Are you a Difficult Parent?

A recent article in Pediatrics examines how pediatricians can manage their relationships with "difficult" patients and parents - those who are clingy, demanding, manipulative, or self-destructive ("Approaches to the Difficult Patient/Parent Encounter").

A litigious father, for example, complains angrily about the diagnosis for his 7-year-old son. A 15-year-old girl constantly challenges her pediatrician's advice. "Patient/parent issues can include psychiatric disorders, personality disorders, subclinical behavior traits, and information overload," the authors write. These patients and parents are no doubt difficult to handle.

But then the authors write that

Parents of children with chronic illnesses may be considered challenging; these parents are vulnerable or even frantic because they are coping day after day with an ill child. Despite recent clinical advances, many chronic diseases cause great suffering and uncertainty.

And I started to wonder whether some doctors simply had compassion fatigue. Often, it seems, patients (or their parents) are difficult because they don't think they are being heard or understood. Sometimes, being a good parent and means being a good advocate for your child's well-being - and therefore being difficult. 

Studies have shown, for example, that the most common type of medical error, medication mistakes, are especially common among pediatric patients. I've written before about radiation overdoses from CT scans that are not calibrated appropriately for children. Parents need to understand these problems and ask questions when their children need a medication or procedure. If they don't understand the answers, they need to ask more questions until they do - no matter how busy the doctor or nurse might be.

And so for 2011, I'm sending out good thoughts to all the parents out there. I hope they ask questions, get the answers they need, and participate actively in their children's health, in the doctor's office and at home. Because if your kids are doing well, you don't need much more than that.

Will Force or Favor Make People Buy Health Insurance?

The mandate that everyone buy health insurance by 2014 is facing a lot of legal challenges. Recently, a federal judge in Virginia decided that the mandate is unconstitutional. There are currently 24 lawsuits challenging various aspects of the Patient Protection and Affordable Care Act, according to a chart created by the Washington Post, with the insurance mandate a top source of friction.

Having both healthy and ill people purchase health insurance distributes the cost of care among both. A responsible society shares expenses for the common good. We don't expect children to pay for their public school education, for example, but expect that they will pay it back when they use their education to get jobs and become tax-paying adults themselves. Similarly, if we want to expand and secure access to health care, we need to all contribute to the expense - even if we are not deriving immediate benefits from our contributions. At some point in our lives, as injuries and illnesses occur, all of us will probably cost insurers more than we are currently contributing in premiums, and we will depend on the contributions of healthier people to cover the cost of our care.

But how do you make sure that enough healthy people purchase health insurance to adequately distribute these costs? Since legislation, now being challenged in the courts, might not work, Fierce Healthcare ran an article on some ways to pay for health care reform even without the individual mandate. Fierce Healthcare drew on a Kaiser Health News story ("Experts Ponder 'Plan B' Options For The Individual Mandate") for ideas, such as:

• Use taxes as an incentive. Raise taxes, then give tax breaks to people who have purchased health insurance.
• Use premium cost as an incentive, as suggested by former CMS director Gail Wilensky. Increase the cost of health insurance for several years for people who do not purchase it when they are first eligible. 
• Use a waiting period as an incentive, as suggested by sociologist and senior health advisor Paul Starr. Prevent those who opt out of insurance from purchasing subsidized insurance on the insurance exchange for several years. Insurers also would not be required to cover those who opt out if they had pre-existing conditions.

As these ideas demonstrate, where persuasion doesn't work, stricter financial penalties often do.

New Vitamin D Recommendations Include Surprising Changes

Last week, the Institute of Medicine (IOM) released new recommendations for Vitamin D and calcium intake that increase the amount of daily Vitamin D recommended for children and adults. Adequate Vitamin D intake is primarily linked to bone health, making it a vital nutrient as Americans age and diseases such as osteoporosis take hold.

The new IOM report, based on an scientific testimony as well as an analysis of almost 1,000 studies on Vitamin D and calcium, recommends 400 to 600 International Units (IU) of Vitamin D daily for everyone ages 1 through 70, and up to 800 IU daily for those over 70 (here is a chart with their recommendations). This is an increase over earlier recommendations of 200 to 400 IU per day for those 70 and under.

What else has changed in Vitamin D recommendations? The IOM found that most Americans do receive adequate amounts of Vitamin D, even though previous studies have shown that they did not. The IOM report stated that, in the past, inconsistent standards were used in blood tests that measured whether people had adequate Vitamin D in their bodies. As a result, many people studied were falsely labeled as Vitamin D deficient. The IOM considers over 20 nanograms of Vitamin D per milliliter of blood to be a healthy level.

Vitamin D might also help prevent serious health problems such as cancer and heart disease, although the IOM disputes these claims. With disease prevention in mind, though, some people recommend taking many times the recommended amount of Vitamin D daily.

The IOM, however, recommends upper level intake limits for Vitamin D. These limits range from 1,000 to 3,000 IU daily for children up to age 8 (depending on their age) to 4,000 IU daily for older children and adults. At these intake levels, kidney problems and other health issues can occur.

Another study of about 4,500 older women in the Journal of Clinical Endocrinology & Metabolism found that women 69 and older were more likely to be frail if they had either too little (less than 20 nanograms per milliliter) or too much (more than 30 nanograms per milliliter) Vitamin D in their blood. With Vitamin D, it looks like the middle path is best.

Food and Class in America

I'm interested in the locavore food movement, and agree with the principles of the slow food movement: think about where your food comes from, and how both the food sources and those who grow and pick the food are treated.

Finding, buying, and/or growing the freshest seasonal foods, however, can be both expensive and time-consuming. Because it takes time and money to be a foodie, the locavore and related foodie movements are class movements as well. Newsweek's November 29 cover article, "Divided We Eat," by Lisa Miller, explores the class divisions that food can create.

"Food has become the premier marker of social distinctions, that is to say - social class," epidemiologist Adam Drewnowski told Miller. "It used to be clothing and fashion, but no longer, now that 'luxury' has become affordable and available to all." Since the cost of nutritious food is rising faster than the cost of unhealthy food, wrote Miller, the poor often can't afford to eat healthy food. Wealthier (and subsequently healthier) families can.

It's clear from some of the content in the Newsweek article that some people are far more concerned about the quality of what they eat each day than about what - or whether - others in their community eat. Eating locally, for example, might be both high-status and tasty, but it doesn't solve the fundamental problems of our flawed food system.

The legislation that expands the FDA's powers to inspect food that passed in the Senate this week, on the other hand, might bring about more profound changes. The new legislation would let the FDA recall food, better access records at places where food is produced, increase the frequency of inspections of food facilities, and inspect a wider range of imported foods, explained Lyndsey Layton in the Washington Post ("Senate approves bill to require foodmakers to find ways to prevent contamination").

An overhaul of school lunch funding is also working its way through Congress now. The Healthy, Hunger-Free Kids Act would expand school lunch funding, increase the number of children who are eligible for the program, and encourage using local food sources for the lunches. The act would also encourage schools to create schoolyard gardens.

Class divisions have real consequences on people's lives. Analyses of health and life expectancy by neighborhood, such as one that a local county public health department conducted earlier this year, make it clear that where you can afford to live affects how long and how well you live. Health, wealth, and class are all related. Expanding access to safe and healthy food might help narrow the health gap between different classes, and perhaps budge some class divisions as well.

How to Have a Happy Holiday

Now that Thanksgiving is past, the holidays are bearing down like a freight train. This is an expensive time of year, and I always wonder how to enjoy the holidays in a way that is both meaningful and affordable.

I like to flip through the catalogs that are arriving by the pound, but I don't really want much that they have to offer. I enjoy the holiday experiences, not the things: family traditions, get-togethers with friends. I was not surprised to run across a WebMD article that backed me up on this.

"In one recent study," wrote WebMD's Katherine Kam, "Cornell University researchers found that purchasing an experience tended to improve well-being more than buying a possession, in part because people are more prone to comparisons and buyer's remorse with material goods" ("Money and happiness: 5 ways your spending style matters"). Memories of positive experiences linger, while things tend to break or wear out over time, wrote Kam.

What else makes people happy? Smaller, more frequent purchases create more happiness than less frequent, expensive purchases, Kam wrote. Buying things for others also makes people happier than buying things for themselves.

So yes, that's me, standing at the skating rink drinking a hot chocolate, or crouched down in a bitter December wind with the kids, looking for hermit crabs and sea anemomes at a local tidepool. I'm just looking for a better balance this holiday season, and hoping to pass it on to the kids: less stuff, more life.

What Spiked Energy Drinks Say About Us

Canned drinks that contain both alcohol and caffeine have been wreaking havoc among young adults over the past year. These beverages, such as Four Loko and Joose, are a health threat because "caffeine masks the effects of alcohol... tricking users into believing they can keep drinking well past the point of drunkenness," wrote Abby Goodnough and Dan Frosch in a recent New York Times article on the drinks ("F.D.A. Expected to Act on Alcoholic Energy Drinks"). The beverages are popular among young adults because they are inexpensive and they come in energy-drink flavors such as lemon-lime, fruit punch, and watermelon.

This week, the FDA sent warning letters to the manufacturers of these "caffeinated alcoholic beverages", stating that the Agency might seize their products as illegal substances if the manufacturers do not change their formulas. The health consequences from consuming these beverages can include alcohol poisoning, car crashes, and even heart attacks in young drinkers.

A Washington Post article about these beverages pointed out that the young adults who consume them sometimes document their drunken exploits on sites such as fourlokostories.com ("FDA, FTC crack down on caffeinated alcoholic drinks"). The stories there, if they are true, show a wide range of dangerous behavior, including drunk driving and fist fights, and often include the phrase "the last thing I remember...." 

In response, Four Loko manufacturer Phusion Products LLC has (begrudgingly) agreed to remove caffeine from its products. But some manufacturers and many young adults who consume these beverages find the FDA warnings intrusive. "It's time the FDA started treating consumers old enough to purchase alcoholic beverages as adults," Gregory Conko told the Washington Post . Conko represents the libertarian think tank The Competitive Enterprise Institute.

Which raises the question: what makes someone a mature adult? Is it simply being old enough to buy alcohol in a store, at age 21, and hopefully consume it responsibly? Being old enough to vote and join the military, at age 18? Graduating from college? Getting married? Starting a career? Buying a house?

With the start of mature adulthood unclear, it's also unclear how to treat young adults who might, or might not yet be, mature. I would like to trust young adults to avoid or limit the use of dangerous products such as Joose. But I also would like to see these beverages, which clearly target young adults, banned so that they aren't tempted by the wrong choice, while we continue to figure out what it means, exactly, to be a grown-up in this society.

New Cigarette Warnings Don't Solve the Problem

The new, graphic anti-smoking warnings proposed by the FDA should be chosen by the middle of next year, and run on cigarette packets by the end of 2012. The warning images do give you pause, such as the picture of the very ill woman in  "Warning: Cigarettes Causer Cancer" and the man smoking through his tracheotomy in  "Warning: Cigarettes Are Addictive."

The new warnings might indeed further drive down smoking rates in the United States. Tobacco companies, though, have already shifted their strategies to sell cigarettes to promising markets abroad, such as China (where over half of the men smoke, according to 2010 World Health Organization statistics) and India.  

"Cigarette companies are aggressively recruiting new customers in developing nations... to replace those who are quitting or dying in the United States and Europe, where smoking rates have fallen precipitously," wrote Duff Wilson in a New York Times article on international cigarette sales and legislation ("Cigarette Giants in a Global Fight on Tighter Rules"). "Worldwide cigarette sales are rising 2 percent a year," Wilson wrote.

To protect their markets, some cigarette manufacturers work to suppress what they consider excessive anti-smoking legislation abroad. Wilson wrote that when Uruguay tried to limit cigarette use by covering 80% of cigarette packages with health warnings, cigarette manufacturer Philip Morris International, whose sales exceed Uruguay's gross income, sued the country.

Driving cigarettes out of the U.S. market, as the FDA is doing, is really just pushing tobacco into other countries that have fewer resources to resist it. In response, the World Health Organization is fighting global tobacco use with its Tobacco Free Initiative, but it's clearly a tough battle.

Health Care Reform and the New Congress

The fight over health care reform continues in post-election Congress, as comments from President Obama and from Rep. John Boehner, who will probably become the new Speaker of the House of Representatives, make clear. This week, Kaiser Health News published a transcript of news conference comments that show the divisions between Boehner and Obama over the future of health care reform.

With so many of their constituents concerned about unemployment, Boehner and the Republicans say that the current plan for health care reform is too expensive to implement now. The Republicans have said that their primary goal over the next two years is blocking the implementation of health reform and other agenda items, and unseating Obama in the next presidential election.
 
Boehner, who called health reform a "monstrosity," said:

I believe that the health care bill that was enacted by the current Congress will kill jobs in America, ruin the best health care system in the world, and bankrupt our country. That means that we have to do everything we can to try to repeal this bill and replace it with common-sense reforms that'll bring down the cost of health insurance.

Unlike the Republicans, the Democrats see substantive health reform as a moral obligation that is worth the investment. Obama explained:

I don't think that if you ask the American people, should we stop trying to close the doughnut hole that will help our senior citizens get prescription drugs, should we go back to a situation where people with preexisting conditions can't get health insurance, should we allow insurance companies to drop your coverage when you get sick even though you've been paying premiums -- I don't think that you'd have a strong vote for people saying those are provisions I want to eliminate.

Republicans who argue that health reform is too expensive tend to ignore the costs of letting the current health insurance system stand. Commonwealth Fund blogger Louise Probst argues that health care has both direct and indirect costs for Americans. Health insurance now averages over $14,000 for a family of four, Probst wrote. "Other leading nations spend half or less of what we do on health care," she wrote, "making it increasingly difficult for American families to retain their standard of living and for American businesses to compete in a global economy." Furthermore, "all Americans pay the nation's health care bill indirectly by way of lower wages, higher taxes, and health benefit costs embedded in the price of non-health-care goods."

Which argument will win: fiscal restraint and job creation, or moral imperative and long-term investment? The outcome will become clear by the next Presidential election.

Should Marijuana Be Legal?

California's Proposition 19, on the ballot for the November 2 election, proposes legalizing and taxing marijuana state-wide. The law would treat marijuana use like alcohol use. For example, it would be illegal to give marijuana to anyone under age 21, and it would be illegal smoke marijuana while driving a car.

It has been legal to use and sell marijuana in California for medical purposes since 1996. To purchase and use medical marijuana to treat or mitigate a serious illness such as chronic pain or cancer, you need a Medical Marijuana Identification Card, obtained by getting a recommendation from your health care provider. Although the Medical Board of California sets standards for health care providers to control which patients get these identification cards, the cards are notoriously easy to obtain.

Proposition 19 takes the medical marijuana law (Proposition 215) one step further, making recreational marijuana use, possession, and cultivation legal for all adults. With or without legislation, the lines between medical and recreational marijuana use are already hopelessly blurred here.

New Scientist's Jim Giles wrote an excellent overview of the issues around Proposition 19 ("All eyes on California for marijuana ballot"). He points out another wrinkle in the debate: the legalization issue ultimately comes down to money. "California's tax authorities estimate that a levy of around $2 per gram would bring in $1.4 billion per year," Giles wrote. "Hundreds of millions of dollars would also be saved in policing costs."

Of course, California's current and proposed laws around marijuana use are in direct opposition to federal marijuana laws. Over the past few years, federal agents have occasionally raided "Cannabis Clubs" that distribute medical marijuana in California and elsewhere. But federal agents have bigger problems to tackle than medical marijuana. In 2009, Attorney General Eric Holder promised to stop raiding medical marijuana sites.

In San Francisco, recreational marijuana use is clearly not prosecuted often. I sometimes come across someone (usually a young adult) smoking marijuana in public, which I don't like, especially if I have my children with me. An NBC reporter from Dallas found a few people smoking it the other day while he was covering the World Series. At least the reporter laughed off the incident, which I think is the best approach. Sometimes you have to pick your battles.

Besides, alcohol consumption, which is far more socially acceptable than marijuana use, is equally unhealthy - just look at information on fetal alcohol syndrome or alcohol-related traffic fatalities. It's a bit hypocritical to make recreational alcohol consumption legal for adults and recreational marijuana consumption illegal for adults. Legalizing marijuana would make it easier to regulate, at least, and still (ideally) keep it out of the hands of minors.

Don't Get Sick if You're Middle Class

The American middle class, created in large part by the G.I. bill after World War II, is suffering especially acutely in the current economy. A study in the journal Family Relations, for example, found that middle class shoppers are increasingly going to thrift shops and yard sales to buy basics they need such as clothes and small appliances.

Freecycle, an organization through which people give away or request household items, is growing in popularity; online coupon sites are everywhere. The only group that seems to have plenty of disposable income in this economy are childless young women.

But where can middle class families find the bargains in health care? The Census Bureau recently released a study that found that the number of people without health insurance rose from 46.3 million in 2008 to 50.7 million in 2009. Half of this increase is among people with incomes over $50,000 per year, who have limited access to government help with health care costs, as a Commonwealth Fund study pointed out recently.

Here in California, where unemployment tops 12%, health care is excruciatingly expensive. This is especially true in the San Francisco Bay Area, as Andrew Van Dam pointed out in a recent Covering Health blog post. For patients without access to government assistance, hospitals in some parts of the Bay Area bill about $35,000 per inpatient (versus about $19,000 per inpatient in Los Angeles County). Here's a Kaiser Health News map that lays out the statistics.

Health care reform helps, but the insurance exchanges that should provide affordable insurance options to those without good coverage aren't legislated until 2014 (although California is trying to fast-track that process in the state). Meanwhile, people who are uninsured or under insured are left to consult Dr. Google if they get sick. At least the doctor is affordable and always in, if not always right.

More Fees, Less Health

With open enrollment coming up, Kaiser Health News' Michelle Andrews wrote an interesting article about how health insurance costs may increase for consumers with the new health care reforms in place. The potential costs, which will especially impact people with family coverage, include:

• Higher premiums and deductibles. Employers and insurers are passing on greater amounts of the cost of health insurance to their employees. "In the past five years, employees' premium contributions have grown 47 percent, while overall premiums increased 27 percent," wrote Andrews. Furthermore, over 25% of employees pay $1,000 or more in an annual deductible that must be paid before the insurer picks up any costs.
• Both co-pays and co-insurance. In addition to small, flat rate co-pays to visit doctors, some health insurance plans will also require people to pay a percentage of the total bill (co-insurance) for hospital stays, ER visits, and/or prescription drugs. Co-insurance is usually about 10% to 30% of the bill, according to a New York Times article on insurance changes.
• Surcharges for dependents. Some insurers will charge extra for each dependent on a plan. Other insurers might charge a surcharge for employed spouses who have access to other insurance through their employers, hoping to drive them off the family plan.

These extra fees seem especially painful in light of a recent Commonwealth Fund study that found that Americans are faring worse in health outcomes than their counterparts in other countries. The 30-year study looked at health care costs and 15-year survival rates for 45-year-old men and women and for 65-year-old men and women, in the United States and in twelve other wealthy nations.

"The United States now spends well over twice the median expenditure of industrialized nations on health care, and far more than any other country as a percentage of its gross domestic product (GDP)," wrote the study's authors, Peter A. Muennig and Sherry A. Glied, in the journal Health Affairs. Although U.S. survival rates have improved during the study time (1975 to 2005), the improvements were greater in the other countries in the study.

The study looked at the impact of population diversity, smoking, obesity, traffic fatalities, and homicides on the health of Americans, but found that these factors did not contribute significantly to the health differences between the U.S. and other countries. Instead, the authors concluded that the high cost of health care might be making the U.S. fall behind the other countries. For example:

• High health care costs have made insurance unaffordable for many Americans. The number of uninsured Americans rose during the study period, and going without health insurance affects both short-term and long-term health.
• High health care costs might divert money from important public health campaigns. "At current spending levels, investments in public health, education, public safety, safety-net, and community development programs may be more efficient at increasing survival than further investments in medical care," the authors wrote.
• Expensive fee-for-service care and the rise of specialized care might lead to unnecessary procedures and poor communication between a patient's different health care providers. Complications from unnecessary procedures and medical errors from poor communication might contribute to Americans' poor health outcomes.

Ideally, health reform will ensure that more Americans have health insurance, create incentives to support public health programs, and reward the medical community for focusing on cost-effective, coordinated preventative care. If consumers become healthier because of these initiatives, insurers will save money on treatment costs. But since we're not there yet, insurers still view Americans as unhealthy and costly, and will continue to charge them heftily for that.    

Stopping Childhood Obesity

At the recent American Academy of Pediatrics' conference this past weekend, childhood obesity was a recurring theme. Obesity is primarily influenced by environment, something that parents have a fair amount of control over. What you feed your child, how active they are, whether you restrict screen time or not, and how much sleep they get all affect your child's weight. With one in three U.S. children now overweight or obese, though, clearly something has broken down.

In his session "Identifying and Treating Obesity Related Comorbidities," William J. Cochran, MD cited these jarring facts:

• Forty percent of children ages one to five years old have a television in their bedrooms, contributing to sendentary screen time
• About 20% of overweight and obese children get too many calories from sugary drinks such as soda
• Most parents and their children don't understand how big a portion of food is, making it hard for them to gauge their food intake
• If a child's parents are obese, that child has a 60% chance of becoming obese. If a child's parents are normal weight, that child has a 9% chance of becoming obese

The CDC states that our society is also "obesogenic," rife with unhealthy food choices and sedentary lifestyles. A family's lack of knowledge or tools to stop obesity just adds to the problem.

The question is what to do about obesity. Policy changes and initatives can help, such as Michelle Obama's "Let's Move" campaign to reinforce healthy behaviors in kids. There have been more extreme measures to stop obesity as well. Because obesity and its unhealthy extreme, morbid obesity, can cause a host of other health problems, such as Type II diabetes, sleep apnea, high blood pressure, and heart disease, on rare occasions parents of morbidly obese children or teens are charged with child neglect or abuse, as a single mother was in 2009 when her 14-year old son weighed 555 pounds. Most pediatricians are understandably reluctant to go down this path, since it would be best if the family could makes changes to help the child control or lose weight.

At the AAP conference, the Nestle Nutrition Institute and the AAP announced a new campaign to stop childhood obesity before it starts, by trying to instill good eating habits in children ages 0 to age 4. Their Healthy Living for Active Families (HALF) Project plans to distribute materials about healthy eating, serving sizes, and physical activity in pediatricians' offices, workplaces, and child care facilities.

Admittedly, Nestle is an odd partner, with its well-known candy brands and scandals over formula marketing in developing countries. Hopefully the AAP's voice will dominate the discussion, and get parents to take the threat of obesity seriously.

Stories Sell Science

In an article in New Scientist this week, epidemiologist Ian Roberts explains how published case reports of miraculous recoveries contributed to the increased off-label use of a blood-clotting drug to stop traumatic bleeding. Based on these case reports, the drug became adopted internationally in civilian trauma rooms and was used to treat battlefield injuries.

"A compelling medical story can burn itself onto a doctor's memory," wrote Roberts. "Stories weave a simple yarn of causation between events, imposing order and banishing uncertainty."

But when Novo Nordisk analyzed this off-label use of its hemophilia drug NovoSeven in a now-halted clinical trial, they found that the use of the drug did not affect the survival rate of the patients who received it. The drug's use might contribute to future life-threatening blood clotting problems in the patients as well, Roberts wrote. 

"The moral of this particular medical story is clear," wrote Roberts. "In the absence of evidence from randomised controlled trials we should remain sceptical about drug efficacy. Medical stories may be compelling, but they do not always give us the full picture."

Stories sell, though, and it's human nature to absorb information more easily through dramatic stories than through, say, an enormous Excel spreadsheet or a jargon-laden medical study.

International aid organizations have known this for quite a while. In their donor literature, instead of just listing depressing statistics about the effects of a famine, natural disaster, or civil war, for example, aid groups such as Mercy Corps also tell the stories of a few people who were affected by the event. They have found that they can get more donations by focusing on a few compelling stories of how they helped stricken individuals. Organization such as Berkeley's Center for Digital Storytelling are also being used to inform people about larger social problems through individual stories of people affected by these problems.

Health care providers (and their patients) are clearly swayed by the power of storytelling as well, as the Roberts article makes clear. But maybe it's time to turn this model around and use stories to promote good science. Scientists, steeped in the details of their research, are often accused of not explaining their ideas in a clear and compelling way. Then they wonder why the public doesn't "get" science, or underfunds scientific research.

Data can be compelling, fascinating, and instructive, but people listen to - and remember - stories. Scientists, and those who work with them to promote their work, need to think about and talk to people who might benefit from the work they do. These personal stories can help explain science to the public, and motivate scientists in their own research as well.

Annual Check-Ups Covered, Among Other Things

This week, a few key pieces of health care reform legislation went into effect, including coverage for preventative care visits. This very concrete change will have a big effect on families, who often coordinate several yearly check-ups for family members. A check-up required for a child to attend school should not cost a family with insurance coverage $200 out of pocket.

Lifetime caps on what health insurance will pay have also been removed, providing more financial security for people with insurance who become seriously ill. Children with pre-existing conditions must be covered by group health care plans as well.

WebMD has a good video interview with HHS Secretary Kathleen Sebelius explaining the changes that went into effect on September 23, and promoting the healthcare.gov consumer health care plan website.

These reforms have had some interesting consequences, though. A recent Fierce HealthPayer article pointed out that insurers such as Anthem Blue Cross, Humana, Aetna, Cigna, and UnitedHealthCare, for example, are trying to drop individual insurance plans for children in some parts of the country to avoid the expense of covering children with pre-existing conditions.

With more people getting and using health insurance under the new reforms, I was not surprised to read that the University of California at San Francisco approved funding for a new hospital complex this month. I wonder how many other hospital-building plans are going forward now that there will be more patients with insurance coverage to pay their bills. Will this new influx of patients (and payments) improve hospital care nationwide?

I've also heard rumblings about shortages of primary care doctors and nurses who will be needed to serve these new patients, a problem HHS is trying to remedy with financial incentives for health care providers who can fill this gap. The ongoing nursing shortage in particular seems to be a deeply entrenched problem nationwide.

I wonder what other changes - anticipated or not - health care reform might bring?

Who Makes a Good Doctor?

A recent study in the September 13 issue of the Archives of Internal Medicine found that it's difficult to for patients to accurately measure the quality of care a doctor might provide. The study of 10,408 Massachusetts physicians, along with claims data from over 1 million adults from 2004 to 2005, found that information about doctors that is made available to patients does not reveal much about how good the doctor will be.

The data available to patients includes a doctor's gender, education, certification, and malpractice claim history. The Archives of Internal Medicine study found that doctors who are female, board-certified, and trained in the U.S. provide slightly better care than other doctors, with board certification carrying the most weight. These distinctions, however, were not statistically very large.

Setting aside physicians who should not be practicing medicine because they have abandoned, neglected, or abused their patients, though, I wonder how exactly to define "quality of care" among physicians. In the doctor/patient relationship, different patients value different qualities: some might prefer a doctor who is the same gender as them, or who has a certain bedside manner, or who received training from an institution they admire, or whose office staff are easy to work with.

A patient who has a strained relationship with their doctor might avoid calling or visiting their doctor or revealing some medically-relevant personal information, even when they were ill or needed follow-up care. Even if the doctor provided excellent care, this patient would probably be better off with a less competent doctor who worked with the patient better.

I'm all in favor of the practice of evidence-based medicine, in which treatment decisions are made based on the best available science. But to some extent, "quality of care" is about the quality of the relationship between the patient and the doctor, which is why it is difficult to measure.

In the end, I like The Lancet's take on this topic in its August 28 issue: that the answer to the question "what makes a good doctor?" depends on who is asking it:

The attributes of a good doctor vary according to the population surveyed. Patients value communication and care, colleagues seek competence and camaraderie, medical students prize cheerfulness. By contrast, admission panels focus on chemistry grades, as if knowledge of ionic bonds is somehow a proxy for the complex human and organisational bonds between doctors, their patients, and colleagues.

Education, Not Knowledge, Favors Health

A recent study of HIV education in rural Ghana found that simply telling people how to prevent the spread of HIV might not do much to slow the spread of the disease. The study, published online in Psychological Science, found that people with limited formal education have not always developed the cognitive skills to understand how to stop the spread of HIV.

The study of 181 adults found that a person's level of formal education, rather than a person's knowledge of HIV/AIDS prevention, best predicted whether or not the person took steps to protect themselves from HIV infection.

"About $8.9 billion has been spent on HIV prevention in Ghana and the surrounding region since 2000, primarily through disseminating facts about the disease," stated a recent press release on the study. "But the effectiveness of these programs has never been adequately studied." The study's lead author, Ellen Peters, explained that "Our findings suggest that those effects, however well intentioned they may be, may not be sufficient without efforts to help at-risk adults to reason correctly with the facts they have been taught."

Unfortunately, the connection between health and education works the other way, too: some parasitic illnesses common in the developing world cause cognitive or physical problems that can interfere with a child's ability to attend school, an issue that I've blogged about before.

Numerous studies in wealthier countries have found a link between educational level and health behaviors: the more education someone has, the healthier they tend to be. The Ghana study looked at the developing world and found the same pattern.

The disease burden is enormous in sub-Saharan Africa, where Ghana is located. Sub-Saharan residents, who make up 11% of the world population, "suffer 24 percent of the world's disease burden -- which is addressed with less than 1 percent of the world's health care spending," Nicholas D. Kristof and Sheryl WuDunn wrote in their book Half the Sky: Turning Oppression Into Opportunity for Women Worldwide. About 2% of the population of Ghana has HIV/AIDS, and the country also contends with high rates of malaria and other health problems.

The Ghana study raises some interesting questions. For example, what role can education play in helping people to learn how to prevent or reduce their risk for these diseases? And should some portion of the limited health care budget in sub-Saharan Africa be spent providing a stronger general education to the population, rather than directly on health care services and disease education?

Eggless

After the egg recall hit home for me recently and we purged all the eggs, I was faced with a list of family meals for the week that lacked an important ingredient: eggs. Cornbread? Can't make it. I couldn't pack hard-boiled eggs for lunch, either, or cook scrambled eggs with cheese and tortillas for dinner (a family staple on deadline-heavy weeks - dinner in ten minutes!).

Since we don't each much meat, I couldn't turn to steaks and burgers to replace recipes with eggs in them. Instead, we drifted in the other direction, toward vegetarian and vegan meals.

A few months ago, I tried to eat vegan food once a week, after I read an article that suggested that avoiding animal protein might decrease inflammation. Even if this isn't true, I thought, it can't hurt to eat more fruits, vegetables, and whole grains for a day. But I'm no vegan. I had trouble making it through the vegan days, as I craved dairy products too much in all their glorious forms (and craved their protein as well, no doubt).

Out of eggless necessity, though, I went back to my handful of vegan recipes and served an old dinner favorite, a vegan pasta with cauliflower recipe.

That took care of one night.

Then, while I was staring into my refrigerator, I realized that I could buy locally-grown eggs at the Farmer's Market. Eureka! I brought the kids to the market with one mission: find the egg stand. I steered them past the kettle corn and corn on the cob, past the peaches and strawberries, to get in line for the organic brown eggs. Once I had two dozen eggs in my bag, I relaxed. At last.

The spinach pie I made with the eggs later that night had a strong, almost gamey flavor, as I've become used to the more anemic eggs that I buy in the store. But I'll keep going back to the Farmer's Market for eggs, until I'm certain the recall is officially over.

Egg Recall Reveals Larger Food Policy Problems

When I read about the recall of eggs shipped here to California, among other states, I printed out the list of the identifying numbers on the recalled cartons and opened my refrigerator. Lo and behold, there were two cartons of recalled eggs that we had purchased recently from the grocery store.

"We should become urban farmers," I told my husband, after he dispatched the eggs down the garbage disposal. At least then we would know where our eggs came from, instead of worrying about tainted eggs shipped from an Iowa mega-farm with a history of safety violations showing up in our West Coast home.

The Washington Post ran a fascinating article this week explaining how cost-cutting consolidation and growth in the egg industry have far outpaced regulation, which lead to the egg recall. "Just 192 large egg companies own about 95 percent of laying hens in this country, down from 2,500 in 1987," wrote the Post's Lyndsey Layton, and most of the eggs come from just five states. Although consolidation has accelerated over the past 20 years, regulation has not. Layton wrote that "the Food and Drug Administration, which has responsibility for the safety of whole eggs, had never inspected the two Iowa-based facilities at the heart of the massive recall that began 10 days ago."

Layton explained that different regulatory agencies divvy up who inspects chickens and who inspects eggs, and that some states do their own egg inspections while others (such as Iowa) do not. These circumstances make it easy for egg inspection to fall through the cracks. New legislation that would require yearly FDA inspections of egg producers is working its way through Congress now.

Unfortunately, legislation doesn't always protect public health. Take agricultural subsidies, for example. In a recent New York Times article about obesity in America, writer Natasha Singer explains that making healthier food cheaper could help Americans eat healthier and lose weight. Government subsidies for the products used in fast foods, though, make them more affordable for consumers than fresh fruits, vegetables, and healthier choices. Singer explains:

The inflation-adjusted price of a McDonald's quarter-pounder with cheese... fell 5.44 percent from 1990 to 2007, according to an article on the economics of child obesity published in the journal Health Affairs. But the inflation-adjusted price of fruit and vegetables, which are not subject to federal largess, rose 17 percent just from 1997 to 2003, the study said. Cutting agricultural subsidies would have a big impact on people's eating habits....

Government policies should support the health and safety needs of the majority of Americans, and we're clearly not there yet, as food recalls increase and healthy food gets more expensive.

Not that everyone has to start a backyard farm; I can't even talk the family into getting a beehive. But I think that we do need to question how our food is produced and where exactly our food comes from and, if necessary, pay more to support food that is healthier and safer until changes in regulations and subsidy policies make that a reality.

Flu Vaccine Season Returns, With a Twist

With the H1N1 "swine flu" pandemic officially over - as of last week - WebMD reports that the CDC is gearing up for a seasonal flu vaccination campaign in September called "Flu Ends with U." Maybe the campaign will help clear up a heap of confusion about flu vaccines these days.

Part of the problem is that flu vaccination recommendations have changed substantially over the past few years. In 2010-2011, for the first time ever, the flu vaccine is recommended for everyone 6 months or older (anyone can have the flu shot, containing killed flu viruses; the flu nasal spray contains inactivated (modified) live flu viruses and is recommended for a smaller subset of people).

In 2009, the CDC recommended the seasonal flu vaccine only for children ages 6 months to 18 years, and adults ages 50 and over (with some exceptions for certain younger adults). In 2008, the flu vaccine was only recommended for children ages 6 months to 5 years old and adults 50 and over (with some exceptions).

The viruses that cause the flu are constantly mutating, and in response a new flu vaccine has to be developed each year, at least until researchers figure out how to make a universal flu vaccine that can provide long-term protection. Researchers make an educated guess about which three flu viruses will cause the most damage in the future, then modify the viruses to use them in vaccines by growing them, usually in chicken eggs, a time-consuming process. If a different flu virus spreads, the vaccine won't protect against it.

The WebMD article pointed out CDC focus group research that found that many people are not happy with the universal flu vaccination recommendations. Catching the flu is not a big deal to many people, but it can have serious consequences for some. On average, about 36,000 people die from flu complications each year, primarily the elderly. In 2009, about 12,000 Americans died from complications of swine flu, mostly those under age 65, according to the CDC.

The flu vaccinations recommendations have changed over the years to protect a wider range of people, and also to keep healthier people from catching and passing on the flu to others. It might be inconvenient to get flu vaccinations for the whole family, but it's still a good idea.

 
Resources:

• The CDC's 2010-2011 Vaccine Information Sheets contain information about both the flu shot and the flu nasal spray.
• Prevent the spread of disease by washing your hands when needed. The Mayo Clinic tells you when and how to wash your hands.

Causes of Early Puberty in Girls

Early puberty in girls is becoming a serious problem. A recent Pediatrics study of 1,239 girls found that the rates of early puberty, measured by breast development at age 7, has spiked over the past decade. The rates of early puberty have doubled for white girls (from 5% to 10%) and also increased for black non-Hispanic girls (from 15% to 23%). Fifteen percent of Hispanic girls also show signs of early puberty at age 7.

Along with large racial/genetic differences in early puberty onset in girls, there are two other potential causes. It might be caused by chemicals in the environment that mimic estrogen or cause other hormonal disruptions, triggering the body to begin puberty. Prime chemical suspects include pesticides and herbicides, flame retardants, and bisphenol A (BPA) (a chemical I've blogged about before), according to an article on early puberty by USA Today's Liz Szabo.

Weight also plays a role. The study found that obese and overweight girls, as measured by their body mass index (BMI), are more likely to start puberty early than normal-weight girls. Fat cells in their bodies create and release the hormone leptin, which can trigger puberty.

Puberty onset is a tricky thing, though, because it is also influenced by other medical, social, or environmental factors. Certain rare medical problems, such as a tumor or meningitis, can cause early puberty. Some studies have suggested that girls are more likely to start puberty earlier than average if they are adopted internationally, don't live with their biological fathers, or if their mothers are depressed.

Whatever the cause, early onset of puberty is both physically and emotionally unhealthy for girls. These girls are more likely to have low self-esteem, have a poor body image, become sexually active earlier, and develop certain cancers later in life, the Pediatrics study stated.

With one in three U.S. children overweight or obese, the rates of early puberty will probably continue to increase. Early puberty is yet another reason to substantively address the many causes of obesity in this country, and to substantively regulate how certain chemicals are used in the environment, food packaging, and foods.

Resources:

• The Environmental Working Group's Body Burden page contains extensive information on the toxic chemicals found in the human body, particularly BPA
• Follow this CDC link to calculate your child's BMI
  
  

Adults and Kids Harmed by CT Scans

Radiation overdoses in both adults and children from computed tomography (CT) scans have lead to a lot of worry and finger-pointing in the news recently.

The issue was uncovered in a New York Times investigation by Walt Bogdanich of patients who experienced strange side effects after receiving CT scans to measure blood flow to their brain. CT scanners take a series of X-rays to create three-dimensional images of the body.

Bogdanich reported that over 400 patients at hospitals in California, Alabama, and Florida received as much as 13 times the recommended radiation doses from CT scanners. After the scans, the patients developed symptoms such as hair loss, confusion, and memory loss, and might now be at increased risk of developing cancer and brain damage.

Most of the scanners in question were made by GE Healthcare, Bogdanich reported. Hospital staff blame the overdoses on faulty training about how to use a new feature of the CT scanners designed to reduce the radiation dose. They say that a glitch in the scanners' software unintentionally lead to radiation overdoses. GE Healthcare, on the other hand, blames the hospital staff for misusing and misunderstanding this feature, and for not tracking the radiation doses more carefully for each patient.

The FDA had been investigating this issue over the past year, but "was unaware of the magnitude of those overdoses until The Times brought them to the agency's attention," Bogdanich wrote.

Meanwhile, Chicago Tribune reporter Judith Graham wrote that many children are receiving unnecessary adult-sized doses of radiation when they get CT scans. Because children often receive CT scans at hospitals for adults, the radiation doses are not always adjusted for the child's weight and size.

Health Care Reform Basics Explained

The family issues activist group MomsRising met with HHS Secretary Kathleen Sebelius in a web chat recently to ask questions that they had gathered from their million-plus membership of mothers. Since I've questioned MomsRising's tactics in the past, I was curious to see how this chat would go. It's certainly an important topic: a HealthDay/Harris Poll of 2,100-plus Americans, released today, showed that many are deeply confused about what changes to expect from the Affordable Care Act that passed in March.

Actress Fran Dreschler, who survived uterine cancer and now works to improve cancer awareness among women through her website Cancer Schmancer, joined Sebelius and MomsRising's National Campaign Director Donna Norton in the web chat.

It was an odd collection of personalities: the articulate, calm Sebelius; the passionate and occasionally off-topic Dreschler; and the smiling, friendly Norton, who wore a MomsRising T-shirt (as MomsRising representatives do when meeting publicly with government officials, a habit that I dislike) in contrast to the smartly-dressed Sebelius and Dreschler.

The web chat touched on some changes coming in 2014 (the health insurance exchange), but focused on what will change in 2010. Changes to expect this year include:

• preventative care coverage without out-of-pocket costs to the consumer 
• new insurance pools for people denied coverage due to pre-existing conditions
• expanded health care coverage for adults up to age 26
• elimination of annual caps on insurance coverage for individuals

Sebelius, Norton, and Dreschler also discussed more innovative disease-prevention strategies included in the bill, such as calorie labeling on menu items in fast food restaurants. I was glad to see MomsRising lead a substantive discussion of health care reform.

A timeline of when various benefits will begin is available on the new healthcare.gov site, which also has an interactive section that lists health insurance options for different groups of people.

It's unclear to me whether health insurance will become less complicated under the new law. Billing paperwork from health care insurers and providers is currently so complex and error-prone that Quicken has developed Health Expense Tracker software that interacts electronically with certain health insurance companies to help consumers keep track of everything. The 1996 HIPAA bill was designed (in part) to reduce and streamline insurance paperwork; instead, it has increased it.

On the other hand, the Affordable Care Act offers Americans assurances that their medical expenses will be covered more fairly. To pay for this, the bill is structured to provide financial incentives for insurers (and other organizations) to focus on preventing disease, rather than dropping patients when their diseases become too expensive. With more than half of all U.S. bankruptcies caused by unpaid medical expenses, it's about time for the change.

Skin cancer, tainted sunscreen, and Vitamin D: Sorting it all out

A 2009 study published in the Archives of Internal Medicine found that about three-fourths of teens and adults in the U.S. are deficient in vitamin D, as are 90% or more of African Americans and Mexican Americans. This is bad news, because vitamin D might help protect against a host of modern ills, including osteoporosis, heart disease, cancer, and dementia. Equally disturbing, though, is the controversy over how to get enough vitamin D.

Your body can get vitamin D from sunlight, certain foods, or dietary supplements. To help prevent skin cancer, though, the American Academy of Dermatology recommends that everyone avoid sun exposure as much as possible, and use sunscreen and protective clothing. Some people, however, believe that high rates of vitamin D deficiency are a result of too many people following these recommendations. Others believe that dermatologists have exaggerated the threat of skin cancer in order to attract more patients.


Earlier this month, for example, a Huffington Post blogger posed as a patient and visited several San Francisco dermatologists, covertly (and illegally) recorded his conversations with them, then criticized their recommendations on removing moles and avoiding the sun. The blogger accuses dermatologists of (among other things) scaring people into getting moles checked out or removed, then trying to upsell them cosmetic skin procedures. The flaws in the blogger's argument, including his questionable ethics, were called out by doctor and blogger Peter Lipson.

Sunscreen itself came under attack earlier this spring, when the Environmental Working Group came out with a report that condemned almost all the sunscreens currently available. The EWG stated that some sunscreens might actually contribute to skin cancer rates. Sunscreens that are inadequate, or inadequately applied, create a false sense of safety in the sun and increase sun exposure, says the EWG. Some sunscreen ingredients, such as retinyl palmitate or oxybenzone, might cause skin cancer or other problems as well.

The EWG's recommended sunscreens use the minerals zinc or titanium to block the sun. Alternatively, you can use sun-protective clothing and hats to provide protection. That's my preference; I'm a fan of the Sun Precautions line of clothes.

It's hard to know exactly how much vitamin D you need as well. Current recommendations range from 200 to 1,000 IU (international units) or more per day, depending on your age, gender, and other factors - such as what health source you consult.

The National Institute of Health's Dietary Supplement Fact Sheet on Vitamin D, for example, suggests 200 to 600 IU daily. The National Osteoporosis Foundation increased this recommendation to 800 to 1,000 IU daily for adults 50 and over. For people at risk for heart disease, a study released in March suggested that they should talk to their doctors about taking up to 1,500 to 5,000 IU daily, even though this exceeds the currently recommended daily maximum of 2,000 IU for adults.

Fortunately, the Institute of Medicine is currently wrapping up a two-year study of vitamin D and calcium recommendations. Their results should be available in October or November. Meanwhile, I'll stick with sun safety, a moderate amount of vitamin D supplementation, and a diet that includes D-rich foods (such as oily fish; D-fortified milk, orange juice, yogurt, and cereal; and egg yolks).

Should HIV-Positive Women Bear Children?

The modern HIV/AIDS epidemic began in California and New York in 1981, and was seen primarily as a disease limited to gay men, injection drug users, and hemophiliacs (remember Ryan White?). Today, however, the disease demographic has shifted radically. About half the people living with HIV/AIDS worldwide now are women of childbearing age, and many of these women want to become pregnant.

The Harvard School of Public Health just released a report that explores this issue, "The Pregnancy Intentions of HIV-Positive Women: Forwarding the Research Agenda." Despite its academic tone, the report is full of riveting information about HIV-positive women and pregnancy worldwide that is sure to spark discussions among the people who read it. The report favors supporting HIV-positive women who want to become pregnant, even in resource-poor countries where health care funding is already strained.

An HIV-positive woman who wants to become pregnant faces three main issues. First of all, she might transmit the virus to her male partner. Even if both she and her partner have HIV, they could still transmit different strains of HIV to each other. Secondly, the woman needs to try to prevent transmitting HIV to the child during pregnancy, labor and delivery, and while breastfeeding (the HIV virus can be transmitted through breast milk). Lastly, the woman needs to stay healthy enough to raise the child.

To help HIV-positive women become pregnant without infecting their partners, the report suggests providing access to assisted reproductive technologies, such as in-vitro fertilization and artificial insemination. The report's authors admit that this is not a great solution. They explain that:

For those who are already on antiretroviral therapy, the combined expenses of ART [antiretroviral therapy] and assisted reproductive technologies are simply out of reach. Even when available, the idea that assisted reproductive technologies could be used by women who are HIV-positive appears to be strongly opposed. This is an area where stigma and discrimination are highly manifest.... many health care providers express the view that HIV-positive women should not have children and should certainly not have access to expensive technologies to help them do so.

Once an HIV-positive woman is pregnant, keeping her and her child healthy is another expensive, complicated hurdle. The woman needs to consistently take expensive antiretroviral therapy (ART) drugs throughout pregnancy and breastfeeding to help prevent transmitting HIV to her child. She also needs to take ART for the rest of her life to suppress the virus and its symptoms and stay healthier.


Parts of the report made me think that helping HIV-positive women get pregnant in resource-poor countries was a Very Bad Idea. For example, paying for reproductive technologies in a resource-poor country is a questionable use of resources. In poorer countries, less than half of people who need HIV treatment get it, according to the HIV/AIDS charity AVERT. Shouldn't limited health care money be used for HIV/AIDS education, prevention, and treatment, where it would do a greater amount of good for a greater number of people, rather than insemination services?

Apparently not. The Harvard report states that "some NGOs [non-governmental organizations] globally are beginning to pressure governments to provide assisted fertility services for people living with HIV/AIDS." The report's authors believe that HIV-positive women (and their partners) should have the same reproductive rights, including the right to bear children, as women who are not HIV positive.
 
Other details from the Harvard report, however, made it clear that this issue is far more complicated than it first appears. Here are a few things that struck me from the report:

• Culturally, motherhood confers far more status to women in some countries than anything else they might achieve. A woman who does not have children might be ostracized by her community.
• In some cultures, women who do not have children  might be accused of being HIV positive, which makes them seek out pregnancy as a protective measure (even if they are HIV positive).
• In some cultures, women don't feel empowered to insist that their partner use a condom to keep the women from contracting HIV.
• Violence against HIV-positive women is a problem worldwide. Along with physical violence, some HIV-positive women have been forced or coerced into being sterilized. Mexico, Chile, and Namibia, for example, have all been accused of forcing or coercing sterilization on HIV-positive women.

There are no simple answers to the problems that HIV-positive women face. But I question the report's assumption that it's best to enforce local cultural norms by helping these women become pregnant.

Women in every country need to be able to achieve both social status and financial security independent of whether they are mothers or in a relationship with a man. When women are only valued as child-bearers, they lose much of their influence in both personal and community relationships. They become vulnerable to poverty, violence, and diseases such as HIV/AIDS.

International organizations should take the wider view and focus on improving the status of women worldwide to decrease the incidence of poverty, violence, and disease. For example, microloan programs and organizations such as Heifer International, which help women and families become financially self-sufficient, are a great success story. When you improve the lives of women, you solve a lot of underlying societal problems.

Fireworks, California Style

Where I grew up, my town put on a spectacular independence day fireworks show every year on the football field at the local high school. My neighbors and my family also lit Roman candles, sparklers, firecrackers, and who knows what else on our block. It got so noisy that one neighbor had to sedate her skittish dog each year.

Here in Northern California, though, it's a different story. The fourth of July falls at the worst time of year for fireworks: the dry season and the foggy season (yes, these two seasons co-exist; the cold marine fog creeps in along the coast all summer long, pulled by the heat of the Central Valley to the east, but the rains generally don't fall from June through September).

Years ago, a friend and I hiked to the top of a hill with a view of downtown San Francisco, wrapped in thick coats against the fog, to watch the fireworks show. Undeterred by the weather, the city shot the fireworks into the fog. Although I heard the booms when they were lit, all I could see were a few pale colors reflected in the overcast sky. Fun.

Putting on your own fireworks show with store-bought ("consumer") fireworks is not an option for most people here. It's illegal to set off your own fireworks in many Bay Area cities (including all of San Francisco and Marin counties), because of the dry-season fire danger and the risk of personal injuries.

The bottom line is that safety laws, combined with the often fog-shrouded coastal fireworks shows, mean that the Fourth of July celebration out here is, well, a dud.
 
Yes, fireworks are dangerous; the tips of sparklers get as hot as 1200 degrees Fahrenheit (!), according to the National Fire Protection Association. Because children are most likely to be injured by store-bought fireworks, the American Academy of Pediatrics (AAP) is opposed to all consumer fireworks.

The few local towns here that do permit consumer fireworks only allow "safe and sane" fireworks (in general, fireworks that are not shot into the air). In these towns, nonprofit groups often sell consumer fireworks as a fundraiser, providing much-needed funding in a time of budget cuts. Many of the groups are raising funds for charities that benefit children (hoping, of course, that children don't light their wares). 

Are consumer fireworks more fun than dangerous, or more dangerous than fun?  This issue raises perhaps the most fundamental question facing today's parents: should we let our kids do what we did?

Most years we've just thrown up our hands and skipped the whole fireworks thing. This year, though, we drove our fireworks-deprived kids to a rural town to watch a fireworks show.

Fortunately, the day was fog-free, and it stayed clear as it got dark. The kids squealed with delight when the first firework went up and lit up the sky with a flower shape. They had never seen a live show before, and for the next half-hour, they ooohed and ahhhed their way through the display.

It was more subdued than the celebrations I remember from my childhood, but it was good to give them something to watch.

The Health Impact of the Gulf Oil Spill

Last week, the Institute of Medicine held a two-day workshop in New Orleans to discuss the health impact of BP's Deepwater Horizon oil spill in the Gulf of Mexico. The spill began with an explosion on an offshore drilling rig on April 20.

In an NPR article about the New Orleans workshop, Richard Knox pointed out that the effect of oil spills on human health has not been studied much, despite a history of several dozen major spills over the past 50 years. Knox explained that:

Only about a quarter of [the oil spills] have been studied for toxic effects on humans. And the studies that have been done are often small and without comparison between groups of oil-exposed and unexposed people. In addition, none has so far looked at long-term consequences of exposure, such as cancer incidence.

As a result, there are a lot more questions than answers about the short- and long-term health impact of the oil spill. The main health concerns for humans include an oil spill's impact on air quality, the health impact of direct contact with oil and substances used to clean up the oil, and the safety of consuming  fish/shellfish caught in the area. Knox also wrote that some researchers believe that children might be especially susceptible to health problems from exposure the the oil.

A CDC fact sheet about the spill warns that particulate matter in the air from burning oil might harm people with chronic medical conditions, discourages recreational swimming in contaminated areas, and suggests avoiding contact with oil spill dispersants used to treat the oil slick.

Knox wrote that previous large oil spills, such as the Exxon Valdez oil tanker spill in Alaska in 1989, have also had mental health consequences. After the 1989 spill, researchers found increases in problems such as post-traumatic stress disorder and anxiety among residents in the affected areas.

The BP oil spill is also harming local economies, adding to the stresses on Gulf Coast residents. Louisiana Governor Bobby Jindal told the Miami Herald today that Gulf waters off his state provide 30% of U.S. seafood and bring in $3 billion per year in commercial and recreational fishing.

To see the BP oil spill superimposed over the area where you live and get a sense of its scale, visit the interactive map www.ifitwasmyhome.com. The map is based on current National Oceanic and Atmospheric Administration (NOAA) data about the spill. Or you can go straight to NOAA to see where the oil is right now or learn more about previous large oil spills in the Gulf.

Living La Vida Cyber

Is communicating over the Internet good for you? Or is it just a crutch?

Reaching people online is different from print or spoken communication for one main reason: you can use new media such as video, audio, and online links to make your communications richer and more realistic, even if what you create is not actually reality.

I'm not surprised that some people with autism spectrum disorders (ASDs) have been drawn to the virtual social world Second Life, for example. In Second Life, people with ASDs can communicate in ways that are not socially acceptable in the real world, incorporating unusual movements into their Second Life avatars, for example.

"The internet has been to the autistic community what sign language has been to the deaf community: a channel of communication that allows them to speak for themselves," explains the newscaster in a 2007 news clip on this phenomenon.




If modern life is sometimes awkward for those of us with passable social skills, it's surely maddening to people with ASDs who have trouble reading social cues such as facial expressions. Second Life is probably a welcome escape for many of them. Some therapists even use Second Life to help people with ASDs practice social skills necessary in the real world, explains T. DeAngelis in an article for the American Psychological Association:

With a therapist's guidance, patients enter a protected area in Second Life designed to help them practice communicating and negotiating in realistic settings. (The area - which is simply a location within the cyberworld - is secured so patients can't enter the main part of Second Life, which [cognitive neuroscientist Sandra Bond] Chapman believes could be overly confusing and disorienting for them.) As in Second Life, both patient and therapist create avatars, or virtual representations of themselves. 

Chapman was quite optimistic about the ability of moderated Second Life sessions to improve the social skills of her patients.

But the the technologies that help people with ASDs learn to navigate the real world also serve to degrade the social skills of people without ASDs. Laptops, smart phones, iPads, and other gadgets now create a wall between people who are stuck together in the same place - a doctor's waiting room, an airport - as each person retreats into their own technology bubble.

Do airports now have televisions in the waiting areas because people really need to keep up with CNN, or because we want to alleviate the awkwardness of sitting quietly among strangers, as we slowly lose our ability to make small talk - and perhaps discover new connections -  with them? We turn to technologies such as foursquare to find out if any of our friends are in the neighborhood, instead of just looking up from the smart phone screen and looking around, hoping serendipity is on our side today.

So there it is. People with ASDs learn social skills for the real world by practicing them on Second Life, and people without ASDs lose some of their real-world social skills by spending too much time in cyberspace. Ultimately, will these two groups of people converge?

COBRA Bites Back

Unless Congress takes action soon, the federal COBRA health insurance subsidy will run out this month, Kaiser Health News writer Andrew Villegas pointed out recently. For people who were laid off from their jobs or lost health care coverage because their work hours were reduced (a "qualifying event" that makes them eligible for COBRA), the federal subsidy covers 65% of the cost of extending their employer-based coverage for 15 months. This subsidy is only available for employees whose qualifying event occurred before May 31, 2010, however, so people laid off in June are out of luck.

Those who have benefited from the COBRA subsidy since March 2009 also hit the 15-month limit this month, Villegas stated, and now must pay full price for their COBRA benefits for the remaining three months of COBRA coverage (in most cases, COBRA coverage only lasts 18 months).  

Plans offered by employers (and extended by COBRA to unemployed workers) usually provide better coverage than anything available on the individual health insurance market. COBRA can be very expensive, however, as cash-strapped former employees must pick up the full cost of a health plan that their employer used to subsidize, along with a 2% administrative fee. One study found that paying full price for COBRA coverage could consume 84% of a laid off worker's unemployment check, according to MarketWatch reporter Kristen Gerencher. The federal subsidy helps make COBRA an affordable option for laid-off employees and their families.

Like unemployment benefits, COBRA was designed as a stop-gap measure, providing temporary coverage while an employee looks for a new job that will provide more permanent, employer-sponsored health insurance (or pays well enough for the employee to purchase individual health insurance). That formula does not work too well in this stalled economy, however. Because good jobs are hard to find, many people rely on COBRA and unemployment benefits for far longer than they were intended.

A while ago, I wondered whether the federal government might use COBRA as a vehicle for health care reform. What if the federal subsidy for COBRA continued indefinitely, allowing eligible ex-employees to continue to receive health care from high-quality private plans, regardless of whether they found a new job or not?

A COBRA subsidy extension might not happen, however, either in the long- or short-term, because it is both expensive and politically volatile for Congress to pursue. Meanwhile, many long-term or newly unemployed people and their families will need to pay much more for health care coverage under COBRA or individual plans, end up in federal or state programs such as Medicaid or the Children's Health Insurance Program, or go without insurance altogether.

Superfood Burnout

I think that the Baby Boomers, concerned about preserving their health as they age, are responsible for our obsession with "superfoods" that can protect us from disease. A while ago, the superfood of choice was antioxidant-packed pomegranate juice - particularly when marketed as the Pom Wonderful drink - which might prevent hardening of the arteries and prevent Alzheimer's disease (although the Pom Wonderful website is careful not to make these claims).

More recently, the acai berry, whose antioxidants might prevent cancer and heart disease, has pushed aside pomegranates as the food of choice. Other holier-than-thou, nutrient-rich foods that we should be eating include quinoa, spelt, and heirloom tomatoes.


Of course it's important to think about what you eat. This Sunday's New York Times had a cover article on the horrifying amount of salt in many processed foods, and salt's role in increasing the rates of high blood pressure in Americans. The food industry, meanwhile, is fighting to keep the salt in their foods to cover up the true flavor of their products' ingredients.


I support the slow food movement, avoid processed foods, and cook from scratch as much as I can. I prowl for stone fruit, corn on the cob, strawberries, and figs at the local farmers' markets when I have time. I have a budget, though, and I don't have hours to cook, or shop for the perfect ingredients, each day.

When exactly did eating healthy morph into an obsession with eating the perfect foods? I want my family to eat well, but that doesn't mean I'm sprinkling acai berries on their oatmeal in the morning.

And can you really enjoy your meals if you're too busy either feeling guilty for eating the wrong things, or self-righteous for eating the right ones? What does this superfood obsession say about us as Americans, who always seem to demand simple answers for complex problems such as heart disease?

Can We Afford to Keep Our Promises?

On June 1, Congress will decide whether to cut Medicare reimbursements to health care providers. This time, providers are looking at - and fighting - a 21% cut. If the cut goes through, providers who accept Medicare patients will need to choose between getting by with less income (Medicare already reimburses at lower rates than private plans), or dropping Medicare patients.

Realistically, with the powerful American Medical Association and other organizations lobbying hard to block the cuts, Medicare reimbursements probably will not be cut right now. As an alternative, Congress might freeze the current reimbursement rates for five years.

Unfortunately, the drama of threats to cut Medicare and lobbying to restore these cuts has been going on for years in Washington, with three delays in the proposed cut this year alone. Medicare reimbursement rates are based on a much-criticized GDP-based formula. As Robert Lowes explains in a cogent Medscape article on the cuts:

Right now, reimbursement is determined by the so-called sustainable growth rate (SGR) formula, which sets an annual target for Medicare spending on physician services based partly on the growth of the gross domestic product. If actual spending tops the target, Medicare is supposed to decrease physician pay the next year to recoup the difference. Congress has called off annual SGR-triggered cuts going back to 2003, so the gap between actual and targeted spending on physician services has continued to grow, resulting in the 21.2% decrease for 2010.

Congress has been slow to revise this formula to reflect the true cost of providing health care to seniors because it would be expensive to do so.

At the same time, President Obama is spearheading an international health initiative to prevent or treat certain tropical diseases such as river blindness and hookworm, reports Sabin Vaccine Institute President Peter J. Hotez in a New York Times Op-Ed. These "neglected tropical diseases" torment over one billion people in the poorest nations, but they are rare in the developed world, and as a result there has been little financial incentive to eliminate them.

Treating and preventing these diseases is not just an act of altruism. Because these diseases affect children's physical and mental development, preventing the diseases makes it easier for the world's poorest citizens to stay healthy enough to gain an education and care for their families. As a result, the economic and political stability of many troubled regions improves, ultimately improving our own national security.

But can we really have it both ways: provide health care coverage for U.S. seniors and the disabled, and help improve health care for the poor in other countries, while our unemployment rate is 9.9% nationwide, raising taxes scares politicians, and about 80 million Baby Boomers are poised to retire and draw on their federal benefits? Have we promised more than we can deliver? And if we have, what will we change to make it right?

Health IT Hits a Wall

It's hard (for me, at least) not to click on the headline "Up to half of Spanish-translated prescriptions include dangerous mistakes" as a May 12 Fierce Healthcare post declared. The post cited a recent Pediatrics study that found that translation programs used by pharmacies to create Spanish-language instructions for patients were deeply flawed.

The Pediatrics study evaluated Spanish medicine labels from 209 pharmacies in the Bronx, New York; most of the pharmacies used computer programs to translate instructions for patients from English into Spanish. Half of the the translated labels used a mixture of Spanish and English, or had grammatical or spelling mistakes, resulting in "inconsistent and potentially hazardous" translations, according to the authors.

"Phrases that were not translated included 'dropperfuls,' 'apply topically,' 'for 7 days,' 'for 30 days,' 'apply to affected areas,' with juice,' 'take with food,' and 'once a day,'" the Pediatrics study's authors wrote. Mistranslated phrases included the substitution of "eleven times a day" for the phrase "once a day."

The move toward e-prescribing, electronic medical records, and other technological advances is supposed to make the practice of medicine safer and cheaper. The famous 1999 Institute of Medicine report, "To Err is Human: Building a Safer Health System" which found that up to 100,000 people die in hospitals each year from medical errors, helped shift the needle toward more standardization and digitization of medicine.

The Centers for Medicare and Medicaid (CMS) encourages the adoption of electronic medical records (EMR) and will soon provide financial incentives to health care providers who adopt them. In February, FierceHealthIT pointed out that "a healthy $20 billion in IT spending [from the stimulus bill]... will largely be funneled through CMS to provide incentives for EMR adoption."

All good, if you support health care reform and patient safety. But throwing technology at problems has its limitations, as the Pediatrics study makes clear. The study's authors suggested more regulation of and funding for better translation programs. Meanwhile, other unresolved IT issues, such as ensuring the electronic security of patients' health information, will continue to pose challenges for health IT for a long time to come.