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A United Nations official arrives in Alabama this week to investigate poverty, inequality and “barriers to political participation” in the state
Alston will spend Thursday in Lowndes County, where he will be looking at issues like health care, access to clean and safe drinking water, and sanitation.
The Guardian reported in September on a study exposing the fact that a small number of people have tested positive for hookworm – a parasitic disease found in impoverished areas around the world – in Lowndes County.
 
What he’ll find if he looks-only 30% of the citizens of the county have functional septic tanks, 1 in 3 live in poverty and 1 on 5 will have no health insurance. That’s OK because he’ll find only 2 doctors, no dentists, no psychiatrists, He’ll find that 1 out of every 100 babies die before they reach a year old (worse than most developING countries) and one in two expectant mothers have little if any prenatal care.
 
Coincidentally, he’ll find that Lowndes County has one of the lowest median property tax rates in the country, Lowndes County is ranked 2682nd of the 3143 counties for property taxes as a percentage of median income..
 
He’ll find a county where slaves outnumbered their masters by 2 to one in 1860 and the population was 26000. He’ll find a county where blacks outnumber whites now by 3 to one but the population is now only 11,000. He’ll find a county where 1 in 5 are living off social security and one in 10 have no car. 
In other words, he’ll find the Alabama people think of when you say the word Alabama.
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Today, Mobile has set its sights beyond historic racial inequality, social inequity, and environmental disasters. Residents, local government, and community-based organizations are forging a consensus on what Mobile’s future should look like, from building an economically strong downtown to providing more easily accessible options for physical activity. Increasingly, community engagement and cross-sectoral partnerships are having a visible impact.

RWJF Culture of Health Sentinel Community Snapshot Mobile Al November 2016

I have to admit when I saw this I was a little taken aback. Tied up with the implementation of a new Electronic Health Record and planning a move to a new space, I figured I must have missed an e-mail or something. Mobile was one of 30 cities chosen by the Robert Woods Johnson Foundation from around the country. They were going to watch us as we developed “a culture of health.” I thought to myself “this is great” and “wow, what a big job.” I only hope that someone has been put in charge that is up to the task.

Because, as it turns out, a “culture of health” doesn’t just mean that we have good doctors and hospitals:

Think of social determinants as the root-causes of health and disease.

Imagine a bucket full of health. This bucket has a hole in the bottom and the health is dripping out (disease). We can mop up the floor below every hour, maybe even squeeze some of the health back into the bucket from the mop. But eventually, the health will be lost because we are not addressing the root of the problem. Instead, we can look for ways to prevent the hole and stop the leak from occurring.

And per the report we have a ways to go:

  • The median household income in Mobile is $38,644 per year, compared with $43,511 for Alabama and $53,482 for the United States (Figure 1).3 Inequality between the city’s black and white residents is striking, with black residents earning about half the median income of white ones. If you are poor you cannot afford good food, educational activities, or safe housing. These all are associated with poor health outcomes.
  • While more likely to have some college education or an associate’s degree in 2014 than they were in 2010 (Figure 2), the percentage of black residents who had a bachelor’s degree or higher in 2014 declined from 2010, despite increases in higher education among white residents. Educational attainment is always associated with better health outcomes. 
  • Teen pregnancy rates in Mobile County are 57 per 1,000 for women aged 13 to 19, compared with 47 per 1,000 in Alabama and 20 per 1,000 in the United States. Teen pregnancy is associated with a lack of knowledge regarding contraception and a lack of access to effective long acting contraceptive methods.
  • The county’s mortality outcomes are higher than the national average for preventable noncommunicable diseases, such as heart diseases, cancer, and diabetes. This reflects limited physical activity, limited opportunities for physical activity, and a very high level of obesity.
  • The city has an uninsured rate of 17%, which is more than 2% higher than the national average.

The report is very complementary of the Mayor’s “One Mobile” initiative and the Three Mile Creek park development.

Unfortunately, the community piece that was cited as most important in transforming our community was “Live Better Mobile.” From the press conference in 2012:

A “Live Better Mobile” program was unveiled today during a news conference. It’s aimed at creating public awareness focusing on three efforts – achieve healthy weights, prevent teen pregnancy, and quit tobacco.

The focus for the 37 community partners participating in the program is on prevention, nutrition and exercise.

“If we’re going to have a significant impact on health and well-being of our citizens, it’s going to take a community effort,” Dr. Bert Eichold of the Mobile County Health Department, said.

The group’s website is now dead. Their FaceBook page hasn’t been updated in a year.

So, Mobile, RWJF and the country are watching us. For the next five years they will be following the health of Mobilians. Are we up to the scrutiny? From the comments:

Talk from the fat cats is cheap. Want to encourage people in Mobile to Exercise? Give them a place to get out and exercise. Spend $70,000 on a weekly Ciclovia event. Pave that Rails-2-Trails from Prichard to Citronelle. Spend a money to construct Exercise Trails instead of spending money constructing Airbus Roads which don’t even have bicycle lanes.

 I just hope someone is in charge…

 

gca0111lThere is a great need to address the social factors that contribute to obesity and to initiate efforts on a broad scale to modify these factors. Much skepticism exists regarding the possibility of achieving success in the treatment of obesity. It is important to note that many of the cardiovascular complications of obesity arise as a result of mild to moderate degrees of overweight. The availability of ancillary personnel, eg, dietitians and exercise therapists, will be required to assist physicians in the treatment of obesity in the clinical setting. Finally, management of associated risk factors (atherogenic dyslipidemia, hypertension, prothrombic state, and insulin resistance) will help prevent the cardiovascular complications of obesity.

Krauss et al, Obesity, impact on cardiovascular disease, American Journal of Cardiology 1998

According to Moss, the first response came from the CEO of General Mills.

“[He] got up and made some very forceful points from his perspective,” Moss tells Fresh Air’sDave Davies, “and his points included this: We at General Mills have been responsible not only to consumers but to shareholders. We offer products that are low-fat, low-sugar, have whole grains in them, to people who are concerned about eating those products. “Bottom line being, though, that we need to ensure that our products taste good, because our accountability is also to our shareholders. And there’s no way we could start down-formulating the usage of salt, sugar, fat if the end result is going to be something that people do not want to eat.”

Report of a meeting about childhood obesity attended by processed food manufacturers in 1999

NPR “How the Food Industry Manipulates Taste Buds with ‘Salt Sugar Fat'”

Americans spent $676 trillion on food in 2012. Of that, 22% was spent on processed food, up from 11% in the 1980s. The percent of the population that is obese was 13% in 1987 and 28% in 2007. The health care expenditure per non-obese person in 1987 (constant dollars) was $2400 in 1987 and $4033 in 2007. The expenditure per OBESE person was $2630 and $5560 in 2007. A cardiologist (the specialty most likely to benefit from the obesity epidemic) makes about $400,000 today. That cardiologist in 1989 made about $200,000 (constant dollars). 

My research

In the world of processed foods, if people choose to drink water from the fountain, Coca Cola doesn’t get paid. The decision point at which the  potential customer decides to put his or her money in a machine and select a product has to happen a whole lot to appease the share holders. The average soda found in a machine costs about $2.00 and (if non-diet) 20 ounces has 227 calories. Why do people want to spend that money and waste those calories? Sugar, Salt, Fat – a new book out by Michael Moss – indicates that we do it because the food in engineered to appeal to all of our senses, leading us to off load some of our hard earned and misleading our bodies into not counting those calories as real. When it became apparent in the 1990s that our food science folks were too good at achieving this “Bliss Point” and childhood obesity was becoming epidemic, industry responded by doubling down on their already proven techniques.

In the fee-for-service world of American medicine, doctors don’t get paid unless people get sick. In the same way that a person walking past a soda machine but drinking from the water fountain is a failure for the vendor, the person who doesn’t have a heart attack is not contributing to the “cardiovascular service line” of their local hospital (they do contribute to the insurance bottom line which is a story for another day). The move Escape Fire (airing on CNN on March 10) “calls out” our current, illness based, system. The movie doesn’t pull any punches regarding patient culpability but makes it clear that our illness system is built on a “Bliss Point” that is unsustainable and does not include confronting the root causes of illness. Our job should be, among other things, counter-programming against the entrenched calorie interests, not benefiting mightily while ignoring 30 years of data regarding the causes and impacts of obesity.

This book and movie, the highly critical article in Time Magazine last week,  the call today of the National Commission on Physician Payment Reform to end the fee-for-service system all point to coming change. I only hope we as physicians end up on the side of health and not fall on our swords trying to protect the status quo.

abrn639lThis post comes 4 and 1/2 hours after completing a marathon. The marathon distance (26 miles, 385 yards)

commemorates the fabled run of the Greek soldier Pheidippides, a messenger from the Battle of Marathon, to Athens.

He died.

Marathoning isn’t for the casual runner. Most people who run marathons are happy if they only spend 4 hours on the course. The flap over Paul Ryan’s misremembering his time had traction, in part, because all of us remember particularly good times and finishing in under 3 hours would have been a really, really good time. To do a marathon well takes about 20 weeks of intensive training for people who are already running, requires continual good health, and requires good weather on the day of the run. My training partner was unable to run today after 20 weeks of training because of an ill-timed stomach bug. I ran into a former resident who is 25 years my junior who confessed that he hadn’t had time to train but he thought he might just knock out a marathon as today was his off-day. Today was hot. He came in over an hour after me.

Marathon runners, though healthy, may put their bodies at a slightly increased risk compared to more moderate runners:

In the new data, presented at the annual meeting of the American College of Sports Medicine, one of the study co-authors, Dr. Carl Lavie, medical director of cardiac rehabilitation and prevention at the John Ochsner Heart and Vascular Institute in New Orleans, reported on the optimal “dose” of running for increasing life expectancy. Among 14,000 runners, the optimal amount of exercise appeared to be about 10 to 15 miles per week. “We were thinking that we would see progressively more benefit the more you ran,” says Lavie. “We thought it would level off at some point. But not only did the runners not get more benefit, but the more they did, the faster they ran, the more frequently they ran, the more miles they ran, they actually seemed to lose any benefit to the heart.”

It is unclear how many of the marathon runners had previous smoking histories, scary family histories, or other risk factors that made them obsessively run but more likely to have an event. You may recall the story of marathon runner Jim Fixx:

Mr. Fixx, whose transition from a heavy young man who smoked two packs of cigarettes a day into a trimmer, middle-aged nonsmoking athlete seemed to insure a healthy life, died at the age of 52 while jogging in Vermont…his father had his first heart attack at the age of 35 and died of another one at 43.

Clearly, in trying to get patients to achieve a healthy cardiovascular workout, counseling people to shoot for a marathon would be silly. Running 10-15 miles a week is probably optimal.  I do not encourage the use of running as a substitute for optimal cholesterol management. When I give exercise prescriptions, I initially ask for 30 minutes a day. Most of my patients are starting at 0, so getting a commitment for 20 minutes of marginally aerobic activity (walk 10 minutes in one direction, turn and return home) with an increase over time (walk a block further this week than you have been doing) is what I hope for. I do not counsel people to run any further than a 10K. I only tell patients that I run marathons occasionally if asked.

Oh, you really want to know? 3 hours and 52 minutes, first place in my age group. Thanks for asking…

swine_cartoonMy daughter was home and we were watching 2 years worth of Downton Abby over the last 3 or 4 days. If you have been under a rock, have no access to popular media, or are purposefully boycotting tales of economic injustice, this is a BBC/PBS series about an English manor house, the lords, the ladies, and their servants (Also, if you are like my friend Tonya Caylor and are busily trying to play catch-up today, don’t read this until the end of your marathon). Last night the “Spanish Flu” of 1918-1919 hit, following the Armistice. The flu conveniently killed off one of the more troublesome characters, setting the stage for the Big Wedding.

While my wife and daughter were watching the costumes and the proper behavior, I was watching the doctor’s response to the flu. The family had just sat down to dinner (so it was likely around 7) without the head butler (who was ill) and the Lady of the house excuses herself from the table.

“Shall I ring the doctor?” someone asks at 7 at night…I can see how telephones were not a doctor’s friend.

“No,” says someone with sense, “it is late.”

That lasts for one scene and as the Countess becomes sicker the doctor is summoned. It is likely 10 pm….I wonder, if it had been the fish monger who rang him would he have gotten out of bed?

The doctor very quickly makes the diagnosis of Spanish Influenza (this part hasn’t changed, when flu hits doctors see flu everywhere they turn) and prescribes milk and cinnamon (the Tamiflu of its day). The case fatality rate on the show (the number of people dead/the number of people infected) was about 33%.

My wife asks me with a look of concern, “That can’t happen today, can it?”

The answer is…someday it will. What likely happened in 1918 -1919 was an antigenic shift of influenza (see picture below)

AntigenicShift_HiRes

What we know is that this happens predictably and occasionally with tragic results:

At least two of the major Influenza pandemics of the twentieth century, H2N2 in 1957 and H3N2 in 1968, resulted from reassortments between viruses from two different hosts, avian and human.

Why is this a problem? Under the best of circumstances, the influenza virus wants to keep the host alive. People, birds, pigs, monkeys all play an important part in the ongoing life of the virus. It cannot live on its own and wanders the world from sick person to sick person. A dead host is not helpful. The reason the 1918 strain was so lethal (20,000,000 known killed worldwide) was partly the human factor (we were moving folks from continent to continent to fight a war) and partly the virus (it in now known that this strain savagely attacks the lungs, leading to quick death in otherwise healthy people). It was not very successful as a virus…

Doctors spend a lot of time worrying about this. We worry for our patients (treatments are limited despite what drug companies tell you), for ourselves (health care workers will be among the first exposed), and for our future (when this happens the response is never pretty).

What should you do? As the Bible tells us, we know not the day nor the hour, but the CDC pays a lot of attention to potential pandemic flu (the belief is it’ll come from pigs and China). We can let our congressmen know that funding for this type of effort is covered in the “general welfare clause” of the constitution and should not be negotiable. When it comes, having warning will allow us plan for treatment (mostly supportive care) as well as to minimize deaths through isolation until it runs its course.

Regular flu season is now upon us, and it kills 50,000 Americans in an average year, mostly the young and the old. There are some things we can do to keep deaths from the regular flu down as well:

1) We can get vaccinated every year. That goes doubly true for health professionals. It isn’t too late this year, in case you’ve yet to get one.

2) The virus is spread through respiratory droplets. We can cover our coughs, wash our hands, and stay home if febrile.

3) While there is a treatment, it is not very effective (reduces febrile days by 1) and must be taken early. If you only have a mild case then rest, fluids, and ibuprofen may be all you need.

If you get the flu, I recommend Downton Abbey. It’ll last as long as the flu and make you feel better, too.

imagesWhen I was 11 or 12 I got a phone call late one evening.

“Did you hear?” the person on the other end asked, “Dusty committed suicide.”

Dusty was mostly a friend of a friend but I knew him on my own from school. The rest of the night was (as I recall) a succession of phone calls as a bunch of 12-year-old tried to make sense out of an event that was senseless. He lived on a farm and had used a gun. There was general agreement that he had not been sad or cried out for help, at least that any of us were willing to admit to. As this was the 1970s and no one knew quite what to do about the situation, there was no counseling or conversation about the event that I can recall. Life went on with Dusty’s seat empty as if he had gone off on a long vacation. I now know that this was likely an impulsive act in a child who had encountered a problem that to his 12 year old mind seemed insurmountable but if the gun had not been available might have seemed a whole lot better in the morning.

A blogger has written a piece that is going viral about her fears regarding her teenaged son. In it she describes this scene:

A few weeks ago, Michael pulled a knife and threatened to kill me and then himself after I asked him to return his overdue library books. His 7 and 9 year old siblings knew the safety plan—they ran to the car and locked the doors before I even asked them to. I managed to get the knife from Michael, then methodically collected all the sharp objects in the house into a single Tupperware container that now travels with me. Through it all, he continued to scream insults at me and threaten to kill or hurt me.

As the father of children now aged 20 and 22 and a physician who comes in contact with many troubled teens, I recognize that Michael’s behavior might become pathological to the point of resulting in harm to himself or others. I also am very aware that these behaviors might even out and Michael might become a great artist/writer/video game maker. Give Michael access to a gun and deny his mother access to mental health resources and Michael shoots himself, becoming another statistic. Worse, Michael shoots his mother and is being tried as an adult because “killin’s wrong.”

Too many real life episodes contain a couple of elements that intersect far too often. Moody, impulsive teenagers and easy access to guns are combinations that often result in harm. Transitioning to responsible adulthood is never easy and is very hard for some teens, particularly those who are troubled. While only 30%-40% of households have a gun, these homes often have multiple weapons. Even if these weapons are locked up, impulsiveness can lead to an action that is irreversible.

Over 20,000 young people were injured or killed by firearms in 2006. Guns are much more likely to be used successfully for a suicide than for other uses. Some arguments against unlimited freedom for guns and gun owners are as follows:

  • More preschoolers (63) were killed by firearms than law enforcement officers (48) killed in the line of duty.
  • Since 1979, gun violence has ended the lives of 107,603 children and teens in America. Sixty percent of them were White; 37 percent were Black.
  • Although correlation does not prove causality, there is a very strong positive relationship between the number of guns and the number of homicides.
  • In countries with low gun ownership, suicide rates are lower (other methods are not substituted)
  • A gun in the home is far more likely to be used for intimidation of another family member than it is for self-protection
  • Adolescent males, particularly smokers, binge drinkers, those who threatened others and whose parents were less likely to know their whereabouts were more likely both to be threatened with a gun and to use a gun in self-defense.
  • If there is an epidemic of criminals being shot while in the act of committing a crime, they are not seeking care at any hospital that reports bullet holes to authorities

As a physician, my primary responsibility is to my patients. I inquire about gun ownership during “well child” exams and inform parents of the safety risks of having a gun in the home. I agree with the American Academy of Pediatrics‘ stance on guns in the home, which is as follows:

Firearm-related injuries and deaths can be prevented when guns are stored safely away from children and adolescents in a locked case. Because of the severe, permanent nature of gun injuries in children, the AAP supports the strongest-possible legislative and regulatory approaches to reduce the accessibility of guns to children and adolescents:

  1. Consumer product regulations regarding child access, safety and design of guns
  2. Child access prevention laws that enforce safe storage practices including the use of trigger locks, lock boxes, and gun safes
  3. Regulation of the purchase of guns, including mandatory waiting periods, closure of the gun show loophole, mental health restrictions for gun purchases, and background checks
  4. Restoration of the ban on the sale of assault weapons to the general public

I would even take it a step further: If you have children, consider not having guns in the house. It could save a lot of lives.

For those of you not in clinical medicine, you may or may not have heard of the retrospectoscope. It is a very powerful diagnostic tool. It is almost never as useful as doctors wish it could be and in the wrong hands it can be dangerous. The scope is used to look into a clinical scenario from the perspective of time and with knowledge of the outcome of the event. In a malpractice trial, for example, the expert is often asked a question like “In your opinion, had the deceased been given a single dose of penicillin before her death, would the death have happened?” When the expert strokes his or her chin, and says “In my opinion, yes, the drug would have saved that patient’s life,” THAT is how retrospectoscope is used,

For those of you who are purposely avoiding current events, a former honors student in neuroscience took an arsenal into a movie theater early Friday morning and shot up the place, killing 12 people. This is a point in time where, if “something” had been done different, folks would not have been killed or injured by this lone gunman. Depending on one’s ability to look into the “scope,” it may be that the gunman was mentally unstable and this is a cry for more and better mental health care (is anyone who walks into a theater and shoots people stable?).  In fact, as evidence mounts that the alleged killer purchased his arsenal and ammunition (6000 rounds) within 60 days of the incident, it seems clear that anyone with that kind of behavior should have been under surveillance, doesn’t it? Though you may not have a home retrospectoscope, I guarantee you that CNN, Fox, and MSNBC have their commercial models running in overdrive.

It is my experience (time for me to use the retrospectoscope now) that there are a whole bunch of messed up people who are able to perform well in school (some on their own, some with the assistance of pharmacology) but have limited interpersonal skills and ability to interact with others. Occasionally, one of these people acts out, sometimes in a spectacular way (such as this) but often in a run of the mill way harming one or several people who may or may not have been trying to help. It is also my experience that we have stigmatized and  reduced resources, such as college counseling centers, designed to help these folks transition into meaningful career paths. We have medicalized a lot of education but are complicit in working with the system for the highest academic achievement instead of taking a more holistic approach. Lastly, we physicians have tolerated the commodification of weapons that exist only to cause harm to other human beings.

I don’t like using the retrospectoscope. The images are too clear and always point to the bad outcome in question. I do wish we would provide more resources to assist adolescents as they transition into adulthood. What kind of scope should I use to see that?

For those of you who read headlines off Google, the one that said 41% of Americans Obese by 2030 should have caught your eye. It did mine. Fortunately, in an odd coincidence, the Institute of Medicine has put out Accelerating Progress in Obesity Prevention, a document on what we as Americans can do to prevent becoming like the cruisers in Wall-E.

From their report, here are the actions we need to take:

Recommendation 1: Communities, transportation officials, community planners, health professionals, and governments should make promotion of physical activity a priority by substantially increasing access to places and opportunities for such activity.

Recommendation 2: Governments and decision makers in the business community/private sector should make a concerted effort to reduce unhealthy food and beverage options and substantially increase healthier food and beverage options at affordable, competitive prices.

Recommendation 3: Industry, educators, and governments should act quickly, aggressively, and in a sustained manner on many levels to transform the environment that surrounds Americans with messages about physical activity, food, and nutrition.

Recommendation 4: Health care and health service providers, employers, and insurers should increase the support structure for achieving better population health and obesity prevention.

Recommendation 5: Federal, state, and local government and education authorities, with support from parents, teachers, and the business community and the private sector, should make schools a focal point for obesity prevention.

Anyone up for a fight???

I do a column for the University on a weekly basis (it doesn’t pay anything either). I am asked to analyze health related news items and determine whether the “lamestream media” headlines are justified in the body of the actual article. What I have found is that for the most part the headlines are sensationalized, the articles are retreads of press releases sent out by the journals, and the scientist quoted in these press releases tend to exaggerate their findings. This was particularly apparent in the article I chose for this week. The headline screamed “Stress Causes Brain  Injury.”  The headline didn’t mention that the subjects were rats,  the stress was rat bondage and to find the injury they had to kill the little buggers (no doubt extra stressful).

The topic is extremely timely, however. Recently, there has been some very interesting human data appearing regarding constant psychological stress (such as exposure to racism) and illness. Unfortunately, these studies are limited because defining stress in the world we live in today is very difficult. Also, sacrificing victims of racism to look for brain lesions would be, well, racist.

I proclaimed the real take home message to this study is “more work is needed.” I really believe that stress reduction cannot hurt and is almost certainly a good thing for one’s health. This site has a nice tool to allow you to measure and monitor your stress level. Immediate reduction techniques mentioned include specific exercises, affirmations, and visualization. As I told the University employees, their plan might include eating right and exercising regularly, taking regular breaks, making to-do lists, being mindful on a daily basis, and using relaxation techniques daily. I have yet to receive feedback from the University President about how he will implement this.

I went to look a some commercial property in downtown Mobile yesterday and was reminded of the Roger Miller song, “King of the Road.” The building, clearly built in the 1920s had gone through a tragedy of some sort. The second story was apparently removed and added onto the structure in the 1940s were about 20 8×8 rooms, each with a sink. There was a door labelled “Office.” There was a common bath for all of the rooms. The word was that it was a “hotel” although I suspect that was being euphemistic. The whole area had been sealed in the 1960s (judging from the papers on the floor) and had not been maintained since. The roof had many leaks, the boards were suffering from dry rot, and even the rats seem to have abandoned the space for fear of disease.

We were looking for potential investment property and this would certainly allow us to invest quite a bit of money (sort of like a sailboat). The truth is that with enough money, the building could be made into a showplace. An article in the New England Journal reminds us that the body does not work that way. In this article people’s blood pressure, cholesterol level, smoking status, and diabetes status looked at in various ways. The investigators found that of the people who were 55 and had everything well controlled, 85% were very likely to live beyond 80 years of age regardless of race or sex. Of people who had two or more of their risk factors uncontrolled or who smoked, 50% were likely to be dead of heart disease or a stroke before age 80.

To fix this building, we would likely have to tear out the entire interior and retrofit it with a modern building. We would end up with a 1920s facade in a 1920s neighborhood but would functionally have a 2010s building. Many of my patients would like to believe that if they let their insides go, I can retrofit them as well. A better approach for the building would have been ongoing maintenance over the past 90 years. It turns out that it is the only approach for the human body.

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