public health

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Popping A Daily Baby Aspirin? Caution: New Guidelines, Amid Controversy

New recommendations from the USPSTF recommend aspirin for far fewer people. (M. Spencer Green/AP)

New recommendations from the USPSTF recommend aspirin for far fewer people. (M. Spencer Green/AP)

When an older woman arrived at a Cambridge medical clinic recently, Dr. Sarah Stoneking was surprised to learn that the patient was taking an aspirin every day.

The patient was nearly 80, and didn’t have a clear reason to take the medication. Aspirin in general, and especially in older patients, can have a lot of side effects, including serious bleeding.

Stoneking, an internist and also my colleague, suggested her patient stop taking the daily aspirin, but the woman refused. She thought aspirin “was a panacea,” Stoneking recalled, one that protected her from the strokes and heart disease that had affected most of her friends. “She took it religiously,” Stoneking said.

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Asleep At The Wheel: Drowsy Driving As A Public Health Crisis

The National Highway Transportation Safety Administration says there were more than 72,000 documented accidents involving drowsy drivers between 2009 and 2013. But that’s just from official police reports, so experts say it’s a gross under-estimate. (Jesse Costa/WBUR)

The National Highway Transportation Safety Administration says there were more than 72,000 documented accidents involving drowsy drivers between 2009 and 2013. But that’s just from official police reports, so experts say it’s a gross under-estimate. (Jesse Costa/WBUR)

It’s midafternoon and I’m fighting to keep my eyes open. It’s a matter of life and death. That’s because I’m northbound on I-93, going 65 miles an hour — with many cars passing me.

Once or twice on the monotonous two-hour drive, a jolt of adrenaline surges through my bloodstream as I suddenly realize I’ve actually drifted off for a micromoment. Thankfully I get home without killing myself or anybody else.

If you say you haven’t had the same experience behind the wheel, I don’t believe you.

The National Highway Transportation Safety Administration (NHTSA) says there were more than 72,000 documented accidents involving drowsy drivers between 2009 and 2013. But that’s just from official police reports, so experts say it’s a gross under-estimate.

After all, there’s no sleep-a-lyzer test for drowsiness like the blood alcohol-level test for drunk drivers. And it’s harder for a cop to spot a drowsy driver than one distracted by a smart phone.

“Twenty to twenty-five percent of all crashes could be fatigue-related — drowsy drivers,” says Dr. Mark Rosekind, the NHTSA administrator. “We could be looking at over a million crashes and potentially up to 8,000 lives lost.”

Rosekind made those remarks during a webcast this week sponsored by the Harvard T. H. Chan School of Public Health and The Huffington Post. The discussion included HuffPost editor-in-chief Arianna Huffington, Harvard sleep expert Charles Czeisler, and Jay Winsten, associate dean for health communication at the Harvard Chan School.

The forum is part of a national campaign against drowsy driving that’s just getting underway.

The idea is to treat drowsy driving as the public health issue that many believe it is and to bring to the campaign the same strategies that stigmatized drunk driving. Winsten master-minded that effort 28 years ago when he coined the term “designated driver” and nagged movie and TV producers to insinuate it into their scripts.

I moderated the online discussion. Here are some highlights:

The Brain Split

Czeisler, who’s the head of the division of sleep and circadian disorders at Brigham and Women’s Hospital, says the sleep-deprived brain can split itself in two. One part goes through the motions of a “highly over-learned task” such as driving. Meanwhile, cognitive centers involuntarily transition from wakefulness to sleep.

“So it’s particularly concerning that 56 million Americans a month admit that they drive when they haven’t gotten enough sleep and they’re exhausted,” Czeisler says. “Eight million of them lose the struggle to stay awake and actually admit to falling asleep at the wheel every month.”

My powerful mid-afternoon drowsiness was typical. “It used to be thought that [drowsiness-related crashes] only happened at night, but that’s because people weren’t looking,” Czeisler says. “Most sleep-deficient driving incidents happen during the daytime because there are so many more drivers on the road.”

And there’s a physiological factor. Mid-afternoon is before the brain’s internal clock “has given us a second wind to help us stay awake in the evening,” he says.

Who Falls Asleep Most?

Three groups are particularly vulnerable to falling asleep at the wheel, Czeisler says: young people, night-shift workers, and the millions of people who suffer from sleep apnea.

“Young people think that because they’re young, they’re fit, they can do anything,” the Harvard sleep researcher says. “But actually, young people are the most vulnerable. More than half of fatigue-related accidents are in people under 25 years of age.” Continue reading

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When Doctors Encounter Human Trafficking: What To Look For

(Ira Gelb/Flickr)

(Ira Gelb/Flickr)

It was 2 a.m. on a typically hectic Friday overnight shift in the emergency department.

A young woman, Kelly, checked into triage, accompanied by her older boyfriend Jim, who explained that Kelly had abdominal pain and some vaginal bleeding. Jim wanted her checked out and maybe some pain medicine to help her rest at home.

Kelly had no identification. She appeared younger than her stated age of 18. I also noticed track marks punctuating both of her arms — a sign of IV drug use. She immediately looked to Jim after answering all my questions.

If this sounds suspicious, that’s because it is. While clinicians are trained to address Kelly’s medical ailment, many of us fail to recognize the larger social cues right in front of us. It appears that Jim is in control of the situation. Kelly is young, maybe very young. As a clinician I must consider Kelly’s living situation, and her relationship with Jim.

As emergency care providers, it is standard practice for us to separate patients from their visitors long enough to at least ask about domestic violence. And for most of us, that would likely be the first concern in this case. But Kelly is actually a victim of human trafficking. Continue reading

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Study Tracks Yik Yak App To Learn More About College Drinking And Drug Use

The Yik Yak app, lower left, is seen on an iPhone on Nov. 11, 2015. (Ronald Lizik/AP)

The Yik Yak app, lower left, is seen on an iPhone on Nov. 11, 2015. (Ronald Lizik/AP)

Consider this message, most likely posted by a college student in or around Brandeis University near Boston: “I just remembered I have a 4loko in my minifridge. Guess who’s getting sloppy day drunk tomorrow!”

Good luck finding the Four Loko fanatic. The post is from Yik Yak, an anonymous, free social media platform popular on college campuses.

Even so, a recent study analyzing Yik Yak posts gathered from 120 campuses suggests that tracking these messages does have an upside: Public health experts say it may ultimately help them learn more about issues like alcohol and substance use.

Over the span of one month, researchers at Johns Hopkins University and the University of Colorado at Boulder found 2,047 health-related yaks — the term for posts on Yik Yak — dealing with themes like smoking, drinking and drug use.

“Because it’s anonymous, people disclose things about themselves that they might not publicly post, either on Twitter or even necessarily to their doctors,” said Michael Paul, an assistant professor and founder of the Information Science Department at UC Boulder,  in an interview.

While big data collected from social media has been used to study public health, such as influenza surveillance through Google search queries and Twitter, the field is relatively new and Paul’s study is the first to look at public health using Yik Yak. Continue reading

Zika And Ebola Grab Headlines, But Lingering TB Worries Many In Public Health More

(Lefteris Pitarakis/AP)

(Lefteris Pitarakis/AP)

For public health nurse Meredith Hurley, the discovery that her town had an active case of tuberculosis threatened an infectious disease nightmare that couldn’t have come at a worse time.

The tuberculosis patient was a young man from Saudi Arabia, living in the Boston area to learn English. He’d been coughing up blood for five days while he traveled on buses and subways, went to class, visited the New England Aquarium, shared a hookah, and hung out with seven roommates who jointly rented a house in the densely populated seaside town of Winthrop, Massachusetts. They hailed from China, Italy, Taiwan, Germany and Turkey and spoke six different languages — but little English.

To make matters worse, the Saudi man’s case occurred at a time when the Massachusetts Department of Public Health had abruptly lost two of its four TB control nurses, reportedly due to budget-driven early retirement. “These retirements were not planned for and a contingency plan was not established,” Hurley says.

The episode is a stark reminder that the ancient scourge of TB is still with us, even though many people think the disease was vanquished in this country long ago. It can pop up anytime. The case also underscores how critical it is for front-line public health workers who understand how to control TB to be available when needed.

The sudden appearance of TB in Winthrop is a tiny piece of a big mosaic. A new report from the Centers for Disease Control and Prevention reveals the number of TB cases in the United States rose in 2015, to almost 10,000 reported cases, after nearly 25 years of steady decline.

In Massachusetts, progress against TB appears to have stalled, after declines in the first decade of the millennium. One in five reported cases involves drug-resistant strains of TB, which are far more time-consuming to treat with expensive drugs that carry burdensome side effects.

In its annual TB update last month, state health officials reported 192 active cases in 2015. Though the number appears small, the stakes involved in each case are high — for the affected individual and for public health. “Challenges include high rates of drug resistance, delays in diagnosis and complex medical and social needs of persons diagnosed with TB,” the state report says.

“I was thinking there were seven more people walking around the community with active tuberculosis, and they were probably going to be spreading it to seven more and then 14 more and then 49.”

– Meredith Hurley,
Winthrop public health nurse

As soon as she heard about the Winthrop case, Hurley — the town’s one-woman public health department — imagined the worst.

She discovered the TB patient had visited clinics three times before getting a proper diagnosis, exposing caregivers and patients each time. That’s not unusual with TB, which is not near the top of many doctors’ list of possible diagnoses.

Hurley began to envision how many people the TB patient exposed in Winthrop, a town of 20,000 residents packed into two square miles.

“We don’t have a lot of space between our neighbors, and for a disease that’s airborne, that can be challenging,” Hurley says. “I was thinking there were seven more people walking around the community with active tuberculosis, and they were probably going to be spreading it to seven more and then 14 more and then 49. It’s a cascading effect.”

Hurley says she badly needed help to figure out how big a problem she was dealing with. Because of the sudden short-staffing at the state health department’s TB control program, she had to enlist the help of a public health nurse in western Massachusetts. Continue reading

Yes, We’re Mammals, But Is It Wise These Days To Promote Breast-Feeding As ‘Natural’?

Public health officials should think twice about the unintended consequences of calling breast-feeding 'natural,' the authors of a new paper argue. (Michael Sawyer/AP)

Public health officials should think twice about the unintended consequences of calling breast-feeding ‘natural,’ the authors of a new paper argue. (Michael Sawyer/AP)

Hippos do it. So do orangutans. There’s no question that for us mammals, nursing is one of those defining behaviors in nature. The question is whether public health officials, in promoting breast-feeding among human mothers, should deploy the term “natural.”

Two academics pondering these and other linguistically charged questions sparked an online frenzy recently with a paper on the unintended consequences of promoting breast-feeding as a “natural” practice — and relating it to the anti-vaccine movement.

University of Pennsylvania ethicist Anne Barnhill and medical historian Jessica Martucci, writing last month in the journal Pediatrics, suggest that by using the word “natural” in campaigns endorsing breast-feeding, public health officials and medical professionals may be inadvertently fueling other groups that reject public health efforts — like anti-vaxxers. Continue reading

Narrating Medicine: How Cultural Differences Challenge Doctors

By Dr. Marjorie S. Rosenthal
Guest Contributor

The pediatric resident was frustrated.

On the exam table was a 6-month-old baby — quite overweight. In fact, the child was heavier than an average 1-year-old. But his mother just laughed when the resident asked how she was feeding the baby.

When the resident and I looked at the medical record, we saw that for months residents had been discussing feeding with the mother. Telling her that she should stop formula feeding because her breast milk was more than sufficient. Telling her not to give solid foods because her breast milk was enough. And telling her that if she was going to give the baby formula or solid food, she should try to pay attention to when the baby’s cry means hunger and when it means a wet diaper or a need for attention.

Over one-third of adults and about 17 percent of children in the United States are obese. And since people who are obese have more high blood pressure, diabetes and heart disease than their peers, it’s not surprising that there are 11 million office visits per year for adults with obesity.

Yet according to a new CDC report, only 40 percent of these 11 million visits for obesity include a discussion of diet and exercise.

Dr. Marjorie Rosenthal (Courtesy)

Dr. Marjorie Rosenthal (Courtesy)

Many health care providers don’t want to talk to their patients about diet and exercise because they think the patients may feel judged. And sometimes doctors don’t talk about fitness and nutrition because they actually think talking won’t change anything. Which makes it safe to assume that office visits for obesity rarely include a discussion about the life experiences of the patients and the parents of patients. This suggests that a critical issue — and a key part of any treatment plan — is never addressed.

Parents’ medical history has always been an important aspect of a child’s medical care. But the central importance of all this has only recently emerged: New research has shown how life experiences affect brain development and hormone responses and how that affects parenting behavior and the health of the child in the next generation.

It’s hard enough to do this with families who speak English and come to the doctor’s appointment ready to talk about themselves. With this overweight 6-month-old, it was even harder: The resident was using a Swahili phone interpreter and the mother was a refugee.  Continue reading

U.S. Health Care Is Less Private, More ‘Socialist’ Than You Might Think

The extent of the government's role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17 in Charleston, S.C. (Mic Smith/AP)

The extent of the government’s role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17. (Mic Smith/AP)

By Richard Knox

Readers, a pop quiz:

The proportion of U.S. health care paid by tax funds is (a) less than 30 percent, (b) about half or (c) more than 60 percent.

If you picked “more than 60 percent,” you’re right — but you’re also pretty unusual.

“Many perceive that the U.S. health care financing system is predominantly private, in contrast to the universal tax-funded health care systems in nations such as Canada, France or the United Kingdom,” David Himmelstein and Steffie Woolhandler write in a new analysis of U.S. health spending in the American Journal of Public Health.

They find that 64.3 percent of U.S. health expenditures are government-financed. And they project the tax-supported proportion will rise to 67.1 percent over the coming decade as the baby boom generation ages and retires — nearly as high as Canada’s 70 percent.

“We are actually paying for a national health program, we’re just not getting it,” Woolhandler says.

tax dollars for U.S. health spending

Now, Himmelstein and Woolhandler have an agenda. For decades, they’ve been perhaps the leading researchers promoting the kind of single-payer health system that Socialist and Democratic presidential candidate Bernie Sanders has put on the debate agenda. One recent poll suggests more than half of Americans (and 30 percent of Republicans) support the idea.

But even if you disagree with the Himmelstein-Woolhandler ideology, their research is generally regarded as sound, and their method is straightforward.

They added up what federal and state governments spend on health through Medicare, Medicaid, the Veterans Health Administration, government employees’ health care premiums, tax subsidies and other programs. They argue that accounting by government agencies (the Center for Medicare and Medicaid) undercounts the real tax burden because it leaves out major pieces of the pie — such as government employees’ care ($156 billion a year) and tax subsidies for private, employer-sponsored coverage (nearly $300 billion).

And whatever you think about Medicare-for-all, it’s a good idea to see the present U.S. health care system for what it is — an increasingly government-funded financing scheme. Continue reading

Rare Common Ground: Gun Dealers And Public Health Workers Unite To Cut Suicides

(Image taken, with permission, from a New Hampshire Firearm Safety Coalition poster)

(Image taken, with permission, from a New Hampshire Firearm Safety Coalition poster)

By Richard Knox

The elegantly dressed woman looked out of place at Riley’s Sport Shop, the largest gun dealer in New Hampshire. Owner Ralph Demicco was behind the counter. He noticed she didn’t make eye contact.

“I’d like to buy a gun,” she said. “Could I see that one?”

Demicco sensed something was amiss. “Should you really be buying a gun?” he asked.

She immediately broke into tears. “I took her into the backroom,” Demicco recalls. “She confided that she’d been released from the state mental hospital in Concord that morning. She said she told her doctor she wasn’t ready to go and if he discharged her she was going to take her life. Apparently he didn’t put any stock in that.”

Demicco asked the name of her psychiatrist, then told her to go home and wait for the doctor to call. Then he called the doctor, who intervened. It was a suicide that didn’t happen.

The incident stuck with Demicco. But it wasn’t until later that he realized that gun dealers could take more concerted action to prevent gun suicides — by far the nation’s leading cause of firearm fatalities. That came after a Dartmouth Medical School injury prevention researcher alerted him that three different customers had killed themselves in a single week within hours or days of buying their guns at Riley’s.

The partnership is a rare instance of common cause between gun enthusiasts and public health proponents, amid increasingly polarized public views.

“That was stunning,” Demicco says. He started meeting with the Dartmouth researcher and other gun retailers and health workers. They decided to create a group called the New Hampshire Firearms Safety Coalition. Their idea is catching on — in Massachusetts, Vermont, Maryland, New York, Virginia, Tennessee, Texas, Colorado, Utah, Nevada and California, according to Elaine Frank, chair of the New Hampshire coalition.

Frank is the Dartmouth injury-prevention specialist who alerted Demicco to the problem. Early on in the coalition’s work, a public health worker came to a meeting after talking to gun shop owners around the state. She expressed surprise they were so positive.

One of the gun dealers in the group said, “I could be insulted by that,” Frank recalls. “He said, ‘Why would you think we’d be less interested in suicide prevention than you are?’ It was absolutely an ‘aha!’ moment.”

The partnership is a rare instance of common cause between gun enthusiasts and public health proponents, amid increasingly polarized public views on how to reduce the nation’s death toll from firearms. It’s not embraced by all gun proponents; some fear it’s a stalking horse for more gun controls.

But it’s a real-life example of what President Obama and others are calling for: a public health approach to the nation’s gun violence crisis.

“The concept of collaboration, which is often lost, is very much alive in this area of suicide prevention,” says Bill Brassard, spokesman for the National Sport Shooting Foundation, which represents gun dealers.

A prominent gun control advocate at the Harvard H.T. Chan School of Public Health agrees. “What you want to do are the things that are easiest to do — the low-hanging fruit — and show we can work together,” says David Hemenway, author of “Private Guns, Public Health.” “It takes a long time to build trust. But this is happening.”

The payoff could be large — potentially bigger than gun control measures proposed to stem homicides.  Continue reading

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Bad Odors And Brain Fog: 5 Things Nobody Tells You About Quitting Cigarettes

On a break from his midday hosting duties, WBUR's Jack Lepiarz lights up outside the station. (Robin Lubbock/WBUR)

On a break from his hosting duties, WBUR’s Jack Lepiarz lights up outside the station. (Robin Lubbock/WBUR)

WBUR’s Jack Lepiarz is no wimp. He not only braves live air multiple times a day as the station’s midday anchor, he also performs around the country as a circus whip-master, and even recently attempted to break the Guinness world record for whip strokes per minute.

But Jack has yet to defeat the most insidious physical and psychological challenge many of us ever face: his smoking habit.

He has plenty of company: Almost 1 in 5 Americans smoke, the CDC says. He writes here about some of the unexpected obstacles involved, in hopes of helping other would-be quitters and their supporters. And he’ll document his fight periodically this year. Please stay tuned. — Carey

I’m about to try again. This weekend will mark my fourth attempt to quit smoking over the last 10 weeks or so. At age 27, I’ve been smoking for a little more than seven years, with multiple attempts to quit every year since three months after I started. When they tell you that nicotine is as addictive as heroin, they’re not kidding.

I’m at the point where I’ve started and stopped so many times that I know what I’m getting into, but every time, I seem to notice a new symptom or side effect of nicotine withdrawal. Almost always, I’m surprised. We hear about cigarette cravings, irritability and other symptoms of withdrawal — but the process of quitting also carries with it some other, lesser known symptoms.

1. The Mental Fog

By far my least favorite side effect, and one that I find the hardest to explain. You know that feeling you have right after you wake up? Half present, half in another world? This is your brain — not on drugs. I’ve described it as similar to going a day without coffee — except worse. (Believe me, I’ve tried.) Or being in a state of constantly having just had two beers. You can’t focus, you can’t sit still, you can’t formulate any thoughts that last in your brain for more than 30 seconds.

Except for how much you want a cigarette.

2. The Smell

This is one that sneaks up on you. Most people know that smoking dulls your sense of taste and smell, but it’s such a gradual process when you start smoking that you don’t notice it. For me, it rarely takes more than 36 hours to get those senses back strongly — and never in a good way.

The first time I really noticed it was last winter, when after a day of not smoking I drank a soda and nearly spat it out. I never knew it was that sweet.

The smell aspect hit me when I tried to quit on a hot, humid day in July. Long story short, we all need to wear more deodorant. Also brush our teeth more. Also, cities just smell awful in general. Also, yes, I recognize the irony of a smoker complaining about bad smells. You notice just how bad cigarettes smell, too.

3. The Constant Hunger Continue reading