Eliminating Food Deserts: A Bipartisan Issue

Cardiovascular disease and hypertension continues to disproportionately burden African-American and Latino communities in the U.S., with a 2017 study showing a correlation between worsening outcomes and residence in racially segregated neighborhoods. In Oakland, CA, food deserts, poor transportation, and high poverty have implications towards poor health outcomes.

As a response, State Senator Henry Stern has proposed Senate Bill 717 to eliminate food insecurity all over California. SB 717 hopes to develop “a comprehensive policy to improve access to more equitable, sustainable, and healthier food choices for all Californians.” In addition to this policy, Senator Stern and the Democratic Party of California need to address the following policy proposals:

• Build off of former President Barack Obama’s National Healthy Food Financing Initiative
• Gain support from the California Retailer’s Association and work with the Northern California Community Loan Fund to offer loan guarantees and subsidies to small business owners wanting to open markets in communities designated as food deserts
• Collaborate across party lines with the Republican Party of California to consider redistricting reforms; this policy may have downstream effects not only for food security, but also for education, healthcare access, taxation, entrepreneurship, etc.
• Align with local grocers, CalFresh, and Supplemental Nutrition Assistance Programs to offer healthier options within existing community structures

Source: Dark Rye by Whole Foods Market

Still, large scale structural policy alone will not create sustainable solutions. Structural policies should be coupled with community-level education and empowerment to source from within. Working with organizations like the Oakland Food Policy Council in California can allow asset mapping and engagement from the ground up.

With innovative bipartisan policies that address rezoning in segregated neighborhoods, collaborate with existing food security initiatives, and promote consortium building within the community, California can aim to eliminate food deserts and improve health outcomes for its vulnerable citizens.

Source: The Hunger Gap

Florida High Schools Initiative for Community Engagement (ICE)

At a time when interracial turmoil and ideological divides are at a boiling point, it is incumbent upon us to introduce our young people to an alternative to bigotry and violence. What better way to do this than provide a platform from which students can engage their communities through mutually transformative service projects?

We are proposing the implementation of a service-learning program that will be fully integrated into Florida’s high school curriculum – the Florida High Schools Initiative for Community Engagement (ICE). Students will be introduced to the skills of community engagement in the classroom and linked with organizations in the community with whom they can collaborate.

 

The evidence for the benefits of service-learning abound.  Other states have successfully adopted similar initiatives.  While currently there are no statewide community service requirements for high school students in Florida, aspects of the infrastructure for the initiative are already in place through the Florida Bright Futures Scholarship Program (BFSP), making Florida ripe for the roll-out of the initiative.

Important stakeholders include high school students, parents, The Florida School Boards Association, the Florida Department of Education (DOE), the Corporation for National and Community Service (CNCS) and local businesses that employ high school students. Students will be introduced to the program through student champions recruited from BFSP. Parents will be engaged through newsletters, parent-teacher conferences and special forums. A grant proposal submitted to CNCS will request funding and logistical support.

Florida AmeriCorps volunteer. AmeriCorps is one of many initiatives of  CNCS

What Can I do to support the Initiative?

We’re so glad you asked!

1. Contact your local school board and let them know you support the ICE program!
2. Call or email  the Florida DOE and tell them you support the initiative!

The Mexico City Policy: Misunderstood, Misguided, and Malignant for Maternal and Child Health

Imagine a woman seeking medical care in the direst of circumstances and a sole health worker prepared to deliver her these services. Now imagine that although the worker’s organization is committed to provide these safe, legal, quality services, a single policy financially incapacitates the care because a minority of citizens in a country thousands of miles away opposes even discussion of certain topics with the patient. This is wasted human spirit. This can mean life or death. And this is the Mexico City Policy, a U.S. federal restriction recently re-enacted and expanded under President Trump as the Protecting Life in Global Health Assistance (PLGHA) policy.

PLGHA requires foreign NGOs to agree not to “perform or actively promote abortion as a method of family planning” as a condition for receiving U.S. government funds NOT ONLY for family planning assistance, as the previous Mexico City Policy declared, but for ALL health programs, including those for HIV/AIDS, maternal and child health, malaria, and global health security, putting billions of annual U.S. aid dollars and, thus lives, at risk. An increase in abortions has previously been found under this intervention and models predict staggering numbers of unintended pregnancies, abortions, and maternal deaths. Not surprisingly, advocates of women’s health around the world from International Planned Parenthood Federation to the United Nations have outlined the deadly consequences of the PLGHA and not only stated their firm opposition to it but have created movements against it.

Modified from: http://www.ippf.org/resource/whats-impact-global-gag-rule

 

The clearest course of action for advocates of women’s health and Global Health in general is to promote passage of the U.S. Global Health, Empowerment, and Rights Act (HER Act), introduced by Senator Jeanne Shaheen and Representative Nita Lowey. The HER act would create a permanent, legislative repeal of PLGHA and the Mexico City Policy, allowing NGOs to continue to operate U.S.-supported health programs without being forced to sacrifice the provision of appropriate care. The HER act fights the financial coercion of the PLGHA and may offer the best chance to restore global faith in the U.S. as the leader of Global Health worldwide.

 

 

 

 

 

 

 

Physician Burnout: The Next Public Health Crisis

Healthcare reform has led to an alarming prevalence of physician burnout in the United States. The increased workload, productivity demands, reduced autonomy, and overburdening administrative tasks for physicians have led to feelings of emotional exhaustion, depersonalization, reduced personal achievement, and decreased effectiveness. As a result, there are higher rates of job dissatisfaction, cynicism/apathy, absenteeism, depression, suicide, and substance abuse. A recent Mayo Clinic study revealed that 54.4% of physicians, spanning all specialties, reported burnout in 2014, compared with 45.5% in 2011.

Source: AthenaHealth (https://insight.athenahealth.com/technologys-role-fixing-physician-burnout)

Physician burnout has negative impacts on the healthcare system. It leads to reduced quality of care, poor patient satisfaction ratings, increased medical errors, decreased patient safety, decreased productivity, and increased healthcare costs. This decline profoundly impacts the doctor-patient relationship.

Since demand for physicians is outpacing supply, AMA estimates a shortage of up to 90,000 physicians by 2025. The viability of the healthcare system is at stake when physicians retire early, reduce clinical work, or leave the profession, thereby further reducing the workforce. The cost to replace a physician leaving clinical practice is up to $1 million, depending on specialty.

In pursuing improved population health, enhanced patient care experiences and reduced costs, institutions neglected the front-line people who bear these burdens. Despite being crucial to the health care industry, physicians are the forgotten patients. Physician burnout is becoming a public health crisis. Given the scope of the problem, national, state, and local healthcare organization leaders must focus on addressing this problem now, before it’s too late. Physician burnout equates to physician abuse. It is imperative that the healthcare industry culture change to value physician well-being over profits. To achieve high quality and affordable health care, a symbiotic relationship must exist between those who provide and those who seek care. Everyone must help to stop this impending train wreck from becoming a national health crisis.

 

The State of Overlapping and Concurrent Surgery and the Next Steps

Surgeons operating in two operating rooms at once has occurred for many decades. This is particularly the case in academic medical centers where residents or fellows, who are doctors-in-training, are delegated responsibility commensurate to their training while the surgeon operates in a separate operating room. There are two different definitions related to this practice. Overlapping surgery is when the surgeon is present for critical portions of each surgery while concurrent surgery is when the surgeon is only present for the critical portions of one surgery. CMS has found this to be appropriate up to a point. As long as the surgeon is present for the critical portions of each surgery, a surgeon is allowed to “run two rooms.”

Difference between Concurrent and Overlapping Surgery

In 2015, the Boston Globe published an in depth report discussing the lack of patient awareness of concurrent and overlapping surgery as well as concerns and implications of this practice that were raised by a surgeon at Massachusetts General Hospital. This led to further investigation by the Senate Finance Committee at multiple institutions including the Cleveland Clinic. Further reports of this practice in Seattle have also surfaced.

The American College of Surgeons, American Academy of Orthopedic Surgeons, American Association of Neurological Surgeons, Association of American Medical Colleges and the American Hospital Association have concluded that overlapping surgery is acceptable while concurrent surgery is unacceptable. Additionally, if during an overlapping surgery a surgeon is not available for the other room a second surgeon must be designated to be immediately available to assist. The Mayo Clinic has found that overlapping surgeries at their institution have had the same 30 day complications as non-overlapping surgeries. A study of a national database has found similar results.

Though it is difficult to start this discussion with patients, studies regarding their opinions on overlapping surgery show 64.6% of patients would prefer to know if their surgeon has scheduled another surgery at the same time. Some hospitals have taken the first step to rectify these concerns and include this information in patient consents. This step should be taken nationally at all hospitals and surgical centers. Further public education should be undertaken to discuss the safety of overlapping surgery. The majority of physicians are compensated based on their productivity which is measured by relative value units (RVUs). The expected number of RVUs would need to be changed to accommodate regulations limiting concurrent or overlapping surgeries. Additionally, while concurrent surgery is not recommended by almost all surgical societies, further steps can be undertaken, such as research in the safety of certain surgeries booked as overlapping, change in productivity of surgeons, and access to surgical care.

Marijuana: A Gray Matter

Featured photo credit

Marijuana remains a Class I controlled substance in federal law, denoting it as a drug with high abuse potential and no acceptable medical use. However, it is legal for medical use in 29 states and the District of Columbia, and is legal for recreational use as well in 8 states and the District of Columbia. States are under enormous pressure to enact marijuana legalization laws due to widespread public support for the policy change and public disdain for the current federal classification, which is seen as irrational and duplicitous given the much laxer legal status of more dangerous substances such as alcohol and tobacco.

This is not to say that marijuana is not dangerous. As an internist and pediatrician, I am keenly aware of marijuana’s potential negative effects on adolescent and adult health and development, the potential for addiction, and the finding of increased marijuana-related traffic accidents in states with legal recreational use. But it is important to note that, unlike other Schedule I substances, rates of physical addiction are much lower, overdose nearly nonexistent, and no change in rates of fatal traffic accidents has been observed. Marijuana is by no means benign, but it is regulated out of proportion to its potential for harm.

Photo credit

Activists on the marijuana issue used to typically fall into three camps: legalize it, legalize medical use, or keep it banned. But increasingly, the two extreme views are more prominent in the public arena. Marijuana is not a black-and-white issue. It can be beneficial, and it can be harmful. Current federal policy listing marijuana as a substance with no acceptable medical use is not consistent with evidence supporting significant efficacy in pain states, multiple sclerosis, and other conditions. Furthermore, maintaining its illegal status at the federal level does nothing to prevent state legalization, while it does prevent adequate research so that smart, evidence-based policies and regulations can be enacted.

I believe the federal government should reclassify marijuana as a Schedule III substance: a drug with potential for abuse less than the drugs in Schedules I and II, with currently accepted medical use in treatment, and with moderate or low risk of physical dependence but high risk of psychological dependence. This would be consistent with current evidence, would allow research study while continuing regulatory restrictions, and may also reduce pressures on states to legalize recreational use. Marijuana reclassification would allow the federal government to stay engaged and help control the discussion around the benefits and risks of marijuana use, rather than sitting idly by as an unrelenting wave of legalization sweeps across the nation.

A bipartisan bill has been proposed in the House of Representatives calling for marijuana rescheduling. Call your representative to support this evidence-based policy change.

Addressing the opioid epidemic

On August 10^th 2017, President Trump declared the opioid crisis a National Emergency. According to the Opioid Addiction 2016 Report published by the American Society of Addiction Medicine, opioid addiction is driving the epidemic of lethal drug overdoses, with 20,101 overdose deaths related to prescription pain relievers in 2015. As illustrated by the CDC below, deaths from prescription painkiller overdoses has accelerated since 1999, especially among women.

Source: Center for Disease Control and Prevention. Prescription Painkiller Overdoses.

Prior to Trump’s declaration, Senator Kirsten Gillibrand (D-NY) proposed a bipartisan legislation, the Opioid Addiction Prevention Act, which would limit the amount of prescription opioids a physician can prescribe to treat acute pain. According to the CDC Acting Director Annew Schuchat, the number of opioids prescribed annually is enough “for every American to be medicated around the clock for three weeks.” As such, the bill would limit the supply of an opioid prescription for acute pain to seven days. The seven-day limit will not apply to the treatment of chronic pain, hospice, or palliative care. The bill also prohibits the refill of such prescriptions.

Responses to the bill have been positive, with several experts noting areas which will require further definition. According to the Yale Journal on Regulation, the bill does not endeavor to “assess how much pain a patient must experience for it to be deemed ‘acute’”. Further, the bill will inevitably increase the number of interactions between the prescriber and the patient, in turn increasing healthcare costs.

To compliment the bill, it is critical that state governments take additional steps. First, educational and awareness campaigns need to be developed for the public. Second, according to the US Department of Health & Human Services, funds will be dedicated to “training and providing resources for first responders to carry and administer FDA approved products for emergency treatment”. Lastly, funds will be made available to expand availability to overdose reversal medications in healthcare settings.

Would a vaccination policy work to control the current cholera outbreak in Yemen?

Last week’s statistics on the cholera epidemic in Yemen, currently the largest in the world, included an incidence of half a million people in 2017, with 2000 deaths since April (http://www.who.int/mediacentre/news/releases/2017/ cholera-yemen-mark/en). Having appeared to successfully contain a first surge in incidence between October 2016 and April 2017, international health organizations in the area saw a much more sudden, drastic increase in the number of individuals affected in May 2017, primarily thought to be due still to the breakdown in the provision of adequate water, sanitation and nutrition as the war that started 2 years ago continues to rage on.

Facilities, workers and supplies that are much needed to provide emergency and primary health services face increasingly greater shortages, having been early victims of the collapsed governmental infrastructure and resources, and because of having been targeted specifically by the fighting forces (less than half of facilities are still fully functional; see photo at http://www.ibtimes.co.uk/civil-war-yemen-two-years-horrifying-conflict-75-powerful-photos-1605848#slideshow/1590015).

Although vaccines, antibiotics and the provision of basic health services would help prevent and control the outbreak, the multiple inter-related factors of population displacement, targeting of health facilities and access points for incoming medical supplies, famine, ongoing war conditions, all in the context of pre-existing poverty, famine, and poor national, state and local health infrastructure and resources, make a reversal of these conditions nearly impossible (https://www-clinicalkey-com.ezp.welch.jhmi.edu/#!/content/journal/1-s2.0-S1473309917304061).

I have been struggling to arrive at a solution – which brings me to this blog; I want to ask anyone out there, with more experience, and perhaps more faith than I have – wherein lies the answer? Individuals, families, friends, communities in this case – have little to no control over their fate; they are fighting against extinction; national healthcare organizations have little remaining resources, and are caught in the midst of the fight between the Saudi-backed President Hadi and the Houthi insurgents. Any positive changes would have to come, as far as I see it, from international health aid organizations such as the WHO, MSF, IRC, and UN-led advocacy for cessation of war.

Policies enabling better distribution and administration of the cholera vaccine and oral rehydration solutions are futile – there is no viable national, state or local infrastructure in place to implement any such policies. How does one defend such policies against the prevailing forces which oppose them, whose interests lie only with the retention of / ascension to political power, and little with the survival of the population at large? (see photo at http://www.who.int/emergencies/yemen/en/)

And yet, vaccine distribution campaigns had been considered (http://www.sciencemag.org /news/2017/06/cholera-vaccine-faces-major-test-war-torn-yemen) and were being planned for, as of June 2017; the government had asked for 3.5 million doses (single dose regimen), yet had given no guarantee that it would reach its intended population, that there’d be health workers to deliver it, or safe locations for such a delivery of vaccines as well as basic health care. In fact, the rampant spread of the disease led the UN to suspend its plan just one month later.

A discussion held (https://www.brookings.edu/wp-content/uploads/2016/02/yemen-transcript.pdf) in Qatar last year by a panel of international experts revolved around economic policies aimed at reviving the economy (even a “war” economy would help dispel the sense of individual futility), depoliticizing of the food and medical aid supplies brought in by international organizations through local ports, de-legitimizing the Houthis and acknowledging them as leaders of a coup d’etat instead, and ultimately preventing them from acquiring weapons. These appear viable alternatives in a country where a ceasefire is nowhere near in sight, and the rebuilding of the much needed health infrastructure would take many years and resources, thus rendering the term “policy” at the local and national level meaningless, for the time being.

Minnesota Needs the Clean Power Plan.

The Clean Power Plan enacted in 2015 aimed to reduce greenhouse emissions from the energy sector, which account for almost 40% of the U.S. carbon dioxide emissions, necessary to halt the predicted destructive impact climate change will have globally.  In March 2017, President Trump signed the Executive Order for Energy Independence, which sent the policy for review by the EPA to either withdraw or rewrite the plan, a lengthy process which will halt the policy’s regulation of power plant emissions.

The Clean Power Plan and all other actions to reduce climate change are necessary for all countries and individuals globally.  Coastal cities, such as Miami, are already dealing with flooding due to the sea level increasing.

Many Americans and Minnesotans may think climate change will have minimal effect on their wellbeing and daily activities.  The impact of climate change in Minnesota has been predicted and witnessed, as tornados, storms, and floods become more devastating and irregular.  Erratic changes in temperatures and precipitation will affect livestock and crop yields.

 

Individually, people should care for their health.  Energy production from coal leads to air pollution and climate change creating or worsening respiratory problems such as asthma, bronchitis, emphysema, and lung cancer, as well as increasing the risk of heart attack, heart failure, and stroke.  The length of allergy seasons has already increased, for example the ragweed season is 21 days longer than in 1995.

Minnesota itself has not hit the emission targets set to reduce the impact of climate change, while the rest of the country has variable progressions.  In Minnesota, we need to be advocates for our health and wellbeing, and to do so, we must encourage others to support the Clean Power Plan and other efforts to combat climate change and turn our focus and investment to more efficient or cleaner forms of energy.

Expanding National Influenza Immunization Program to Adolescents in South Korea – A social justice perspective

Influenza, or “the flu”, is a common infectious disease that ranges in severity, with some cases even resulting in death.

In South Korea, the number of the flu patients in 2016 was a record high, and more importantly, the flu season started 7 weeks earlier than usual (See Graph 1).

In an effort to curtail the effects of influenza, the Korean government introduced a Free Influenza Immunization Program for children ages 6-12 months in October 2016, and expanded the coverage up to 59 month-old children from September 2017.

In response to this, many people are now arguing for the expansion of the program to include school-aged children and teenagers (up to ages 18 years) as well.

Cost and Parental Concerns

The Korean government expressed its strong concerns at a policy forum held last month, and stated that covering 6,500,000 school-aged children every year is not practical due to a limited workforce and budget. However the socioeconomic cost of influenza is $25 billion USD, and it was also reported that vaccination in this age group could save the cost up to 7 billion USD.

Additionally any side effects from the vaccines are taken seriously by parents. However, the influenza vaccine safety has already been proven.

My position

Despite these concerns – which should be taken seriously – I, as a primary care physician and public health advocate, support the expansion of the program.

Regarding cost, it would be reasonable to cover younger children first and then expand to teens. Various parental concerns need to be fully addressed through community or school level meetings.

More importantly, I would like to introduce the notion of social justice highlighting ‘herd immunity’. Children respond well to the vaccine. Even though they are just a fraction of the population, immunizing them could significantly diminish the chance of a widespread outbreak.

This effort is part of being a good citizen, and enhancing our social benefit by protecting more people.