preventive medicine


Do You Really Need That Tetanus Booster? One Man’s Ordeal

A patient suffering from tetanus (painting by Sir Charles Bell, 1809, via Wikimedia Commons)

A patient suffering from tetanus (painting by Sir Charles Bell, 1809, via Wikimedia Commons)

By David C. Holzman
Guest Contributor

I didn’t think it was a big deal. I’d stepped on a shell in Wellfleet Harbor, and it had sliced into my foot, and drawn blood. Heck, I didn’t even think tetanus bacteria hung out in salt water — they like soil, especially if the icing atop its cake is manure. But my anguished Jewish mother was all “get over to AIM [the local health clinic] right away, before lockjaw has a chance to set in.”

Of course, the power of the Jewish Mother to inflict fear and guilt is legendary. So I ultimately hauled my derriere over to AIM. But there was a problem.

I had first learned I was allergic to tetanus shots when I was 17 — two decades earlier. I don’t remember what I’d stepped on, but I’d ended up having to go back to AIM a couple of hours after the tetanus shot, so that they could check out the hives that had sprouted from feet to nether regions to scalp. While I was in no immediate danger, I was advised that the specter of anaphylactic shock loomed over any future tetanus shots.

But now at AIM once again, I wasn’t anticipating a problem because a year after the hives, I’d stepped on something on a trip in England. But the nice doctor who had given me that injection swore that he’d quit the profession if the preventive shot he’d given me with the tetanus shot failed to protect me from hives, or any other reaction.

So I figured the docs at AIM would also know what to give me to prevent a reaction. But instead, they gave me some gobbledygook about how I should really wait until I got home — which was Washington, D.C. at the time — and let my own doc give me the shot. But the docs at Group Health, my then-HMO, were equally stymied by my predicament. Continue reading

‘Sitting Is The New Smoking’? Well, No, But Got Your Attention

A sign in the MIT gym (Sprax Lines/WBUR)

A sign in the MIT gym (Sprax Lines/WBUR)

I’d been nagging — I mean, gently reminding — my husband to arrange some sort of standing work desk for himself for months, so when he came across this big sign in the MIT gym recently, he texted me a photo as reassurance that mine was not a voice in the wilderness. My message had been reinforced in a palace of fitness.

Any sort of “You’re right, honey” is surely pleasant, but I found myself also struggling with some ambivalence that I can sum up in one word:


That is, do the health data really show that sitting is tantamount to smoking, the ultimate unhealthy behavior?

I didn’t rule it out. In recent months, study after study has suggested that sitting too much can shave years off your life — even if you work out. We’ve written about some of them, and included Dr. Eddie Phillips’ nicely turned phrase, “Sitting is a ‘disease state.’

I certainly don’t want to feel that every time I cuddle up next to my wife on the couch it’s the equivalent of lighting a cigarette.

But the ‘new smoking’ headlines have been proliferating to the point that the phrase seems to be turning into one of those little viral units of culture called memes. Runner’s World warns: Sitting is the new smoking even for runners. Wired reports from the center of its universe: In Silicon Valley, Sitting Is The New Smoking. Baltimore TV weighs in: Sitting Is The New Smoking, with the sub-headline, “Are chairs causing more deaths than cigarettes?” And even the august Harvard Business Review: Sitting is the Smoking of our Generation.

I suspect that one particular researcher may have particularly helped fuel the sitting-smoking meme. From the Los Angeles Times piece headlined, “Don’t Just Sit There.”

“Sitting is the new smoking,” says Anup Kanodia, a physician and researcher at the Center for Personalized Health Care at Ohio State University’s Wexner Medical Center. As evidence, he cites an Australian study published in October 2012 in the British Journal of Sports Medicine that compared the two pastimes. Every hour of TV that people watch, presumably while sitting, cuts about 22 minutes from their life span, the study’s authors calculated. By contrast, it’s estimated that smokers shorten their lives by about 11 minutes per cigarette.

For a reality check, I turned to Dr. David Katz, director of the Yale University Prevention Research Center, fellow of the American College of Preventive Medicine and author of Disease Proof, a new book he describes as sharing “the truth about what it takes to get to health” and offering the skill set needed to get there. I asked him to take my question — “Really? Sitting is the new smoking?” — and riff on it as he saw fit. His response, lightly edited:

It seems to be the case that for any message to break through in our popular culture, it’s got to be hyperbolic. As we’re talking, one of the hot news items is that Oreos are more addictive than cocaine, all of this based on a study of about three rats. It’s completely overblown. That’s what we do.

So the specifics of smoking and sitting would be best addressed by looking at populations that do both and asking what ‘gets’ them. If you’ve got populations that sit comparably, and one group smokes and one doesn’t — and we’ve had that natural experiment, we’re a very sedentary society, we all do a lot of sitting — but there are smokers and non-smokers, and smokers tend to die younger and horribly. So clearly smoking is worse than sitting.

But there’s what the message says, which isn’t quite true — smoking is clearly worse, and if you are a person doing both, I’d say focus on giving up the cigarettes and then we’ll get you out of your chair — but I think what he message is meant to imply rather than what it states explicitly is that this is a threat to health, being too sedentary, spending too much time on our backsides. Continue reading

Can My Company’s Wellness Program Really Ask Me To Do That?

doctor exam

(Wikimedia Commons)

“Wellness” is like apple pie, isn’t it? What could possibly be bad about companies helping their workers be healthier?

I wouldn’t dream of finding fault with many typical wellness offerings: Quit-smoking programs, on-site gyms, more appealing cafeteria salads. Good for worker, good for employer, everybody’s happy. But consider this email I received from an employee at a major national retailer:

I see you’ve written several articles about the new health insurance laws, etc. The company I work for has [a major national insurer]. Last year we received a $25 discount bi-weekly if we filled out a health questionnaire, which of course everyone felt compelled to do as that would be a savings of $650 per year. Most people I spoke to felt uneasy doing it, as they felt it would lead to other invasive practices. Well, sure enough, this year, if you DON’T smoke cigarettes you get $10 off bi-weekly, but to get the additional $25 not only do you have to fill out a questionnaire, but everyone employed [here] (and taking the health insurance) has to have a screening which involves:
1. Waistline measurement
2. Blood pressure measurement
3. Blood draw to test for glucose, HDL and triglyceride levels.
If you do not pass these tests, you will lose your $25 if these are not brought down to an acceptable level by August (when we will be tested again).
Needless to say, this really shook a lot of people up, as it is so invasive, and is this even legal?
Would love to hear your thoughts on this.

Let’s cut to the chase. Yes, it’s legal. And it’s a huge trend that began with only “carrots” — discounts on gym memberships, fun health fairs — and is now progressing to sticks. Or at least, to carrots that can feel a whole lot like sticks.

There are some important limits on what your company’s wellness program can do. More on that soon. But here’s the bottom line: Under federal law, your employer can vary your health insurance premium by up to 20 percent based on a “health factor;” that goes up to 30% as of 2014 and the government could eventually raise it as high as 50%.

Why should you foot the bill for all your Marlboro-packing, Miller-cracking, Big-Mac-chomping co-workers?

Readers, what do you think? On the one hand, if you’re a fit, non-smoking, careful eater, why should you have to help foot the bill for all your Marlboro-packing, Miller-cracking, Big-Mac-chomping co-workers? An unhealthy lifestyle is known to be a major contributor to health care bills. and health costs have skyrocketed for years, sending premiums through the roof, hurting businesses and costing jobs. Any levers to bring them down must surely be tried.

On the other hand, there is clearly a potential yuck factor here. Having my employer measure my waist, or draw my blood??? Getting weighed and monitored in the workplace setting, or in the personnel filing cabinet, may not always be comfortable. What if my boss starts a “fun” pedometer contest among our company’s departments and I’m the morbidly obese one? What about my medical privacy? Continue reading

Surgeon General To Speak at Harvard On National Prevention Strategy

Marking my calendar, thought you might like to as well. Doctors for America sent over an invitation to hear the U.S. Surgeon General, Dr. Regina Benjamin, speak at Harvard Medical School on March 21 about the national prevention strategy (Did you know we had one?) as it nears its first anniversary. All health care professionals are welcome and admission is free but you need to register in advance here.

In her recent speech at TEDMED above, Dr. Benjamin recalls that her immediate family could not attend the White House press conference at which President Obama announced her appointment, because her brother had died of HIV, her mother died of lung cancer a year later, and a few years later her father died of complications of a stroke. “All preventable diseases. And so I hope that other family members don’t have to  suffer through the loss of family members,” she says.

From Doctors For America:

In June 2010, Dr. Benjamin unveiled the nation’s first National Prevention Strategy – a roadmap for increasing the number of Americans who are healthy at every stage of life. The NPS recognizes that everyone – health care providers, businesses, educators, government, and communities – have a role to play in transforming our communities into forces for health promotion. Continue reading

Pediatrician’s Dilemma: Drop Families That Refuse To Vaccinate?

A young boy is vaccinated against MMR in Scotland in 2007.

Question: If parents refuse to have their children vaccinated, is it ethical for a pediatrician to respond by refusing to be their doctor?

Answer: That’s under continuing debate. But a new report finds that 25% of pediatricians do “dismiss” anti-vaccine families from their practices.

Question: Readers, what do you think? And please let us know if reading this post changes your opinion at all.

Dr. Ian Sklaver, an experienced pediatrician at Garden City Pediatrics in Beverly, welcomes parents’ questions about vaccines. If they want to spread out the shots so not as many are given at one visit, he’ll do it. He wants them to be as comfortable with vaccines as possible.

But if a family refuses crucial vaccines and will not be budged, “then I suggest to them that I am not the right doctor for their family,” he said in an e-mail. “I would not feel like I was providing good care to someone who was refusing immunizations. I certainly would try to change their minds, but I have had to ask a handful of patients to leave.”

“If the overwhelming abundance of scientific information and my own strongly held beliefs do not convince them, then I have to let them know that I think their decision is leaving their child at risk of grave harm and I would not want to be a part of that decision,” he said. “I also have to consider the other children in my waiting room who would be exposed to the unimmunized child, putting them at risk as well.”

A new study out this month finds that Ian is far from alone. The national survey of several hundred pediatricians found that a substantial minority, about 25 percent, do always, often or sometimes “dismiss families” from the practice if they refuse vaccines in the “primary series” — the basic vaccines including polio and diphteria.

Dr. Allison Kempe

It’s no easy decision. “The bottom line is that it really is an ethical dilemma for pediatricians,” said Dr. Allison Kempe, lead author of the paper in the American Journal of Preventive Medicine. “I can tell you that personally, it’s an ethical dilemma for me.”

The issue of vaccine refusal has bedeviled pediatricians for years, and persuading reluctant parents to vaccinate has become a huge time-sink in many practices. No matter how many scientific studies come out exonerating vaccines of any role in the autism epidemic and touting the good they do, many parents continue to fear the shots.

Dr. Kempe’s data, gathered in 2009, found that vaccine refusals appeared to be on the rise: nearly one-tenth of pediatricians and family practitioners reported that 10% or more of parents refused at least one vaccine in a given month. Almost 80 percent report at least one refusal in a typical month.

So at what point can or should a pediatrician ethically draw the line? Continue reading