Fixing the Pharms

Whether you love or loathe pharmaceutical companies, it's clear that we have a problem with pharmaceutical delivery in the U.S.

First of all, some drugs are inexplicably expensive. There's the $93,000 prostrate cancer drug Provenge, for example,  which I've blogged about in the past ("The Skewed Values of Drug Prices"). A more recent example is Anascorp, an orphan drug (used to treat rare diseases) approved by the FDA in August to treat scorpion stings. Anascorp has been used in Mexico for many years, at a cost of $100 per dose, but in the U.S. it now costs  $12,000 per dose, according to a recent Kaiser Health News blog post on the topic ("Treating a Scorpion Sting: $100 in Mexico or $12,000 in U.S."). Blog author Jenny Gold points out that patients need up to five doses of the anti-venom to recover.

It's not fair, however, to blame the cost entirely on the manufacturer, Rare Disease Therapeutics. Gold writes that hospitals in Arizona purchase Anascorp for about $3,700 per dose, then mark up the price to cover their own costs, including the cost of providing care for uninsured patients. It's a long and tangled journey from a $100 dose to a $12,000 dose, and one that does not serve patients well.

More common drugs aren't faring much better, however. There is currently a shortage of generic injectable drugs used to treat cancer and other serious medical problems, an issue covered earlier this month by another Kaiser Health News blog post ("Drug Shortages Affect More Than half a Million Cancer Patients").

The problem has become so acute that it triggered a presidential smackdown, a.k.a. an executive order, in October that demands FDA action and includes Justice Department investigations of possible price gouging.  There are many reasons for these drug shortages, such as a shortage of raw materials needed to make the drugs, and a limited number of manufacturers, who drop production of the drugs if they are not profitable enough or if they have problems with the manufacturing process (as sometimes happens with vaccines).

What's the cure for all this? Don't get sick, silly. But failing that, as we all do from time to time, it seems clear to me that the government needs to flex its muscle with the pharmaceutical companies that bring both great good and great expense to health care.

Taxpayer-funded research should not lead to drugs that taxpayers cannot afford when they need them. The pursuit of blockbuster drugs - those that earn $1 billion or more per year in revenues -  should not undermine the development of less profitable, equally necessary treatments for other diseases. Government incentives and regulations should ensure that a wide range of manufacturers are providing the medications that Americans need.

What vaccines say about parents

Two vaccines targeted to children have been in the news this month: a vaccine in clinical trials in parts of Africa that offers some protection from malaria (which is a leading cause of death in African children, according to the World Health Organization), and the human papillomavirus (HPV) vaccine, which prevents infection with certain cancer-causing strains of the HPV virus. Although the HPV vaccine has been recommended for tween girls for several years, the CDC will likely recommend it for boys as well soon.

Each of these vaccines is quite unique. The malaria vaccine, if approved, would be the only vaccine that prevents a parasitic infection (all other vaccines prevent infection with certain viruses or bacteria). The HPV vaccine is one of only two vaccines that can prevent cancer (the other one is the Hepatitis B vaccine, which prevents infection with a virus that can cause liver cancer). Until recently, the HPV vaccine was the only childhood vaccine recommended only for girls, not boys, because HPV infections can cause cervical cancer.

The malaria vaccine, which is only about 35% effective in preventing malaria, is being heralded as a major breakthrough in preventing a disease that can be deadly in children, especially as the mosquitoes that transmit malaria become resistant to pesticides. On the other hand, the HPV vaccine, which prevents infection with certain strains of HPV that can cause serious health problems such as cervical cancer, genital warts, and oral cancers, has triggered a lot of angst and hand-wringing. It has been criticized as a pharmaceutical boondoggle (costing about $400 for the three-dose series), an invitation to promiscuity for the tweens who receive the vaccine, or (when the vaccine is mandated), a governmental intrusion in the lives of people.

Malaria is transmitted by mosquitoes, while HPV is generally transmitted by sexual contact, which is part of the reason some Americans are squeamish about the HPV vaccine. Vaccines are a public health initiative, though, and American parents tend to forget this as they fret about whether a vaccine will reset their child's moral compass.

Although many parents view vaccines as an individual choice that affects only their family, a vaccine doesn't just protect one child from an infection. Most vaccines also prevent the child from transmitting an infectious disease to someone else. Others might be vulnerable to a disease because they are unvaccinated, too young to be vaccinated, have an illness that prevents them from getting a vaccination, or because (often unknown to them) they have not developed immunity to a disease after being vaccinated.

The HPV vaccine recommendation was extended to boys because they also transmit the virus, even if they are generally at less risk for developing cancer from the virus than girls are. It can be hard, though, to persuade parents to think about their neighbor's children as well as their own.

Ignoring Long Term Care

In print and screen advertisements, retirement is often portrayed as a time to start a second career, spend more time with the grandchildren, volunteer for a worthy cause, or travel around the world. Any health problems can be managed with prescription medications and moderate exercise.

Realistically, however, many Americans will ultimately need long-term care in a nursing home or in their own homes when they get older. Medicare, which in most cases does not cover long term care, predicts that 12 million elderly will need long term care by 2020, and HHS predicts that 40% of 65-year-olds will ultimately go into a nursing home for some period of time. Non-skilled long term care is often provided by family and friends, such as help with daily activities, while skilled long-term care often must be paid out of pocket.

With the recent demise of the CLASS Act, a section of health care reform designed to encourage Americans to purchase long-term care insurance, the issue of long term care has come to the forefront. The CLASS Act had fiscal flaws, with high monthly costs for insurance, but dropping it does not solve the problem of long-term care. In this economy, with many families struggling, few want to contemplate the stress and expense of caring for an ill spouse or relative. But ultimately, many of us will need to help out.

Kaiser Health News' Howard Gleckman suggests providing long-term care in the future through universal coverage or through insurance policy incentives. Whatever the solution, the current gaps promise to cause many problems for families as the large generation of Baby Boomers ages, along with the rest of us.

Did You Feel It?

I thought it was a truck going by, but that's what I always think when the little earthquakes strike. It took me a moment to realize what it might be. It was near the end of the work day for me, but my laptop was still on, so I logged on to the U.S. Geological Survey site to find out that it was a magnitude 3.3 earthquake near Oakland, CA yesterday. I was far enough away that I barely felt it.

I reported it on the USGS "Did You Feel It?" page, adding my data to everyone else's, not just because I've been studying statistics lately but because it's exciting to make even a small contribution to science. I showed a printout of responses to my children later and they were interested, too; one of them had felt the earthquake, the other had not.

The USGS site shows math and science in action, data gathered and maps produced for the public good. It's much more interesting to see concepts applied than to, say, memorize the times table. Science that you can feel, hear, and touch is fun to learn, and Americans definitely need to learn more science (perhaps starting with Republican presidential candidate Michele Bachmann and her misguided comments on HPV vaccination).

I wanted to thank the USGS for making science fun and relevant yesterday. Did I feel it? Yes - surprise and excitement and a twinge of worry as the earthquake passed through and I looked up its magnitude online. Did my kids feel it? Yes - surprise and excitement as they realized that science had just rattled their world a little.

Should Smokers Be Banned from Hospital Jobs?

Texas' Baylor Health Care joined the Cleveland Clinic and other hospitals in banning smokers from hospital jobs, Fierce Healthcare reported today. As Alice Wolke of My FOX Houston explained in an article about Baylor Health Care's decision, "on the company's Careers page, the rules are laid out:

• Applicants who admit to nicotine use will not have their applications processed
• Anyone who is hired will be tested for nicotine
• If you test positive, your job offer will be withdrawn
• After a positive result, you can reapply for the job after 90 days"

By enforcing this policy, Baylor might be setting a healthy example for patients at its hospitals. To be ruthlessly practical, barring smokers from employment also saves the hospital system a lot of money in employee health care costs. The CDC's Vital Signs public heath site is featuring adult smoking statistics this month, and the numbers are statistics they quote are disturbing: the 19.3% of American adults who smoke (as of 2010) create $96 billion yearly in medical costs.

Barring employment to people with certain medical risks or conditions, however, sets a disturbing precedent. Some people argue that these methods are intrusive of medical privacy, especially considering the high levels of chronic disease and other health problems in America. Others point out a certain hypocrisy in targeting employees who smoke while ignoring those who drink heavily or make other risky health choices when they are not at work.

This month, the Department of Health and Human Services is taking a less punitive approach to better health, launching the "Million Hearts" Initiative to prevent one million strokes and heart attacks between now and 2016. Focusing on "proven, effective, inexpensive interventions" that can prevent heart disease and stroke, the initiative includes many stop-smoking measures, such as:

• Providing Medicare funding for stop-smoking medications
• Funding mass media anti-smoking campaigns
• Creating smoke-free (not smoker-free) workplaces
• Possibly reimbursing health care providers better for preventative care such as stop-smoking counseling.

Yes, it's time to reduce the shockingly high number of Americans who smoke. But I think it's more effective to use a carrot than a stick.

Rethinking Children's Hospital Ratings

A study published recently in Pediatrics cited the "statistical uncertainty" of using mortality rates in children's hospitals to rank their quality. The study of approximately 473,000 U.S. patients discharged from children's hospitals in 2008 found that adjusted mortality rates at the 42 hospitals studied did not vary much by the hospital's ranking ("Statistical Uncertainty of Mortality Rates and Rankings for Children's Hospitals").

In a cogent Reuters article on the topic, Frederik Joelving points out that death rates, " which carry heavy weight in commercial rankings like the U.S. News & World Report Best Hospitals, are mostly indistinguishable from a statistical point of view" ("Hospital ratings for kids a roll of the dice: study").

Dr. Chris Feudtner, lead author on the Pediatrics article, told Reuters that when patients look for a hospital, along with rankings they should also consider other issues, such as its proximity to their home. Statistics seem to promise clear answers to complicated questions, but sometimes they can't deliver that.

Few Cancer Patients Join Clinical Trials

With cancer rates soaring - an estimated 1.5 million Americans were diagnosed with cancer in 2010, according to the National Cancer Institute - there's an increasing need for better cancer treatments. But fewer than 1% of cancer patients join clinical trials.

In an article just published in the Annals of Surgery, Waddah B. Al-Refaie, MD and colleagues found that just 0.64% of patients with solid tumors enrolled in clinical trials. They analyzed data on 244,528 cancer patients from the California Cancer Registry from 2001-2008 ("Cancer Trials Versus the Real World in the United States").

The authors point out that the few patients who do join trials do not represent the wide range of U.S. cancer patients. Patients who do enroll in clinical trials tend to be white, younger than 65 years old, and have late-stage cancer, the authors state. This lack of diversity makes it hard to assess how well a new drug might work on other types of patients.

There are many reasons why cancer patients don't join clinical trials. Some of the barriers are financial: doctors don't always tell patients about clinical trials for fear of losing patient revenue to the trial, and insurers don't always cover the cost of clinical trials for patients (although that should change with reform in 2014), explains Betsy de Parry on Candid Cancer ("Low enrollment in clinical trials is hampering progress"). Some barriers are more complex: patients might not live near clinical trial sites, and minority patients might distrust medical authorities, particularly around clinical trials, points out the National Cancer Institute, in a web page on trial participation that is older but still relevant.

The bottom line is that trial participation is inadequate to develop better, potentially life-saving treatments that so many cancer patients need. Information about joining cancer clinical trials is available online at the National Cancer Institute's website.

Leaving for Private Practice

Recently, several doctors that my family uses told me that they are leaving the hospital where they practice to become independent. I was surprised to hear this, because I had read that the the opposite is true: doctors are leaving private practice for the safety of a steady hospital salary.

Our doctors' frustrations, however, were legion. They disagreed with the hospital's billing practices, and were disappointed with the poor upkeep of the buildings. They suspected that political wranglings would block planned renovations to the hospital.

I had to agree with them on all these counts. As exhausted new parents, we tangled with the hospital's aggressive billing department just a few weeks after my oldest child was born. One of the hospital's parking garages has no elevators, which is fine unless you are pregnant, injured, nauseous, or disabled. Once, we had to carry a seriously ill child through a long, dark, underground tunnel in the belly of the hospital to hand-deliver a specimen for testing.

While sending us and our insurer bills regularly, the hospital also periodically asks for donations to its charities and building campaign. I decided long ago that we had given enough.

Despite the hassles, though, we have received excellent care from the doctors affiliated with the hospital, which kept us coming back. It's been nice to have most of our providers all in one place. Now we will need to drive all over town for doctor's visits, as our trusted community of doctors slowly disperses.

New Gun Law Restricts Health Care Providers

Florida recently passed a law making it illegal for doctors to ask patients whether there is a gun in their house during a routine health care visit. The law, CS/CS/ HB155, which became effective in early June, makes some exceptions for EMTs and paramedics, who frequently treat people injured by gun violence.

But the law's wording makes it clear that Florida firearm owners are primarily concerned about their own privacy. The law prohibits recording firearm ownership in a patient's medical record, prohibits "harassment of patient regarding firearm ownership during examination," and prohibits "discrimination by insurance companies" against firearm owners.

Asking about, or counseling against, gun ownership is not an idle issue. As physician Erin N. Marcus points out in a New York Times essay on this topic:

As a general internist in South Florida, I often see the effects of gun violence. Many of my patients have been injured or disabled by a gunshot, or had a family member shot and killed. Shortly after the new law went into effect, local television stations broadcast a story about a 4-year-old in Miami who was accidentally shot by his 17-year-old half brother, who was playing with a .22-caliber rifle.

Asking patients questions about their sexual habits, alcohol consumption, gun ownership, and other "off-limit" topics is part of a doctor's job in providing good health care to a patient. This information is used privately by the doctor to ensure better care, not reported to local authorities. Questions from health care providers about illegal activities, such as illegal drug use or texting while driving (illegal in some states) don't provoke public outrage. Questions about legal gun possession do.

Recruiting Providers Who Trained Abroad

With a shortage of health care providers looming, the U.S. is trying to tap foreign-trained professionals to fill the gap. There are two tactics to achieve this, as several recent articles in Fierce Healthcare point out: giving temporary visas to nurses currently living and working abroad, and creating on-ramps for foreign-trained health care professionals living in the U.S. to practice medicine again.

As Fierce Healthcare points out, these policies would not just increase the number of people practicing medicine in the U.S., they would also add more diversity and language/cultural competency skills to the current health care workforce.

A bill approved by the House of Representatives, H.R. 1933, would double the length of time that foreign-trained nurses could work in U.S. hospitals from three years to six years, although the bill allows fewer of these visas than were granted in the past. These nurses would work in areas with nursing shortages that also serve Medicare and Medicaid patients, the Fierce Healthcare article explains.

Fierce Healthcare points out that, despite a crushing shortage of tens of thousands of health care professionals nationwide, this bill only grants 300 visas and serves about a dozen hospitals. Many of these hospitals are located in the bill sponsor's home state of Texas.

Meanwhile, the Welcome Back Initiative seeks to recruit underemployed foreign-trained U.S. residents back into medicine. The initiative funds free resource centers that provide information on getting appropriate credentials to practice in the U.S., educational programs, and job opportunities. The initiative currently serves only nine areas of the country, however, virtually ignoring the Midwest and the South.

These recruitment tools, if limited (and, I suspect, politically fraught), are at least a step in the right direction toward solving a serious provider shortage in health care.

Can Stem Cells Stop MS?

Later this year, a small clinical trial will begin in Europe to test the use of stem cells to manage or possibly reverse the progress of multiple sclerosis, a disease in which a patient's immune system attacks the myelin sheath that protects nerve cells from damage. The disease tends to first strike when a patient is in their 20s and 30s, and it causes a range of symptoms (which vary widely by patient) such as fatigue, numbness, and balance problems.

For the trial, stem cells will be taken from patients' bone marrow and then injected into their blood, Pallab Ghosh reported for BBC News Health ("Doctors begin major stem cell trial for MS patients"). Promising earlier studies have used these stem cells to "retrain" the patient's immune system not to attack the myelin sheath.

Multiple sclerosis is more common in areas farther from the equator, such as the UK and the northern United States, as this fascinating geographic map of cases illustrates. The incidence of MS appears to be increasing, particularly among women, with some blaming the Western diet and vitamin D deficiency.

Ghosh points out that this trial also aims to address the problem of medical tourism among MS patients, who sometimes seek expensive and unproven stem cell treatments outside the UK. The trial will provide scientific evidence of the efficacy of stem cell treatment.

The phase II trial begins at the end of the year, investigating whether stem cell treatment is effective in human subjects and what side effects it might cause. The trial includes 150 patients and is predicted to take five years, with a possible phase III trial (comparing stem cell treatment to standard MS treatments) to follow before any new treatment can be brought to market.

The Business of Health Care Can Make You Sick

The business of health care is not always good for your health, at least if you look at the ongoing problems at Johnson & Johnson (J&J). I've written before about problems with the company's McNeil division, which manufactures many household medicines such as children's Tylenol. Over the past two years, some products manufactured at McNeil have been recalled due to musty odors, inadequate active and inactive ingredients, or metal particles found in some of the bottles.

Ultimately, J&J shareholders sued the company. In response, board members recently filed a 122-page report in federal court that examined what they believe went wrong at the company.

In an article about the report earlier this week, Businessweek's Alex Nussbaum and David Voreacos explained that the trouble seemed to begin when J&J acquired Pfizer's consumer health-care unit in 2006, which added many products to the company and strained manufacturing facilities. Management turnover, staffing cuts, and squabbles between different groups of staff contributed to quality control issues as well, Businessweek reported ("J&J Blames Staff Cuts, Pfizer Deal for Tylenol Recall Flood").

Businessweek pointed out that Johnson & Johnson has recalled a range of products over the past year, including "contact lenses, artificial hips, insulin cartridges and prescription drugs across J&J's 250 subsidiaries." Because so many people use their products, the problems at Johnson & Johnson are everyone's problems. What exactly is in that bottle of Tylenol in your medicine cabinet? That depends on how J&J makes and implements its business decisions.

The Fi ve Percent

A recent study found that about half of U.S. health care expenses are incurred by just five percent of U.S. patients. These 2009 figures were just released in a data brief by the nonprofit National Institute for Health Care Management Research Foundation. The data brief found that the U.S. spent an average of $8,086 per person on health care in 2009, almost twice the $4,166 per-capita cost in 1997. Ranked by expense, the top 5% of patients (civilian and non-institutionalized) cost a mean of $35,820 per year, and the top 1% of patients cost $76,476 per year in 2009, according to the brief.

Who are these high-cost patients, the five percent? The brief stated that they tend to be 55 or older and have at least one chronic condition. (I've read elsewhere that  patients with chronic conditions consume 75% of the health care budget.). Many of them have hypertension, high cholesterol, or diabetes. Increasing obesity rates are driving the increase in many costly chronic conditions.

Other factors are also driving up health care costs. These factors include costly new medical technologies, the increased use of defensive medicine to avoid malpractice suits, and economic incentives such as fee-for-service payments that discourage adequate management of chronic conditions, according to the brief.

The brief did not have any suggestions about how to curb health care expenses. Clearly, the rate of chronic conditions in the U.S. is one of the roots of the problem (although other reforms are also needed in the health care system). But the time and energy it takes for an individual to prevent or adequately manage a chronic condition are at odds with our culture, which rewards unhealthy workaholism and weakens the community ties that can foster healthy choices.

"Mommy, why is my hot dog bun blue?"

I'm a bit of a food safety zealot, poking cooked meats with thermometers and whisking leftovers into the refrigerator. But it's hard to keep food fresh and safe when you eat outdoors. On the second day of a camping trip last summer, for example, my daughter held up a bun and said "Mommy, why is my hot dog bun blue?" Horrified, I tossed the bun right away, along with a bag of its azure-tinged companions.

One in six Americans will get food poisoning this year, which causes about 3,000 deaths annually and, not surprisingly, spikes in the summer months. The CDC argues that forces such as the centralization of food production and increased consumption of food produced outside the United States make it increasingly difficult to prevent these outbreaks. Currently, Salmonella bacteria are infecting alfalfa and spicy sprouts in the northwestern U.S. and New Jersey, and a strain of E.coli bacteria in vegetables has killed almost 50 people in Germany and other parts of Europe.

It's scary stuff. But even without food contamination that originates in a farm or a factory, Americans do a pretty good job of giving themselves food poisoning on their own. To prevent food poisoning caused by lax food preparation habits at home, the USDA, FDA, CDC, and the Ad Council just launched a consumer ad campaign. Their clever, friendly campaign encourages everyone to keep food preparation areas clean, separate raw meat from other ingredients, cook food to the right temperature, and chill uneaten food adequately.

To remind us all to be careful with food this summer, here's a sample of the ads:

Health Reform and the ER

Many years ago, I developed a sore throat and a cough at the tail end of recovering from a cold. The sore throat became worse and worse each day, so I called my primary care doctor. But her office refused to see me. They were swamped with patients, it was flu season, and "you just have the flu," the receptionist told me.

Ultimately, sick and fed up, I dragged myself to my local emergency room. There, the professional and refreshingly compassionate nurses evaluated me and gave me a prescription for antibiotics to treat a raging sinus infection. When I recovered, I found a new primary care provider.

The problem I had was what many uninsured patients face every day: no access to a primary care provider. Without this access, they, like me, end up in the emergency room for urgent but non-emergency problems. This frustrates emergency room doctors and nurses, but they also understand that some patients don't have other choices for care. A pediatric emergency room doctor once explained to me that there was a tacit understanding between some uninsured parents and ER staff that many visits were not true medical emergencies, but their children had an urgent medical problem and the ER was the only place they could go.

Massachusetts legislators hoped to mitigate this and other problems with the health care system by mandating insurance coverage for all state residents, who must be insured through private or government plans. This grand experiment, initiated in 2006, has not turned out exactly as they had planned. But a recent study in the Annals of Emergency Medicine found that, although ER visits increased in Massachusetts after 2006, the number of "low-severity visits" decreased slightly ("Emergency Department Utilization After the Implementation of Massachusetts Health Reform").

Ideally, Massachusetts health care reform should have more dramatically decreased emergency room use. Increasing insurance coverage, however, also increases the need for primary care providers, and these providers are in short supply in both Massachusetts and elsewhere. The state's subsidies to expand health care coverage "do nothing to increase the supply of medical services in a market suffering from shortages of everything from family doctors to nurses to hospital beds," writes Shawn Tully in an article about health care reform for CNN Money ("5 painful health-care lessons from Massachusetts").

The CNN article, and a recent article on the LA Times ("One in three employers may drop health benefits, report says"), also point out that as health care reform is rolled out nationally, many employers might drop insurance coverage for their employees and choose to pay a non-compliance fine instead. This would increase the government's fiscal burden of health care.

There are a lot of challenges ahead for health care reform, and I hope the state and federal governments can work all this out. Although there's work to be done, I'm glad that Massachusetts is making some progress with reform, because I know how frustrating, costly, and inefficient it is to be forced to use the ER when you can't get care elsewhere.

Low-tech Bone Density Test Could Cut Health Care Costs

A paper presented today at the 93rd annual Endocrine Society meeting in Boston describes a possible link between bone density and facial wrinkles in women. The study's principal investigator, Lubna Pal, MD, looked at the number and depth of face and neck wrinkles and facial skin firmness in 114 post-menopausal women in their 40s and 50s.

Pal and her colleagues found that the women with fewer wrinkles and firmer skin also had greater bone density. Bone density was measured by dual X-ray absorptiometry (DEXA) and by ultrasound ("Severity of facial wrinkles may predict bone density in early menopause"). Skin wrinkles and bone density may be related because collagens that are present in both bones and skin change with age, Pal stated. In the future, measuring wrinkles could be a low-cost method of evaluating bone fracture risk in older women, Pal said.

Today, we face both the enormous expense of treating chronic diseases, costs which consume about three-quarters of the U.S. health care budget, and a large aging population poised to strain or end Medicare. Health care providers will probably increasingly turn to low-cost tests such as the wrinkle test, effective generic medications, and wellness campaigns to help manage their patients' health.

Doctors' Job Choices Have Political Consequences

The New York Times ran an interesting article today about the political consequences of the job choices that doctors are making. Historically, many doctors have owned their practices, explained journalist Gardiner Harris ("As Physicians' Jobs Change, So Do Their Politics"). As business owners, they fought for fewer restrictions on practices that they felt were hampered by business expenses such as taxes and high malpractice insurance premiums. They tended to vote Republican.

Today, however, more and more doctors are joining hospital staffs in order to avoid many of the business headaches of running a practice and to have a better work/life balance, Harris explained. "As more doctors move from business owner to shift worker," wrote Harris, "their historical alliance with the Republican Party is weakening...."

With the hospitals running the business side of medicine, these doctors have become more focused on wider social issues in medicine such as covering the uninsured. They are also more likely to vote Democratic. Harris wrote that this shift has helped Obama pass the health care reform bill.

This focus on social issues is not exactly altruistic. Hospitals benefit when more people are insured, because then the hospital does not have to absorb the cost of treating the uninsured. Doctors employed by hospitals who advocate for expanding insurance coverage benefit their employers, just as doctors with their own practices who advocate for limiting liability claims hope to benefit their own businesses.

The bottom line? Being an entrepreneur is not very appealing to many doctors these days. Many are choosing to exchange the freedom of self-employment for the stability of a staff job.

As I read the New York Times article, though, I realized that the patients that doctors treat have a very different experience of the workplace. The recession has forced many people into self-employment - whether they want to do it or not. As jobs with good salaries and benefits have gone away, people who have been downsized or laid off, or who recently graduated from college, have reinvented themselves as freelancers, independent contractors, or entrepreneurs in order to pay the bills.

Without employer-provided benefits, one thing that these accidental entrepreneurs really need is the affordable, comprehensive health insurance coverage that health care reform is trying to deliver. When more doctors were entrepreneurs themselves, they looked at health care reform through a business lens and fought it as a threat to their own livelihood. With more doctors employed as staff members, and protected from some of the vicissitudes of the marketplace, many are now more sympathetic to those who are forced to take on the risks of entrepreneurship.

Lessons from Zombies

I've spent many, many hours on the CDC website researching different health topics over the years. But this week they provided advice on a health hazard that I'd never considered before: a zombie invasion.

"The rise of zombies in pop culture has given credence to the idea that  a zombie apocalypse could happen," wrote Assistant Surgeon General Ali S. Khan in a May 16th Public Health Matters blog post. "The proliferation of this idea has led many people to wonder 'How do I prepare for a zombie apocalypse?'"

It turns out that preparing for an invasion of the undead involves the same steps as preparing for any other disaster: make a disaster kit, and create a family emergency plan. While citizens of zombie-infested areas flee town through escape routes they'd wisely planned out in advance, Khan assures us that "CDC would conduct an investigation much like any other disease outbreak. CDC would provide technical assistance to cities, states, or international partners dealing with a zombie infestation."

By framing disaster preparedness in terms of zombie preparedness, the CDC brought media attention to the issue. The clever blog post has been mentioned in a wide range of media outlets, such as ABC News, The Atlantic, and Fox News. Zombie preparedness is a humorous antidote to the hurricanes, earthquakes, and other disasters regularly covered in the news, for which, of course, we really should be prepared.

Humor - and zombies - convey the message of disaster preparedness much better than a carefully crafted CDC press release ever would. Health information is often conveyed by drawing on our fear of disease or injury: get this screening test now to catch cancer in its earliest and most curable stage! Childproof your house to protect your baby! It's exhausting to worry about so many health issues. Maybe more people would follow health advice if some of it were conveyed with a lighter touch or a more positive spin. Bring on the zombies, I say.

Goodbye, Firehouses

Many years ago, a neighborhood firehouse in San Francisco was quietly converted to a battered women's shelter. If you have to take a firehouse out of commission, at least turning it into a shelter keeps the building's function in the realm of public service. But that type of firehouse conversion is not the norm here. I was dismayed to read a profile in the San Francisco Chronicle today of a converted firehouse in San Francisco that has been recently renovated into two multi-million-dollar townhouses.

Real estate in the Bay Area has become much more valuable over the past few decades, while California's Proposition 13, passed in 1978, continues to limit the amount of property taxes that can be collected from these properties. Property taxes help pay for emergency services, among other things, and without adequate funds, many smaller fire stations have closed - and often renovated into luxury properties. Currently, 51 fire stations in San Francisco serve a population of roughly 815,000 people.

San Francisco was destroyed by the earthquake and subsequent fire of 1906, and the fire did far more damage than the earthquake. Fire returned after 1989's Loma Prieta earthquake, fueled by a broken gas line, destroying parts of San Francisco's Marina District. This video compilation from the San Francisco Chronicle shows some of the extensive damage caused by the 1989 earthquake, such as the partial collapse of the Bay Bridge:

There is no large earthquake here without a fire, it seems, and many people wonder how well the fire department could handle another earthquake. To help bridge this gap, the San Francisco Fire Department now trains citizen groups in basic disaster skills, including rescue and disaster medicine. Because if you need fire fighters or paramedics, it's no use banging on the door of a townhouse that contains a fire station's original fire pole but cannot help anyone in need.

Drug Shortages: Blame Policies, Not Agencies

A recent article in the Washington Post by Rob Stein pointed out shortages of 211 medications in 2010, including lifesaving drugs used in emergency rooms and oncology wards ("Shortages of key drugs endanger patients"). What is causing this shortage? "Experts cite a confluence of factors," writes Stein:

Consolidation in the pharmaceutical industry has left only a few manufacturers for many older, less profitable products, meaning that when raw material runs short, equipment breaks down or government regulators crack down, the snags can quickly spiral into shortages.

Stein points out that there are especially acute shortages of generic medications (which aren't very profitable for manufacturers), especially sterile injectable medications (whose manufacturing processes are complicated and error-prone). There are also shortages of raw materials (often imported from abroad).

Stein cites the shortage of the leukemia and lymphoma drug cytarabine due to problems obtaining raw materials and manufacturing the drug. Cytarabine is a vital cancer drug that many hospitals have been forced to ration to patients. Inadequate medication substitutions have also lead to patient deaths, he said.

It's easy to blame the FDA for some of the problems with the drug supply. As Stein explains, "some industry representatives blame part of the problem on increased oversight by the FDA, which has made drug safety a higher priority after coming under intense criticism for being too lax." If the FDA would just skip a few manufacturing facility inspections, the supply pipeline would be smoother?

Drug supply problems don't originate with the FDA, however. Pharmaceutical manufacturers, eager to turn a healthy profit for their investors, would rather chase the next blockbuster drug (earning $1 billion or more in profits yearly) than thanklessly churn out low-profit items such as generic drugs and vaccines. Increasingly, venture capital firms that might fund new drug development would rather fund profitable new technologies than invest in better treatments for diseases.

The financial market, while it plays a role in drug development, should not drive public health decisions. The antidote to this problem is thoughtful legislation. Laws such as the Orphan Drug Act, which I've written about before, have successfully helped pharmaceutical companies refocus some of their energies on patient needs rather than profits.

Maybe the FDA could require that a company whose FDA-approved drug reached blockbuster status must ramp up its generic manufacturing to a certain level - building more manufacturing plants for a needed drug, or adding a popular vaccine to its roster -  before any more drugs are approved. Why not? Stronger regulations and incentives can encourage pharmaceutical manufacturers to diversify their assets and create a safer and more stable supply of drugs for everyone who might need them some day. 

Meningitis Vaccine Extended to Infants

I'm off to the ASJA Conference this week to moderate a panel on using widgets to maximize your blog (ahem, see the widget on the right for a link to the conference info). But this week's food for thought is the menigococcal disease vaccine Menactra, generally given to tweens and teens (and sometimes to at-risk children as young as 2), which the FDA just approved for children as young as 9 months old.

Will parents get the two-dose vaccine to help prevent bacterial meningitis in their young children - a rare but frightening disease that progresses so fast that it can outrun antibiotics? Or will they turn down the vaccine because there are already so many other vaccines on the CDC schedule for children under 2 years old? I'm wondering how this will play out.

Why it Matters How VCs Spend Their Money

In the biotechnology sector, when non-profit and government organizations can't or don't provide funding, venture capital firms (VCs) often do. The for-profit VCs, of course, want a good return on their investment -- first through promising clinical trials that lead to FDA approval for a product, then through wide and profitable adoption of the product by patients and their health care providers.

But because this process can take a decade or even longer, many VCs are putting their investment dollars into other projects with a quicker payout, particularly social networking, according to a recent Fierce Biotech post by John Carroll that cites a Reuters survey on the topic ("VCs: Chill sets in on biotech as social networking gets hot"). "Why invest in biotech companies which face years of risky clinical trial work," writes Carroll, "when you can grab a stake in a social networking company and potentially cash out in a year or two?"

This investment fickleness is one reason why we need government agencies like the NIH to fund promising research. But we also need VCs, because they have the deep pockets and the business expertise to bring needed health products to market, as long as their investors are willing to make long-term investments.Venture capital-funded companies are developing new vaccines, pain medications, gene therapies, and cancer treatments, to name just a few products.

Venture capital firms invested $5.9 billion in the first quarter of this year, and $784 million of that went to biotechnology, according to the MoneyTree (tm) Report created by PricewaterhouseCoopers, the National Venture Capital Association (NVCA), and Thomson Reuters. The software industry ($1.1 billion) and "Internet-specific companies" such as social networking sites ($1.2 billion) received the biggest pieces of the VC pie in the past quarter, according to an April 15 press release from the NVCA.

Venture capital firms invested more money in biotechnology over the past quarter than in the last quarter of 2010. But the NVCA press release stated that the money is divvied up among far fewer biotechnology companies now than in the past. This means that VCs are funding a smaller range of potential therapies.

It's hard to predict which therapies will succeed, but we need better treatments for widespread problems such as cancer and chronic pain. Ultimately we all benefit when VCs patiently fund the greatest possible number of promising therapies, instead of diverting funds to look for the next FaceBook.

RFID tags in Medicine

Radio frequency identification (RFID) tags can track people, equipment, and paperwork in a variety of settings. They are currently used to track objects ranging from military equipment and nuclear materials to more mundane retail merchandise. These chips are either passive, transmitting a signal only when an electronic device requests information, or active, constantly transmitting a readable signal.

RFID tags are gaining traction in medicine. Surgeons can use "smart" sponges embedded with RFID tags in the operating room, for example. Separate devices can electronically count the number of sponges used and scan the surgical site to make sure none are left in the body, where they can cause pain, infections, and other problems. RFID-embedded identification bracelets placed on infants in maternity wards and linked to alarms prevent unauthorized people from taking the infants from the area.

Outside the hospital wards, RFID-tagged pharmaceutical containers make it easier for the FDA to track the drugs' movement (especially the movement of controlled substances such as the pain reliever OxyContin) and to verify that the drugs are not counterfeit. Some paper medical records have been RFID-tagged to help health care workers find misplaced files.

The Affordable Care Act encourages the use of technology such as electronic medical records and RFID tags to improve medical care and (not coincidentally) to stretch health care dollars by decreasing administrative costs and other expenses. Technology like RFID chips, which can prevent expensive and damaging human errors, should remain just one tool used by health care providers, and does not relieve them of their responsibility to provide the best care they can. Tools can help them with data collection and analysis, but empathy, observation, and insight remain distinctly human, and necessary for good health care as well.

The Skewed Values of Drug Prices

The eye-popping pricing strategies for two pharmaceuticals have been big news lately. First, the cost of a weekly progesterone injection, designed to prevent premature births in at-risk pregnant women, jumped from about $20 per shot to $1,500 per shot.

What happened? The active ingredient of the shot had been compounded by pharmacies as needed by physician request to prevent premature births in the past, while the FDA quietly looked the other way. But in February, the FDA officially approved KV Pharmaceutical's version of the shot, Makena, and KV Pharmaceutical decided to raise the price - a lot.

It was a stunning move for a product whose development was partially funded by taxpayers through the National Institutes of Health, and whose approval had been fast-tracked and supported by the FDA's Orphan Drug Act, according to a recent FDA statement. In response to public outcry, KV Pharmaceutical later dropped the price to $690 per dose. 

Then, on March 30, Medicare announced (in a preliminary decision still in the comment phase) that it would cover the $93,000 price tag of Dendron Corporation's prostate cancer vaccine Provenge, which extends life for a few months in cancer patients.

Dendron's website currently runs an ad for Provenge called "Jonathan's story." In the ad, the patient says "fighting my cancer could mean meeting my new granddaughter, who is due in a few months."  But ironically, current health care policy pits infant health against health care for the elderly.

Is it wise to pay for medication that could extend a long life a few months longer, while allowing companies to create financial barriers to accessing medicine that could help an infant get a healthy start on life? It isn't if you look at health care as a tool to extend healthy years of life, a view that is currently shifting kidney allocation rules, as I've blogged before. In an opinion piece in the Washington Post this weekend, a prostate cancer survivor points out a similar resource allocation problem with Provenge:

One thing I can assure you is that I would never ask Medicare to pay $93,000 for a treatment to extend my life four months. However, I would ask Medicare officials this: if Provenge is prescribed to me as a possible treatment and I turn it down, could I put the savings into a college fund trust account for my grandchildren? I feel the country would benefit much more from educating three of its citizens than from keeping me around another four months. I have a hunch Medicare's answer would be no. 

We need to ask what society owes to two vulnerable populations - pregnant young women at risk of preterm delivery, and terminally ill older men. Rather than pittting ACOG against the AARP, we should step back and ask what is a reasonable amount of funds to invest in protecting each of these populations. And what is a fair and ethical price to charge for the medications they need?

MD Face-Off: Generalists vs. Specialists

Much has been written about the shortage of primary-care doctors needed to treat the influx of patients anticipated when the Affordable Care Act is fully implemented in 2014. To help solve this problem, Kaiser Health News reported today that some states are expanding the role of nurse practitioners to serve as a patient's primary care provider. The KHN Daily Report also cited a Chicago Sun-Times article about the increasing number of medical school students who choose to enter primary care fields ("More young doctors choosing careers in primary care"). These students are spurred on by health care reform's financial incentives for this choice, such as increased Medicare reimbursement.

But like many things in medicine (heck, in life as well), fixing the problem is more complicated than it first appears. More doctors alone don't always mean better patient care. In February, The Commonwealth Fund reported that a nationwide survey of about 2,500 Medicare patients found that patients with more doctors in their area weren't any happier with their care than patients with fewer doctors in their area. Improving health policy and organizing health care networks better might be more effective than adding more doctors to the mix, the survey's authors said in Health Affairs, which posted the study.

And when we look at the "doctor shortage" problem, should we focus on supporting generalists or specialists? Fierce Healthcare recently reported that a shortage of surgeons (not general practitioners) in some areas of the country leads to higher mortality rates after motor vehicle accidents. A recent study in the Journal of the American College of Surgeons found that in areas with fewer surgeons, accident victims are less likely to receive timely life-saving surgery.

Not that every doctor should specialize, though, because specialization in medicine has its own limitations. The title of a March report from the New England  Journal of Medicine shows the absurdity of current specialization trends: "Specialization, Subspecialization, and Subsubspecialization in Internal Medicine." The report's authors explain that formalized specialization fragments care, and the time spent maintaining certification might undermine a doctor's broader knowledge of his or her field. Patients, on the other hand, are impressed by the skill set implied by specialization. Health plans promote specialization as a marketing tool to attract more patients. There must be a reason to create each specialty, though, the authors write. "A proliferation of specialties without adequate justification may simply confuse the public without creating a social good," they conclude.

Ultimately, the problem of generalists versus specialists comes down to policy: what mix of generalists and specialists will best serve the public good? And what policies need to be in place to provide a steady supply of each type of doctor needed, and to help both types of doctors provide the best possible patient care?

Japan and America, Post-Quake

I'm not a morning person, but on Friday, March 11 I woke up fast when I heard the news announcer on the clock radio say something about a 9.0 earthquake in Japan, and a tsunami afterward, heading for the West coast where I live. The tsunami arrived a few hours later, around 8:00 a.m. PST, smashing boats together in Santa Cruz.

Since then, I've been following the news out of Japan as closely as I can, both because I've been writing about it for work and because I live in California. First, there were fears of another major earthquake on the West coast, at the other end of the Pacific plate. Then the worries shifted to the damaged Fukushima Daiichi nuclear reactors in Japan that were leaking radioactive materials, a scenario made more vivid by a somewhat misleading New York Times forecast of the jet stream whipping its way east from Japan. Stories about panicked Americans buying potassium iodide began to pop up in the media.

There's a certain myopia at work here, though. With Japan 5,000 miles away, for example, the radiation risk to the West coast is minimal. People in Japan are obviously much, much closer to the source. Furthermore, some of the daily aftershocks in Japan are bigger than some of the big earthquakes we've had out here, such as the Loma Prieta quake in 1989, a 6.9 on the Richter scale. Our troubles are small in comparison to Japan.

I worry about natural (and manmade) disasters as much as the next person. I've got my earthquake kit - I put it together long ago - and water bottles stashed around the house. But right now it's Japan that needs our help, and whose problems loom the largest.

How to Live Longer

Over the past two decades, aging institutes have sprung up in many states, often affiliated with academic institutions. These institutes look at how to live a long life and how to extend seniors' healthy years and decrease their disease and disability rates.

Improving the quality of life among seniors is not a strictly altruistic goal; keeping seniors healthy offsets the considerable expense of caring for a large aging population. As the roughly 80 million Baby Boomers start to enter retirement, the question how do you live a long and healthy life? is being asked with increasing urgency.

A new book, The Longevity Project, by psychology professors Howard S. Friedman and Leslie R. Martin, tries to answer the first part of that question. The authors analyzed data from a study of the lives of 1,500-plus Americans, begun in 1921 by Stanford psychologist Louis Terman.

The authors took a rigorous approach to their analysis, which they conducted over 20 years. As they explain on the book's website:

We used both sophisticated statistical models and a variety of examinations of personalities, social relations, and behaviors. We looked at people who shared characteristics—those with similar personalities, say, or a history of divorce—to see whether those traits predicted their health over time. Many of our findings took us by surprise.

Friedman and Martin found that people who are persistent and prudent in their approach to life tend to live the longest. Helping others helps you live longer, but having pets doesn't. Marriage benefits men, but not women. The most upbeat, happy people don't necessarily live the longest.

I'm interested in the book, as it looks at what habits contribute to a long life - a topic in which everyone has a personal interest. I'm also curious about how much it addresses the second half of the question - how to make long lives healthy ones - a topic in which society has a vested interest as well.

Surrounded by Lefties

I have a very personal interest in Tara Parker-Pope's blog post about lefties, based on a New York Times article about left-handedness by Perri Klass, "On the Left Hand, There Are No Easy Answers." Not because I'm left-handed - I'm not - but I am surrounded by lefties at home.

I'm sympathetic to the problems of being a leftie in a world dominated by righties (who make up about 90% of the population). But my three lefties get their revenge in my household. When I reach for a pair of scissors at home, half the time they don't work (for me) because I grabbed the left-handed ones. When we eat out, I need to make sure the lefties are sitting to the left of me, or we will bump elbows, possibly setting off a tantrum, depending on the leftie's age.

My lefties are a very creative bunch, though, I have to admit. They've turned tinfoil and Kleenex boxes into robot shoes, created a computer keyboard out of a piece of cardboard, and made their own fake iPod which they taped my real headphones to (hint hint, Mom). There's an endless procession of plays, songs, stories, and artwork, and we're always running out of glue and tape for projects, which disappear as fast as any office supplies that I accidentally leave lying around. And musical instruments are piling up so fast at our house that I've started to trip over them.

Of course there's lots of (somewhat self-serving) leftie-spotting in my family, usually identifying highly educated or highly creative lefties. Look - that doctor is a leftie! Obama is a leftie! My teacher is a leftie! Mark Twain, Gandhi, Benjamin Franklin - the list goes on.

I grew up in a family with no lefties, and my husband's family was evenly split. Here, though, they're in the majority. I like my pack of lefties, and the leftie refuge that is my house. When I go out, I'm among my rightie kin, but at home, the wild, mysterious (and often inexplicably sticky) lefties rule.

Changing Who Gets a Kidney

The nonprofit that oversees how human kidneys are distributed to people in need of a transplant is trying to change the distribution rules. Their goal is to maximize the number of years of life that a donated kidney can provide by changing how recipients are chosen.

The United Network for Organ Sharing (UNOS), which oversees organ donations from cadavers (not living donors), currently distributes kidneys based on who has been on the waiting list the longest. This process favors older patients over younger ones. A new UNOS plan that is currently open for public comment would prioritize kidney recipients based on two factors: the recipient's potential lifespan post-transplant (used when distributing the healthiest available kidneys), and whether the recipient's age is within 15 years of the donor.

These changes would most likely benefit patients who are younger than 50 years old more than the current system does. Recipients ages 50 and older would probably be less likely to receive a kidney under the proposed plan than under the current plan. Details about the plan are available online in the UNOS report "Concepts for Kidney Allocation."

In response to accusations of age discrimination, the report points out that since 1990, the percentage of potential recipients between ages 18 and 49 who have received a transplant has decreased, while the percentage of potential recipients ages 50 and older who received a transplant increased. The new plan was proposed to make the distribution system more fair.

Over 80,000 Americans are on the waiting list for a kidney, according to the National Kidney Foundation, and there are not enough kidneys available for everyone in need. The question is how to manage the valuable resource of a donated kidney.

A Washington Post article by Rob Stein about the proposed changes raises the larger question of how to ration limited health care resources. University of Pennsylvania bioethicist Arthur C. Caplan told Stein that the UNOS proposal "could have implications for other decisions about how to allocate scarce medical resources, such as expensive cancer drugs and ventilators during hurricanes and other emergencies."

Caplan explained, "We don't want to talk about rationing much in America. It's become taboo in any health-care discussion. But kidneys reminds us there are situations where you have to talk about rationing. You have no choice."

The UNOS report is grappling with a very complex topic, and it is the product of almost six years of work. I'm impressed by its attempt to analyze and improve an established system for kidney distribution. Academically, the topic is fascinating: what criteria do you use to make decisions about medical ethics?

But I have also interviewed kidney recipients, and those still on the waiting list, for stories I have written. I can't forget that there are so many individuals whose chances for a healthy or extended life are directly affected by UNOS policies; whatever UNOS decides, there will be winners and losers.

Lessons From Bacteria

The American Academy of Microbiology just released a Microbes & Oil Spills FAQ that explains how microbes can help clean up oil spills such as the 2010 spill in the Gulf of Mexico. The microbes that can consume and break down different types of oil are mostly bacteria and fungi.

The FAQ proved once again the amazing versatility of bacteria, a topic I've blogged about before. Bacteria native to the area of the spill, who draw their energy from consuming and breaking down oil, reproduce to increase their numbers when more oil is present in the water, and slow reproduction when less oil is present.

The FAQ pointed out that the oil leaked in a spill can outpace the microbes' ability to respond to it, and microbes can't always break down oil components easily or quickly. But the microbes' ability to remove some oil from the water and to expand and contract their numbers in response to what's in the water is impressive.

Although bacteria can spontaneously help mitigate the environmental impact of an oil spill, however, we can't control how they will respond to an environment that we create. Our overuse of antibiotics, for example, has contributed to the rise of antibiotic-resistant bacterial superbugs.

A CBC study of bacteria in raw chicken, reported on the Association of Health Care Journalists' Covering Health blog, found antibiotic-resistant bacteria in all the samples tested. Why? Because the chicken farmers gave large amounts of unnecessary antibiotics to healthy chickens so that they would grow larger.

Bacteria have survived because they are adaptable; I hope that one day we can plan better for both the advantages and the disadvantages of this ability.

Gourmets, Guilt, and Parenthood

I'm probably not a real foodie, because I used to live just a few blocks away from Alice Waters' Chez Panisse in Berkeley and I never actually ate there. Chez Panisse advocates humanely, locally, and sustainably-produced meat, fruits, and vegetables. As the restaurant's website explains for the uninitiated,

Since 1971, Chez Panisse has invited diners to partake of the immediacy and excitement of vegetables just out of the garden, fruit right off the branch, and fish straight out of the sea. In doing so, Chez Panisse has established a network of nearby suppliers who, like the restaurant, are striving for both environmental harmony and delicious flavor.

I thought about the time I spent in Berkeley when I read B. R. Myers' "The Moral Crusade Against Foodies" published in The Atlantic online. In the essay, he equates the foodie quest for the perfect food or meal not with morality and environmental harmony but with with gluttony. "The Catholic Church's criticism [of gluttony] has always been directed against an inordinate preoccupation with food - against foodie-ism, in other words," Myers writes.

Those with personal or religious (or medical?) restrictions on what they eat are laughed at by foodies, Myers writes:

In the involuted world of gourmet morals, constancy is rudeness. One must never spoil a dinner party for mere religious or ethical reasons. [Michael] Pollan says he sides with the French in regarding 'any personal dietary prohibition as bad manners.'... guests have a greater obligation to please their host... than vice versa.

The obesity epidemic clearly demonstrates that you are what you eat. But for some people, what you eat also reflects your class, income, and general merit. And those are more important factors for them than health.

Meanwhile, a study came out in the journal Child Development that found that 8 to 12 year old children of working mothers tend to have higher BMIs than those whose mothers don't work, particularly the older children in the study.

"The longer a mom's employment - whether she's toiling at a regular 9-to-5 job or works irregular hours - the more likely her child is to gain more weight than is healthy," wrote Kathleen Doheny in a WebMD article about the study. Working mothers might have heavier children because they spend less time planning and cooking healthy meals at home than mothers who don't work.

"This is a not a reason for moms to feel guilty," said the study's lead researcher Taryn Morrissey unreassuringly. After all, anything that makes mothers feel guilty, worried, or horrified usually gets media attention (Tiger Mom, anyone?), and this study has received a lot of press.

A mother who overthinks food because she wants to define herself and her class by what she feeds her children might be amoral and shallow. A working mother who does not spend enough time thinking about and planning what she feeds her children might be making her kids overweight and contributing to the obesity epidemic. The middle ground, where feeding the family is a function of budget, time, and effort (and where this task is not assigned immutably to the woman in the family), is a quiet, perhaps dull place. But that's where most of us live.

The Feds Clarify Healthy Eating

I know I'm not the only person who didn't like the My Pyramid healthy eating guide published in 2005 by the U.S. Department of Agriculture (USDA). The graphic features a stick figure climbing a pyramid made up of what looks like slices of pumpkin, lime, cherry, lemon, blueberry, and huckleberry pie. I don't think that's what the USDA meant to convey.

In late January, though, the USDA and the U.S. Department of Health and Human Services (HHS) got a few things right with their new (2010) Dietary Guidelines for Americans. The guidelines are reviewed and updated every five years. This latest update focuses more clearly on combating the rising rates of obesity and chronic disease among Americans.

The updated guidelines encourage Americans to pay attention to the amount of calories they consume and the amount of exercise they get. The guidelines also encourage replacing unhealthy foods with more nutrient-rich foods at each meal. Specifically, Americans should limit the amount of sodium, saturated fatty acids, dietary cholesterol, trans fatty acids, solid fats, added sugars, refined grains, and alcohol they consume. They should eat more fruits, vegetables, whole grains, fat-free or low-fat dairy and soy products, low-fat proteins, and seafood.

The new recommendations also stress eating a wider variety of healthy foods. For example, Americans should eat more red, orange, and dark-green vegetables, and eat a wider range of proteins (such as beans, nuts, and seeds). I think that a lack of variety - or perhaps simply a lack of imagination - is one of the greatest flaws of the typical American diet, which seems to be built on the four pillars of chicken, cheese, bread, and soda.

To help you start eating better, the February issue of Real Simple has an article on "The 30 Healthiest Foods." These foods include whole-grain pasta, barley, almonds, kale, avocados, sweet potatoes, oranges, and pumpkin. I recently made Real Simple's nutrient-rich recipe for spinach salad with salmon, barley, and oranges, which was very good, and a nice start for a healthier year.

What to Do About Household Toxins

Chemicals in paints and household cleaners might be contributing to a rise in childhood cancers, according to the toxin watchdog group Safer Chemicals, Healthy Families. The group is a coalition of individuals and organizations such as Physicians for Social Responsibility, the Environmental Defense Fund, and Moms Rising.

A recent WebMD article, "Childhood Leukemia, Brain Cancer on the Rise," explained that Safer Chemicals, Healthy Families believes that chlorinated solvents (used in paints and spot removers, for example) and lindane (a chemical sometimes used to treat scabies) might be contributing to rising childhood cancer rates. The number of childhood leukemia and brain cancer diagnoses has been increasing about 1% a year over the past 20 years, according to Boston University environmental health professor Richard Clapp.

The article states that improved diagnostic techniques might mean that these cancers are not really becoming more common, they are just being diagnosed more accurately. Some experts also believe that the chemicals and pesticides used today are more targeted, and thus less harmful, than those used in the past.

Still, it is worth thinking about our day-to-day exposure to toxins and their impact on our health. Safer Chemicals, Healthy Families would like to expand the 1976 Toxic Substances Control Act to better regulate the wide range of chemicals now in use in everyday products. Their website includes a resource page with links to nontoxic tips.

Surely everyone can take a few steps to decrease their household exposure to potentially harmful substances: replace a cleaner with a non-toxic alternative, switch out some standard produce for organic alternatives (start with the Environmental Working Group's dirty dozen, the most pesticide-laden fruits and vegetables), or order the Oregon Environmental Council's Eco-Friendly Home Checkup Guide.

Optimism and Teen Girls' Health

A new study of optimism has had a lot of media buzz lately, in a society somewhat obsessed with measuring happiness. The study raises questions about how optimism affects health in adolescents.

The study of 5,634 tweens and teens in Australia, published recently in Pediatrics, found that the more optimistic the participants were, the less likely they were to develop symptoms of depression. This effect was especially apparent among girls ("A Prospective Study of the Effects of Optimism on Adolescent Health Risks").

The study participants were surveyed to find out whether their levels of optimism were very low, low, high, or very high. The gender differences in how optimism affected them were striking. "Compared with girls with very low levels of optimism," the authors wrote, "boys with the same level of optimism were approximately half as likely to be depressed." 

Adolescent girls in the western world, who are more likely than adolescent boys to become depressed, are often expected to be cheerful and helpful. Are glum girls frowned upon where glum boys are tolerated? I worry that teen girls might feel pressured to deny or suppress occasional sadness, making those feelings more difficult to overcome.

Optimism can be difficult to measure, because people are often encouraged to act and think optimistically, whether or not they actually feel optimistic, so that they will be happier. But happiness is also a result of personality, history, life circumstances, and many other variables.

It's good to try to see the positive side of even difficult circumstances; an optimistic viewpoint is helpful in life. But it shouldn't be required all the time.

Would You Want to Know?

If you could find out what diseases you might have in the future, would you want to know? Researchers at Tufts Medical Center in Boston recently asked people this very question.

The survey they conducted, and whose results were published in a recent issue of Health Economics, asked 1,463 participants whether they would take a blood test to learn whether they would develop Alzheimer's disease, arthritis, breast cancer, or prostate cancer in the future. They were also asked how much they would pay for that test ("Willingness-to-pay for predictive tests with no immediate treatment implications: a survey of US residents").

Most participants in this hypothetical scenario said that they would want to know whether disease would strike in the future, particularly prostate or breast cancer. They would also be willing to pay up to several hundred dollars to find out.

About a quarter of participants, however, said they would not want to take the blood test. Researchers found that those who were healthier, older, well-educated, and female were more likely to decline the test. "Major concerns expressed included the cost of the test, living with the knowledge of one's disease risk, and the lack of preventive measures [to stop the disease from occurring]," a press release on the survey explained.

Is it better to know, or not to know, what illness you might develop in the future? For some people, it's easier not to know, to not add another worry to their life. I was surprised to learn that most people do want to know what diseases they might develop, though, even if they can't do anything to stop them.

Knowledge is power, and the participants that would want to take the blood test said that they would make the most of their time if they knew they were slated for a life-altering illness in the future, spending more time with family and traveling, for example.

A serious illness brings its own clarity to a person, stripping away trivial concerns, and refocusing their energies on the people and things they care about most. I wish more people had this clarity - without any traumatic trigger such as illness.

Skipping the New Year's Resolutions

No one I know seems to make New Year's resolutions any more. When I ask, people usually shake their heads and say that they don't think these resolutions are practical or helpful.

WebMD agrees. Rather than saddling yourself with a list of intimidating resolutions, it's better to make small, consistent, and measurable changes over time, writes Neil Osterweil ("In One Year, Out the Other").

I'm a list-maker myself, and I tend to write long lists of things to do. But staring at a multi-page to-do list is not motivating, especially first thing in the morning. Earlier this year, I read that it's better to just pick a few things to do each day. One life coach even suggests limiting your to-do list to a three-inch-square sticky note each morning, and not adding anything to your daily list once it's written ("If It Won't Fit on a Post-It, It Won't Fit in Your Day").
 
So I decided to write a short to-do list each day. I try to make my tasks concrete and make sure each one moves me toward my professional or personal goals. As a result, I have found that it's easier for me to cross everything off the list, which makes me feel and become more productive. With a shorter list, it's also easier for me to figure out how to divide up my time each day.

A list of ambitious New Year's resolutions is an extreme version of a long list of tasks to do; often, it will just make you miserable. Perhaps the recession has taught us to rethink our expectations, focus on smaller, more achievable goals, and enjoy a sense of accomplishment more often.