Front Line Health Workers are at Risk in the Fight to End Polio

Front line health workers are still at risk in the fight to eradicate polio.

Polio is a preventable disease but eradication efforts require security for front line health workers. Insecure areas serve as a cauldron for polio and other diseases. Multi-drug resistant TB is on the rise in North Korea where a chronically malnourished population is at risk to TB. It's leaders, like those in the Pakistan's tribal areas, need to be held accountable.

In the meantime, some in developed countries deny their children the benefits of life saving vaccines.

  http://www.nytimes.com/2013/08/23/health/polio-outbreaks-seen-on-two-continents.html?src=recg

Reducing the Gun Suicide Rate in America

                                     

             The mass shootings in Aurora, Colorado and Newtown, Connecticut have provided us with a window to examine our attitudes towards guns. As a public health professional, I believe that we need to take a public health approach to preventing gun violence. Tragically, in the United States, there were more than 30,000 deaths, including 17, 000 suicides, from gun violence in the United States in 2005 – the equivalent of 100 Boeing Dreamliners crashing and killing all their passengers and crew.   

            Some in the pro-gun lobby, including the National Rifle Association (NRA) are arguing that it is not guns that kill people, but people that kill people.  These same arguments were once used by the automobile industry to resist government mandated safety improvements for new cars. Detroit claimed that it was not the cars that kill people, but unsafe drivers who did. After decades of government-mandated safety improvements, which the auto industry resisted – everything from seatbelts to roll bars, to safety glass - cars are much safer and traffic deaths are down dramatically. And drivers are still the same as they always were. So indeed, it was unsafe cars that kill people.  

            The gun lobby has done its utmost to keep public health researchers from conducting studies on gun violence. Likely they are afraid of the inevitable conclusion about gun ownership – guns don’t provide us with security in our homes. In fact, they increase the risk that someone in the family will be the victim of a firearm homicide. We have seen this recently with the tragic death of Reeva Steenkamp, the girlfriend of Olympian and Para-Olympian Oscar Pistorius. Reeva was a stunning model, and a promising young law student. She was either murdered or accidentally killed in Pistorius’ bedroom with a 9 millimeter handgun.   

            In spite of the NRA’s efforts to squelch research into firearm violence, David Hemenway of the Harvard School of Public Health recently published a study about the relationship between guns and suicide. Hemenway found that in states with lax gun laws, suicide rates with guns are 3.7 times higher than states with tight gun laws, while other types of suicides are the same. So, having access to a gun in the home puts the family at greater risk of a suicide (especially when there are young people in the home). The study also points out that people who attempt suicide with a gun usually succeed, while those who try other means often fail and then often go on to lead normal lives after treatment. To paraphrase the singer Jimmy Buffet, a gun-suicide is “a permanent solution to a temporary problem.”  

            The NRA has taken its efforts to squelch research and information sharing about the relationship between guns and homicide/suicide to new heights with its support of laws that are being promoted in more than 20 states that prohibit doctors from talking to their patients about gun violence.  In fact, Florida has passed such a law, though it is still being contested in the courts. Imagine this – a patient comes into the doctor’s office and says “Doctor, I am feeling depressed and suicidal.” Under these laws the doctor cannot even ask the patient about the presence of firearms in the patient’s home.  Nor could the doctor advise the patient to get the guns out of the home, at least temporarily.

            There are many steps that could be taken to reduce the number of gun suicides in America.  But I am conscious of arguments that the Second Amendments seems to give us the liberty to own guns and prevents the government from restricting this right.  So I am going to make some policy recommendations that respect peoples’ rights to bear arms, but will reduce the rate of violence.  First, the Federal government should eliminate all restrictions on research by national institutes into the relationship between guns and homicides/suicides.  Second, the Federal government should increase the amount of funding available for such research to make up for the years in which research was suppressed by the NRA. Third, the Federal Government should launch a special study to look into the relationship between guns in the home and family violence. Fourth, the Federal Government should, under its obligation to protect the First Amendment rights of free speech, ensure that every physician in the country is fully informed of the dangers of gun violence and encouraged to warn patients about these dangers. Finally, states and localities should require gun owners to keep their guns under lock and key, except when they are being used at a safe practice range.  These simple policies will not restrict any individual liberties, but will go a long way to reducing the tragic national scourge of suicide by firearm.  

Do Guns Kill People or Do People Kill People?

Here in the United States there is a lot of misinformation about the cause/effect of Australia’s gun ban on crime in that country. Some are arguing that Oz's gun ban has lead to higher rates of violent crime.  Plausible?  

Never fear, Snopes is here to "take aim": at these “statistics: 

http://www.snopes.com/crime/statistics/ausguns.asp. 

This Washington Post article shows that, while it may be difficult to prove a correlation between Australia’s gun ban and its homicide rate, there is a strong correlation between the ban and suicide rates.  http://www.washingtonpost.com/blogs/wonkblog/wp/2012/08/02/did-gun-control-work-in-australia/. 

Researchers in the US have found the same effect. David Hemenway of the Harvard School of Public Health published a study about the relationship between gun laws and rates of suicide. Quick and dirty - in states with lax gun laws, suicide rates with guns are 3.7 times higher than states with tight gun laws, while other types of suicides are the same. So, having access to a gun in the home puts the family at greater risk of a suicide than in a home without a gun (especially when there a young people around). The article also highlights the obvious that people who attempt suicide with a gun usually succeed, while those who try other means often fail and then often go on to lead normal lives after treatment. http://www.nejm.org/doi/pdf/10.1056/NEJMp0805923.)  To paraphrase the singer Jimmy Buffet, a gun-suicide is “a permanent solution to a temporary problem.” 

The link between gun ownership and suicide is not an insignificant problem because suicide is the second highest cause of death among people under 40 in the US. In 2005, 46 Americans committed suicide with a firearm per day, accounting for 56% of daily suicides. It is clear that the rate of firearm suicide is related directly to the availability of guns and that suicides in the US could be greatly reduced if firearms were less available. 

Some other interesting facts from Johns Hopkins School of Public Health: homicides are the second highest cause of death among youth aged 10 – 24 and 82% of these are firearm related. One-third of these deaths among youth are suicides. The US has a higher (by far) gun-related homicide rate among adolescents than the next 25 industrial countries (this alone calls into question the idea that “guns don’t kill people.”) 

The argument that “guns don’t kill people, people kill people” does not seem to hold water. With stricter gun laws, far few young people would die of homicide and suicide. 

Ed’s policy prescriptions:

• If you own a gun make sure it’s locked away so that young people have no access to it whatsoever;
• If you have someone in the family experiencing mental illness, do not have a gun in the home; 
• If you’d like to reduce the rate of homicide/suicide in the US, support tighter rules on gun ownership; 
• If you’d like to reduce your chance of gun-related violence, consider moving to Australia (just a joke).

A Neighborhood Energy Debate and its Parallels to Public Health

Recently the neighborhood I live in has been embroiled in a controversy about whether to invite the local natural gas (NG) company into the neighborhood to supply heating and cooking fuel. NG would be supplied by a newly built pipeline into the neighborhood. Currently, homes have either electric heating or propane gas heating.  Propane gas is delivered by truck and pumped into underground tanks stored near the house.  Many are keen to have the option to hook up to the NG pipeline, but others have indicated a strong reluctance to have the pipeline come into the neighborhood.  They prefer to continue to depend on their propane tanks or their electric heating. 

A key concern of the anti-pipeline proponents is the perceived risk of injury or death from a pipeline explosion.  The costs of conversion, although easily covered by a couple of years of energy savings, and a plausible increase in home value, are also a key bone of contention. 

I was wondering whether I could work a discussion of this energy debate into my public health blog.  I do see some similarities.

First, a lot of misinformation is being spread, not unlike the type of misinformation spread by vaccine deniers.  Some have said the price of propane and NG are about the same – not true – here in North Carolina, NG is significantly under priced compared to propane. In fact, NG is about half the price of propane.

Scare tactics have been used – dire warnings about the dangers of exploding gas pipelines, along with pictures of explosions have been circulated. In fact, transporting gas by pipeline is significantly safer than transporting it by truck. In the health field, vaccine deniers have been spreading false warnings about the dangers of the flu vaccine.

Third, people tend to miscalculate risks.  Without carefully weighing the risks of the two main alternatives – NG or propane, the risks from a new pipeline do appear significant. Similarly, people who forego flu vaccines this year are risking serious illness or death from the flu. A risk that is considerably higher than any risk from the vaccine itself.   

It is not easy to calculate true costs.  Those whose homes are heated by electricity seem content with this approach, though electricity has been shown to be about three times as costly as NG.  And electric heating has the highest environment costs, perhaps due to the continued use of coal to produce electricity in our region.  Most of these environmental costs are externalized; to be borne by others far away in the form of polluted air, and water.

There is also an element similar to herd immunity at work.  Most likely the availability of several alternative energy sources will increase the price of the homes in the neighborhood.  But even those who oppose the pipeline will benefit if and when it comes.  Free ridership is alive and well in the energy sector.

And finally, in spite of the facts, some people are just reluctant to change their behaviors, even if they know they are not doing themselves any good.  Not unlike our approach to health behaviors.  

Addressing the Epidemic of Random Violence

Another unspeakable tragedy has taken place in Newtown, Connecticut.  A familiar story – a mentally troubled person gets access to assault weapons and plenty of ammunition.  Then he senseless takes the lives of innocents he doesn't even know (notice the use of the pronoun “he”).  And again the clamor for gun control echoes across the land.  Gun control alone will not address the complex problems that have led to a rash – dare I say an epidemic - of random violence.  

A comprehensive approach to the problem of random violence is needed.

Firstly, a massive overhaul of our mental health system is required.  We need to find a way to de-stigmatize mental health care and those who access mental health services.  We need to overhaul the laws that make it difficult or impossible to identify and treat troubled individuals who demonstrate a propensity for hurting themselves and others – even without their consent.  We need to find creative ways to make schools safer without turning them into fortresses.  And finally, we need to get assault weapons and assault weapons ammunition off the streets and out of the homes.   Perhaps we need to examine what are the legitimate uses of body armor.  Who needs it in a civil society?   

An overhaul of the mental healthcare system will require a complete rethinking of how mental healthcare is provided.  We need to provide mental healthcare as an integral part of the primary healthcare system.  And it needs to be covered by insurance.  Families who are dealing with troubled loved ones need to have access to counseling and care as well as the legal means to take action when individuals cross the line from troubled to dangerously disturbed. 

Access to schools needs to be dramatically tightened up.  Right now almost anyone can walk into most schools in America with or without a weapon. If this means more personnel dedicated to school security, so be it.  We have a crisis of unemployment anyway.  Using a combination of technology, social media, and human and physical barriers, access to schools must be denied to those who have no need to be there. 

Speaking of gun control. 

We cannot rely on politicians to solve this issue for us.  Citizens need to take this issue up by voting out all those who refuse to budge.  As long as the gun lobby has more power than the citizen lobby, we will not have any progress on controlling access to guns, including automatic assault weapons intended to kill enemies on the battle field.    If nothing happens, we only have ourselves to blame. 

No Health Without Mental Health

 

It’s well known that mental health is a prerequisite for overall health.  But In the United States and in countries around the world many people lack access to affordable mental health services.  Without access to care, people suffer in silence from depression, anxiety, and other psychoses.  Mothers suffer alone from postpartum depression.  Adolescents, suffering from treatable mental health conditions, often resort to self-harm, risky behaviors, and even suicide.  Individuals and families suffer from the ravages of alcoholism and related family violence.  

When tragedies such as the mass shootings at Virginia Tech or in Aurora, Colorado take place, the lack of mental health care for individuals in desperate need is highlighted in the news media, but often only briefly.  But every day, the poor and minorities suffer from inadequate access to mental healthcare.  Even well-off people are can be denied care because of the stigma attached to mental health problems or because insurance does not provide coverage.

In the United States and around the world, health care systems are overstretched by the burden of infectious diseases, non-communicable diseases, accidents and violence.  But this is no excuse to ignore mental health.  It’s time to pay attention to the mental health of the population. Everyone has a right to mental health. The poor and minorities need access.  Even the middle class people need to be freed from the stigma of seeking care for mental health problems.  And insurance companies should find ways to provide coverage for mental health care.

There is no health without mental health.  We must promote access to mental health care for all.    

High Unemployment, Shortage of Medical Doctors

OP-Ed (Haugh)

With High Unemployment, Shortage of Medical Doctors Anticipated

Three recent health-related articles in the New York Times are somehow gnawing me.  All are about whether and how poor people are going to get access to health care.

The first article by Pam Bullock discusses a recent study by Harvard researchers that showed that when more people have access to Medicaid, fewer people die. The study covered three states, Arizona, Maine and New York, that had recently expanded their Medicaid programs.  With the new Medicaid programs, the number of deaths declined by a total of 1,500.  Bullock quotes several public health experts, apparently from all sides of the debate on Obama Care, as giving the study a thumbs up for credibility.   Diane Rowland, of the Kaiser Family Foundation said “In the midst of many claims about what Medicaid does and doesn’t do, it actually shows that it cannot only be beneficial for health, but in preventing some of the premature deaths of the uninsured.”  http://www.nytimes.com/2012/07/26/health/policy/medicaid-expansion-may-lower-death-rate-study-says.html?pagewanted=all

Sometimes we criticize such studies for proving what we already know intrinsically.  I mean – isn’t it just common sense that providing poor people with access to medical care through health insurance should be of benefit to them, making them healthier and prolonging their lives?  Isn’t it obvious that sick people will benefit from care, and that poor people will delay or avoid care if it has to come out of their own pockets, when there is precious little in those pocket.  Maybe it’s common sense, but now, thanks to researchers at the Harvard School of Public Health, we have evidence providing a link between access to insurance and better health outcomes for the poor. The politicians around the country who are thinking about rejecting the federal government’s offer of expanded Medicaid should factor these findings into their equations. Citizens too should demand better and expanded Medicaid programs.

 

And the next article in the NY Times that captured my attention was one by Suzy Hansen entitled What Can Mississippi Learn from Iran?  It turns out Mississippi did learn a lot from Iran. Iran installed a system of community-based health care centers in rural areas that provided access for poor people and a sophisticated referral system for getting people to the correct level of care.  Now agencies in Mississippi, such as HealthConnect, are reaching out to poor people in their homes following the Iranian model.  But why did we have to learn from Iran?  Community-focused health care is no more rocket science than community policing.  My colleagues in the Peace Corps in Korea in the early 1970s were reaching out to villagers to make sure that they were taking their TB meds – and it worked.  Korea’s TB rate plummeted and has remained low in spite of the legacy of war and poverty. http://www.nytimes.com/2012/07/29/health/policy/too-few-doctors-in-many-us-communities.html?src=me&ref=general

Hansen paints a depressing picture of life in the Mississippi Delta where Delta towns have been ravaged by successive economic downturns.  The state’s dismal health statistics are straight out of the 1960s. But the Governor is threatening to close down its lone abortion clinic, leaving women with now access to essential reproductive health services. The heroic individuals providing community-based care to Mississippi’s rural population deserve our admiration.  I guess we have the ayatollahs to thank for this.

 

And finally, an article by Annie Lowrey and Robert Pear  laments that by 2025 the United States will be experiencing a severe shortage of doctors, estimated at over 100,000.   The authors point out that as early as 2008, less than half of primary care doctors were accepting new Medicaid patients – so much for the salubrious effects of Medicaid access.  The aging of the baby boom (yours truly) is partly responsible for this shortage of docs.   But why is it that we can’t fill this gap – we have a huge unemployment problem among well educated people.  Why not gear up for the looming shortage of medical personnel?  And why not look for other creative solutions to fill the gap?  We can train more physician assistants, nurses, nurses’ aides, community health workers, and barefoot doctors.  We can employ the existing workforce more effectively, think about training more personnel overseas (if our institutions can’t gear), and even about continuing to “import” talent from abroad; hopefully while ensuring that the source country doesn’t suffer shortages as a result.   It doesn’t make sense to use the high cost of educating and training personnel as an excuse for inaction.   What is the price of lack of access, delayed care, and other forms of rationing that will surely lead to plenty of premature mortality?   Surely the cost in lost productivity alone will be astronomical.  And we shouldn't forget the potential value of greater and more effective preventative efforts; also a high value investment.   

So, here is an area where there is plenty of opportunity for smart young people to get educated, trained and employed.  All we need is the will, a well-thought-out plan and adequate financing (which will surely produce a robust economic and financial return).  Let's educate and train at least 100,000 healthcare personnel by 2025.  Then let's get everyone enrolled in an insurance plan, such as Medicaid. Instead of a disastrous shortage of healthcare personnel, we can have plenty of young people employed and adequate financing for their services. Then maybe Iran will come and learn something from us. 

  

http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?pagewanted=all