July 16, 2012
As a longtime medical director of one of the country’s largest and oldest public hospitals my colleagues at Bellevue and I frequently encountered what we called “canary patients,” patients who, like canaries in a coal mine, signal larger and less visible problems ahead. Annual influenza epidemics and the possibility of highly lethal mutations from birds to pigs to people have mobilized an international coalition of scientists and public health officials. Other diseases both contagious and non-contagious circulate globally with devastating effects, markers of political, social and economic instability and reverberations of history that is very much alive.
Tibetan, Russian, and Chinese patients are routinely admitted with weight loss and fever. Their x-rays have the telltale signs of tuberculosis in its infinite variations. The crowded petri dish like prison systems of the ex-Soviet Union or the overflowing refugee camps in Katmandu, Nepal for the waves of refugees fleeing a Chinese gunpoint takeover of their society are the laboratories for breeding and spreading TB. Both inadequate and incomplete drug treatment regimens create the Darwinian storm for hyper-resistence to emerge. TB is alive and flourishing throughout the world a bell weather of social and political unrest and/or public health failure.
A young man from Africa, Asia or the US with fever and chills and swollen lymph glands sits in a chair in the Urgent Care Center. His almost forgettable viral symptoms will resolve spontaneously. However his follow-up HIV test two weeks later turns positive. Fueled by crystal meth an active anonymous sex scene drives a continuing conversion rate. An HIV “morning after pill” combined with a normal life expectancy on suppressive medications plus persistent intravenous drug abuse keep HIV in the differential diagnosis for physicians everywhere under any circumstance for a variety of patient’s complaints both exotic and mundane.
A jaundiced taxi driver from Egypt is wheeled in by his son. A US citizen for over twenty years he has cirrhosis and will need a liver transplant urgently. This year hepatitis C has passed HIV in its death toll. Ironically colonial public health officials introduced and spread hepatitis C and HIV in widespread vaccination campaigns with unsterilized syringes generations ago in Africa and the Middle East. The race for widespread testing, “know your Hep C status” and improved drug treatment regimens and the promise of a vaccine are reminiscent of HIV disease twenty plus years ago.
A few doors down on a stretcher lies a young Guatemalan woman with a football sized heart from Chagas disease acquired decades earlier and endemic in poor areas of Latin America. She barely survived the hazardous journey through Mexico to Texas after her missing husband’s right hand was left on her doorstep. The Evangelical dictator/general, Efrain Ríos Montt, now awaiting trial, waged a genocidal war against the country’s indigenous populations; the violence destabilized the entire area that has become home to drug traffickers. The trypanosome, the Chagas vector is now entering our blood supply.
In Bellevue’s Survivors of Torture program the earliest victims of the latest terror waves throughout the world from the Lords Resistance Army before Kony went viral on YouTube to the seemingly eternal Sudanese conflict over oil and desertification overflow the waiting room before news makes the headlines.
The canary’s message here is about post-colonialism, climate change and energy wars.
I look at the abdominal x-ray of a heavily tattooed young man in leg irons and handcuffs in an orange jump suit escorted by a phalanx of uniformed officers who is lead to our psychiatric emergency room after swallowing silverware at New York City’s Rikers Island prison complex. MS-13 is visible in black ink on his neck. The Central American gang Maras Salvatrucha has made it to New York City. Originally, these gang members grew up in L.A., children of refugees from the Central American wars of the 1970s sponsored by the US backed Contras. Deported as teenagers to ‘home’ countries they never knew, they formed the most brutal gangs imaginable and have made it back to the U.S., and to Bellevue. The “Mexican problem” has crossed the border, the New York State border.
These canary patients, and many others with resistant malaria, gonococcus, E. Coli along with PTSD and gender based violence as weapons of war are early warning signs of problems that are headed to our shores. Our public health systems and emergency rooms are ground zero for the detection and first response to outbreaks anywhere. The patients seeking medical care and assistance in our midst are the earliest signals. We need to listen and be prepared.