Monthly Archives: January 2013

The Verdict on US Health: Shorter Lives, Poorer Health Part I

Posted by on January 31, 2013 Comments Off on The Verdict on US Health: Shorter Lives, Poorer Health Part I

If national defense were a simple matter of military might, the United States would have no concerns. We are clearly the military power of the century–the go-to nation when military power is to be projected.

The premise of this blog is that national defense depends upon more than military power–including economic power and the health of the citizenry. If that premise is correct, we’ve got problems.

As Americans we like to think we have the best of everything including a health care delivery system. That is simply, and demonstrably, not true.

A consensus report of the Institute of Medicine concludes that we face shorter lives and poorer health compared to other advanced countries.

A chart shows part of the problem, deaths before age 50:

US Deaths Before 50 Compared to Peer Countries

The latest report has a table showing the US in 17th place in longevity at birth.

US Life Expectancy at Birth Compared to Peer Countries
We are worse than other countries in 9 areas.

1. infant mortality and low birth weight
2. injuries and homicides
3. adolescent pregnancy and sexually transmitted infections
4. HIV and AIDS
5. drug-related deaths
6. obesity and diabetes
7. heart disease
8. chronic lung disease
9. disability

Next blog will deal with some of the report’s recommendations and conclusions.

The Safety of Our Children: Vaccinations

Posted by on January 28, 2013 Comments Off on The Safety of Our Children: Vaccinations

If there is one aspect of health we care most about, it is that of our children.

We are afraid to do the wrong thing, which might be doing something and might be doing nothing.

Vaccinations are the first major encounter our children have with the health care system.

By major I mean:

Under the recommended plan from the Centers for Disease Control and Prevention, children today are vaccinated against 14 infectious diseases, receiving up to 24 vaccines by their second birthday, and up to five in one office visit.

There has been controversy about the frequency of vaccinations, about the content of vaccines, and about the necessity of the vaccines at all in the absence of the diseases they protect against.

The last reported case of diphtheria in the US occurred in 2003.

The last reported case of polio in the US occurred in 1986.

I do not claim to know the incidence and severity of side effects and reaction to these and other vaccines.

Here is what I know:

  1. When a disease like smallpox was eradicated, the routine vaccination was halted.
  2. The diseases that we are vaccinated against have not been eradicated. We live in a small world: we travel to other countries, and others travel here. HIV/AIDS was brought here on a plane. We do not want to be like the Native Americans, wiped out by diseases from Europe because we were not vaccinated.
  3. The risk and incidence of reactions are minimal compared to the severity of an infectious outbreak.
  4. Science brought us the life-saving vaccines, not hunch or intuition.
  5. The Institute of Medicine of the National Academies has issued a report on childhood immunizations and found:
    1. the childhood immunization schedule is considered one of the most effective and safest public health interventions available to prevent serious disease and death. Furthermore, the committee’s review of the literature did not find high quality evidence supporting safety concerns about the immunization schedule.
    2. The committee’s efforts to identify priorities for recommended research studies did not reveal an evidence base suggesting that the childhood immunization schedule is linked to autoimmune diseases, asthma, hypersensitivity, seizures, child developmental disorders, learning disorders or developmental disorders, or attention deficit or disruptive behavior disorders.
    3. The committee found no significant evidence to imply that the recommended immunization schedule is not safe.

The bottom line: in all of our health care decisions we are playing the odds–life never affords us certainty. The odds favor vaccination according to schedule. Listen to your pediatrician–vaccinate your children.

Violence Prevention and Mental Health

Posted by on January 24, 2013 Comments Off on Violence Prevention and Mental Health

The White House plan to reduce gun violence has substantial mental health provisions:

Children and Young Adults

  1. Project AWARE (Advancing Wellness and Resilience in Education) directed at students in schools
    • Mental health “first aid” training for teachers
    • Referral services for students
  2. Support individuals 16 to 25 outside of and beyond school
  3. School-based violence prevention, including mental health services for trauma and anxiety
  4. Train 5,000 mental health professionals to serve in the schools
  5. Initiate a national conversation to address stigma associated with mental illness

Ensure Mental Health Coverage

  1. Issue final regulations on private health insurance coverage of mental health treatment
  2. Ensure that Medicaid programs are meeting mental health parity requirements

In addition:

  • The $150 million Comprehensive School Safety program will help finance new school resource officers (police) or mental health professionals (psychologists, social workers, counselors).
  • The hiring decisions will be with local school districts.

My Take (this is a blog, isn’t it?)

  1. The problem of obtaining adequate mental health coverage for anyone is a major challenge because:
    1. There is neither a test nor a cure for mental illness, which means that diagnosis is expensive and difficult, and management is expensive and difficult
    2. Mental illness resembles a chronic illness with transitory remission, so there is a temptation to halt treatment during remission and hoard resources to deal with crises.
    3. Nearly all families and individuals, save the super wealthy (think $1 million in annual income), have insufficient resources to address the full spectrum of mental illness symptoms, some of which require residential treatment for long period to be optimally addressed
  2. Large segments of the population continue to provide moral diagnoses rather than accepting a medical diagnosis of mental illness
    1. Depressed people are seen as lazy and unmotivated; bipolar people are seen as lacking discipline
    2. The symptoms are largely invisible and intermittent–mental illness is only partially and rarely someone walking down he street talking to imaginary people.
    3. Consequently, a large part of the public is unwilling to finance the treatment of those seen as slackers.

    Bottom line: the Administration is to be commended for first steps, but any reasonable approach will require billions not millions of dollars

Snacks: the 4th meal of the day

Posted by on January 21, 2013 Comments Off on Snacks: the 4th meal of the day

Let’s say a woman consumes 1500 calories a day to maintain weight and a man consumes 2000. It varies from individual to individual according to your rate of metabolism, your physical activity, your body build, and other variables. More than that–you gain weight.

To lose a pound requires taking in 3500 calories less–or about 500 calories daily to lose a pound in a week.

According the chart below from The Hartman Group, Americans eat 2.3 snacks daily, with chips and soft drinks the most popular.

Consider the math: the chips in the vending machine run 160 calories each. An 8-ounce soft drink can has 97 calories. The calories for that one snack are 160 + 97 = 257. If that is an average snack and there are 2.3 average snacks per day, the total snack calories are: 2.3 x 257 = 591

Of course no one eats an average snack–sometimes we eat less; most of the time we probably eat more to compensate for those in the averages who are not snacking at all.

If you are maintaining weight, cutting out snacks is likely to help you lose a pound a week–assuming you continue to maintain current activity levels while dieting.

If you are gaining weight at a rate of a pound a week, the other three meals may not be the problem.

Clearly, the fourth meal daily can help you lose or gain a pound or more weekly.

snacking-in-america-large

ED use drops when medical practices extend office hours – amednews.com

Posted by on January 17, 2013 Comments Off on ED use drops when medical practices extend office hours – amednews.com

This article from the American Medical Association news service caught my eye because it discusses an issue central to the challenge of providing quality health care at the lowest feasible cost, to individuals and the society: ED use drops when medical practices extend office hours – amednews.com.

With the recent US Presidential election following the passage of the Patient Protection and Affordable Care Act (PPACA) aka “Obamacare,” the issue of access to health care has been prominent.

Access, however, does not merely mean having health insurance, although that is certainly important.

Access also means that the health care provider needs to be open and available. Those of us beyond a certain age can remember when the family doctor made house calls, even in urban and suburban areas.

All of us know that those times are gone, except perhaps in some small, rural communities. Attempts to revive house calls in some areas have not always endured or proved worthwhile.

A study in Health Affairs, 31:12, December 2012 finds that emergency department usage declined 20 percent and unmet medical needs declined over 40 percent when physicians stayed open extended hours.

In the absence of such access, patients go to the nearest hospital emergency room for non-emergency care. The result is a burden on emergency facilities treating more urgent cases as well as an added, and unnecessary burden, on health care insurers. Those costs through higher premiums are passed to the consumer: businesses and individuals.

This study points to a very important lesson: we can improve health care AND lower costs. One important detail is that the practice staying open might mean the availability of a nurse practitioner rather than a physician.

Improving access to health care in a time of fiscal restraint is going to require more innovative use of health care providers, especially nurses, physician assistants, and urgent care facilities. Not only does this study make that clear, but as James King, MD, a family physician in Selmer, TN suggests that practices partner with urgent care facilities in the community that supply after-hours care if the doctors can’t offer these services themselves. “Your patients know to go there, and then the urgent care center knows to get information back to their primary care physician when they’re seen” by their regular office.

Flu season: where statistics and anecdote meet

Posted by on January 14, 2013 Comments Off on Flu season: where statistics and anecdote meet

No missing that it is flu season. Like hurricanes in Florida, fires in California, and tornadoes in Oklahoma, either the media reminds us or our friends do.

Massachusetts just declared a flu emergency. The Centers for Disease Control and Prevention (CDC) map showing that there are widespread flu cases in 41 states is on all the news media websites and news reports. And the flu deaths have just surpassed the 1 of 14 deaths threshold to officially be called an epidemic.

There seem to be a lot of people with the flu or flu-like symptoms, which seems strange. The flu vaccine is not something new. It is readily available, far more cheaply than getting the flu is. If you are an hourly worker, it costs the equivalent of 1-2 hours of work, but the flu costs you 8 hours of work.

I think there are four reasons why there is so much flu.

1. Many people do not get the flu shot even when it is available for free, as in many workplaces. There is magical thinking involved. The vaccine is dangerous, they think, or, “it will make me get the flu.” Often there is a fear of needles.

Comparing vaccination rates from November to the previous year, they are about the same: less than 3 out of 8 people. By March of last year, less than 1 out of 2 individuals had been vaccinated. Trends from November to March are likely to be similar this year.

Flu_vaccinations2012
The next two reasons are a bit more complicated.

This table shows the reports of testing of flu strains around the country totaling over 9,000 tests with slightly less than a third positive. There are about 4 times as many Type A as Type B positive tests. Of course, many people with the flu do not get tested. They may call their doctor, who either prescribes an anti-viral or tells them it is too late, that they should drink plenty of liquids, and look for the signs of pneumonia.

Flu_week52_1

So, the next reason is:

2. People contract a virus that is not influenza.

The next image shows tests done at the CDC for different strains. The sample is much smaller, about a seventh of the previous number of positive tests. Note that strains of both Type A and Type B influenza were identified. About a fourth are Type B.

Flu_week52_2

And here are the strains in the 2012-2013 vaccine:

On February 23, 2012 the WHO recommended that the Northern Hemisphere’s 2012-2013 seasonal influenza vaccine be made from the following three vaccine viruses:
an A/California/7/2009 (H1N1)pdm09-like virus;
an A/Victoria/361/2011 (H3N2)-like virus;
a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses).

Note the absence of B/Victoria lineage from the vaccine, so the final reason:

3. People contract an influenza virus for which they have not been vaccinated–even though they received this year’s flu vaccine. There has been talk of a vaccine with four strains (quadri-valent) rather than the current three strains (tri-valent), but none yet operational in the US.

4. Even those who get the flu shot do not get perfect immunity. Immunity depends on the weakened or killed virus stimulating the production of antibodies. Everyone’s immune system is different, and those with weaker responses get less protection. Indeed, older folks get a strengthened vaccine now, so that aged immune systems can be stimulated to trigger an adequate response. Also, the antibodies stimulated tend to stay concentrated in the bloodstream, not the lining of the lungs where the virus enters.

Conclusion: The flu virus is inconvenient at best and deadly at worst. You may not get adequate protection from the vaccine, but you get zero protection without it. And get the pneumonia vaccine as well, if you haven’t already: real good chance of a secondary infection if you get the flu and haven’t gotten the pneumonia vaccine.

Are the troops healthier than before?

Posted by on January 10, 2013 Comments Off on Are the troops healthier than before?

Military troops are healthier than before with less arterial plaque than previous studies showed. So says a study published in the Journal of the American Medical Association

Whether our military is healthier is an important question, going to the heart of the reason for this blog. The study also makes clear how difficult answering that question is.

The study compares arterial plaque from autopsies of US soldiers in Iraq to the findings from similar studies on soldiers in the Vietnam and Korean conflicts.

The implicit assumption is that deceased soldiers are a random sample of the larger military population, or at least that deceased soldiers from different wars are comparable samples.

For example, the sampling is quite different in the 3 conflicts, with a larger number and larger percentage of deceased soldiers available to the Iraq War study than from the earlier conflicts, which had much higher number of combat deaths.

Table 3 JAMA 20121226

The authors, as in all good science, do an admirable job of listing in the Comments section all the possible variables unaccounted for. Probably the most striking change between the earlier and current study subjects is that in earlier wars tobacco consumption was encouraged, while by the time of the latest conflict the military had successfully lowered smoking rates within the ranks. That rate is over 30% while the civilian rate is closer to 20%.

In addition, both military and civilian populations have profited from the availability of statin drugs. The military may have improved arterial health today, but that health may be better, the same, or worse than civilian equivalents. I cannot help but assume that the Army still produces bacon for breakfast nearly every morning by baking it in its own grease per this recipe, under Note.

Even with the limitations that the authors list, the study provides an intriguing look at disease across demographic categories.

Table 1 JAMA 20121226

It appears that older more sedentary occupations, ranks, services are all likely to show greater evidence of arterial plaque.

For example, the Marines show the least while the Air Force shows the most. Higher ranks show more plaque. Higher educational levels show more plaque, as education is a likely correlate of rank, implying more sedentary activity and perhaps greater age.

Policy, Politics, and Guns. Oh my!

Posted by on January 7, 2013 Comments Off on Policy, Politics, and Guns. Oh my!

No solutions here. Just some clarifications of a complicated subject.

1. While we have a constitutional right to “bear arms,” there is no obligation to do so.

Some people need guns. Most of us don’t. If you are a hunter (and not a bow hunter), you need a rifle or shotgun when you are hunting, but you can lock it up soundly the rest of the time.

For most people the use of a gun for self-defense is illusory—you aren’t going to get to the gun before someone gets to you.

Criminals often get guns by stealing them from licensed owners—so your gun is making lots of people unsafe.

Your gun is much more likely to be used for a suicide or discharged accidentally than for self-protection.

2. The constitutional right is not unlimited. The First Amendment is not unlimited: child pornography is not protected speech. The Second Amendment is not unlimited.

    a. There are prohibitions on owning automatic weapons and sawed-off shotguns.

    b. There is no protection for magazines with 30 rounds.

    c. The recent Heller case establishing a personal right was a 5-4 decision. Such decisions are often reversed when there is an absence of a national consensus.

3. There is no historical evidence that personally-owned guns have maintained freedom. There is clear evidence that they are the source of death from homicides, suicides, and accidents.

If we take a fantasy trip to an authoritarian United States of the future—several lifetimes from now, we will find that the U.S. military outguns any opposition, so in that fantasy world, only defections with weapons would have any impact on regime change.

In the present, civilian weapons are used to kill other civilians.

4. Personal automobiles are no more likely to be taken away than firearms, yet vehicles are registered, require proof of proficiency to operate, and require liability insurance.

The idea that anyone is taking away the firearms of the US civilian population is an excellent marketing ploy that has been successfully implemented several times in the past half century: someone suggests that there will be gun control as a first step to confiscation, and gun owners rush to the store to get more.

I do not claim to have answers to the problem of more than 30 thousand deaths from firearms annually.

However, I assert that in a democratic society we have the means to address the problem—and the obligation. We can do so with minimal inconvenience to anyone who wishes to legally own a firearm for hunting, target-shooting, or self-defense, while making it prohibitively inconvenient for individuals who wish to shoot school children.

Firearm Trends Leave Me Clueless

Posted by on January 4, 2013 Comments Off on Firearm Trends Leave Me Clueless

One of the more interesting aspects of firearm mortality is the trend over the past 15-20 years. Beginning in 1994 the rate of mortality began to drop. That was the year that the assault weapon ban passed. Note that the rate of firearm deaths was close to the rate for deaths in motor vehicle accidents.

Injury Deaths 1979_2007

The rate of firearm deaths dropped from 1993 to 1999 and has remained level since then. The rate of death from motor vehicle accidents has dropped, but not as steeply.

The rate of death from poisonings has nearly tripled. What is that all about?

It might be thought that the assault weapons ban brought down the death rate, but that is not likely. The chart below compares 1993 to 2004, showing that the rate for suicide with firearms dropped about the same as the rate for homicides. I may be mistaken, but assault weapons are not the weapon of choice for suicide. Something else must have been happening in those ten years, or until 1999, at least. I don’t know what it was, but it would be nice to replicate it.

Firearms 1993_2004

When events like the Newtown massacre dominate the airwaves, we would like to act to prevent the next one. I think we should act to prevent the next one. However, the data demonstrate how difficult it is to decide what will work. An effective policy does not have to solve the problem by ending all future incidents: it just has to demonstrate a substantial change in a positive direction. That will be challenge enough.