Field Notes #31

Writings from palliative care doctor Anna DeForest; a New Yorker investigation into what happens when a private equity firm buys a nursing home; and why do mosquitoes bite some of us more?

These are all stock images. No one I know. No bug on my arm. No real places. The words, though, are really by Dr. Anna DeForest.

Hello, friends! Welcome to the finale of August. The new school year is around the corner, or perhaps it’s already begun where you are. I am mourning summer, but I am also reminding myself that summer technically lasts until September 21, and that our warm days will not go — poof! — and turn into chilly sweater days, even if Pumpkin Spice Lattes are now out. We have time. We have both more time and less time than we imagine.

Here are three interesting things I’ve run across lately: a tidbit on mosquito attraction (It’s not your imagination! They like some bodies more!), thoughtful thoughts on palliative care, and a searing story about what happens when private equity firms take over nursing homes.

In other news, I’m watching the water crisis in Jackson, the capital of Mississippi, where the city’s main water treatment facility has failed. Some homes and businesses have low or no water pressure, and in others, there is water but it is unsafe and must be boiled. From the early reports, this seems like it is an indefinite problem with no quick fix. So many details are unclear, and this early sketch will no doubt have errors. Here’s an early Twitter thread of local organizations taking donations to help. It’s a health issue and a safety issue, and horrific.

On to the Field Notes…

1} Do mosquitos bite you more often? Why?

We have not seen many bugs this summer and very few mosquitoes. Every so often a dragonfly, with its unmistakable wingspan, like an insect 747, careens into view, or a plump, fuzzy bumblebee hovers by the flowers, but otherwise, not much. Quiet times.

Most years, though, especially in my childhood in Maryland, mosquitoes were as much a part of summer as blue crabs and corn on the cob, slip-n-slides and lightning bugs. My parents hung an electric bug zapper near the house, and the bzzzz crackle competed with the crickets in the evening music.

But where you are going with this, Brianne? I am going to this story: Why do mosquitoes bite some people more than others? in ScienceLine from NYU, which answers the question I’ve long wondered. I don’t really ever get bitten that much, but other people I love seem to get munched on constantly. Why? We joke about them being so sweet, so irresistible, but really, who knows?

Here are, according to various cited studies (“Landing preference of Aedes albopictus (Diptera: Culicidae) on human skin among ABO blood groups, secretors or nonsecretors, and ABH antigens”) and scientists, are factors that make it more likely a mosquito will be drawn to you:

1. O-type blood. Yes, really. Mosquitoes love people with type O blood more than all other types.

2. Pregnancy. “Pregnancy seems to be a big winner for mosquito attraction, probably because mothers-to-be exhale 21 percent more carbon dioxide (quite a turn-on to the six-legged species) and are on average 1.26 degrees Fahrenheit warmer around the belly than their non-pregnant counterparts, due to the temperature of amniotic fluid.”

3. Beer. Why? “…Possibly because of the increase in body temperature it causes or because skin markers change when metabolizing cocktails.”

How are the mosquitos where you are?

2} “When Private Equity Takes Over a Nursing Home”

This investigation by Yasmin Rafiei in The New Yorker magazine is worth a read. It is long, detailed, wrenching, and infuriating — the story of one nursing home, St. Joseph’s Home for the Aged in Richmond, Virginia, after it is bought by a private equity firm and renamed Karolwood Gardens, with reduced staff and a shadow of its former home.

Yasmin Rafiei @YasminRafiei

Just over a year ago, I read a paper which showed that when private equity buys nursing homes, death rates go up 10%. I was a med student at Stanford, but I halted my studies to investigate. Today, that investigation was published in @NewYorker

newyorker.comWhen Private Equity Takes Over a Nursing HomeAfter an investment firm bought St. Joseph’s Home for the Aged, in Richmond, Virginia, the company reduced staff, removed amenities, and set the stage for a deadly outbreak of COVID-19.

Yasmin writes:

Since the turn of the century, private-equity investment in nursing homes has grown from five billion to a hundred billion dollars. The purpose of such investments—their so-called value proposition—is to increase efficiency. Management and administrative services can be centralized, and excess costs and staffing trimmed. In the autumn of 2019, Atul Gupta, an economist at the University of Pennsylvania, set out with a team of researchers to measure how these changes affected nursing-home residents. They sifted through more than a hundred private-equity deals that took place between 2004 and 2015, and linked each deal to categories of resident outcomes, such as mobility and self-reported pain intensity. The data revealed a troubling trend: when private-equity firms acquired nursing homes, deaths among residents increased by an average of ten per cent. “At first, we didn’t believe it,” Gupta told me. “We thought that there was a mistake.” His team reëxamined its models, testing the assumptions that informed them. “But the result was very robust,” Gupta said.

Cost-cutting is to be expected in any business, but nursing homes are particularly vulnerable. Staffing often represents the largest operating cost on a nursing home’s ledger. So, when firms buy a home, they cut staff. However, this business model has a fatal flaw. “Nurse availability,” Gupta and his colleagues wrote, “is the most important determinant of quality of care.”

At homes with fewer direct-care nurses, residents are bathed less. They fall more, because there are fewer hands to help them to the bathroom or into bed. They suffer more dehydration, malnutrition, and weight loss, and higher self-reported pain levels. They develop more pressure ulcers and a greater number of infections. They make more emergency-room visits, and they’re hospitalized more often.“They get all kinds of problems that could be prevented,” Charlene Harrington, a professor emeritus of sociology and nursing at the University of California, San Francisco, said, of residents at homes with lower nurse-staffing levels. “It’s criminal.”

In her investigation, Yasmin sought to look at a story behind the statistics. She chose found a nursing home that had been run by nuns, the Little Sisters of the Poor, for 147 years, and was now to be sold. She visited it, while it was run by nuns, and after. It sounds like a nursing home out of a dream, out of a movie, turned into a nightmare.

Her investigation is searing and unforgettable. Read the full story here.

3} “What do I do with a thing like that? I hear it, and I help where I can.” — Anna DeForest

On Twitter last week, in a thread about the 2022 Gold Foundation Reading List for Compassionate Clinicians, someone recommended A History of Present Illness, a novel by Anna DeForest that has just come out, and thus missed the window of the 2022 list. A History of Present Illness looks enticing, and now I’m seeing Anna’s interviews and essays all over the place, on NPR and Literary Hub and The New York Times book reviews.

Anna — Dr. DeForest — is a palliative care physician, which is not the same as hospice. Hospice is care at the end of life, while palliative care is care to improve your living, ease your pain, address your symptoms, during any stage of serious illness. “Hospice means a roadside inn for pilgrims and indigent travelers. Palliative means more concerned with the experience than the reason it happened to occur,” she writes in “Ask Me About Death and Dying: On the Work of Palliative Care,” a winding rumination in Literary Hub. (I can’t tell if it’s an excerpt from her book, but I think it must be so.)

Here’s one section that is staying with me:

What is it, exactly, that you want me to do? The woman who was asking had metastatic cancer in her abdomen. Yesterday we told her that she had no options  left for treatment. With her permission we shared a prognosis of weeks to a few months. Her face didn’t move as the news broke. She looked off to the left at the wall. And someone gave the speech on the philosophy of hospice, and she shared a hope to go home. It is the next day, with the logistics all already in process, that she asks.

What am I supposed to say now, what am I supposed to be thinking about? I can’t tell you how everyone I meet feels about the things we tell them, though young in this work I have seen a few trends. And something I see a lot is people who feel that their lives got away from them, they were always just watching, as from the station looking at faces flicking by on a moving train, and what is left to them now in the time they have left is only fear and suffering of unclear significance. What do I do with a thing like that? I hear it, and I help where I can.

What do we all do with a thing like this? Listen. Help where we can.

Read the full essay, which is stocked with many more insights than I can do justice to here.

And a last thought:

“Their lives got away from them….” I read this, and I thought too of all of us still in our lives, not yet having heard a dire prognosis, not yet seeing clearly how much or little time is left. What can we do with a thing like this?

To our journeys,

Brianne