Kim’s public health blog

The Wall Street Journal and others today have discussed the possible heart disease developed among children labeled as having ADHD. Most medicines have undesired side effects. The issue is deciding when the benefit outweighs the risk. While the stimulant drugs used to control ADHD are found valuable by parents, one msy wonder how much of the acting out is the result of poor discipline rather than disease. It is too simple to diagnose a ‘condition’ and prescribe a drug. Maybe this wake up call from the American Heart Association will help more parents consider behavioral therapy rather than drugs to help their children. We have not investigated if when the children become adults there performance may be less productive for having been on drugs all their lives.

“For the first time since the Spanish influenza of 1918, life expectancy is falling for a significant number of American women,” according to a study published in PLoS Medicine. Lead author Christopher J.L. Murray, M.D., a physician and epidemiologist at the University of Washington, and colleagues at the Harvard School of Public Health. Women seem to learn slowly from the adverse behavior of men. While the survey cannot pin direct cause and effect to these results, the public health community has seen the excess of obesity, smoking, minimal exercise, poor diet and the adverse effects of increasing urbanization upon the population. To change these outcomes it will be necessary to change the infrastructure of the social support system, instead of maintaining the current barriers between health, social service, mental health, primary care and nutrition programs.

A paper reviewing use of antioxidants, published by the Cochrane Library, found that supplemental antioxidants do not reduce mortality and that some — including vitamin A, beta-carotene and vitamin E — could increase mortality. The review combined evidence from more than 200,000 people.  I wonder how many more studies of over the counter nutritional supplements showing lack of effect, or possible danger, will be needed before the FDA is given authority to regulate the claims made by the ‘nutritional’ industry.  It would be useful if various watchdog groups provided information on how much the groups who promote these scams give to congressional campaigns.  

The Robert Wood Johnson Foundation has just released a landmark report and founded the Commission to Build a Healthier America. The report and commission spell out the reason for studying disparities in health status and state that much ill health has little to do with medical care and everything to do with the social support system provided within communities. The commission will study health disparities within the U.S and recommend actions to change support systems to improve everyone’s health. Tables within the current report show how far the U.S. has fallen behind the other developed countries in caring for its citizens during the last 40 years. Part of the problem is clearly the focus on technology and research while loosing sight of social needs.

An NIH-funded study using magnetic resonance imaging (MRI) brain scans, led by Children’s Hospital Bostonneurologist Michael Rivkin, MD, suggests that prenatal exposure to cocaine, alcohol, marijuana or tobacco (alone or in combination) may have effects on brain structure that persist into early adolescence. While this should not be terribly surprising it is one more evidence of the failure of our social system to protect children from conception through maturation. There is increasing evidence that any level of lead in children’s blood is hazardous, yet we still have not applied what we have known about household environments for 50 years. Too many parents have to reside, with their children, in unsafe rental housing. Very few cities have codes that require inspection of rental housing for compliance with housing standards before they can be leased. We fail young and often immature parents with lack of support in family raising and then complain about the children’s failure in schools and often violent behavior. We spend too much time studying problems and fail to translate research into practice.

The News Media today publish two stories about the inability of Congress to come to grips with changes needed to the health care system. First, Senator Baucom fails to understand that Medicare is rapidly going broke but he is trying tu repeal cuts in the Medicare payment system.  He should be concentrating on the cause for Medicare’s  forthcoming insolvency, the excess of preventable chronic disease in a growing aging population with a payment system that focuses on the wrong interventions. Secondly, Congress is concerned about a “Dr. Shortage”. For the most part this is a myth. The ’shortage” is in primary care. The third party payment programs short change primary care and focus om specialty care. Thus, young doctors $100,000 or more of debt choose a spocialty that will reduce their debt most rapidly,  As usual politicians focus on perception rather than reality.

The news media are having their usual feeding frenzy about the latest report on foodborne disease outbreaks outlined this week by the CDC.  Washing fresh fruits and vegetables can reduce the risk of food poisoning, but only irradiation kills almost all disease-causing bacteria  according to a study presented at the American Chemical Society’s annual meeting in New Orleans. The researchewrs noted “washing with plain water did not reduce bacteria levels in spinach or lettuce. Chemical treatment did not significantly reduce E. coli in spinach leaves, and was less than 90 percent effective when it came to removing E. coli from lettuce.” But, irradiation “reduced the level of E. coli by 99.99 percent in lettuce, and by 99.9 percent in spinach.” The researchers also noted that “salmonella died more easily when exposed to radiation, while E. coli was a little bit more resistant.”  
If we can just get the public away from the ‘Jane Fonda” syndrome about radiation being bad, we might make more progress in food safety. Suing food producers will not improve  food safety.

The Wall Street Journal today highlights a report from PricewaterhouseCoopers putting the value of the waste sloshing around in the health care system at a whopping $1.2 trillion a year, or 50% of the total spending..  However the “waste” may be more in the eyes of the auditors than real.  For example waste includes such items as missed appointments, medicines not taken, Dr’s recommendations not followed, diseases associated with adverse behaviors. It also believes there is much administrative waste in the way medical services are delivered.  There are many deficiencies in the system , much of it due to illogical legislation and federal laws, or services delivered that are usually unecessary but are used to prevent lawsuits. The headlines in The Journal make good copy. Probably 50% of the “waste” could be averted,  Even $600 billion dollars a year are well worth saving.  This will not happen without a major overhaul of our broken system.

Since Mumps vaccine was introduced there has been a significant drop in new cases, as seen in this graph.

However in 2006 a resurgence of mumps ocurred in the upper central USA.  There was only moderate uptake of a second dose of mumps  vaccine putting adolescents and young adults at risk.  This shows a similar pattern to the Measles outbreak in South Texas twenty years ago which lead to recommendation of a second dose of vaccine in middle school.  The difference was that 98%+ of the Texas students had received their vaccine dose as recommended. This was not the case with the mumps vaccine. Part of the problem is anxiety anong parents about supposed ill effects from vaccines, grossly overestimated but pushed by the media for its value as a scary story. Future studies will help to evaluate the national vaccine policy, including whether the administration of a second dose of MMR vaccine at a later age or the administration of a third dose would provide higher or more durable immunity.
N Engl J Med 2008;358:1580-9.

Senator Kennedy has it absolutely right in commenting on policy changes to rein in the health care system. He is quoted in ‘The Hill’ as saying ” reducing the cost and improving the quality of healthcare in the United States cannot be accomplished without changing the way patients with chronic diseases are treated and the way medical providers are paid. He is joined by Dr. Carmona, former Surgeon General who says “We are obviously not doing enough to reward real value in healthcare,” pointing out that treatments for the chronically ill with conditions such as diabetes and high blood pressure consume a grossly disproportionate share of the nation’s spending on healthcare. Seventy-five cents of every dollar you’re spending on healthcare is on chronic disease, much of which is preventable.” With healthcare costs continuing to mount, rates of chronic illnesses like diabetes rising and the Baby Boom generation advancing in age, the situation will deteriorate without change, he cautioned. “The bank is breaking now and it’s only going to get worse.”