Archive for the ‘Uncategorized’ Category

Eliminating Food Deserts: A Bipartisan Issue

August 20, 2017

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:

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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.

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Source: The Hunger Gap

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The State of Overlapping and Concurrent Surgery and the Next Steps

August 20, 2017

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.

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 SurgeonsAmerican Academy of Orthopedic SurgeonsAmerican 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.

Addressing the opioid epidemic

August 20, 2017

On August 10th 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.

Opioid Epidemic

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?

August 20, 2017

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.

Shhh..not here, the kids are listening!

August 20, 2017

The largest democracy in the world is having problems, the most recurring is keeping half of its population safe. In the last few years India has been plagued with cases of gang rape, sexual assaults, molestation, child sexual abuse and other forms of sexual conflicts. While the cases are not first time occurrences, the exponential increase in these offenses is cause to worry. UNICEF reported that about 50% of the children have faced some form of sexual abuse. While this statistic is unsettling, the reality is most children and parents are in denial of the abuse and grow up accepting it as a way of life.

Experts say sex education and awareness is fundamental to battling this growing epidemic yet many government officials in India believe otherwise. Following the 2007 UNICEF study, the central government promoted a sex education program called the Adolescent Education Program, however this move was met by widespread opposition across the nation with 6 of the largest states ultimately banning sex education in their schools as it was against “ Indian Culture”. They propagated the ban claiming it would increase premarital sexual activity amongst youth and corrupt their values. This ban later spread to 12 states, nonetheless even the states where there is no ban, sex education is typically limited to elite private schools. In rural and lower income public schools where the need is greatest, education is is limited to descriptions of the human anatomy.

                                            ban_on_sex_education

Organizations such as the Family Planning Association of India have been leading efforts to overturn the ban but have only been instrumental in adding an addendum such as “Family Life Education” to some curriculums. To combat this issue effectively, to allow their women and children to be safe, the government of India needs a nationwide comprehensive sex education program for children and adolescents.

 

Supervised Injection Facilities to Mitigate Rhode Island’s Overdose Crisis

August 20, 2017

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https://www.shutterstock.com/search/overdose

Rhode Island, the smallest state in the United States, had 336 overdose-related deaths in 2016, double the number of deaths in 2010. Since 2011, illicit drug overdose deaths increased 250% with the crisis expanding to include a 15-fold increase in fentanyl-related deaths.

In August 2015, Governor Gina Raimondo signed an executive order, directing the Department of Health and Department of Behavioral Healthcare, Developmental Disabilities and Hospitals to co-convene an Overdose Prevention and Intervention Task Force with community and stakeholder participation. The Task Force developed an action plan aiming to reduce overdose deaths by one third by 2018.

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Source: Rhode Island Department of Health

Because the number of deaths continued to climb, a second executive order was signed in July 2017, calling for community and school-based prevention education, and a directive to explore “a comprehensive harm reduction strategy for intravenous drug users to decrease risk of overdose, infection, and assault.”  

Harm reduction strategies include distribution of clean needles, outreach, peer support, naloxone training, substitution therapy, and supervised injection facilities.  These approaches mitigate the adverse effects of high-risk behaviors associated with drug use by reducing stigma, and legal and social barriers to care.

Vancouver SIF

Source: The Stranger

Supervised injection facilities (SIFs) are an effective public health strategy because their impact is multi-faceted and based in harm reduction. SIFs reduce death from overdose, increase access to services for healthcare and recovery, and improve community safety.

With good results in Canada and campaigns for SIFs in New York and other US locations, Rhode Island is not alone in this crisis. Supervised injection facilities can help stem the exponential increase in deaths and unbearable toll this overdose crisis is taking on individuals, families, and the state.  It is crucial that the Overdose Task Force and Governor Raimondo support local implementation of this evidence-based life-saving strategy.

Tackling Democratic People’s Republic of Korea’s diabetes challenge: implementing an HgA1C screening policy

August 20, 2017

Diabetes mellitus, a noncommunicable disease, is the leading cause of disability-adjusted life years (DALYs) in the Democratic People’s Republic of Korea (DPRK). If untreated, diabetes can lead to vision loss, heart disease, and kidney disease.Screenshot 2017-08-20 14.19.19The 2014 DPRK Ministry of Health’s data showed a diabetes prevalence in adults of 1.9 per 10,000 people. Contrastingly, the 2015 International Diabetes Federation (IDF) reported a prevalence in DPRK’s adult population of 440 per 10,000 or 1 in 22 adults. Moreover, the report estimated that 62.9% of adults with diabetes are undiagnosed.

Diabetes diagnosis can be made with a blood test HgA1C, which measures average blood glucose levels over the past 3 months. Inconsistent data are related to DPRK’s lack of a national policy on HgA1C screening, which limits the effectiveness of the DPRK’s health surveillance system to acquire reliable data and impede the population from being diagnosed. Stakeholders such as the World Health Organization, the IDF, the Pyongyang University of Science and Technology are supportive of a national HgA1C screening policy, but DPRK government’s lack of action has been limited due to at least funding shortage, lack of modern equipment, and trained technical staff.

As public health professionals, we firmly advocate for a national HgA1C screening health policy to monitor the diabetes prevalence and effectively diagScreenshot 2017-08-20 16.39.10nose diabetes across the DPRK population. It provides physicians with better guidance on how to treat diabetes, and increase awareness of diabetes not only among patients but also the general public. The DPRK government should view the cost of implementing it in the broader context of cost savings from the early detection and treatment of diabetes, delayed progression of the short and long-term complications, reduced disability, and enhanced quality of life.

 

Naloxone Availability and the Canadian Opioid Crisis

August 19, 2017

 

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There were over 2,400 deaths attributed to opioid overdose in Canada last year. One approach to reduce fatal overdoses is the use of the opioid antidote, naloxone, to reverse acute opioid toxicity. Naloxone is safe, and easily administer by laypeople and first responders.  Termed ‘take home naloxone’ (THN), distribution to the general public can reduce the number of fatal overdoses.

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Canadian policy makers have taken many steps to increase naloxone availability. Naloxone is approved for dispensing by pharmacies without a prescription. It can be distributed in emergency departments to people at risk. Many provincial harm reduction programs have expanded naloxone dispersion programs; the Toward the Heart program in British Columbia has given out over 50,000 THN kits since 2012, and used over 10,000 times to reverse opioid overdoses.

More recently, paramedics, fire fighters and police are carrying naloxone as first responders to acute overdoses, and in case of personal exposure. Healthcare professionals have welcomed increased naloxone availability nationally.

While these have been positive steps, uptake has been slow and is not keeping up with the rise in deaths. In Canada, provision of healthcare services is determined by provincial governments; as such, the above policies on THN distribution are disjointed across Canada leaving entire provinces without plans for naloxone. In the past, the Canadian federal government has positioned itself against harm reduction measures for drug abuse. Vocal critics of THN programs including experts in addiction believe that focusing on naloxone access distracts from looking at overprescribing and addition as core elements of the opioid crisis.Screen Shot 2017-08-19 at 11.16.16 AM.png

We are calling for a renewed federal government position to guarantee equal access of THN for each province through mandates to equip all first responders with naloxone, remove the need for prescriptions to carry naloxone, and increase publicly funded THN kits in all ten provinces and three territories of Canada. Expanded access to THN is an essential component for a national coordinated strategy to combat the opioid crisis.

 

Media
https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/Environmental%20Scan%20%20Access%20to%20Naloxone%20Across%20Canada_Final.pdf
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Leprosy: To decisively eliminate the world’s oldest disease, we need to start by finding the missing thousands in India.

August 18, 2017

Leprosy, a disabling infectious disease affecting the skin and eyes, is sometimes called the world’s oldest disease. Leprosy is curable and effective treatment is available, but does not reach all of those who need it. Despite the WHO’s declaration to eradicate leprosy as a public health threat by 2000, over 200,000 new cases are detected every year globally. More action is urgently needed, since failure to detect leprosy is causing avoidable disability and further infections.

(Source: WHO, 2014 via UN data, http://chartsbin.com/view/34810)

India is worst-affected, accounting for over half of global leprosy cases in 2015. Myopic policies and social norms have sustained the epidemic: In 2005, India discontinued the previous policy of door-to-door visits by health workers, citing funding constraints, relying instead on individuals to actively come forth. This proved ineffective in a society where those with leprosy are often shunned and discriminated against.

Momentum has returned, with encouraging progress. In Autumn 2016, a record 320 million Indians were screened in a renewed door-to-door campaign. But it’s too early to celebrate successes. Two States/Union Territories have remained to achieve elimination and other four reported prevalence rates >1/10.000 population, while progress across the other thirteen states/union territories is mixed. Observers have noted that the reliability, volunteer quality and thoroughness of efforts in some states is clearly insufficient.

It’s the time for stakeholders to step up and strengthen existing campaigns: a lot more progress may be possible in India! We have a real opportunity to re-energize leprosy detection activities through increased community awareness, capacity building, and active management of diagnosed cases. State-level health systems must not hide behind competing pressures but allocate proper time and skilled staff to leprosy. APAL, representing those affected, should expand its remit and rigorously monitor implementation – calling out those States and implementers that do not deliver, looking for partners if needed. It’s agreed by experts that when active case detection campaigns are run by charities or governments many more cases are found than have been previously reported in government statistics. Finally, WHO and its donors, in the next budget round, need to back up their rhetoric on neglected tropical diseases with funding commitments and advocacy vis-à-vis the Indian government. Without stronger and properly monitored campaigns in India, we will not eliminate leprosy in this country and current achievements could become lost opportunities.

(by @bsepodes and @fconrad4)

“The drug that brings people back”: naloxone availability in Maryland

August 18, 2017

Opioid-related overdoses have continued to increase in the United States since 1990 and remain one of the leading causes of death among several diverse populations. These trends are reflected in Maryland where rates of deaths from overdoses has been increasing dramatically. Naloxone, a safe and effective opioid antagonist, is one of the few substances that can combat overdose without risk of abuse or harm. However, when naloxone is only available to health care professionals, it’s impactfulness is not fully realized. Currently when a person overdoses, peers are only likely to call 911 10% to 56% of the time due to fear of police presence and legal retribution.Maryland intox deathsEffective June 1st, 2017, anyone can get naloxone at Maryland pharmacies without a prescription by mandate of a statewide standing order. By allowing and enabling people to administer naloxone without emergency personnel presence, people are able to save lives without the risk of punitive legal response. This also allows the public safety sector, including Baltimore Fire and Police Departments, to be able to focus their care on more stable patients. With local and national governmental support in combating this epidemic, major pharmacy chains Walgreens and CVS already carry over the counter naloxone in Baltimore. In addition to pharmaceutical availability, the Turning Point Clinic and Maryland Addiction Recovery Center offers support and training to anyone seeking naloxone. However, the social stigma associated with drug addiction and this prescription remains for those with opioid addiction and their friends and families.

As health care professionals we firmly support timely availability of naloxone in pharmacies free any form of stigma that opioid users so frequently face. Maryland Pharmacist Association executive director Aliyah Horton said that pharmacists wish to discuss administration and “why they need it in the first place”. We urge the Maryland Pharmacist Association partner with the Maryland Department of Health and Mental Hygiene to develop competency trainings for pharmacists and best practices for dispensing naloxone in a way that makes customers feel safe and respected so that this critical public health policy is utilized to it’s fullest potential. With the additional 50 million dollars from Governor Hogan, we believe this is a viable option that offers a well-rounded response towards this crisis.