Public health

The Federal Deficit and the Health of American Citizens

July 12th, 2011 | No Comments | Source: Commentary

It was nice while it lasted, but the brief surge in optimism surrounding debt-reduction negotiations died Sunday, when Speaker of the House John Boehner announced that his party wouldn’t swallow President Obama’s proposed $800 billion tax increase as part of a package designed to save $4 trillion.

If nothing else, the collapse of the negotiations made it clear that Republicans don’t care about the deficit per se. What they care about is cutting federal spending and taxes, and they’ll do that even if it means partially dismantling popular entitlement programs in the process.

One would think the GOP would have gotten the message that this was a bad idea when a reliably Republican district in upstate New York elected Democrat Kathy Hochul to fill a vacant House seat in a special election last month. Hochul’s entire campaign revolved around preserving Medicare and denouncing a plan by Republican Paul Ryan to transform it into a voucher program, cutting benefits in the process.

In fact the draconian spending cuts envisioned by GOP deficit hawks would impact the health of American citizens far more profoundly than the Ryan plan envisions.

That’s because, as I argued here and here, public health isn’t a medical problem at all. It is a socioeconomic one, and cuts to many programs other than those proposed for our health entitlement programs will affect national well-being and health as a result.

Take Canada for example. That country provides universal, free access to health services for all citizens. If poor access to health care (a problem that would be exacerbated by GOP cuts to health entitlement programs) was the only factor driving poor health outcomes, then we shouldn’t see poor, or less educated people experiencing poor outcomes in Canada. But these differences do exist, in spades. In a recent study of 15,000 Canadian adults for example, participants in the lowest income group were nearly 3 times more likely to die of any cause than those in the highest income group. They were also more likely to have diabetes, high blood pressure, cancer, cataracts and many other conditions. The study revealed similar disparities when participants were stratified by educational level. (more…)


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The Mobile Phone-Brain Cancer Link

June 22nd, 2011 | 2 Comments | Source: Commentary

Some of the greatest discoveries in the history of modern medicine came from scientists who noted spatial and temporal relationships between events that had not been previously recognized, and deduced from their observations that the events were causally linked.

In 1854 for example, John Snow observed that high cholera death rates in 2 districts of Soho were linked by a common water supplier. Snow created maps (pictured) to display the link and eventually traced the outbreak to one of the supplier’s water pumps. He convinced the supplier to remove the pump handle and treat the water with chlorine, and that promptly ended the epidemic. Snow’s work was canonized as a founding event in the science of epidemiology.

Then in 1928, Alexander Fleming–already renowned as a brilliant scientist with an untidy laboratory–accidentally spilled a beaker filled with a fungus (genus, Penicillium) onto a petri dish containing the staphylococcus bacteria, just before he left on vacation.

Upon returning, Fleming noticed that staph colonies close to the spill had died. Fleming subsequently showed that the fungus produced a substance which killed staph and many other bacteria. He named the substance Penicillin. The discovery revolutionized the treatment of bacterial infections and spawned the entire pharmaceutical industry in the process.
Last month, Finnish scientists used similar spatiotemporal analyses to explore the purported link between mobile phone use and brain cancer. Unfortunately, their results were not nearly as clear-cut as those of Snow and Fleming.

Here’s the Story
Mobile phones produce radio-frequency electromagnetic fields. To date, no study has proven that the radiation is tumorigenic, but doubt persists because it has proven difficult to quantify the amount radiation exposure in various areas of the brain, and the long latency period before cancer first develops and becomes clinically manifest. (more…)


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Should the US Destroy its Cache of Smallpox Virus?

February 17th, 2011 | No Comments | Source: Wall Street Journal

Smallpox killed between 300–500 million people during the 20th century. As recently as 1967, 15 million people were infected and 2 million died from smallpox. Amazingly however, a massive, global vaccine-based effort to eradicate the disease was declared a complete success in 1979. That feat stands among the greatest achievements in the history of medicine. In fact to this day, smallpox remains the only human disease to have been completely eliminated from the face of the earth.

End of story, right?

Well, not exactly. Today, officials believe that the only samples of the virus in existence are stored in refrigerators at the CDC and in a Russian government lab in Siberia. At these tightly guarded facilities, scientists use the specimens to develop treatments which would be used in the event that very bad people somehow found a way to release the virus into a world containing billions of unvaccinated people.

For this to happen, bioterrorists would have to secure unsanctioned samples of the virus (none of which are known to exist), steal it from the above-mentioned facilities, or genetically engineer it (a task believed to be extremely difficult using current technology, since the virus’ genome is long and complex). It’s also possible that the above-mentioned facilities could release the virus accidentally.

The probability that any of these events will happen is exceedingly small, so public officials have debated for decades whether the known, remaining samples of smallpox virus should be destroyed.

The debate now appears headed for a resolution. Representatives of 34 countries including the US and Russia are meeting to decide the matter. The group will make recommendations to a governing body, the World Health Assembly, in March. The Assembly plans to decide the matter in May. (more…)



Supply, Demand and the Price of a Flu Shot

January 14th, 2011 | 2 Comments | Source: Commentary

Somehow, it seems a bit odd that classical microeconomic theory should apply to the price of a flu shot. After all, the jab has proven to be effective in reducing mortality from an infectious disease that kills about 36,000 Americans each year. But it does. Perfectly.

Flu shot providers from retail drugstores to physician’s offices are slashing prices for this year’s seasonal flu vaccine in response to consumer demand that has been much weaker than expected.

Just one year ago, enormous media coverage and public uncertainty surrounding a burgeoning pandemic of H1N1 flu motivated 110 million Americans to get the H1N1 vaccine. Nearly equal numbers of people took the seasonal flu vaccine as well.

Those in charge of planning and producing this year’s seasonal flu vaccine figured that people would remember the hysteria from a year ago, and those memories would drive up demand for the jab this winter. They also took into account new CDC recommendations, which call for everyone over the age of 6 months to get vaccinated.

They eventually decided to produce 163 million doses of the vaccine, a 50% increase over last year’s supply. Commercial outlets and doctor’s offices stocked-up on the vaccine in anticipation of the rush.

But the predicted increase in demand never materialized, at least not so far. Why? To date, the flu season has been mild, and press coverage of the annual flu season has been sparse. It seems that when flu is out of sight, it’s also out of mind.

And with vaccine demand in the tank, flu shot distributors have responded by cutting prices on flu shots, just as economists would predict.

For example, Rite Aid is distributing discount coupons for beauty items to folks who come in for a shot. The retail giant told the Wall Street Journal last week that it has dispensed 635,000 vaccines so far this year, and that it now expects to inoculate 300,000 less people than originally planned. Walgreen’s is also on record as saying its initial goals for flu vaccines were “aggressive.”

For its part, Kroger, the nation’s largest grocer, recently cut the price of its flu shot by $5 to $19.99 in most areas of the country.

Physicians’ offices haven’t been immune to the fall-off in demand. “We can’t give them away,” Thomas Haugh, a practice administrator in Raleigh, N.C. told the Journal. Demand is off 25% at his clinics, and that prompted a price cut from $25 to $15.

In normal years, the flu shot is a financial winner for retail distributors and doctors alike. They usually charge between $20 and $30 per shot, and achieve profit margins of 30-50% on the service. But the downside is that the shots must be ordered months before they’re needed, and they can’t be returned because the vaccine changes each year in response to never ending mutations in the virus that causes seasonal flu.

Of course, it’s not too late for suppliers of the flu shot. Flu season isn’t half-way over yet. An upsurge in reported cases, perhaps associated with some press coverage could result in a sudden surge in demand for the vaccine.

Economists have already told us what that would do to the price of a flu shot.


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Blood Supply Testing and Chronic Fatigue Syndrome

December 20th, 2010 | 2 Comments | Source: Science, Wall Street Journal

One year ago, researchers at the National Cancer Institute published a paper that linked Chronic Fatigue Syndrome with an obscure retrovirus known as XMRV. The article caused a stir because 4% of the supposedly healthy people in the study were infected with the virus. That could mean nearly 12 million Americans are infected with a poorly understood virus that potentially causes a poorly understood disease.

There has followed a mad dash to commercialize a blood test for XMRV, since arguably, the nation’s blood supply needs to be screened for the virus. Unfortunately, progress on this endeavor has been slow.

Like HIV-the virus that causes AIDS-XMRV is a retrovirus. XMRV has also been associated with prostate cancer, although no one really knows whether the virus causes diseases of any kind in humans.

Labs involved the effort to develop an XMRV blood test include those at the CDC and the National Cancer Institute, as well private sector programs at Roche, Abbott and Gen-Probe.

Scientists at Abbott are working with the Cleveland Clinic and Emory University. They have created unequivocally positive blood samples from monkeys that were deliberately infected with XMRV. The infected monkeys produced antibodies to 3 proteins on the surface of the virus, but blood levels of these antibodies became undetectabe within weeks after the infection. Tests based on these antibodies can therefore generate false negative results. False negative results can also be caused by the unusually long delay between the time the monkeys were infected with the virus and the time the antibodies appeared.

Even if these issues can be overcome and the antibody test subsequently proven to be useful on human blood, there would remain additional challenges in commercializing the test. For example, the elapsed time between when the blood is obtained and when it is tested could impact test results.

“When there is a new agent that we don’t know a lot about, it’s always a process,” Michael Busch lamented in an interview with the Wall Street Journal. Bush is the director of San Francisco’s Blood Systems Research Institute and a participant in the working group tasked by the Feds to study the potential impact of XMRV on the nation’s blood supply.

Final Thought: It’s hard to criticize a proactive effort to commercialize a blood test for a virus that could be contaminating our nation’s blood supply, but it sure would be nice to know that XMRV actually causes human disease, and that it actually can be transmitted through a blood transfusion. #CartBeforeTheHorse?


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New Superbug Alert

December 3rd, 2010 | 1 Comment | Source: Washington Post

Scientists have discovered a new, highly transmissible gene that could, quite easily in fact, open a frightening new front in the ongoing global war against superbugs.

The antibiotic resistance gene, NDM-1, was first identified in 2008 a Swedish patient that had received hospital care in New Delhi. NDM-1 produces an enzyme that allows bacteria to destroy most antibiotics. It exists on plasmids, which are pieces of genetic material that are easily shared between bacteria including E coli and other species that can cause pneumonia, urinary tract infections and blood stream infections.

NDM-1 probably evolved in parts of India where poor sanitation and overutilization of antibiotics provide a perfect environment for the creation of antibiotic-resistant bacteria.

The gene has been identified in 3 US patients. All had received medical treatment in India, and all recovered from their infections. It has been found sporadically in Britain, Australia and nearly a dozen other countries as well. Most affected patients were “medical tourists,” that is, people seeking less expensive medical care in India.

“We need to be vigilant about this,” said Arjun Srinivasan, an epidemiologist at the CDC told the Washington Post. “This should not be a call to panic, but it should be a call to action. There are effective strategies we can take that will prevent the spread of these organisms.”

The NDM-1 gene does not appear to be transmitted by coughing or sneezing, but rather through exposure to contaminated sewage, water and medical equipment. Inadequate hand-washing also likely plays a role. The CDC has advised doctors to look for it and isolate patients that have it.

The scientists who discovered NDM-1 warned that it had become endemic in many areas of India and Pakistan.

“What we saw (in south-Asian hospitalized patients) is the tip of the iceberg,” Timothy Walsh, a Cardiff University professor of microbiology told the Post. “For every person in the hospital, you can imagine there are a vast majority of people out there carrying NDM around.”

Meanwhile, the Indian government denounced the news as a scare tactic designed to discredit the nation’s exploding medical tourism industry. That industry attracts 450,000 patients per year and will likely generate $2.4 billion in revenue in 2012.



CPR: Go with the Chest Compression!

December 2nd, 2010 | No Comments | Source: Wall Street Journal

Nearly 300,000 people per year in the US collapse suddenly and die as a result of cardiac arrest, in which a heart attack or something else causes the heart to cease pumping blood effectively. The condition is fatal in minutes unless afflicted individuals receive cardiopulmonary resuscitation.

The vexing public health problem with cardiac arrest is that many witnesses hesitate to administer CPR because they don’t want to get involved with the “mouth-to-mouth” part of the process. Some won’t do it because they are grossed-out by vomitus that may be in the patient’s mouth. Others worry that they might catch an infectious disease from the patient. Tens of thousands of lives are lost each year because of this hesitation.

That’s why the results of a new study by Bentley Bobrow and colleagues at the Arizona Department of Health Services were a cause for celebration after being released last week. The results of the study showed that cardiac arrest patients that received only chest compressions (not mouth-to-mouth) from witnesses had higher survival rates than patients who received CPR the old fashioned way (compressions plus mouth-to-mouth).

The study was published in the Journal of American Medical Association. It included 4,415 adults that sustained cardiac arrest between 2005 and 2009. In the study, survival rates (measured at hospital discharge) were 13.3% in the chest compressions only group, 7.8% in patients that received conventional CPR, and 5.2% for those who received no CPR.

“Anybody can do hands-only CPR by pushing hard and pushing fast in the center of a person’s chest,” Michael Sayre, an associate professor at Ohio State University and a CPR expert told the Wall Street Journal.

Responding quickly to the findings, the American Heart Association modified its CPR recommendations. The new recommendations call for adults to emphasize chest compressions rather than mouth-to-mouth resuscitation. The AHA recommendations can be seen here.

Note that when kids are found unresponsive, they do indeed need mouth-to-mouth resuscitation since the causes for the condition in kids is usually respiratory, not cardiac.



Texting-Related Automobile Fatalities

October 22nd, 2010 | No Comments | Source: MSNBC

Drivers who were distracted by talking or texting on cellphones killed approximately 16,000 people between 2001 and 2007 according to an scientists at the University of North Texas Health Science Center.

To make their estimate, Fernando Wilson and Jim Stimpson compiled data on deaths attributed to distracted driving from the National Highway Traffic Safety Administration. For ancillary analyses, they also used FCC data concerning cell phone ownership and text messaging volume.

The scientists found that in 2002, Americans sent about 1 million text messages per month. By 2008, this figure had exploded to 110 million per month. “Our results suggest that recent and rapid increases in texting volumes have resulted in thousands of additional road fatalities in the United States,” they wrote in the American Journal of Public Health.

The shocking statistic comes at a time when overall traffic fatalities are actually down in the US. In fact according to the Transportation Department, the number of traffic fatalities in 2009 (33,963) was lower than at any time since the mid-1950s.

“Distracted deaths as a share of all road fatalities increased from 10.9% to 15.8% from 1999 to 2008, and much of the increase occurred after 2005,” wrote the scientists. “In 2008, approximately 1 in 6 fatal vehicle collisions resulted from a driver being distracted while driving.”

Numerous studies have shown that talking on a cell phone distracts drivers, even if they use a hands-free set-up. Of course, texting, emailing and other smartphone applications provide an even greater distraction since users must take their eyes off the road in order to carry out those functions.

Approximately 30 states have made it illegal to text message while driving. In other jurisdictions, hands-free devices are required for drivers who use cellphones.



What are USDA Grade-A Eggs, Anyway?

October 4th, 2010 | No Comments | Source: Wall Street Journal

In the wake of the recent nationwide outbreak of salmonella that sickened 1,000 people and triggered the recall of a half-billion eggs, people have begun wondering just what that “USDA Grade A” badge on the sides of egg cartons actually means.

Remarkably, some believe the badge means a rabbi has blessed the eggs as kosher. Others assume it signifies the eggs are safe to eat; perhaps they even passed a test for pathogenic bacteria like salmonella.

Both suppositions are wrong, it turns out. What the badge actually means is that a “grader” from the US Department of Agriculture has checked the eggs at an egg-packing plant for size and color and assured that their shells were not cracked. That’s it.

Since the salmonella outbreak, officials at the USDA have redoubled their efforts to remind the public that their agency isn’t responsible for assuring the safety of the nation’s egg supply. That responsibility, the officials insist, belongs to the Food and Drug Administration

So what does the USDA do, exactly? Well, it regulates the safety of meats consumed in the US and it promotes US food products here and abroad. That badge on the egg cartons is a product of the second, marketing function of the USDA.

Commenting on the seemingly obvious idea that one government agency should be responsible for food safety, Connecticut Democrat Rosa DeLauro had this to say to the Wall Street Journal: “The USDA stamp should have a clear and consistent message to consumers—not a stamp of quality assurance that may be misinterpreted as a stamp of safety.”

Meanwhile, the FDA and the Justice Department are gathering outside the doors of the egg producers at the center of the recall. The FDA hasn’t decided whether it ought to have a badge of its own, by the way.


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Are US Cigarettes Deadlier than those Made Elsewhere?

September 8th, 2010 | No Comments | Source: Cancer Epi. Bio. & Prev., MedPageToday

Levels of cancer-causing nitrosamines are higher in US-made cigarettes than those from other countries, according to scientists at the Center for Disease Control.  That means they can potentially cause more cases of lung cancer.

To reach these conclusions, David Ashley and colleagues group measured mouth levels of a highly carcinogenic substance known as NNK, and urinary levels of its major metabolite, NNAL in 126 smokers from New York, Minnesota, Australia, Canada and England. The US smokers used several popular brands including Camel Light, Marlboro, Newport and Newport Light. The scientists counted butts to assure smokers from each location consumed the same numbers of cigarettes.

It turned out that 24 hour mouth levels of NNK (in nanograms) were 1,490 in New York, 1,150 in Minnesota, 1,010 in England, 449 in Canada and 350 in Australia. There was a direct correlation between mouth levels of NNK and urinary levels of NNAL.

Of note, 2 recent studies have shown a direct relation between urinary NNAL levels and lung cancer risk.

Together, these findings suggest that “higher levels of tobacco-related nitrosamines in the smoke of US cigarette varieties lead to higher mouth-level exposure to NNK and increased NNAL, which may be associated with excess lung cancer burden,” wrote the scientists.

The scientists also hypothesized that high levels of NNK in US tobacco products result from domestic curing processes and the blends of tobacco used during production.

Unfortunately, lowering nitrosamine levels in US cigarettes might not make them safer because that may increase the amounts of other carcinogenic substances.

As well, the scientists “did not look at the two dozen other cancer-causing toxins,” according to John Spangler of Wake Forest University. “And it did not examine chemicals that might affect heart disease, stroke, emphysema, and other diseases caused by tobacco use,” he added.

The findings appear in Cancer Epidemiology, Biomarkers & Prevention.



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