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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.

I live and practice in Mobile, Alabama. Alabama is ranked #2 in the supersizing of America with 31% of our adults in the obese range and 14% of our children. The Trust for America’s health, who compiled the above data, lists some policy opportunities to reverse the trend (should we in Alabama chose to). These include:

  • Support obesity- and disease-prevention programs through the new health reform law’s Prevention and Public Health Fund
  • Align federal policies and legislation with the goals of the forthcoming National Prevention and Health Promotion Strategy.
  • Expand the commitment to community-based prevention programs
  • Continue to invest in research and evaluation on nutrition, physical activity, obesity and obesity-related health outcomes and associated interventions.

I was reminded of the ranking of our state by a future medical student who is very interested in healthy eating and obesity prevention, and he met with me to call my attention to Wholesome Wave, a program designed to inexpensively deliver fruits and vegetables to low-income patients.

Obesity is a huge (no pun intended) problem without an easy fix. In my conversation with Will, we talked at length about how the problem is a mixture of diminished opportunity to purchase and eat healthful  foods combined with limited opportunities to participate in physical activities.Programs such as this are a start but need to be combined with biking, walking, and other means of burning calories.

US News and World Reports offers another opinion. They found 22 experts

including nutritionists and specialists in diabetes, heart health, human behavior, and weight loss

who reviewed and rated 25 diets in seven categories, including short- and long-term weight loss, ease of compliance, safety, and nutrition.

The winner, as identified by the experts, was the DASH diet, rated 4.1 out of 5 (lots of vegetables, fruits, low in fat). The loser, the Paleo diet (eat only what cave men eat) was only rated 2.0 out of 5. The website offers a feature where readers can identify with a YES or  NO whether or not the diet worked for them. Although liked by the experts, the DASH diet has only been tried by 1600 readers and only 24% found it effective. By contrast, the Paleo diet had been tried by 30,000 folks with roughly the same amount of weight loss. The winners, based on readers clicking YES were the Vegetarian, the Vegan, and the Eco-Atkins (#10, #14, and #17) which had 93% self reported success by over 40,000 readers.

Fad diets tend to work in the short run by limiting food choices and forcing participants to select lower calorie options. This is reflected in the number of people who reported losing weight with the “bad diets.” This weight tends to come back as people revert to old habits hence the ongoing problem of obesity. On the other hand, losing weight is more than choosing healthy foods. Losing weight is always ultimately about burning more calories than you take in. The DASH diet is a healthy long term diet and, for example, would work even better if it included actual dashes. The Paleo diet to be effective would have to include participation in activities only a cave man might do. As to what that might be, you’ll have to use your imagination.

From the US Congress, 1837

Mr. L. insisted that the same reasons which had been urged by the gentleman from Louisiana (Mr. Johnson), in support of his amendment, applied with equal force to Mobile. That city was known to be increasing in population, wealth and business, with great rapidity. It was situated in a climate regarded as somewhat unhealthy at certain seasons, but its immense trade required the employment of seamen and boatmen at all seasons of the year, and if hospitals were to be provided for sick seamen and boatmen at the expense of the Government at any points, he regarded the southern cities as the places most entitled to notice. The amount he had proposed was small, and he hoped his amendment would not be rejected. The amendment prevailed without a division.

The last sentence seems sort of quaint today, doesn’t it. This was the discussion that ensued when the Marine Hospital in Mobile Alabama was funded in 1837. This bill funded hospitals in New Orleans, Mobile, Portland, Newport, and Wilmington, North Carolina, at a cost of $115,000 each.

Why were these hospitals needed? Most illness and death at the time was due to infectious disease. Most sick folks were treated in their homes;  physicians (or other healers) were in attendance, but the nursing was done by family members. In port cities, merchant seamen were necessary to transport goods  from America to Europe (here in Mobile, it was transporting cotton to Liverpool, England). To quote from the National Library of Medicine:

These seamen traveled widely, often became sick at sea, and then, away from their homes and families, could not find adequate health care in the port cities they visited or would overburden the meager public hospitals then in existence. Since they came from all the new states and former colonies, and could get sick anywhere, their health care became a national or Federal problem.

What began as a loose network of hospitals eventually became the US Public Health Service.

In the 1870s, when the Marine Hospital Service was federalized, the city of Mobile saw the need to provide these types of services for her citizens, and the Board of Health was created (by Alabama constitutional mandate). The duties included:

  • Examine all cases of malignant, pestilential, infectious, or epidemic disease
  • Exercise general supervision over sanitary regulation
  • Supervise all matters pertaining to quarantine
  • Supervise all measures of detention, disinfection, and purification of vessels from ports against which quarantine is proclaimed

The county health officer was employed by the Board to oversee the above. In addition, he was required to maintain vaccine and vaccinate all indigent people free of charge (that would be smallpox and rabies in 1873). He was also directed to maintain a dispensary where poor, sick people could receive care.

Fast forward to today. The traditional “health department” is performing roughly the same tasks as outlined in the 1870s, immunizations, control of infectious illnesses (in Mobile, mosquito control is a big part of this), and care of the  sick who happen to be poor. They are, it seems, victims of their own success. Malaria is unheard of in Mobile except when it arrives in a person who has traveled here with the parasite already incubating in his or her bloodstream. Vaccination has moved to the physician’s office with the Vaccines for Children program. Community Health Centers have taken over care of the poor sick. The public health focus needs to be on prevention and early detection of chronic illnesses. These account for 70% of American deaths and most of our disability. Many chronic illnesses are a consequence of tobacco use, poor diet, sedentary lifestyle, and risky behavior.

In Louisville, Kentucky, the “Board of Health” is now the Louisville Metro Department of Public Health and Wellness. Not only do they do they perform the traditional health department role but they

  • provide education regarding health behaviors that affect health, such as tobacco use
  • distribute condoms to prevent STIs
  • work to combat childhood obesity through physical activity
  • work to eliminate food deserts through food justice
  • sponsor a health equity speaker series

They do this in a belief that they can address the root causes of health disparities by supporting projects, policies and research working to change the correlation between health and longevity and socioeconomic status.

A far cry from running the quarantine station, is it not?

On Sunday, All Saints Episcopal Church in our neighborhood is playing “In sickness and in wealth”  with a discussion to follow. This documentary uses people’s stories, people who work at the same company but have dramatically different lives, to illustrate the contribution to poverty and societal stress to the ill health of some Americans. The documentary makes the following point:

What needs to be done is to make sure that everyone is allowed access to the same opportunities even if they do not have the economic resources.  This would involve providing resources such as quality education, decent housing, access to affordable health care, and access to healthy food and safe places to exercise to everyone despite gaps in affluence.  Having access to such resources would simulate the control felt by the affluent when they come to make such choices regarding health.

The documentary was done in 2007. Things have not gotten much better. My friend Josh Freeman recently wrote about a presentation he saw by Stephen Woolf on the same topic done this year (found here). Josh reports that Stephen presented information familiar to those of us with an interest in public health but somehow lost in the debate over health insurance, such as that to truly improve health the practitioner needs to go outside the hospital or office to the community, where these causes of ill health are located.

Doctor Woolf advocates the use of “Health in All” policies.  These policies take into account the reality that decision-making regarding transportation, land use, built environment, taxes, housing, agriculture, and environmental justice, for example, affect health.  For example, the fact that  2.3 million (2.2%) of continental US households are more than a mile from a supermarket and do not have access to a vehicle should inform policies regarding public transportation and land use, among others.

Turns out, we can purchase better health. If we want to make improvements in the health of our citizens, we probably should focus as much on education and improving the overall living environment (including improvements in working conditions) as we focus on health care insurance. There is now a calculator that allows counties to compare where they are to where they could be if only their citizens were better educated. For Mobile County, for example, just by improving our educational status to that of Shelby County (Alabama’s best) we could avert 459 deaths in the county.

To quote my friend, Josh, about the same observation in a Kansas comparison:

No drug comes close to this. No treatment of any kind comes close to this. If a new drug were shown to reduce mortality from a disease by 5%, or even 1%, it would get incredible advertising – hundreds of millions of dollars – and huge publicity, in both the scientific and lay press. But the simple fact that so many more deaths could be prevented, so many lives could be improved, by addressing the social determinants of health, is scarcely covered, and hardly funded at all.

The town in which I live has seen its share of trouble. Some of the trouble is caused by nature. As I sit here writing this, we are being visited by a violent thunderstorm, as we are almost every day during the summer. Not only do the thunderstorms sometimes cause damage, but the heavy rains provide an environment where mosquitoes (as well as other insects)  propagate at a level most people cannot even imagine. It was no accident that William Gorgas, E O Wilson, and others focused their great intellects on insects after growing up in Mobile. We got a lot of bugs, many of which cause diseases in humans. Oh yeah, and every couple of years we get hurricanes. Some, like Katrina, create enough of a stir that we forget about the bugs for a while.

As if this weren’t enough, humans seem intent on adding to our woes. Southern novelists have filled books on the theme of  “man’s inhumanity to man.” In one of the greatest ironies of all, America’s quest for cheap oil (drill, baby, drill) landed 4.9 million barrels of oil in the Gulf of Mexico. Much of this oil went on to disrupt the economy of Alabama either directly (can’t catch fish through oil) or indirectly (wanna drive 300 miles and see if the beaches are clean today?).

Given hurricanes, oil spills, lots of mosquitoes that might carry West Nile disease, not to mention the general hardships of living, life can be tough. This being the case, we on the coast should cultivate and value the ability to quickly recover from disasters and get back to status quo.

That is why I read with interest that a “Resilience Capacity Scale” has been developed. The initial story that I read (“What’s our resilience capacity?” Mobile Press-Register, link now available) did not lead me to believe this new scale would be useful. The article implied that the information used to create the scale was unfairly biased against Alabama and Mississippi. In searching for that article to link to, I found another article from an Alabama newspaper, with site comments that do seem to show anger at this perceived bias. Here is a representative response:

This study was funded by the John D. and Catherine T. MacArthur Foundation and administered by the University of California, Berkeley. No doubt the 12 economic, socio-demographic, and community connectivity indicators are from the perspective of the socialist mentality of the John D and Catherine T. MacArthur Foundation and their fellow travelers at the U of California at Berkely [sic].

I have subsequently spent a little time with the instrument, found here. The purpose, it turns out, is not to further the socialist agenda  but:

One way to assess a region’s resilience is by its qualities to cope with future challenges, a concept we label resilience capacity. Developed by Kathryn A. Foster, member of the BRR research network and director of the University at Buffalo Regional Institute, the Resilience Capacity Index (RCI) is a single statistic summarizing a region’s score on 12 equally weighted indicators—four indicators in each of three dimensions encompassing Regional Economic, Socio-Demographic, and Community Connectivity attributes. As a gauge of a region’s foundation for responding effectively to a future stress, the RCI reveals regional strengths and weaknesses, and allows regional leaders to compare their region’s capacity profile to that of other metropolitan areas.

The capacity is determined by an assessment of regional economic capacity (resilient communities have a narrow range of income across households, diversification of the  economy, affordable housing relative to income levels, and hospitable business environments as measured by business churn and access to venture capital and broadband), socio-demographic capacity (resilient communities have high levels of college-educated people and low levels of non-high school graduates, low proportions of the population with disabilities or living in poverty, and high proportions of people with health insurance) and community connectivity ((resilient communities have high rootedness and familiarity, with low in- and out-migration and high homeownership coupled with commitment to place demonstrated by the presence of civic organizations and high voter turnout). Mobile did not do badly in economic resilience (170/361) and community connectedness (171/361) but did very poorly in socio-demographic  (303/361).

So our global score of LOW (229/361) does not reflect the discounting of church membership (as was suggested in our local paper) but instead is reflective of our poorly educated populace who have a relatively high rate of disability, who are less likely to be employed and more likely to live in poverty, and who are less likely to have health insurance than all but 61 of the metropolitan areas assessed.

Following the Gulf Oil Spill, a leadership driven process produced a report entitled A Roadmap to Resilience. In this process, several hundred community leaders came together to “Build regional capacity for long term resilience.” They pledged to “Keep it simple.” This report is 194 pages and includes everything from drug education to building a $500,000,000 bridge with federal funds. Turns out, they could have greatly increased the resilience of Mobilians by focusing on three things:

  • An education system second to none from K-graduate school
  • Universal access to healthcare
  • Full employment

I think for those of us down here on the mosquito coast, that’s not too much to ask.

The Robert Wood Johnson Foundation and the University of Wisconsin have put together a web site which compares the health status of counties within states. Originally done by the University of Wisconsin for Wisconsinites, last year they expanded it to all (well, all but 115) counties in the United States. The local paper dutifully published an article, identifying Mobile County as a low performing county (#46, down from #43 last year) and the neighboring county of Baldwin as a high performing county (#3). The next day, the paper decided to get serious, publishing an editorial identifying what was measured

Social factors and health habits are taken into account in the health rankings, including obesity, smoking, high school graduation rates, air pollution, access to health care, access to exercise and life expectancy.

and pointed out that perhaps building a walking trail would solve all of our problems

From a health standpoint, trails offer cheap and easy opportunities for exercise. Families can walk together; those beginning an exercise program can try a one- or two-mile stretch of trail and improve.

In reality, being third in the 45th ranked state is nothing to brag about. Anyone who knows anything about who lives in cities as opposed to who lives in suburbs likely can make an educated guess as to why Baldwin (suburbs) has better health statistics than Mobile (city) and it has little to do with a 2 mile walking trail.

A more interesting comparison tool, found here, compares counties against others of similar demographics and economics. In this comparison Mobile County still doesn’t fare very well (average life expectancy 73.6 years, peers 73.5-77.8 years, every marker worse than peers except immunization rates and prenatal care access) but Baldwin is no great shakes either (average life expectancy 76.6 years, peers 75.5-78.2 years, worse than peers except in breast cancer survival, infant mortality, and suicide rates).

The purpose of the rankings is not, or so says the University of Wisconsin, to facilitate boosterism but in the hopes that communities will use this information to work towards improving the health of the citizens. I hope that the local paper (as well as the media outlet of any communities whose “rankings” were not what they would like) will look at this page where action steps are discussed. These action steps include working together as a community, finding programs and policies that work, implementing strategies, assessing needs and resources, evaluating efforts, and picking priorities. Additionally, they have targeted advice for community leaders, educators, health professionals, and government officials, and public health officials.

Here is the advice for the community leaders, in case anyone from the local paper is paying attention

  • Get the word out. Reach out to people you know and see every day about the County Health Rankings report, e.g., at a local Chamber of Commerce breakfast or at an urban planning meeting. Post information about the report on a listserv, website, or e-newsletter.
  • Organize. Meet with local leaders and community residents to discuss barriers to health and ways to overcome them. Host a town hall meeting or invite people to one.
  • Get policymakers to pay attention. Tell them about how their county or counties ranked and open a dialogue about ways to improve health in your community.
  • Be an advocate. Step out as a spokesperson about the rankings and the health issues you care about and rally other community leaders to take action.
  • Contact your local public health department about participating in a local task force or, if none exists, organize one to tackle these pressing issues in your community.
  • Ask your local or state health department about what they’re doing in response to the report to make sure you aren’t duplicating efforts.
  • Share your resources. Offer your time, staff, and/or funding with community partners. These are resources that can go toward community plans and programs aimed at tackling factors that affect health.
  • Communicate your message. Write an op-ed or talk to local media about the rankings and what needs to be done to improve the health of your community.
  • Start a conversation. Talk to your friends, colleagues, neighbors, and family members about the health of your community and what everyone collectively can do to make it healthier.

Now that the word is out in Mobile, I hope we’re able to make the rest happen here.

I was reading an article in the New England Journal of Medicine about Accountable Care Organizations last night and was reminded of “path dependence” as an explanation of why healthcare is in the state it is in today. A summary of what these organizations should be able to do is found below

What’s not to like? Turns out there some barriers in moving from our current system to our new system. The first is that doctors do not work well together to deliver coordinated care. Sandbox was not our strongest subject in school. Secondly, physicians have been especially slow to embrace technology (if the stethoscope was good enough for Laennec, it should be good enough for me). You can get your money on another continent but not your health records. Lastly, hospitals have been the capital engine of the health care market and it is possible they may not relinquish control.

This last point illustrates the problem of path dependency. As discussed in the article

Established institutional relationships tend to persist because of “path dependence”: decisions about the future are constrained by decisions made in the past, even though circumstances may change. Although it is unequivocally inefficient, inequitable, and otherwise problematic to finance health care with a combination of employer-based coverage, Medicare, and Medicaid, it has proved impossible to change this structure.

Why work to change course? If you have to ask this, read this post.

Addendum: The president’s oil spill commission came out and said that most of the oil money should go to environmental restoration, to the dismay of Alabama coastal economic leaders. As I discussed previously here, part of the proposal was to strengthen primary care in the region so I should be disappointed but in truth I think they are correct. At any rate, you can still hear the croud chanting “Monorail, monorail, monorail!”

I feel like I have a fairly unique perspective on the Deep Water Horizon incident (it is not an accident) in the Gulf of Mexico. First, because I have lived for 45 of my 50 years on the Gulf Coast. Second, because of the 5 years I was not on the Gulf coast, 4 of those were spent in the diving Navy. Third, because as a physician I feel qualified to comment on the health effects of the incident.

Louisiana has always had a love-hate relationship with the water of the Mississippi as well as the water of the Gulf, and control through levees has led to significant wetlands loss. Based on my time in Louisiana and now in the Alabama coast, I can report Louisianans also have a love-hate relationship with Big Oil.  Those of us on the coast have learned to co-exist with energy extraction technology (lots of jobs) but have not demanded care and caution be taken by those companies over time.  In Drawing Louisiana’s New Map: Addressing Land Loss in Coastal Louisiana the National Academies point out that the oil and gas companies in the past dredged canals for exploration which led to significant wetlands loss. There are currently 10 major navigation canals and 9,300 miles of pipelines in coastal Louisiana serving about 50,000 oil and gas production facilities. These canals, which are perpendicular to the coast, have created new open water areas, drowning wetlands and allowing salt-water intrusion into freshwater ecosystems. The result—land loss hot spots. “There is also evidence,” the report says, “that extraction of large volumes of oil and gas has exacerbated the problems of inundation and saltwater intrusion”—that is, withdrawing oil and gas along geologic faults seems to exacerbate subsidence in coastal Louisiana. Former Governor Blanco, in fact, cut a deal with the federal government to allow deep water exploration in exchange for revenues to fix the wetland loss caused by such infrastructure development.

From my experience in the diving Navy, I can tell you that the federal government does not have any better technology than BP does when it comes to working a mile down. The depth limits of human beings going down to fix something is about 330 feet of sea water (fsw). The depth limit for people going down in a saturation environment to fix something is around 1500 fsw. Beyond that and you have teeny remote controlled robots trying to use a wrench to fix things. In the Navy we learned not to drill a hole we can’t plug and we learned you can’t plug anything easily below 1500 fsw. That still seems to be the case.

The medical aspect of this incident is more uncertain. We know people will suffer acute illnesses from exposure no matter how protected they are. We know that for the workers there will be excess cancers due to exposure to hydrocarbons. We also know that for people who eat seafood there will be ingestion exposures for years to come. For the rest of Americans, though, the exposure to hydrocarbons is more likely to be lethal in a different way. Thanks to our love affair with the car (40% of all oil consumed in this country, average commute 104 minutes) we are not expending enough energy and consuming too many calories to boot. Could it be that 70% of Americans are obese for a reason? If Americans were to rearrange their lives to spend less time in the car and expend more energy in other activities we would be a much healthier nation. In addition, maybe the Louisiana wetlands (and other more be-soiled places) would eventually recover and we might not feel compelled to punch holes in the bottom of the ocean we can’t close up.