Public health measures are those not aimed at individuals but at society as a whole, or subgroups within society. Physicians are charged not only with promoting the health of their own patients, but as a profession we (and health care professions in general) are charged with promoting the public health.
Public health measures, however, are highly likely to cross into politically charged areas. This should not deter the promotion of public health.
Issues that we deal with regularly involving public health include vaccination programs and laws surrounding vaccine requirements, fluoridation of public water supplies, helmet laws, and even gun laws. We have never, however, written about air pollution as a public health concern (except for dubious claims that air pollution is linked to autism).
The health risk of air pollution
Air pollution as a health risk is nothing new, but several recent studies are focusing attention on this issue. Recently the Royal College of Physicians produced a report in which they claim that 40,000 deaths per year in the UK can be attributed to poor air quality, both indoors and outdoors. (more…)
A new word has been added to the public’s vocabulary – the Zika virus. It seems we have one more infectious agent to worry about. Here are the facts as we currently understand them regarding the recent Zika epidemic, and also some rumors and conspiracy theories that need debunking.
The Zika virus (of the viral family Flaviviridae, an Arthropod-Borne or arbovirus) is spread through Aedes mosquito bites, the same mosquitoes that also spread dengue fever, West Nile, and yellow fever. The infections themselves are usually mild, causing fever, rash, joint pain, and conjunctivitis. Many of those infected (about 80%) may even have a subclinical infection, meaning they do not notice any symptoms.
According to the World Health Organization:
Zika virus is diagnosed through PCR (polymerase chain reaction) and virus isolation from blood samples. Diagnosis by serology can be difficult as the virus can cross-react with other flaviviruses such as dengue, West Nile and yellow fever.
It’s nice when a question can be resolved with objective numbers of unequivocal outcomes. Subjective outcomes give scientists a headache.
In this case we are talking about the effect of vaccine exemption laws on vaccine compliance rates. The question here is not the ethical one, the rights of parents to determine the fate of their children vs the right of the state to protect the health of children and the public health. I think the latter trumps the former, but some disagree.
Regardless of what you feel about the ethical question, we need to know if the laws we pass to achieve our goals actually work, or if they don’t work, or even have unintended consequences. Having an admirable goal is not enough; when you make actual decisions (practice decisions, policy decisions, healthcare decisions for you and for family) you want to know that those decisions are having the desired effect.
A few years ago, an Ocala, Florida, pediatrician, as part of a routine visit, asked a patient’s mother whether she kept firearms in the home. She refused to answer, feeling the question constituted an invasion of her right to privacy. The pediatrician then terminated the relationship and told the mother she had 30 days to find a new doctor for her child. In another incident, a mother reported she was separated from her children while medical staff asked them whether their mother owned firearms. And, according to a Florida legislator, he was told to remove firearms from the home during an appointment with his daughter’s pediatrician.
Complaints to Florida legislators about these and similar incidents prompted the introduction of a bill that would have, among other things, criminalized any
verbal or written inquiry by a . . . physician, nurse, or other medical staff person regarding the ownership of a firearm by a patient or the family of a patient or the presence of a firearm in a private home . . .
As finally passed by the legislature and signed by Governor Rick Scott, the 2011 Firearm Owners Privacy Act subjects physicians to disciplinary action for making “verbal or written inquiry” into a patient’s firearm ownership when the physician does not “in good faith believe” such inquiries are “relevant to the patient’s medical care or safety of others.” The Act included amendments to the Florida Patient’s Bill of Rights and Responsibilities, adding similar provisions. (The Act also applies to health care facilities, but here we will discuss only its effect on physicians and their patients.) Physicians may not enter any information regarding firearm ownership into the patient’s medical record if they know this information is not “relevant to the patient’s medical care or safety, or the safety of others.” They may not “discriminate” against a patient “based solely on the patient’s Second Amendment right to own firearms or ammunition.” Finally, physicians must refrain from “unnecessarily harassing” a patient regarding firearm ownership during an examination. (more…)
It’s a seldom mentioned aspect of my professional history that I used to do a lot of trauma surgery in my youth. I did my residency at a program that included a county hospital with a busy trauma program where I saw quite a bit of vehicular carnage and an urban hospital (which has since closed) where I saw a fair amount of what we in the surgery biz call gun and knife club action. During my time as a PhD student, I moonlighted as a flight physician for the local helicopter rescue service, Metro Life Flight, where I took care of patients with everything from cardiac disease requiring transfer to the Cleveland Clinic to near-drownings during the summer at the Lake Erie resorts, particularly Put-in-Bay, to obstetrical transfers (which terrified me) to, of course, the unfortunately copious run-of-the-mill vehicular trauma. I saw the sort of tragedy that could result. Then, in the late 1990s, as I did research for my surgical oncology fellowship in Chicago, I also moonlighted as a trauma attending at a local suburban level II trauma center.
At that point, I realized that trauma was not my thing, as I couldn’t see myself at my present advanced age doing the sort of physically and emotionally demanding work that required fast decisions. It stressed me out too much; which is part of the reason why I went into surgical oncology in the first place. However, I have an appreciation for those who do do trauma. I also realize that trauma is, in a way, the “purest” form of surgery in that it involves taking a body broken by mechanical forces and trying to repair it, all the while keeping the patient alive until the repairs can heal. I will, however, miss the enjoyment I get hearing presentations on tree stand falls during hunting season.
I don’t mention my youthful flirtation with trauma surgery so much because I think it’s something so fascinating that I must tell it. (If that were the case, I’d have been mentioning it much more frequently in my blogs and social media than I have before.) Rather, it lets you know why I was so distressed when this story was forwarded to me a few days ago. It’s a Reuters report entitled “Injuries soar after Michigan stops requiring motorcycle helmets“:
The public fight over the human papillomavirus (HPV) vaccine is still raging. The debate partly reflects the underlying logic of health prevention measures, which is essentially a statistical game of risk vs benefit. Unfortunately thrown into the mix are ideological opponents to vaccines who are distorting the facts at every turn.
Notice that I said this was a “public” fight, because it is not a serious scientific dispute. There is sufficient evidence to confidently conclude that the HPV vaccines currently available are safe and effective. All medical interventions will contain some risk, it is never zero, but vaccines in general, and the HPV vaccine specifically, have minimal risks and clearly prevent disease.
In addition there is a social angle to the HPV vaccine in that it is given to children to prevent a sexually transmitted disease.
The science of the HPV vaccine
An analysis of 26 Traditional Chinese Medicine products found 92% were contaminated with pharmaceuticals, heavy metals, or the DNA of animals, including traces of cat, dog, rat, or pit viper.
Two weeks ago I detailed the pervasive problem of poor quality supplements. The main reason for this seems to be weak regulatory standards that prioritize the rights of manufacturers to sell supplements over the rights of consumers to buy safe, high quality, properly-labelled products. Call it “health freedom“, where the freedom belongs to producers, who in many countries are largely freed from most of the quality and safety regulations that are in place for licensed prescription and non-prescription pharmaceuticals. The result of weak regulation is that few supplements sold on the market today have been properly tested for safety or effectiveness, and there are few quality standards for the production of these products.
Not surprisingly, there are persistent signs that consumers may face real risks to their health from using these products. Now a new study from Australia confirms what past studies have already shown: adulterated and contaminated herbal remedies are the rule, rather than the exception. They often contain undeclared ingredients ranging from potential allergens to heavy metals to endangered species. (more…)
The Michigan House of Representatives: Not the brightest bulbs on the Christmas tree.
We have a problem with antivaccinationists here in Michigan. It’s a problem that’s been going on a long time that I first started paying attention to in a big way a few years ago when we started seeing pertussis outbreaks again due to low vaccine uptake. It’s a problem that’s persisted as last year we suffered from outbreaks of pertussis and measles, again because of pockets of low vaccine uptake. And what is the reason for these pockets of low vaccine uptake? Well, consistent with what we already know, namely that the risk of pertussis outbreaks is elevated in states where exemptions to school vaccine mandates are easier to get, it’s because our state is one of the worst in the country when it comes to nonmedical exemptions to vaccines. Indeed:
Michigan has one of the highest vaccine-waiver rates for kindergartners in the country, three times the national median, according to the Centers for Disease Control and Prevention. And the number of kindergartners getting vaccine waivers is growing. In five years, it’s increased 23 percent, the CDC says.
Oregon Health Plan (OHP), the state’s Medicaid insurer, will no longer cover planned home and birth center births for women whose pregnancies aren’t classified as low risk, based on newly-established criteria. The Health Evidence Review Commission (HERC), a group of experts designated by the state, came up with criteria that will exclude women with a substantial list of conditions, such as high blood pressure, diabetes, previous cesarean section, multiple gestation (more than one fetus), and various complications in previous pregnancies. Feelings ran high on both sides of the issue, which was described as the most contentious ever to come before the HERC.
The HERC’s decision was based on an exhaustive 100-page evidence review; a review, according to them, hampered by the low quality of the evidence on the safety of planned out-of-hospital births. Actually, there is a paucity of evidence altogether. Studies and statistics from other countries, like the Netherlands, were of limited utility because those countries have more stringent midwifery education and training requirements and non-hospital births are better integrated into the health care system.
Most planned out-of-hospital births in Oregon are attended by what are known as direct-entry midwives (DEM), as opposed to nurse midwives, and a few naturopathic doctors. (We’ll look at the many variations of midwifery in a minute.) Since OHP pays for 23% of Oregon births, the economic impact on direct-entry midwives could be substantial. This effect will be amplified when other insurers, who are expected to follow OHP’s new criteria, change their own coverage rules. (more…)