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Worcester Medicine
From the Editor
President's Message
Disease Should Be Man's Only Enemy
An Overview Of The Metropolitan Medical
Response System
Dealing With Hysteria
Preparing For Outbreaks Of Bioterrorism As I See It
Historical Perspective: 19th Century Water
Cures Schedule For "Health Matters" TV Program
EDITORIAL The unthinkable happens...The public's health in Worcester County becomes threatened, or worse - comes under attack. An extended medical community in Central Massachusetts responds. This issue of Worcester Medicine describes the resources activated should the unthinkable become all too real. The WDMS Editorial Board knows you will appreciate this primer on Medical Homeland Defense here in Central Massachusetts. Our special thanks are offered to Thomas Connell II of the Metropolitan Medical Response Team and to Dr. Fromson. Additional thanks are given to medical student Lora Schwartz for her extensive article entitled, "Syndromic Surveillance". We also thank UMASS Medical School student Kathy Kalkbrenner for her thoughtful "As I See It", and historian Sande Bishop for a well-researched article on nineteenth-century water cures. And as always, special thanks to the great friend of this journal -- Dr. Leonard J. Morse, Commissioner, Worcester Public Health Department. Thank you.
President's Message Editor's Note: The following speech was given by the new president of the Worcester District Medical Society, George Abraham, MD, MPH at the annual business meeting of the organization held April 9 at Worcester's Beechwood Hotel. Thank you for the honor you have bestowed on me as the next president of WDMS. I have more hair than my predecessor, Dr. Primack, who hastens to assure me that I will not look like him at the end of my term, which was the reason I accepted the nomination. There has not been a more serious challenge to the practice of the art of medicine than now, and we are at the crossroads of deciding whether we should continue to be a part of it or bow out. We, as physicians, have been forced to move away from the humanism and the science of medicine to worrying about survival of our practices and the harrowing nightmares of business difficulties. It is no surprise, then, that the cream of the intelligentsia in the US today, are opting for alternate vocations and there is a progressive reduction in the number of applicants to medical schools, foreboding a serious dearth of skilled physicians in years to come. We in organized medicine are forced to ask ourselves, `Quo Vadis', where do we go from here? In the coming year, we, as a society, hope to be able to put the finishing touches to professional liability reform that has been so ably started this year. With the continuing decline in the economy, the common person is struggling to survive and keep up with medical costs. As the numbers of the uninsured increase, our society will be called upon to develop strategies to make healthcare affordable and attainable. In the coming year, we hope to draw on your collective wisdom as we look for ways to help our more disadvantaged patients. The value of community education has been underscored in the landmark effort to educate the lay public through our new television program `Health Matters', under the able leadership of Dr. Bruce Karlin and members of the Public Relations Committee. This and other such projects will increase our visibility as a society and draw us closer to the public we try to serve. We eagerly solicit suggestions for potential projects to initiate in the coming year that may be of relevance to us as a membership and to the community at large. As we look around us in the room, we notice a significant dearth of our younger colleagues some of whom have not opted for and so, have not experienced the full benefit of membership in the society. Through our young physicians' section, we hope to attract some of them, to establish a continuing line of dynamic leaders in this society. Most importantly, the art and humanism of medicine can get lost in the pressures of business and finances, interpersonal and physician-patient relationships may dissolve under time constraints to perform more in the shrinking workday. We hope to transcend the barriers of institutional affiliation and philosophy and come together as a society, to revitalize the nobility and joy of service to the community and our patients, of mentoring and education, the reason we all chose to enter this profession. I am proud that our society is one of the most active and vibrant not only in the state but across the country. To that end, may I humbly request your cooperation and wisdom as my fellow office-bearers and I begin our term. Thank you! George Abraham, MD, MPH, is the director of ambulatory care and preventive medicine, St. Vincent Hospital at the Worcester Medical Center and assistant professor of medicine at UMASS Medical School.
Disease
should be man's only enemy "They fancied themselves free, and no one will ever be
free so long as there are pestilences." The only enemy to mankind should be disease. Unraveling the mystery of pathology has always been the mission of medical research. As a result, in the twentieth century, life expectancy in the United States increased from 42 to 73 years! Although the United States-sponsored American Medical Commission, working in Havana in 1900, successfully implicated the mosquito as the vector in the transmission of Yellow Fever, the two countries, Cuba and the United States, have severed relationships for more than half of that century (1). Sadly, hatred among people has resulted in the continuation of violence and preventable tragedy throughout the world into the twenty-first century. The most infamous example is the death of approximately 3000 innocent people on September 11, 2001. Forty-five years ago, while serving in the U.S. Army, I was infected accidentally and became seriously ill with hemorrhagic fever (2). My colleagues and I were engaged in vaccine production to be used to prevent the inhabitants in a remote part of the world from becoming infected upon exposure to the virus which, in nature, is spread by the bite of a tick. My laboratory-acquired infection established that the virus was also transmissible by aerosol. Today that virus, Kyasanur Forest Disease virus, is among those included in the bio-terrorist's arsenal. Ignited by hatred, medical knowledge may be used to harm, maim and kill. Unfortunately, the anthrax killings, following the 9-11 tragedy, and the threat of resurrecting a conquered menace, small-pox, appear to be just the beginning of the list of biologic arms. The impact of the terrorist attacks throughout the world and the fear of future events have become preoccupations of private and public concern. And it is very unlikely that the threat of biological or physical terrorism will disappear soon. These considerations have introduced bio-terrorism as a new public health discipline. In preparation, the Worcester Department of Public Health has implemented the following measures: increased community surveillance, expanded synergy with other municipal departments and private agencies, and the establishment of the Metropolitan Medical Response System. Surveillance: On a daily basis, certificates of death, reportable communicable diseases and absentee rates from school and private industry are reviewed in order to promptly recognize variations from the norm. Interdepartmental Communication: The Public Health Department joins the Police, Fire, Law, Emergency Medical Services, Public Works, Communications and School Departments to orchestrate with the Worcester Emergency Management Agency and with other organizations the responsibilities and actions needed within the sphere of each group's expertise. Metropolitan Medical Response System: Under the direction of James Gardiner, deputy director of Public Health and Thomas Connell, MMRS coordinator, the DPH, in conjunction with the aforementioned municipal departments, three Worcester general hospitals and the Worcester District Medical Society, an elaborate plan of coordinated professional services to be executed in the event of an array of emergency situations has been developed. Plans for emergency needs include the following: an adequate amount of surge hospital beds, the establishment of mass immunization procedures and environmental protection actions, the management of mass casualties and fatalities and environmental decontamination. The MMRS program is Federally funded and our responsibility has expanded to include 80 towns and cities in central Massachusetts, including nine hospitals (Region 2). To quote a July, 2002 Mayo Clinic Proceedings article on bio-terrorism preparedness; "An effective public health response to a bio-terrorism event will depend on a few key factors: the ability of medical professionals to rapidly recognize the clinical signs and symptoms caused by a bio-threat agent; the ability of laboratory professionals to rapidly detect and confirm the identity of the agent; an epidemiolgical investigation to determine the source of the infection; and most importantly, communication and coordination among all responders involved in the event" (3). Thanks to so many participants, Worcester has rapidly become prepared to address the threatening issues of a very troubled world. Hopefully, healing will restore our collective dignity and our respect for one another, and the world's resources will be directed toward the conquest of disease, relief of human suffering and the preservation of our environment. Leonard J. Morse, MD Commissioner of Public Health, City of Worcester, MA and Professor of Clinical Medicine and Family Medicine and Community Health, University of Massachusetts Medical School. REFERENCES 1. Woodward, T.E., Beisel, W.R., and Faulkner, R.D. Marylanders Defeat Philadelphia: Yellow Fever Updated. Transactions of the American Clinical and Climatological Association, 87, 69-101, 1976. 2. Morse, L.J., Russ, S.B., Needy, C.F. and Buescher, E.L. The Disease and Immune Responses in Man Following Accidental Infection with Kyasanur Forest Disease Virus. The Journal of Immunolgy, 88:2, February 1962. 3. Meyer, R.F. and Morse, S.A. Bio-terrorism Preparedness for the Public Health and Medical Communities. Mayo Clinic Proceedings, 77:7,619-21, July 2002. The Metropolitan Medical Response System (MMRS) contract between the city of Worcester and the U.S. Department of Health and Human Services (HHS)1 was executed on May 20, 2002 to enhance emergency services capabilities relating to the health and medical needs of victims of a Weapons of Mass Destruction (WMD) Event. Worcester authorities recognize that the resources of the city and the Greater Worcester region would be overwhelmed by the magnitude of destruction, disability, and loss of life in a nuclear, chemical or biological attack. It is therefore the intent of Worcester, acting in concert with the leadership and technical expertise of the MMRS Steering Committee and the Massachusetts Department of Public Health, to augment current capabilities through planning, training, and pharmaceutical and equipment acquisition. By these actions, the city intends to minimize the devastating effects of a WMD attack on the citizenry under our protection. Through the MMRS contract, Worcester's Department of Public Health retained me as an independent special operations and emergency services consultant. I have been tasked with the coordination and management of the overall project. HISTORY The Metropolitan Medical Strike Team (MMST) systems concept began in the Washington metropolitan area in 1995. Using the combined personnel and equipment resources from Washington DC, Arlington County, Virginia and Montgomery and Prince George's County, Maryland the MMST was the first of its kind in the civilian environment. Primarily a chemical response team, the MMST was capable of providing initial, on-site, emergency health and medical services following a terrorist incident involving a weapon of mass destruction (chemical, biological, radiological and/or nuclear.) Building from the initial efforts of the Washington Metropolitan Area, MMST, OEP (HHS Office for Emergency Preparedness) sought to develop a similar team in the city of Atlanta in preparation for the 1996 Summer Olympic Games. As a result of the initial success of the Washington Metropolitan Area and Atlanta MMST, Congress, as part of the Defense Against Weapons of Mass Destruction Act of 1996 (more commonly known as Nunn-Lugar-Domenici), authorized HHS to develop additional MMST. The legislation allowed OEP to contract with 25 additional cities including Boston. In an effort to show the importance of engaging all appropriate shareholders in a systems approach to preparedness and response, OEP changed the MMST name to Metropolitan Medical Response System or MMRS. This name change reflected OEP's ongoing effort to bring together emergency services with public, private, and mental health communities. In the last seven years, the number of MMRS cities has grown to just over one hundred and twenty with the New England cities of Worcester and Springfield, Massachusetts: Hartford, Connecticut; and Providence, Rhode Island; being added in 2002. SUMMARY OF THE PROJECT CONTRACT Worcester's contract with the HHS centers on eleven deliverables including an initial meeting with the federal MMRS Project Officer, a Development Plan, and eight Operational Plans. A total allocation of $400,000 is disbursed in drawdowns as component plans are submitted to, and approved by the federal Project Coordinator. The Operational Plans, currently under development, include: The Basic MMRS Plan, Pharmaceutical and National Pharmaceutical Stockpile (NPS) Management. An overview plan for managing the human health consequences of a terrorist incident involving the use of weapons of mass destruction (WMD), e.g., a chemical, biological, radiological, nuclear, and/or explosive device capable of creating mass casualties. The plan deals with regional mass casualties caused by bioterrorism or other outbreaks of infectious disease or other public health emergencies. Managing the Health Consequences of a Biological WMD. This plan will be integrated with existing or planned local and State health surveillance plans for bio-terrorism and influenza pandemic planning. Responding to a Chemical, Radiological, Nuclear, or Explosive WMD event. The optional plan for a Metropolitan Medical Strike Team. The MMST operational plan includes provisions for MMST activation, deployment, WMD agent identification, extraction of victims from the incident site, antidote administration, human decontamination, triage and primary care, and the preparation of victims for transportation to definitive care facilities with sufficient supplies of appropriate antidotes to assure adequate treatment. The plan for Managing the Forward Movement of Patients. This plan addresses issues arising in the event that local resources are insufficient to provide the definitive health care required for all of those directly affected by the event). Consideration will be given to all available modes of transportation (e.g., vehicular, railroad, aircraft). Local Hospitals and Healthcare Systems. This plan will be developed to ensure a surge capacity to accommodate 500 critically ill patients in hospitals and or alternative care facilities. The MMRS Training Plan identifies training requirements for the following MMRS personnel: first responders, EMTs, paramedics, vehicle drivers, emergency room personnel, and other hospital personnel who will be providing care to victims of a WMD event. MMRS Equipment Plan. THE REGION AND THE STATE The Worcester MMRS program has adopted as its operational region, Worcester County and some adjacent municipalities, which together form a geographical region, identified as Region Two. For emergency planning purposes, the Massachusetts Department of Public Health recognizes 5 geographic regions as they exist on March 30 2000 of which one is Region 2. The Region encompasses an area of 1,852.4 square miles or 22% of the Commonwealth. Nineteen percent of Massachusetts' citizens, nearly one million people, reside in this area. Worcester's early decision to identify all of Massachusetts EMS Region II as its catchments area has been hailed in local and state circles as ambitious, yet altruistic. As a result, the Massachusetts Department of Public Health (MDPH) is viewing our progress as a model for state planning efforts. Additionally, Worcester's decision to accept responsibility for planning for Central Massachusetts has led to serious funding discussions with Health Commissioner Howard Koh to secure Health Resources and Services Administration (HRSA) and Centers for Disease Control (CDC) funds that have been awarded to the Commonwealth. As part of the continuing effort to keep open lines of communication between the Worcester MMRS and the Commonwealth's MDPH, I have been serving on both the HRSA Massachusetts Hospital Preparedness Planning Committee, the CDC Bio Terrorism Preparedness and Response Advisory Committee, as well as numerous related workgroups. 1 MMRS Program oversight and funding was transferred to the Department of Homeland Security in 2003 2 This Paragraph and portions of the following paragraph were paraphrased in large part from the "Origins of MMRS" a public domain document available on the Office of Emergency Preparedness Web Site. 3 Title 105 Code of Massachusetts Regulations Part 170.101 The new millennium has brought with it unexpected events and their consequences. Hopes were that reaching this significant milestone in history would herald novel steps toward eradication of war, disease, poverty, and ignorance. It seems almost the opposite has taken place. Since New Year's Day 2000, the citizens of the Commonwealth have experienced the shock, trauma, and bereavement of the September 11 terrorist attacks. We have also witnessed an anthrax scare, sniper attacks on defenseless citizens, kidnappings, America at war in Iraq, and most recently, the threat of the Sudden Acute Respiratory Syndrome (SARS) epidemic. Institutions that we have relied upon to protect us from these experiences seem to have woefully failed us. The unthinkable has taken place, our country was attacked in an inconceivable fashion, within minutes thousands of lives were lost, and we are still searching for those involved in planning and supporting these actions. Law enforcement appeared stymied and unable to apprehend snipers until too many lives were taken, the source of the deadly anthrax has yet to be found, and a virus has morphed into a lethal contagion. Not only are these events traumatic, the lack of a clear and definitive resolution is an ongoing source of stress, sadness, and maladaptive methods of coping. Five to eight weeks after the September 11 attack, a survey of over one thousand adults living within close proximity to the World Trade Center found high levels of depression, post-traumatic stress disorder (PTSD), and substance abuse.1 Yet, one need not be a victim of a disaster in order to experience stress. In fact, stress can be viewed as a normal and usual response to everyday life experiences. We react in both a physical and emotional way. The physical signs include rapid heartbeat, headache, stomachaches, and muscular tension.2 The emotional signs of stress can range from excitement, celebration and joy, to frustration, anxiety, and anger.3 Experiencing stress stops becoming a normal coping mechanism and becomes a problem when there is a dramatic imbalance between the time ones experiences stress and the time when one does not. Exercise, relaxation techniques, and taking the time to acknowledge the perceived stressors are all methods that we have adopted to periodically cope with those we encounter in our everyday activity. Directly or indirectly experiencing trauma can result in stress to such a degree that, as hard as we may try, the methods we have used to counter everyday stress become less effective. Such trauma can result in physical or emotional shock that leaves us feeling stunned and completely overwhelmed. With the advent of real time reporting of the news, millions of us witnessed the unexpected death, severe injury, and emotional reactions of those involved in these horrific events. Even though we may have been hundreds or thousands of miles away from the actual event, many of us experienced traumatic stress. Its hallmarks include affective numbing, autonomic arousal, and re-experiencing the event itself. In managing traumatic stress, it is important to recognize these symptoms. Specifically, they include difficulty sleeping, decreased performance in work or school, decreased attention and concentration, feelings of hopelessness and sadness, lability of mood, social isolation, fear of being alone, and flashbacks of the traumatic event. These symptoms usually decrease over time. If they do not, professional help may be required. Also, individuals who already have pre-existing mental health issues may be more vulnerable to traumatic events and may experience a greater stress reaction for a longer period of time. A community is made up of individuals, some with special needs, nuclear and extended families, groups of friends and those with similar interests and spiritual affiliations, governmental agencies and support services, health care providers and other professional groups, educational institutions, and businesses. One way that trauma can be managed is by establishing an ongoing dialogue among those with whom you feel comfortable and safe. This can be in the context of individual discussions or in a group context at any level in a community organization. It is important to note that children may experience stress, not only from witnessing the actual event but also from their perception of their own parents' reaction. In addition, due to their developmental status, children may be even more vulnerable to traumatic events. Adults need to adhere to routines and remain as organized as possible, continue to exercise regularly, eat healthy meals, and avoid excessive alcohol use. As difficult as it may be, we need to be aware of changes in feelings and behaviors that could indicate depression, anxiety, or maladaptive management of stress. Most importantly, throughout the organization of the community we need to remain connected to those we find supportive and share our feelings and memories. John A. Fromson, MD is vice president for professional development, Massachusetts Medical Society and clinical instructor in psychiatry, Harvard Medical School. REFERENCES: 1. Williams, J.S., Depression, PTSD, Substance Abuse Increase in Wake of September 11 Attacks, NIDA Notes, Vol. 17, No. 4 (November 2002), 2. Ford, J., Managing Stress and Recovering from Trauma: Facts and Resources for Veterans and Families, A National Center for PTSD Fact Sheet, October 26 20;39; 57 2002 3. Ibid. 4. Beauchesne, MA, Kelley, BR, Patsdaughter, CA, & Pickard, J. Attack on America: Children's Reactions and Parents' Responses. Journal of Pediatric Health Care. 16(5)213-21, 2002 Sep-Oct. 5. Veenema, TG, Schroeder-Bruce, K. The Aftermath of Violence: Children, Disaster, and Posttraumatic Stress Disorder. Journal of Pediatric Health Care. 16(5)235-44, 2002 Sep-Oct. Milwaukee, WI -- 1993: Cryptosporidium contaminates the water supply resulting in over 100 deaths and 4,000 hospitalizations. Analysis of emergency medicine records shows increased numbers of diarrhea cases starting weeks before the outbreak WORCESTER, MA September, 1983: Hepatitis B outbreak begins among I.V. drug users. The epidemic is officially recognized a year later after six deaths from fulminant hepatitis. In both of these cases, recognition of the outbreak occurred weeks to months after it began. However, syndromic surveillance systems could have detected and acted upon each of these earlier to prevent fatalities and spread. With the occurrence of anthrax bio-terrorism in 2001, the need for efficient and accurate outbreak surveillance became imperative. The goal of syndromic surveillance is to detect anomalous patterns of disease, either natural or bio-terrorist related, in a timely enough manner to allow an effective response from public health authorities. The Metropolitan Medical Response System (MMRS) based at the Worcester Public Health Department has implemented a syndromic surveillance system for Central Massachusetts in a collaborative effort between clinical care providers and public health. BACKGROUND: Historically, surveillance systems have relied on confirmed diagnoses and enforced mandatory reporting, even though experience shows there are both time delays in data submission, analysis, and reporting, as well as poor compliance. Syndromic surveillance, however, is based on syndrome and sign complexes rather than on diagnoses. Since terrorist bio-agents are likely to produce non-specific syndromes and are unlikely to be recognized immediately by clinicians, syndromic surveillance allows attention to be focused on several possible diseases for further investigation. Syndromic surveillance is also faster than waiting for definitive diagnoses, allowing a real-time response to the epidemic. The Centers for Disease Control (CDC) recommends implementing the National Electronic Disease Surveillance System (NEDSS), to provide a standards-based approach to surveillance, though no approach has yet been defined. Multiple groups around the country have developed innovative approaches to syndromic surveillance. This project requires investigating all available options and implementing the approach that best fits the needs and capabilities of central Massachusetts. CHOOSING A SURVEILLANCE SYSTEM: Effective syndrome surveillance requires real-time reporting, a large patient population, coverage of the variety of locations at which patients will seek care, and safe guarding patient privacy. In order to be practical in central Massachusetts, syndromic surveillance needs to avoid expense, extra work, and reliance on real-time electronic healthcare records. It must be easily learned, understood and used. The surveillance system must benefit both clinicians and public health staff. Public health nurses, infectious disease physicians, the Worcester District Medical Society and the Worcester Public Health Commissioner were consulted in the establishment of a surveillance system for central Massachusetts. After analyzing the multiple systems available, the Rapid Syndrome Validation Project (RSVP) system was deemed the best option for meeting the above requirements. Public health nurses, infectious disease physicians, the Worcester District Medical Society and the Worcester Public Health Commissioner were consulted on how to effectively implement RSVP. The RSVP developer at Sandia National Labs in New Mexico, Dr. Alan Zelicoff, set up a system for central Massachusetts. Clinical leaders in nine central Massachusetts Emergency Departments and two primary care sites in Worcester have learned how to use the system and are customizing implementation for their facilities. Two regional microbiology laboratories also input data useful to the system. HOW THE RSVP SYSTEM WORKS: Syndromic surveillance entails three components: data gathering, data analysis, and messaging. Data gathering can be done automatically using sophisticated computer programs that review electronic medical records, ICD-9 billing codes, or other electronically transmitted healthcare information. However, these systems require real-time electronic data, new software packages and operating expenses beyond the scope of many health care clinics of central Massachusetts. Alternatively, data can be gathered manually using surveys, checklists or physician reported information a potentially time consuming task. Without the filters used in automated systems, data-entry systems may generate a large volume of mundane information that may delay detection of potentially serious cases needing investigation. The RSVP system solves these problems. Participating clinicians enter data into a web-based interface only about those patients who, in their experienced, clinical judgment, meet the criteria of having one of six syndromes of interest. Therefore, no software other than a web-browser, a standard feature on most computers, is necessary. Data entry, both demographic and clinical information, is by either "point-and-click" or touchscreen technology, allowing for a fast process --approximately a minute of clinician time per case. Most importantly, there is a low "signal to noise" ratio, meaning the experienced physician is only entering concerning cases into the system rather than all cases. Instead of relying on automated filters, this system relies on physicians to differentiate patients with syndromes rather than patients with less severe or worrisome complaints. On the other end, Public Health officials analyze the data a post relevant feedback or alerts that are immediately available to clinicians via the feedback screen. Epidemiologists use statistical and geographic analysis to monitor regional outbreaks and initiate investigations. RSVP relies on informed epidemiologist analysis to determine events of significance. Currently the RSVP system can help monitor for suspected cases of the Severe Acute Respiratory Syndrome (SARS) virus as well as other local outbreaks of important infectious diseases such as West Nile Virus. In the future, the RSVP system can be expanded to measure student absenteeism, zoonotic disease surveillance and possibly automated healthcare data, all of which could increase sensitivity to outbreak detection. Lora Schwartz is a medical student at the University of Massachusetts Medical School Becoming a physician: Lessons from abroad In September 2002, I was fortunate to have the opportunity to spend a month at the Nyumbani Orphanage outside of Nairobi, Kenya. With the help of faculty at UMASS, I had arranged a clinical rotation in which I would divide my time between staffing the on-site clinic of the orphanage, which houses 85 children with HIV and AIDS, and working with the community-based outreach team that serves families in and around Nairobi. Never having had the experience of travel outside the United States, I expected that I would find the rotation to be both rewarding and difficult. I returned home with much to reflect upon, and will share one or two impressions and conclusions. First, we are an incredibly privileged group of professionals. In an era of medicine in which the discussion seems so dominated by financial woe, we too easily forget that we have much to be grateful for. I say this because I spent rounds one morning at Kenyatta National Hospital, where no one is admitted without first providing proof of ability to pay, and where a hospital becomes a prison until you do so; no one is discharged until the bill is settled. Some individuals die at the doors of the hospital for such a lack of ability to afford care. Inside, children sleep two to a bed and receive three meals a day consisting of bread and tea. Pain control is erratic since medication stores within the hospital are unpredictable; something as simple for us as regular strength Tylenol -- or a suitable alternative -- may easily be unavailable for days. The first child I examined that morning was nine years old, admitted with a chief complaint of more than six years of abdominal swelling; his tumor was not only palpable, but visibly apparent. His chest x-ray was filled with high-density infiltrates, presumed metastases. Although he had been in the hospital for days, a definitive diagnosis had yet to be made. For all that is needed to improve our system of health care, there is so much that is wonderfully impressive and excellent about it. On days when it seems that everyone is tired, overworked, and struggling to do more with less, it does a world of good to stop and consider that the medicine we practice is far less challenging than it could be, and that the things we never give a second thought to are the very same things that physicians in other parts of the world envy us for having such easy access to: basic medications, the ability to feed patients nutritiously, an adequate number of beds in a clean facility. Acknowledging the reality of how much we have to be grateful for is important; it is a positive force that allows us to continue making improvements, to feel proud of the system of care we are a part of. But it should also make us humble, more patient with those with whom we work, more generous at the bedside in giving our time and attention to the people we are taking care of. My time with the community-based team took me to the slums of Kibera, where over 800,000 of Kenya's poor live and work. This is the second largest slum on the African continent, where shelters are constructed of sticks, mud, and newspaper, the structures standing within inches of each other. There is no electricity or water sanitation. From a distance, the miles over which this community is spread appear as a patchwork quilt of tin roofs. Inside, collections of six or more live within a space not larger than two exam rooms. There are no government-sponsored social programs, no system of public education. The absence of such an infrastructure means that generations of poor will continue to live and die within the confines of the slum; the specter of HIV and AIDS looms here as yet another public health threat, one of many competing for the lives of young and old. Kenya is a poor country, and the quality and scale of poverty experienced by so many living there is unlike anything here in the US. Yet it begs the question of why such a wealthy nation as ours is willing to tolerate hunger and homelessness of any degree. In a more immediate sense, here in Worcester the battle to dismantle the PIP shelter wages on, and in the midst of one of our harshest winters in recent memory, many of our fellow citizens suffered the cruel pains of being turned out into the street without even the modest comforts of the PIP shelter during the long, cold days. Some hold the view that the men and women who rely upon the presence of the PIP are not a wholly sympathetic group; I take a dim view of such assertions. Moreover, I believe that part of our responsibility as health care professionals is to insist that all members of our community have a fundamental right to adequate shelter, food, and medical care. I challenge those who believe otherwise to spend an evening at the PIP with the men and women who seek refuge there, and the outstanding medical professionals who care for them. It will be an eye-opening experience, and an excellent example of the very best that medicine has to offer. In my four years as a medical student, I have never seen medicine practiced with such passion and commitment as I have seen at the PIP. The things I saw and learned in Kenya challenged me in many ways, personally and as a student in training. I returned with a greater appreciation for the many gifts we enjoy in the practice of medicine, a deep gratitude for the plentiful resources we have access to here, and a renewed sense of responsibility toward others here and elsewhere who know too well the pains of poverty. Kathy Kalkbrenner is a fourth year medical student at the University of Massachusetts Medical School, Worcester. America's nineteenth century Romantic philosophy, religious revivalism and social reform suggested that health and happiness were available to everyone. Carrie May, a patient at the Saratoga Spa in 1857, composed the above poem about the palliative effects of Water Cure. Whatever the results, this `blissful' treatment was surely more pleasant than bleeding and purging. Water cure establishments stressed the liberal use of water, internally and externally. They also advocated rest, outdoor exercise, a spare diet, temperance and avoiding tobacco. Hydropathy, or water cure, developed as one of the alternatives to heroic medicine in the treatment of disease -- any disease: pain, palpitations, dyspepsia, piles, costiveness, diarrhea, neuralgia, or debility. Water has a long history as a natural sustainer and restorer of health, but the fashion of hydropathy seems to have originated in 1826 with Austrian Vincent Priessnitz. Priessnitz, a farmer, claimed to have cured himself by bathing in a local cold spring. Soon, he set up a water cure business, practicing this healing art without a license. Water Cure Manual, by Dr. Joel Shew, printed in 1848, relates that after Priessnitz cured a miller of gout, the miller's "wrathful" physician prosecuted Priessnitz. The miller was summoned before the court to give testimony. On being asked who relieved him, he replied, "Both. The doctor of my money; Priessnitz of the gout." Among the nearly 2,000 patients treated by Priessnitz was Robert Wesselhoeft, who claimed he was cured in 1840 of rheumatic fever. Wesselhoeft subsequently immigrated to Boston, earned a medical degree, and opened a hydropathy practice. Americans embraced the system with characteristic enthusiasm for healthy living, and probably too because it lacked repugnant invasive treatments. In 1842, Dr. Oliver Wendell Holmes scandalized Boston society by attacking Wesselhoeft as a quack, saying that his practice was "...a mingled mass of perverse ingenuity, of tinsel erudition, of imbecile credulity, and of artful misrepresentation." Wesselhoeft was forced to abandon his successful water cure practice in the village of West Roxbury but established another in 1845 in Brattleboro, Vermont. Very possibly, young Seth Rogers of Danby, Vermont, was familiar with Wesselhoeft's popular institution. Rogers was the youngest of twelve children, a prosperous farmer's son, who studied medicine at the University of New York and in Castleton, Vermont. Upon graduating, Rogers spent two years in New York City as an assistant to Dr. Joel Shew, a hydropath. Shew, an authority in the movement, authored many books and manuals about hydropathy and published Water Cure Journal, a monthly magazine boasting a circulation of 50,000. Rogers then came to Worcester. There are various possibilities about why Rogers chose to come to Worcester. He might have been recruited to teach at Worcester Medical Institution, where he gave lectures in 1850 and 1851. He might have come because of a friendship with fellow Quaker and Worcester businessman, Edmund Earle. Or he might have been directed to Worcester by S. Weir Mitchell, father of neurology, a friend of both Rogers and Earle. Regardless, Earle built and equipped the Worcester Water Cure for Rogers because Ann Buffam Earle had been crippled as a child by a fall from a horse. He hoped the water cure would ease her suffering. Treatments usually required four to six weeks. The regimen was strict and predictable. In fact, Susan B. Anthony, after months of traveling and giving speeches, took respite at her cousin Dr. Seth Rogers' establishment on Fountain Street in Worcester and described her stay thus: "First thing in the morning dripping sheet; pack at 10 o'clock for 45 minutes, come out of that, take a shower followed by a sitz bath, with a pail of water at 75 degrees poured over the shoulders, after which dry sheet, then brisk exercises. At 4 p.m. the program repeated, and then again at 9 p.m. My day is so cut with 4 baths, 4 dressings and undressings, 4 exercising, one drive and 3 eatings, that I do not have time to put two thoughts together." She failed to say that the day started at 4 a.m., when patients were completely wrapped in wool blankets and made to perspire until the blankets were wet. Heads were covered in cold compresses. Hydropathy was popular with both sexes, but the centers especially appealed to women. Water Cure Journal promoted hydropathy as well as temperance, women's rights, dress and medical reform. The Journal addressed such topics as abortion, frequency of sexual intercourse, masturbation and barrenness -- all issues of interest to women and subjects rarely discussed in an age of exaggerated modesty. Rogers in Worcester avoided the condemnation that greeted Wesselhoeft in Boston. In 1855 he was accepted into the Massachusetts Medical Society. His obituary in the Boston Medical and Surgical Journal relates that "he went to Europe in 1852 for 16 months to make up the deficiencies in his training," leaving his brother Elisha in charge of the Worcester institution. In 1862, it seems he closed Worcester Water Cure "to become a surgeon of Col. Higginson's Negro regiment, the 1st South Carolina Volunteers." He did not practice again in Worcester. T.W.H., presumed to be Thomas Wentworth Higginson, wrote in Rogers' obituary in the Boston Transcript that he "was for some 10 years at the head of a large sanitarium in Worcester,...and always a prominent Abolitionist and woman-suffragist." T.W.H. continued, "In the single attribute of personal and almost magnetic hold upon his patients, I have never known the equal of Dr. Rogers." His nephew, James Rogers, who assisted at the Water Cure (and later married Edmund Earle's daughter), wrote in an unpublished biography, "There was the consumptive, who with feeble step and hacking cough sought some relief from the inevitable doom awaiting him. There also were also the asthmatic and the gouty all seeking the healing influence of water. And my uncle, full of life and of faith in his theory, packed, rubbed, soaked and douched them; attended to their diet and their clothing; and afforded besides, the peculiar consolation which a young, a handsome and energetic physician can always impart, especially to a forlorn woman. In idolizing the man they forgot their ailments." (Predictably, Priessnitz's success has been described similarly, "His success stemmed from... applying the mystical healing powers attributed to Priessnitz' personality.") Despite the Boston Medical and Surgical Journal's (Apr. 10, 1845) description of water cure as, "one of the known modes of mongrel practice; and also as of the last of the great medical farces being played for the diseased imaginations of semivaletudianarians," water cure advocates increased many nineteenth century Americans' knowledge of important health care issues. Bathing became common, far different from the customary occasional summer dip in the pond. Women adopted short hair as they emerged dripping from the water cures, a style adopted by the suffragettes. Walking in the open air encouraged exercise in an era when frailty was the norm. Practitioners demonstrated success with drug-free, non-invasive treatments, employing gentler and increasingly popular "alternative" therapies. One wag described the water cure movement as "a way out of the wilderness of pills and powders by floating down a stream of water." Sande Bishop is a local historian specializing in the development of medicine in Worcester. In Memoriam Richard Church, MD died on August 3, 2002 after a long illness. He practiced family medicine for twenty-two years in Millbury following the death of his father, Noble Church. Dr. Church graduated from Millbury High School, Amherst College and Tufts Medical School and served in World War II in the Medical Corp. He was a school physician in Millbury and served as Medical Director at State Mutual Assurance Company in Worcester. He was an avid hiker and belonged to the Appalachian Mountain Club. His loss is mourned by his wife, daughter, three sons and seven grandchildren and by all his fellow physicians. ~ By A. Jane Fitzpatrick, MD
JOHN DEE, MD John Dee, MD, died in the Hospice Residence in Worcester on May 3, 2002 after an illness. He was 94 years old and for a number of years had made his home with the family of his younger daughter, Janet. John was always a "Class Act", part of an era now quickly passing from our world. I met Dr. John Dee and his family when I arrived in Worcester in July of 1956. John and his lovely wife, Mary, were the finest and most helpful couple that a new physician with a wife and three young children could hope for. We mourned with John when Mary died in 1993. They were a close and loving couple and John's life without her was made easier by his lovely daughters Martha and Janet. John and Mary were always there to help when my wife and I dealt with a serious illness that struck our youngest child. They were ideal neighbors. Helping friends was the way they did things and John's smile was always a welcome sight when things were tough. This was a man who was a close and loving husband, a devoted father, and a wonderful neighbor. My family and I are forever grateful for having known him. John Dee was a physician, an internist and cardiologist by training. He was, by instinct, a dedicated humanitarian doctor. He never forgot the working people of Brockton where he was born and grew up, as he dealt with his patients. He was careful, competent and courteous, always treating his patients with the utmost respect and always giving them the best that he had and all the time that they needed. He served honorably and with quiet distinction in many leadership roles at Worcester City, Fairlawn, and Holden hospitals. John graduated from Wesleyan University and also received a Masters' degree there. Not many people knew, however, that John was an outstanding baseball player at Wesleyan, even going on to play semi-pro ball in the Cape Cod league. Thereafter, John graduated from the Harvard Medical School and trained in medicine and cardiology at Worcester City and the Rhode Island hospitals. John served as a Major in the Army Medical Corps in Europe during World War II. This doctor had a long and full life as husband, father, friend, and community leader but above all, he was a physician to and for his patients. He was always at his office desk, house calls, and in the hospital dressed meticulously and formally – never without a tie and jacket. John had "Equanimitas". He and others like him are now very few among us. We miss him and share his family's grief and loss. ~ By Edward Mason, MD
BURTE GUTERMAN, MD On April 4, 2003, Dr. Burte Guterman died in Naples, Florida. He and his beloved wife, Mim, had planned to spend the winter of their lives there, in active and busy retirement. After many years of productive, beneficial and community – oriented work, they had chosen to spend the long New England winters in the gentler climate of Florida. Unfortunately, that was not to be. About four years ago, Burte suffered a massive stroke that took away the sweetness of the life that he and Mim had so looked forward to. Mim and Burte were together until the last as she cared for his every need. They were a couple to the very end of the sixty-two years they had shared. Burte Guterman exemplified everything that was good in our times -- the latter half of the twentieth century in Worcester, Massachusetts. Burte was born here. He attended public school, graduated from Classical High School and then from Clark University in 1939. During his lifetime Burte served his alma mater in numerous leadership roles and his efforts will remain a part of Clark history. Burte graduated from medical school at Washington University in St.. Louis, where he developed an interest in psychiatry, neurology and electroencephalography. He continued his training at Yale University and became expert in brain function and human behavior. This doctor served his country during World War II and in the Korean War. He returned to Worcester where he practiced with distinction and honor at all of our hospitals. He served as a professor of psychiatry and neurology at the University of Massachusetts Medical School. His patients knew a warm, caring, deeply intuitive physician. His students had a clear thinking, direct and friendly instructor. We, his colleagues, experienced a man among men. He was kind, helpful, accommodating, understanding and always there with a smile. Burte always found time to be a leader in the Worcester Medical Society. He was an Annual Orator and served on many committees. The Scholarship Committee, which provided financial aid to medical students, owes its very existence to his efforts. A scholarship bears his name. As a member, he quietly accomplished much and was one of the Society's most loyal and dedicated participants. Above all, Burte Guterman was a devoted husband and loving father to his wife Miriam and his children, Peter and Janie. Janie's two children have lost a loving grandfather. We in the general community mourn the death of an exemplary citizen. Medical colleagues will have the memory of a great doctor. Those of us who were fortunate to count him as a friend have suffered a great loss. ~By Edward Mason, MD
HERBERT JORDAN, MD Soon after his mother died when he was 13 years old, Herb Jordan left his boyhood home in South Carolina and moved to relatives in Pennsylvania. There he developed his interest in old cars, motorcycles, and then in healing. At the University of Kansas he earned not only Medicinae Doctoris, but also received a doctorate in public health. The deadly tornado of 1952 occurred shortly after he had located in Worcester, and with his new medical colleagues he worked to exhaustion caring for victims. Herb enjoyed his practice at Fairlawn (his favorite hospital) for many years. When that facility was transformed, he settled down at St. Vincent and Memorial. Dr. Jordan was a physician and friend to many patients including those in nursing homes. They looked forward to his visits, brightened when they saw him, had confidence in his ability and appreciated his empathy. His wife Barbara predeceased him by eight years. Dawn Jordan, their daughter and great joy, is a leader among Worcester medical assistants. Herb Jordan (whose family name Smerican cannot be traced beyond the 19th century immigration) saw his patients until 5:00 pm on a recent Friday. He then went home, had dinner and watched the evening news. While concerned with such matters as HIPPA, E-Health and the new issues on privacy, he fell asleep. He did not waken. Herb was 90 years old. ~By Stuart R. Jaffee, MD
EMIL J. KOENIG, JR., MD Dr. Koenig, of East Sandwich, passed away on February 5, 2003. He leaves his wife of 37 years, Judith, two sons, Emil J. Koenig, lll of Leominter and Bruce S. Koenig of Holden, a daughter, the Rev. Judith Fox of Rochester, NY and two step-sons, James D. Cole of W. Barnstable and Christopher J. Cole of Wellington, FL. He was born in Holden and lived there and in Rutland until he moved to the Cape twenty-three years ago. He graduated from Holden High School where he was co-captain of the football team. He graduated from UMass at Amherst, where he played varsity football and turned down a trial with a professional football team to enter Tufts University Medical School. Dr. Koenig served a rotating internship at the Rhode Island Hospital, after which he joined the Holden Clinic to work in Family Practice while awaiting a call from the US Army. He received orders and became a captain and a flight surgeon in the Army Air Force and was assigned to a B24 group whose task was to bomb oil fields to the north from Froggia in Southern Italy. He served there until the end of the war and returned home in the Fall of 1945 with a good record and a Bronze Star. He then did a surgical residency at the Springfield Hospital and returned to the Holden Clinic Group to practice. From 1965 to 1979, he was Chief of Surgery at the Holden District Hospital. In 1979, Dr. Koenig moved to Cape Cod where he was Medical Director and a staff physician at the Barnstable County Hospital until 1992. Dr. Koenig was a member of the AMA, Massachusetts Medical Society, Worcester District Medical Society, the College of Surgeons and the OB/GYN Society. He also belonged to the Sir William Osler Society at Tufts University and Alpha Omega Alpha and the American Legion. He was an accomplished artist and wood carver and enjoyed gardening, flying and horseback riding. Dr. Koenig is fondly remembered by former patients and friends. ~By Leroy Mayo, MD
WDMS launches TV "Health Matters" program The Worcester District Medical Society is proud to announce the launching of "Health Matters" a public access program on TV 13, WCCA, Worcester's Cable Access program. Over 50 physician members volunteered to appear on this educational, half-hour show on health and disease, which features an interview format hosted by a physician. The show is the brainchild of Dr. Bruce Karlin, chair of the WDMS public relations committee. Following is the "Health Matters" program schedule, which can also be accessed on the web site www.wdms.org.
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