they experience higher rates of medical errors and worse clinical outcomes, in addition to receiving lower-quality care (Green et al., 2017).
“Patients who are spoken to, rather than talked with, may experience less effective interactions with providers, less empathy and acknowledgment of concerns, and worse health outcomes.”
One approach to observing communication discrepancies in the healthcare system is by looking at language and dialect discordance. Even when interactants speak the same language, they may use and interpret terms, idioms, and metaphors differently.
providers, less empathy and acknowledgment of concerns, and worse health outcomes (Butler et al., 2021). Furthermore, patients with low health literacy skills who receive care from providers unprepared to communicate are more likely to belong to at least one of the following categories: low socioeconomic status, immigrant background, older age, or rural residence (Murugesu et al., 2022). Medical schools and hospitals have been criticized for not focusing enough on communication training, as medical personnel in the past have not been adequately prepared to appreciate and inquire about non-clinical factors impacting care, such as housing conditions, stress, and nutrition (Butler et al., 2021).
Despite the negative effects of poor communication, problems with doc-
To best understand this concept, it is important to look at real-life examples of communication disparities. In their 2022 study titled Challenges and solutions in communication with patients with low health literacy: Perspectives of healthcare providers, Laxsini Murugesu and colleagues conducted a survey with 396 primary and secondary healthcare providers to explore the extent of communication skills in the healthcare sphere. Of the respondents, 31% faced difficulties in recognizing low health-literate patients. Additionally, 50% of providers rarely used health literacy-specific materials. Overall, there was an expressed need for provider support in helping to recognize and assess low health literacy.
Chijoke Nze, contributor to the 2017 AMA Journal of Ethics article Language-Based Inequity in Health Care: Who Is the ‘Poor Historian’?, recounts a situation where he, a third-year medical student, took the initiative to treat a patient whose English was “fair at best.” The patient, “Mr. S,” was a 56-year-old
Brazilian construction worker who had recently undergone hip replacement surgery. When he entered the emergency room with symptoms of nausea, vomiting, food intolerance, and general malaise, the doctors struggled to collect information from the patient. There was no effort to bring in an interpreter, and Nze recalls that nobody encouraged him to get one either. However, Nze acted anyway and was able to learn that Mr. S had been taking a medication that was causing the symptoms. Mr. S had not understood what the medication was, therefore he had not mentioned it initially to the doctors treating him. Although it is fortunate that Nze was able to communicate with Mr. S and identify a diagnosis, a feat of this nature must not be considered a medical miracle. The treatment Nze provided to Mr. S should have been a part of routine clinical care, not an extra effort made by a medical school student to provide the best care possible.
Rectifying issues of communication is essential to any successful healthcare system, as communication during medical interactions can influence patient satisfaction, adherence to doctor recommendations, and the likelihood of malpractice claims (Ashton et al., 2003). There is also evidence that good communication during medical interactions results in better disease outcomes. This result follows the simple logic that patients who are communicated with better will feel more comfortable providing information to their doctor regarding their history and symptoms. In addition to improving the communication skills of doctors, it should also be a medical imperative to address the health literacy skills of patients. This will allow patients to better navigate the medical realm and communicate well with their providers. Strong health literacy skills result in many benefits: feeling understood and supported by healthcare providers, having sufficient information to manage personal health, actively managing personal health, actively engaging with providers, navigating the healthcare
system, finding good health information, and understanding health information well enough to use it (Murugesu et al., 2022).
Public health and medical professionals have proposed several mechanisms to improve doctor-patient communication. Firstly, doctors should work to provide openings for patients to complete four actions during appointments: provide a complete health narrative, ask questions, express concerns, and be assertive (Ashton et al., 2003). Furthermore, future research should focus on developing strategies for providers to ensure patient understanding. Potential areas of exploration include learning how to recognize low health-literate patients, supporting patients in taking responsibility for their health, and executing the teach-back method (Murugesu et al., 2022). The teach-back method, according to the Agency for Healthcare Research and Quality, is a way for medical providers to check the understanding of their patients. Essentially, the method encourages providers to ask patients to state in their own words what they need to know about their health. The teach-back method allows providers to confirm that patients can follow specific instructions and adhere to treatment regimens. Furthermore, the method has been proven to decrease canceled appointment rates and improve patient satisfaction and outcomes.
Focusing specifically on public health interventions, there are many ways for those not directly working in hospitals and clinics to improve communication in the health sector. Public health professionals can help ensure strong communication by assembling diverse workforces throughout all levels of employment, including leadership. Additionally, they can collaborate with community partners to build awareness and identify priorities and struggles. Public health professionals are able to
References:
Agency for Healthcare Research and Quality. (2024, February). Health Literacy Universal Precautions Toolkit, 3rd Edition. https://www.ahrq.gov/health-literacy/ improve/precautions/tool5.html.
Ashton, C., Haidet, P., Paterniti, D., Collins, T., Gordon, H., O’Malley, K., Peterson, L., Sharf, B., Suarez-Almazor, M., Wray, N., Street, J. (2003). Racial and Ethnic Disparities in the Use of Health Services. Journal of General Internal Medicine, 18(2), 146-152.
Butler, S., Sheriff, N. (2021). How poor communication exacerbates health inequities - and what to do about it. The Brookings Institution.
Centers for Disease Control and Prevention. (2022, August 2). Developing Inclusive Communications. https://www.cdc.gov/healthcommunication/Comm_ Dev.html. Green, A., Nze, C. (2017). Language-Based Inequity in Health Care: Who Is the “Poor Historian”?. AMA Journal of Ethics, 19(3), 263-271. Murugesu, L., Heijmans, M., Rademakers, J., Fransen, M. (2022) Challenges and solutions in communication with patients with low health literacy: Perspectives of healthcare providers. PLOS ONE, 17(5).
ensure that health information is accessible and available in several different formats, including audio, video, braille, large print, and visual imagery (CDC).
In order to fundamentally improve communication, health sector workers must unequivocally refute the idea that substandard communication is unavoidable or not worth the cost of addressing. There is a moral imperative to provide high-quality care to all patients, regardless of their ability to communicate or comprehend information. Upcoming generations of medical trainees must be taught that strong communication, especially with low health-literate individuals, is both expected and feasible. With communication being such a vital and instrumental component of the human experience, it only makes sense that its place in medicine is respected and practiced to the highest degree.
Edited By:
Malpractice or Ignorance: A Discourse on the Current Prominence and Prevalence of Medical Malpractice
The Disproportionate Burden of HealthcareAssociated Infections in LMICs
Written By:
Ruviha Homma
Healthcare facilities are supposed to be places where people receive safe, effective, and timely care in a sanitary environment. However, this is not always the case. As a result of receiving care at a healthcare facility, some people can develop additional bacterial, fungal, and viral infections, leading to worse health outcomes. Commonly known as healthcare-associated infections (HAI), these infections are the most frequent adverse health event experienced during the delivery of care and are generally preventable conditions.1
The WHO defines HAI as an “infection occurring in a patient during the process of care in a hospital or other health care facility which was not present or incubating at the time of admission.”1 In addition to affecting patients who are currently hospitalized, HAI can appear in a patient after being discharged from a facility and can also affect the staff who provide care.1 A patient may acquire an HAI through different transmission pathways, including through cross-contamination between patients and healthcare workers, infections at surgery sites, and contaminated implants and prostheses.2 These infections are caused by
various microorganisms, such as fungi, viruses, and bacteria, all of which can lead to adverse health outcomes, especially in immunocompromised patients.3 As HAIs are mostly caused by unhygienic practices and environments, the occurrence of HAI outbreaks in a healthcare facility is an important indicator of the quality and safety of patient care.1
Beyond indicating the practices of a healthcare facility, HAIs continue to be a large cause of morbidity worldwide. This burden is well-documented in high-income countries (HICs) that have established HAI surveillance systems as well as in an abundance of published studies. In these countries,
“As HAIs are mostly caused by unhygienic practices and environments, the occurrence of HAI outbreaks in a healthcare facility is an important indicator of the quality and safety of patient care.”
it is estimated that around 7.6% of hospitalized patients have at least one HAI.1 However, the burden of HAIs is not as well-understood for low- and middle-income countries (LMICs) due to a lack of data. The limited studies on this issue report that HAI rates are higher in LMICs than in HICs with estimates of around 10.1% to 15.1% in patient populations, though, in reality, this prevalence could be much higher.1 Regardless of the exact statistics, LMICs are no doubt disproportionately affected by HAIs compared to wealthier countries.6
A number of factors contribute to this inequity, including the lack of surveillance systems to monitor HAIs. While many HICs have implemented coordinated surveillance systems, only 23 out of the 147 LMICs reported a functioning national HAI surveillance system in 2010.1 HAI surveillance is highly demanding and burdensome on countries that already have limited staff and resources.1 However, a lack of surveillance data prevents countries from understanding the current state of HAIs and reducing infection rates overall.1 Additionally, infection prevention and control (IPC) programs, which are usually implemented in healthcare facilities to reduce HAI transmission, are often inadequate in LMICs.5 Basic IPC practices, such as handwashing, contact precautions, and using personal protective equipment are frequently not adhered to due to a lack of training and resource constraints.5 Broader societal issues with sanitation and hygiene, poor socioeconomic conditions, a lack of access to care, and populations that are largely affected by malnutrition and other infections exacerbate HAI burden in LMICs as well.1 In addition, prolonged hospital stays due to HAIs can incur financial burden on both the weak health systems of LMICs and patients and their families.1 To make matters worse, there has been an increase in antimicrobial resistance (AMR) of the microorganisms that cause HAIs.5 Although this affects essentially all healthcare settings, it is most concerning in LMICs, as AMR can grow rapidly as a result of poorly-controlled antibiotic use, high prev-
alence of infections in facilities, limited IPC measures, and weak surveillance.5
With these factors exacerbating the burden of HAIs in LMICs, it is necessary to implement strategies and programs in these countries to address this issue. First off, HAI surveillance systems must be established in all countries. A teaching hospital in Rwanda recently implemented an HAI surveillance system, allowing healthcare professionals to obtain an accurate picture of HAI burden and to implement measures aiming to reduce HAI rates.4 While a robust HAI surveillance system is a more sustainable, long-term strategy to address HAIs, LMICs may not be able to establish systems alone, so financial and logistical assistance from outside organizations may be necessary.
IPC programs must also be improved and enforced in healthcare facilities. To create a workforce that is equipped to adhere to IPC protocol, LMICs
should develop educational programs to train health care professionals in infection control.5 Basic equipment to prevent infections, such as antiseptics and antimicrobials, should also be made readily available, and hygiene measures should be enforced as well.5 Bundling these measures into one intervention has proven to be successful in reducing HAI infections in LMICs.7 In 15 LMICs specifically, intervention bundles consisting of education, performance feedback, and outcome and process surveillance improved adherence to IPC protocol and reduced the incidence of HAI.7 This relatively low-cost intervention has the potential to successfully reduce HAI burden in resource-limited settings.
With these solutions in mind, it is imperative that this inequity is addressed by the global community. As HAIs are largely preventable conditions, all countries, global organizations, and healthcare professionals have a respon-
World Health Organization. (2011). Report on the burden of endemic health care-associated infection worldwide. https://iris.who.int/bitstream/handle/10665/80135/9789241501507_eng.pdf?sequence=1
Haque, M., Sartelli, M., McKimm, J., & Abu Bakar, M. (2018). Health care-associated infections – an overview. Infection and Drug Resistance, 11, 2321–2333. https://doi.org/10.2147/IDR.S177247
Centers for Disease Control and Prevention. (2021, November 10). Healthcare-associated infections. https:// www.cdc.gov/hai/index.html
Lukas, S., Hogan, U., Muhirwa, V., Davis, C., Nyiligira, J., Ogbuagu, O., & Wong, R. (2016). Establishment of a hospital-acquired infection surveillance system in a teaching hospital in Rwanda. International Journal of Infection Control, 12(3). https://doi.org/10.3396/ijic. v12i3.16200
Vilar-Compte, D., Camacho-Ortiz, A., & Ponce-deLeón, S. (2017). Infection control in limited resources countries: challenges and priorities. Current Infectious Disease Reports, 19. https://doi.org/10.1007/ s11908-017-0572-y
Maki, G., & Zervos, M. (2021). Health care–acquired infections in low- and middle-income countries and the role of infection prevention and control. Infectious Disease Clinics of North America, 35(3), 827–839. https://doi.org/10.1016/j.idc.2021.04.014
Rosenthal, V. D., Maki, D. G., Rodrigues, C., Álvarez-Moreno, C., Leblebicioglu, H., Sobreyra-Oropeza, M., Berba, R., Madani, N., Medeiros, E. A., Cuéllar, L. E., Mitrev, Z., Dueñas, L., Guanche-Garcell, H., Mapp, T., Kanj, S. S., & Fernández-Hidalgo, R. (2010). Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line–associated bloodstream infection rates in the intensive care units of 15 developing countries. Infection Control and Hospital Epidemiology, 31(12), 1264–1272. https://doi. org/10.1086/657140
sibility to aid in preventing the disproportionate burden of these infections on LMICs.
Edited By:
Malpractice or Ignorance: A Discourse on the Current Prominence and Prevalence
Opioid Use Disorders and The Rise In Infectious Diseases
Written By:
Alison Lu
The opioid epidemic, which emerged in the early 1990s, is a public health issue that continues to remain significant in the United States. This crisis stems from a dramatic increase in prescription opioids to treat pain, specifically chronic pain. Nearly 400,000 individuals have lost their lives to opioid-related overdoses since 1999. In recognition of the severity of the situation, the US Department of Health and Human Services officially declared the opioid epidemic a public health emergency in 2017. However, the opioid epidemic is causing another problem in the US: the surge of infectious diseases due to the proliferation of high-risk environments where drug use occurs
Originally, individuals with opioid use disorders were primarily prescribed oral opioids as part of their treatment regimen. However, over time, many shifted to alternative consumption methods, such as injection drug use. This shift developed into a risky practice of sharing syringes, needles, and other drug injection equipment. This sharing significantly elevated the risk for acquiring and transmitting infectious diseases, such as human immunodeficiency virus (HIV) infection with or without AIDS and hepatitis C virus (HCV). Moreover, those who inject drugs are oftentimes subjected to adverse environments such as homelessness, incarceration, and engaging in high-
risk sexual practices that further exacerbate the risk of contracting and spreading infectious diseases. The statistics are striking: individuals who inject drugs account for 12% of new HIV infections and 60% of new HCV infections annually in the US. These numbers demonstrate a strong correlation between injection drug use and the prevalence of infectious diseases, such as HIV and HCV.
Multiple statistics highlight the increased rates of infectious diseases, such as HIV and HCV, among individuals who inject drugs For instance, in a 2015 HIV outbreak affecting 181 people in Scott County, Indiana, approximately 90% of those infected
with HIV were also injecting prescription opioids, with over 90% also co-infected with HCV. Furthermore, a survey conducted among 2,200 patients at an urban emergency department in Northern California revealed significant rates of HIV and HCV co-infection among individuals who inject drugs. These figures were found to be 6.2% and 53%, for HIV and HCV infection respectively, among this group compared to 1.8% and 3.4% for HIV and HCV infections respectively, among those who never injected drugs. Additionally, the study highlighted a concerning trend: emergency department patients with HIV or HCV infections who also injected drugs were less likely to receive treatment for their
infections compared to individuals who never engaged in injection drug use. This underscores the importance of HIV and HCV screening protocols for patients who inject drugs in the emergency department setting.
By prioritizing such measures, we can effectively address the immediate health risks associated with injection drug use and work towards mitigating the impacts of the opioid epidemic on public health.
“Emergency department patients with HIV or HCV infections who also injected drugs were less likely to receive treatment for their infections compared to individuals who never engaged in injection drug use.”
While implementing drug policies to reduce overall drug usage is important, it is critical to prioritize the development of a comprehensive program aimed at preventing infectious diseases among people who inject drugs. Key components of this program should include:
1. Unrestricted legal access to sterile syringes and needles: This can be achieved through initiatives like needle exchange programs or enhanced pharmacy services. The goal is to ensure that individuals who inject drugs have access to clean equipment, minimizing the risk of infectious disease transmission.
2. Expansion of treatments for opioid dependence: Increasing access to treatments such as methadone and buprenorphine is essential. These medications can help individuals manage opioid dependence, reducing the likelihood of engaging in risky injection practices.
3. Behavioral interventions: Educational programs are vital in awareness and knowledge of sexual transmission of infectious diseases. By empowering individuals with information, safer practices are encouraged and the spread of infections can be reduced
It is also quintessential to acknowledge the structural drivers contributing to both the opioid epidemic and the rise in infectious diseases. Structural inequalities play a significant role in rendering certain populations more vulnerable to opioid addiction. Examples of such structural inequalities include disparities in economic opportunities, market-driven healthcare, inadequate regulation of pharmaceutical drugs, and limited access to effective drug treatment. Moreover, there exists a harmful stereotype associated with individuals who inject drugs, or those living with infectious diseases like HIV that makes it difficult to access and engage with treatments. While interventions focused on changing individual attitudes are important, it is also necessary to focus on improving community and societal norms to promote tolerance and combat discriminatory attitudes towards individuals with opioid use disorders . This approach would encourage more people to seek treatment for infectious diseases without fear of stigma or discrimination. Without addressing these underlying factors, meaningful and effective change to reduce the prevalence of infectious diseases among individuals who inject drugs will be challenging. There is a clear correlation between
References:
Grebely, J., & Dore, G. J. (2011). Prevention of hepatitis C virus in injecting drug users: a narrow window of opportunity. The Journal of infectious diseases, 203(5), 571–574. https://doi.org/10.1093/infdis/jiq111
Tara A Schwetz, Thomas Calder, Elana Rosenthal, Sarah Kattakuzhy, Anthony S Fauci, Opioids and Infectious Diseases: A Converging Public Health Crisis, The Journal of Infectious Diseases, Volume 220, Issue 3, 1 August 2019, Pages 346–349, https://doi.org/10.1093/ infdis/jiz133
Jones, J. F., Legaspi, J., Chen, E., Lee, K., & Le, J. (2020). Emerging Viral and Bacterial Infections: Within an Era of Opioid Epidemic. Infectious diseases and therapy, 9(4), 737–755. https://doi.org/10.1007/s40121020-00335-0
https://rdcu.be/cLXl6
https://www.cdc.gov/drugoverdose/epidemic/index. html
DeBeck, K., Kerr, T., Li, K., Fischer, B., Buxton, J., Montaner, J., & Wood, E. (2009). Smoking of crack cocaine as a risk factor for HIV infection among people who use injection drugs. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 181(9), 585–589. https://doi.org/10.1503/ cmaj.082054
Anderson ES, Russell C, Basham K, Montgomery M, Lozier H, et al. (2020) High prevalence of injection drug use and blood-borne viral infections among patients in an urban emergency department. PLOS ONE 15(6): e0233927. https://doi.org/10.1371/journal. pone.0233927
https://doi.org/10.1371/journal.pone.0233927 High prevalence of injection drug use and blood-borne viral infections among patients in an urban emergency department
injection drug use and the heightened risk of contracting infectious diseases, highlighting the urgent need for harm reduction interventions to mitigate the impact of the opioid epidemic and its association with infectious diseases.
