Category Archives: Medical Features

Rough Beasts & Public Health

Rough Beasts & Public Health



“Some rough beast, its time come round at last,

Slouches toward Bethlehem, waiting to be born”

William Butler Yeats

In early June, a patient checked into a Contra Costa County Health Department outpatient clinic in Richmond, Ca., with a fever of 101.2, flu-like symptoms, and a cough. The man sat in a waiting room—the clinic serves hundreds of thousands of people each year—until the physician could see him. Because the patient could not speak English, the doctor called in a Vietnamese interpreter. The rest was drill: blood pressure, ear and throat examination, listen for congestion.

But then a bell went off in the doctor’s head.

She had the translator ask the patient if he had recently traveled. Yes, he replied, he had just returned from Vietnam, presently ground zero for avian flu, a particularly malevolent virus that has killed more than 60 people and decimated chicken populations throughout Asia.

The doctor put a mask on the patient, moved him to a room by himself, and called the Health Department. Blood samples were drawn and county and state health labs went into overdrive, scanning for a molecular code designated H5N1-A. For a few scary days it looked like Richmond might be the first U.S. beachhead for the disease, but in the end it turned out to be a standard Type A influenza.

On one hand the incident demonstrated the strengths of public health. “The businessman who returns from Vietnam is going to see a private doctor,” says Dr. Wendel Brunner, Director of Public Health for the county’s health services. “A private doctor has about 12 minutes to see a patient, four of which are filling out insurance forms. They aren’t going to ask the patient’s travel history, and they are not likely to call the health department.”

On the other hand, Brunner is facing a $5 million cut in his $60 million budget, and high on the list of cuts are translators, who not only interpret, but also accompany nurses who conduct house visits. Without a translator, the Richmond doctor would never have asked the travel question.

The arrival of the next great pandemic has always been a “when” not an “if,” and firewalls for stopping it are getting thinner.

“Nobody knows how bad it [the pandemic] will be,” says World

Health Organization (WHO) General Director, Lee Jong-Wook, “but we can’t be optimistic.”

So far, H5N1-A is only a threat to those exposed to infected birds, although there are scattered cases of person-to-person transmission. But the virus has spread from domestic fowl to wild ducks and domestic pigs. The latter are worrisome, because pigs have served as a viral bridge to humans before. If avian flu mutates into an easily transmissible form, the world could be in considerable trouble

H5N1 presently has a startling mortality rate of between 47 percent and 83 percent, but most experts think it unlikely that it will maintain that level of lethality. People in Asia have tested positive for the flu’s antibodies without exhibiting symptoms, indicating that not everyone who contracts it gets deathly ill. Nevertheless, WHO estimates that such a pandemic would hospitalize 30 million people and kill eight million.

Other researchers, like Michael Osterholm at the University of Minnesota, say the death toll could range from 180 million to 360 million worldwide, including 1.7 million in the U.S. Olsterholm is the Director of the Center for Infectious Disease Research and Policy and an associate director of the Department of Homeland Security.

Even if avian flu has only the fatality rate of the 1918-19 pandemic—2.7 percent— it would have a catastrophic effect. That pandemic killed 675,000 Americans and anywhere from 50 to 100 million people at a time when the world’s population was less than a third what it is today, and when populations were far more isolated.

“If you want to see why a pandemic today will be far greater than the 1918 flu, ” says Dr. Donald Francis of Global Solutions, “just sit in a European airport and watch all the costumes walk by.” Francis, whose firm is trying to generate money for vaccines, was one of the earlier identifiers of HIV, and part of the WHO/Center for Disease Control (CDC) team that finally cornered and eliminated smallpox in 1977.

But at the very time avian flu is threatening to mutate into a worldwide killer, public health budgets in the U.S and across the globe are being systematically starved of funding.

Budget problems like Brunner’s are hardly limited to Contra Costa County.

Each budget year those of us in community clinics have to fight for our very existence,” says San Francisco’s Nancy Lewis, FNP, MSN. “We are considered expendable,” she says bluntly. She calls the cutbacks of public health facilities and personnel “alarming.”

County and state health budgets have been declining for years, and Congress plans to cut Medicaid by $10 billion over the next five years. Medicaid is the nation’s largest health insurance program, covering some 50 million low-income people.

That will have a cascading effect on the states, many of which are already cutting recipients from the rolls. Tennessee is dropping some 300,000 people, and Missouri is cutting 90,000. For those still covered, states are proposing higher co-payments.

“State and local governments are in such a budgetary crisis that they are forced to cut things that they know are good for the public,” says occupational physician and former president of the American Public Health Association (APHA), Dr. Barry Levy.

According to public health officials and epidemiologists, cutting health care creates the perfect breeding ground for pandemics.

Public health funding seems almost designed to create a crisis. For instance, according to health writer and Pulitzer Prize winner, Laurie Garrett, one of the key things hospitals need to respond to a pandemic is ” surge capacity,” or the ability to double their ability to treat patients.

Garrett says, “What’s happened with managed care is that hospitals have eliminated surplus beds and surplus personnel. So, far from being ready to deal with surge capacity, we’re actually understaffed and we have massive nurse shortages all across the country.”

Asked about “surge capacity,” Brunner just laughs. “We don’t have surge capacity for a bad winter.” He goes on to explain that private insurers calculate that “It is cheaper to turn patients away than have empty beds.”

According to the American Hospital Association, between 1980 and 2000, some 900 hospitals were closed nationwide in the name of “efficiency.”

A scarcity of beds has consequences. The Society for Academic Emergency Medicine found that delays in getting patients into hospital beds meant greater medical complications, more patients ending up in expensive Intensive Care Units, and higher mortality rates.

If anything, the international situation is worse.

Countries like China, according to Calcutta based journalist P. Sainath, have largely defunded their health care programs, as the recent SARS outbreak demonstrated. “The Chinese saved tens of millions by closing down rural clinics, and then lost billions because of SARS,” he said. “Everywhere the rights of the poor are being whittled away, and we will all end up paying a price for it.”

During the 2003 SARS outbreak, Chinese villagers told Garrett that they didn’t seek medical care because a single day in a hospital represented a year’s income.

SARS eventually infected some 8,000 people, killing 800 of them.

According to the May 6-7 WHO conference in Manila, early intervention is the key to stopping or moderating a pandemic: “if action is delayed…it will be too late to implement effective local, national, or regional responses.”

WHO recommended a crash program on developing a vaccine and stockpiling the anti-viral drug, Tamiflu.

According to the Financial Times, however, only 12 countries have made a serious attempt to stockpile, and the U.S has only enough Tamiflu for about 1 percent of its population. In contrast, France and England can cover about 20 percent of their populations.

Nor is Tamiflu a magic bullet. “It is not clear that Tamiflu is effective,” says Brunner.

On developing a vaccine, Levy agrees with WHO’s recommendation, but warns that “We are way behind where we should be on vaccine development.”

Vaccines also have their own difficulties. “The problem with vaccine development is that vaccines don’t make money,” says Francis, illustrating his point with a chart indicating that while worldwide sales of vaccines brought in just a little over $6 billion in 2001, Lipitor and Prilosec sales alone earned pharmaceutical companies $12 billion.

When private industry does get involved, it can be costly. In 1970, WHO paid about 1 cent per dose for smallpox vaccine. When the Clinton Administration asked Dynport, the company that manufactures smallpox vaccines for the military, to ramp up production for civilians, its price was $25 a pop.

There were lessons learned from the 1918-19 pandemic. In his book,

“The Great Influenza,” John Barry notes that a Public Health Service post mortem on the disaster found, “What could help, more than doctors, were nurses. Nursing could ease the strain on a patient, keep a patient hydrated, calm, provide the best nutrition, cool the intense fevers. Nursing could give a victim of the disease the best possible chance to survive. Nursing could save lives.”

But the U.S. has a major shortage of nurses at the bedside, as does much of the world. According to Rockefeller Foundation estimates, Africa is short one million health workers and Europe has a crisis that parallels the U.S. Add to that the shortage of hospital beds, and Osterholm’s projection may not be far off the mark.

“We’re not in the preventive mode here,” says Lewis, “but the let’s-fix-them-after-the-fact mode of hospital care. Under such circumstances it would be very difficult to care for the tens of thousands of patients who would not get a necessary influenza vaccine on time.”

Keeping nurses healthy will also be a problem. “Medical workers are at risk,” says Brunner, “because they are literally in people’s faces.” He points out that the first SARS victim was a medical worker.

“New strains of influenza, particularly things like the avian flu, are the most worrisome to me and many nurses,” says Lewis. “This is especially so in light of last year’s debacle when the influenza vaccines were contaminated.”

According to Gina Johnson, RN, public health case manger at the Rolling Meadows Clinic, Cook County, Il., not enough has been done to prepare medical workers for what they may face in a pandemic. “We need to start getting education about Asian avian flu, SARS and new strains of tuberculosis as soon as possible (so that) we don’t get it thrown at us at the last minute.”

She adds, “nurses want to be given the proper tools and protection as soon as possible so in the advent of an emergency we don’t get burnout and feel overwhelmed.” Johnson has been in public health for 12 years in Illinois and Iowa.

In a pandemic situation, Osterhold predicts that “healthcare workers would become ill and die at rates similar to, or even higher than, those in the general public.”

One recent influx of money for public health comes from the Department of Homeland Security to prepare for bioterrorism. Brunner estimates the county receives about $1 million from Home Security, which he is happy to get because he says “it helps the Health Department deal with all communicable diseases.”

But others worry that Homeland Security’s concerns end up diluting the mission of public health.

“Bioterrorism distracts public health from its true mission,” says Dr. Victor Sidel, Distinguished University Professor at Montifiore Hospital in New York, and past president of the APHA. Sidel calls the spending on biowarfare “wasted funds” and says the real problem is that “public health has been starved, and is being starved.”

Brunner also wishes there were the same kind of focus and funding on “what is really killing our people, which are chronic diseases, like cancer, HIV, diabetes, cardiovascular problems, not to mention violence.” He also worries that the bioterrorism focus may “divert attention and intellectual resources from public health issues that are more important.”

Sometimes the problems seem almost overwhelming.

Francis says that “there is not the in-hospital or in-public health capacity to deal with a flu pandemic,” and Brunner agrees that the inability of U.S. medicine to respond in the way it should “is built in.”

Besides the insufficiency of beds in the U.S., according to Osterholm, there are only 105,000 mechanical ventilators, between 75,000 and 80,000 of which are in constant use. Ventilators are particularly important if a pandemic takes on the characteristics of the 1918-19 flu, in which a major killer was acute respiratory distress syndrome (ARDS).

Lewis says “The bottom line is that we are about as ready as they were in 1918 when millions died here in the US. But they had an excuse. There wasn’t much of a public health infrastructure and no vaccine. We have no excuse for not fully utilizing the resources that are available to us today.”

Levy argues, “We are in a major crisis and we need something on the order of a Manhattan Project,” adding, “the greatest threats out there to us are not military, they are disease.”

For Sidel, the solution is long-term: “What we need is a decent medical care system, a universal system that unites public health and medical care,” and points to U.S. Rep. Barbara Lee’s HR 3000 as a step toward creating a system that “will prepare us for what will surely come.”

In the meantime, Brunner successfully lobbied to keep his Vietnamese translators, and the Supervisors “restored most the cuts in Health Care.” So Contra Costa has dodged yet another bullet—for now.

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Medical Outsourcing

Medical Outsourcing


Nov.-Dec. 2004

A surgeon sits at a state-of-the art computer station in Bangalore, India, analyzing a three-dimensional image of a U.S. patient’s kidney. He notes some potential trouble spots and sends his findings off by email. The transaction by Wipro Health Sciences, an Indian based company, saves a U.S. hospital 45 percent on the procedure.

A German drug firm, Mucos Pharma GmbH, contracts out the testing of a new treatment for neck and head cancer to Siro Clinpharm of Mombai, India. Siro finds volunteers to test the drug in half the time and expense the German company would encounter in Europe—and without having to first test the drug for safety.

A North Carolina man without health insurance had a life-threatening heart condition requiring a new valve, which would cost him $200,000 in the United States. He flew to New Delhi, where doctors replaced his heart valve with one from a pig for a total cost of $10,000, including roundtrip airfare.

For almost a decade, the U.S. medical industry has been outsourcing records and financial transactions to places like India, Hong Kong, Singapore, Pakistan and the Philippines. But recently outsourcing has spread beyond number crunching and word processing to basic medical services. From biopsy analysis to cardiac surgery, the health business has discovered there is gold in going foreign.

Outsourcing began in the middle-90s with medical transcriptions, a $16 billion industry that is growing at a yearly rate of 15 percent. In the old days, a doctor would write up a report and submit it to an insurance company. Now, just talk into a phone and the report goes off into digital cyberspace, to be downloaded to Europe, Asia or Latin America.

But medical transcriptions were just the toe in the door. “Telemedicine” now covers (reader, take a deep breath); medical billing; accounting; creation of patient information; patient registration; checking insurance coverage and eligibility verification; medical coding; insurance denial/rejection analysis; drug research and testing; analysis of digital lab slide images; creation of digital templates for prosthetics; and biopsy analysis.

So far, “telemedicine” has not figured out how to take your temperature, but a Swiss company called LifeWatch can monitor your vital signs from a fair distance away.

However, “telemedicine is less about cutting technology than it is about the buck. When Health Partners of Minneapolis sends a report to the Philippines, the information technology (IT) programmer works for 1/9 what an IT programmer makes in the U.S. When medical billing specialists Alpha Thought axes a $10 an hour job in Chicago, it ships it to New Delhi, and realizes a 25 percent saving.

Some firms, like Cbay Systems of Annapolis, Md.—the fourth- largest medical transcription company in the United States—send virtually all their work abroad. Cbay outsources 95 percent of its transcriptions to India and is projected to earn $100 million in 2005. Given that an American accountant can earn up to $4,000 a month and his Indian counterpart $400, it isn’t hard to see where that $100 million comes from.

Few politicians have challenged the collateral damage inflicted by outsourcing medical services, although Tennessee recently enacted a bill that gives preference in awarding state contracts to data entry and call-center firms that agree to keep jobs in the U.S. Some 30 other states are considering similar legislation, reflecting growing concerns over medical records and privacy. In California, SB 1451 was approved by the legislature in September but vetoed by Gov. Arnold Schwarzenegger. The bill would have provided privacy protection for patients whose medical records are outsourced.

National legislation has also been introduced. U.S. Rep. Edward J. Markey’s (D-Mass) HR 4366 would require a patient’s approval before any such information could be shipped abroad. There is also a Senate bill (SB 2481) to restrict the U.S. government from offshoring medical records and jobs, but given that most hospitals and all medical firms in the U.S. are private, the bill skirts the real impact of the trend: job loss.

Suresh Menon of HealthScribe, one of India’s largest medical transcription companies, put his finger on the legislation’s weakness: “Most hospitals in the U.S. are under private control and the bill does not seek to debar third party U.S. contractors from outsourcing work to Indian medical transcriptions.”

The legislation certainly hasn’t overly alarmed the Indian market. Anand Mahindra, president of the powerful business lobby, the Confederation of Indian Industry, told the Asia Times that the legislation was “unfortunate” but its impact would be “small” because U.S. federal contracts are a trifling part of the industry.

According to a study by Forrester Research, the U.S. will move some 3.3 million jobs offshore by 2019, jobs that translate into $136 billion in lost wages.

The soothing line from the medical industry is that medicine can’t really be offshored.

“General practitioners and surgeons will have a job forever,” assures TK Kurien, president of Wipro Health Sciences.

John Challenger, CEO of Challenger, Gray & Christmas, a Chicago-based “outplacement” firm, adds, “You can’t go overseas to see a doctor or a nurse or get physical therapy.”

People in the profession disagree.

“We are very concerned about outsourcing to other countries,” says Deborah Burger, an RN and president of the California Nurses Assn. (CNA). Berger argues, “If we don’t do something right now, patient care is going to be compromised. If we wait too long, corporations will control how the medical profession provides care.”

In part that is already underway. Dr. Roy D’Souza in Bangalore, who analyzed those kidney images for Wipro, is a case in point. He also downloads and studies CT scans and MRIs.

So is U.S. trained physician Prathap C. Reddy, whose Apollo Company runs 37 hospitals in India. Apollo offers cardiac surgery for $4,000, a saving of $26,000 over the same procedure in an American hospital. One reason is that a U.S. cardiologist makes $300,000 on the average, while his counterpart in India earns $65,000. More than 5 percent of Apollo’s patients are westerners and the numbers are growing.

When one factors in nurses, technicians, and support staff, medicine on the cheap does more than squeeze a few high-priced U.S. heart surgeons. Savings on hospitalization may be anywhere from 200 percent to 800 percent in places like India, according to Ames Gross and Rachel Weintraub, reporters for Medical Devicelink, the industry’ online publication.

So is our loss India’s gain? Not exactly.

Medical transcription jobs—80 percent of which comes from the United States— have indeed poured into India, which just passed the Philippines as the No. 1 recipient of such offshoring. But such jobs have little impact on the one-third of India’s poor who live on less than $1 a day, or the two-thirds of the population that lives in rural areas. Indeed, offshoring can make things decidedly worse for the locals. The Andhra Pradesh state government, for instance, is siphoning off desperately needed water from farmers in order to provide it to the Vannenburg Intelligence Technology Park’s 20-acre campus. Much of the water is used for landscaping the Park’s lush lawns and flora. The government has also raised electricity rates for hard-pressed consumers, while at the same time giving IT firms a 25 percent break on their bills.

There are also safety and environmental concerns about offshoring. Increasingly, U.S. medical firms are moving major parts of their operations abroad. Respironics, Inc., of Murrysville, Pa., is shifting its research and development, manufacturing, drug discovery and testing and health care services to China, the Philippines, and Hong Kong, according to Medical Devicelink.

Labor and materials are cheaper abroad, but environmental laws are also much weaker. Waste management may be the local river, with all the consequences that implies for local residents.

The combination of offshore savings, coupled with the Bush administration’s massive corporate tax cuts has allowed Health Maintenance Organizations (HMOs) to move from marginally lucrative in 1998 to immensely profitable today. In the last nine months of 2003, HMO profits jumped 73.3 percent, and the industry’s net worth climbed 70 percent, from $23 billion to $39 billion. Profits are projected to rise another 16 percent in 2004.

Drug companies have also elbowed their way to the tax trough. Bristol Myers-Squibb, Merck, and Pfizer successfully lobbied for a tax “holiday” provision in the recent $137 billion tax reduction bill: $100 billion in foreign drug sale profits will be taxed at a rate of 5.25 percent, instead of 35 percent. The “holiday” is supposed to be temporary, but tax “holidays” have a habit of turning into endless summers. As Martin Sullivan of Tax Notes told the Financial Times, the windfall may keep industry happy for awhile, but “as they build up profits again, it’s more than likely there’ll be another amnesty because they’ll start lobbying again.”

Instead of creating jobs, the cash the companies saved on taxes and reaped from price hikes allowed them to finance a major reorganization of how they did business. Instead of adding to their domestic workforce, they created an army of “labor saving devices” which has raised profits, but kept the unemployment rolls high. They also went foreign, using some of their newly reaped capital to finance offshore production, from building actual factories, to financing high-speed information networks.

This is why the U.S. is presently in the unprecedented situation of seeing its median household income fall 3.4 percent, at the same time, productivity is rising 12 percent. While this is a long-term trend, it sharply accelerated in recent years. According to the Economic Policy Institute, “In the 2000-03 period income shifted extremely rapidly and extensively from labor compensation to capital income.”

Part of this shift has been from the acceleration of outsourcing to low wage, non-union locations. In early October, the Business Roundtable hosted 150 corporate leaders at a $1,400-a-head conference on how to speed up the process of sending U.S. jobs abroad. The conference, according to the Asia Times, urged the Bush administration “not to be swayed by the public furor over the loss of American jobs overseas and not to espouse policies that would prevent American firms from getting jobs done cost-effectively, including outsourcing and subcontracting to countries like India and Russia.”

The medical industry is flush with cash, and cash provides clout when it comes to influencing legislation and lobbying. Most people assume the big players in politics are economic giants like oil and gas, defense and agribusiness. But according to the Center for Responsive Politics, the medical industry poured $91.5 million into the 2004 elections. Only banks, lawyers and real estate interests handed out more in an effort to influence legislation and tax policy. Almost two-thirds of those monies goes to Republicans.

The current trends suggest that medical outsourcing will accelerate over the next decade, and CNA’s Burger warns that while the medical industry may lag behind other industries in introducing new methods and technologies, there is growing concern among medical professionals about outsourcing. “We are not immune to the potential drain of jobs in our profession,” she says.

Some of that drain is not so “potential.”

The huge drug multinational, GlaxoSmithKline, recently announced it was moving one-third of its clinical trials offshore to countries like India and Poland as a cost-cutting measure. A pharmaceutical industry source told The Guardian that clinical trials can cost one-tenth of those in the west, and that GlaxoSmithKline was also moving its research to India. It has opened a research facility in Singapore as well.

Unless the hemorrhage is stanched, the medical profession could shrink dramatically. Along with that contraction will go well paying jobs, many of which have medical plans linked to them.

Over the past three years, 68 percent of the industries that have been losing jobs tend to provide health coverage to employees. By contrast, 55 percent of the job growth is in industries that do not provide health care, according to a recent Economic Policy Institute study. All but five small states are experiencing this trend.

It would be a stretch to put the growing crisis of health care coverage on the back of outsourcing, but given the projection that some 3.3 million relatively well-paying jobs will go foreign in the next 15 years—and that estimate may be conservative—it is certainly part of the problem.

One of offshoring’s central selling points is that it will lower health costs. But Burger of CNA is deeply skeptical that “telemedicine” will reduce costs or improve medicine. “Sometimes we go along with these new technologies and gizmos because they are supposed to save money,” she says, “but nothing in medicine had gotten any cheaper. In fact, costs and profits are way up.”

Burger argues that offshoring and cybermedicine are about cutting human providers out of the process, and increasing profits, not lowering the cost of health care. “When you actually work with human beings,” she warns, “you can’t cut corners.”


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The Complex Terrain of Aging

The Complex Terrain of Aging

Registered Nurse

Sept. 2007

Conn Hallinan

Carl Bloice

3207 words

The earthquake that struck Kashiwazaki, Japan in July, 2007 did more than smash up houses and kill 11 people: it exposed a fault line that had nothing to do with the island nation’s unstable perch on the Pacific Ocean’s “Ring of Fire.” All of the dead were over 65

The great heat wave that battered Chicago 12 years ago made life about as unpleasant as it can get in that Midwest city, but for older people—most of whom were poor and minority—it was a killer.

No one knows for sure how many people the heat wave that rolled across Europe killed in August 2003, but in France the death toll was at least 15,000, the majority of them elderly.

Natural disasters have always had a way of shaking the glitter off systems and revealing the underlying fissures, be it inadequately maintained levees in New Orleans, or in the cases above, a systemic failure by social, political and medical institutions to deal with a demographic tsunami.

By the year 2050, the number of humans 65 years or older will increase from a little over 600 million to two billion, two-thirds of whom will be in the Third World. “Aging is affecting virtually every country,” United Nations General Secretary Ban Ki-Moon told a Tokyo conference on aging this past April. “The world has never seen such rapid, large and ubiquitous growth in the number and proportion of elderly people.”

In the U.S., the number of people over 65—currently 35 million— will double by 2030, jumping from 13 percent of the population to 20 percent.

At the same time the elderly population is climbing—adults over 85 are currently the fastest growing demographic group in the U.S.—the number of doctors and nurses who treat them is declining, and the population of traditional caregivers is either stagnant or falling.

What makes this particularity challenging is that geriatrics, the branch of medicine that deals with the diseases, debilities, and care of older people, is an enormously complex kaleidoscope of medical procedures, government policy, and demographics. If things go wrong in any of these areas it can lead to a train wreck.

For example, in the aftermath of the 1995 Midwest heat wave, researchers found that it was not so much the temperature that killed people, but poverty, isolation and fear. Many elders were too poor to afford air conditioning; they lived alone, and were too afraid to go out in the mean streets of Chicago. Isolated behind locked doors, they baked to death.

But tying together all the strands that make up the complex field of geriatrics is not a simple task.

On one level, the infirmities of age like diabetes, arthritis, incontinence, and high blood pressure are medical conditions that can be treated with drugs. But as Dr. Claudia Landau, Geriatric Curriculum Coordinator and an Associate Clinical Professor of Medicine at the University of California, Berkeley argues, when it comes to treating older people, “The medical model is not going to work.”

Geriatrics, she says, needs doctors and nurses to be as much sociologists and anthropologists as medical workers. “They have to know whether their patients are poor or rich, they need to know the total terrain. If you don’t attend to all of the elements you are not going to care for old people very effectively.”

The medical model is relentlessly pushed by an avalanche of television ads on treatments for incontinence, diabetes, and high blood pressure, what researchers Dr. Carol L. Estes and Steven P. Wallace, PhD, call the “commodification” of aging by a “medical-industrial complex” whose bottom line is money.

Adult diapers and drugs produce significant profits for their manufacturers, creating incentives to promote these products,” write Estes and Wallace in Social Injustice and Public Health. “As a consequence, behavioral therapy, which is time consuming and not very profitable, is rarely used even though it is more effective.”

While bladder control seems like one of aging’s minor aliments, it is a major reason older people are institutionalized.

Studies show that conditions like incontinence, diabetes and high blood pressure respond just as well to exercise and dietary regimes as they do to target drugs. Indeed, many times the drugs create the problems.

Dr. Wendel Brunner, now Director of Public Health in Contra Costa County, California, recalls that when he was working in a clinic, “Old people would come in with bags of medicine. I would throw away most of it, and they would get better.”

Treating older people takes certain skills that most general practitioners and specialists don’t have. One of those skills is listening. “As we get older our homeostasis changes and doctors need to be tuned into that. You have to listen and take the time. You have to value communication,” says Landau. She calls this “cognitive medicine.”

Is an older patient disorientated because he or she is losing their mental facilities, or because of depression? Do they have an infection? (which can be difficult to spot because older people tend not to run fevers). Or is their medication wrong?

A doctor or nurse certified in geriatrics is trained to triage these very questions.

But out of 145 medical schools in the U.S., only nine have geriatric departments. There is only one geriatric doctor for every 5000 people in the U.S. Fewer than 9,000 of the 650,000 doctors in the U.S. are certified in geriatrics and fewer than 3 percent of medical students take courses in the subject. As a result, the number of U.S. geriatricians has fallen by one-third.

It’s a problem,” warns William Satariano, a professor of Epidemiology and Community Health at UC Berkeley’s Public Health School and an expert on aging.

Doctors, for example, need to be particularly careful when prescribing drugs to elders. Diuretics are commonly proscribed for controlling high blood pressure, a chronic disease many older people suffer from. But if patients are not properly hydrated, diuretics can cause dizziness and falling. Some 350,000 Americans fall and break their hips each year, of which 40 percent will end up in nursing homes. A fifth will never walk again.

Side effects can be exaggerated when different doctors prescribe drugs without any centralized monitoring. “Multiple doctors prescribing multiple medicines cause multiple problems,” says Brunner.

Wallace and Estes found that many doctors tend to under treat older patients, with some claiming “those over 80 should receive no curative treatments…because they have lived out their ‘natural lives.’”

But a Harvard study found that when 90 year olds were put on Nautilus trainers they got better. Landau recalls advocating physical therapy for older patients when she worked in a public health clinic, only to be accused of “torturing” them by some staff members. “I told them to humor me and lo, and behold, people got better.”

One reason why there are fewer geriatric doctors is that they are among the lowest paid in the profession. While radiologists and orthopedic surgeons average $400,000 a year, geriatricians average $150,000 a year. Brunner, however, is not overly sympathetic to this argument: “It is hard to feel bad about any doctor’s income. The problem is not that we don’t pay doctors enough.”

The shortage is not restricted to doctors. Only 720 of the 200,000 pharmacists in the U.S. have geriatric certification, and the situation is only slightly better for social workers.

Bonnie Martin, RN, a geriatric nurse in San Francisco, and a member of the California Nurses Association’s Board of Directors, says the situation in nursing is “very similar.” According to Martin, “very few RNs choose to work with the elderly and very few NP (nurse practitioners) attend geriatric programs.” Much of the care for the elderly “is left to LVNs (licensed vocational nurses) and certified nursing care, in spite of the fact that the elderly need more complex nursing care than most other patient populations.”

Joan Stanley, RN, Senior Director of Education Policy of the American Association of Colleges of Nursing, and Mathy Mezey, RN, a professor at New York University, write, “The care of older adults is now the number one business of the U.S. health care system, cutting across hospitals, home care and nursing homes.”

Stanley and Mezey argue that “Evidence shows that older-person care delivered by nurses with specialized geriatric knowledge and skills improves outcome,” by improving patient assessment, reducing falls, and lowering costs.

Yet less than 1 percent of the 2.7 million nurses in the U.S. and Canada are certified in geriatrics and only 27 percent of nurses in baccalaureate programs have required classes in geriatric medicine.

Martin says the reason is that “nurses in LTC (long term care) tend to be paid significantly less, have fewer benefits and are not considered among the nursing ‘elite,’ an outgrowth of how little we value our elderly.”

Elder care is falling increasingly on aides, whose pay averages $9.34 an hour. The low pay and lack of benefits results in large yearly turnovers. What is more, the traditional pool for such aides—women age 25 to 54 with little education—is not growing to match the rise in the elder population.

Another dimension of the problem is part of Landau’s “total terrain”: class, race and gender.

There has long been a significant gap between the care that whites, as compared to minorities, receive, and who delivers that care. In 2004, a commission headed by Lewis W. Sullivan, former Secretary of U.S. Department of Health and Human Services, found that “From cancer, heart disease, and HIV/AIDS to diabetes and mental health, African Americans, Hispanic Americans, and American Indians tend to receive less and lower quality care than whites, resulting in higher mortality rates.”

Inferior care, Wallace told Registered Nurse, has a “weathering effect” on people, by which he means the “accumulated impact of being poor, living in poor conditions and the high stress of living in a racist environment,” all contributing to deteriorating health.

For instance, Wallace says that “food insecurity” among minorities is twice that among non-Latino whites, and that food insecurity is associated with a host of chronic diseases like diabetes, hypertension, and coronary heart disease.

This disparity of access to health care has an impact on what U.C. Berkeley’s Satariano refers to as “the middle years, where the accumulation of insults the poor suffer play out. It is during these middle years that we begin to lose some of our resistance to disease.”

New research finds that poverty level income—$10, 210 for a single person, $13,690 for a couple—falls short of meeting basic needs. According to the National Academy of Social Insurance, people need to earn between 150 percent to 300 percent above the poverty line “to meet basic living expenses without assistance.”

Gender creates yet another dimension to the problem. Women, age 45-55, with a family income of less than $35,000 a year, make up the overwhelming bulk of people who volunteer their labor to care for aged parents or grandparents. Some 80 percent of them hold full-time jobs. It is this “informal” labor force that keeps the crisis of elder care from going into free fall.

More than 20 million U.S. employees have ailing parents, and only one percent of the companies they work for pay for subsidized elder care. Medicare will not pay for long term care (LTC), and Medicaid will only do so once the elders’ assets are exhausted. The result of the government’s unwillingness to take any responsibility in this area means that 64 percent of LTC is “informal,” and another 28 percent is a combination of informal care and elder resources. The average informal caregiver puts in 18 hours a week.

The problem of long term care is the elephant in the room when policymakers and planners gather to talk about health care systems,” Mary Jane Koran, a member of the National Commission for Quality Long Term Care told the House Sub-committee on Labor, Health and Human Services in February of this year.

The Bush Administration’s solution to the LTC crisis is to push market driven schemes, like reverse mortgages and private long term insurance. More than eight million Americans have purchased LTC insurance, only to find that companies throw up one road block after another when it comes time to cash in. A study in California found one in four claims were denied. In the meantime the industry has pulled in more than $50 billion in premiums.

As for reverse mortgages, they essentially wipe out one of the few assets working class people can pass on to their children.

According to the American Association of Retired People, this informal labor network is valued at anywhere from $275 to $350 billion a year, more than twice what Medicare costs.

But demographics are working against “informal” care giving as a solution to the LTC crisis because people are having fewer children. In 1955 the average family size was 3.7. In 2000 that figure was 2.1. According to a study by the Robert M. LaFollette School of Public Affairs, “The average working couple has more living parents than children.”

Because people are living longer they are more vulnerable to Alzheimer’s disease. According to the Alzheimer’s Association, by age 85, nearly 50 percent of the population will be stricken with the disease. Relatives will care for over 85 percent of those.

As for the caregivers: no good deed goes unpunished. “Women of all races tend to have jobs that either do not provide health care, are lower paying so they can’t afford private insurance, or they work part time in order to care for their family and have no benefits,” says Miller. “Therefore, by the time they become eligible for Medicare, their health may be significantly worse.”

Because women are paid less, and may end up missing work to act as caregivers, they also end up drawing less Social Security. The Academy of Social Insurance estimates that family caregivers give up about $659,000 in lifetime wages and pension benefits.

Another part of the “total terrain” has to do with where people age.

Studies show that elders do better if they stay in their homes rather than going to a care facility. Staying in place also saves money. But most homes are not designed for elders.

Satariano, the author of “The Epidemiology of Aging: An Ecological Approach,” argues that “The problems of older people require addressing things that some people think of as falling outside the realm of health care,” like the design of cars and houses. This, he says, means pulling city planners and building contractors into the mix. “How do we design more walkable communities? Can we build communities that have short distances to walk to stores, supermarkets where they [elders] can purchase fresh fruits and vegetables?”

Since up to 70 percent of diseases that afflict seniors are behavioral, not genetic, this is not just a matter of providing people better cuisine. Eating properly and exercising by walking in safe, well lighted parks, is part of the formula for what Satariano calls “adding life to years, not just years to life.”

Satariano’s “ecological,” approach argues for creating environments that are senior friendly. “Houses should be designed with a minimal number of steps, bathroom walls should be reinforced for attaching supports, and doors made wider for wheelchairs.”

Wallace told Registered Nurse the same approach to improving elder health should be applied to planning communities. Reflecting roofs, cooling trees, and parks—so-called “heat islands”—would reduce hot weather deaths. City planners and zoning boards should encourage the building of “granny units” so family can be nearby. He says these initiatives should be no more controversial than putting fluoride in the water to reduce tooth decay: “You just do it!”

The core problem is that we don’t need more medicine, we need to set up communities so that people can become more active,” says Wallace.

Instead of thinking what we need to do to keep people in their homes—where 90 percent of older people want to be—long term care gets caught up in cross currents and ideological debates,” says Wallace, “where free market advocates see privatization as a solution to everything.”

Martin adds a human element to LTC: “There is a huge emotional and physical toll to being institutionalized. There is a complete loss of privacy, dignity and control over your life. You are told when and what you eat. On shower days you are stripped naked, wrapped in a towel, placed in a shower chair and dragged down the hall to the shower room.”

Brunner agrees that avoiding institutionalization is important. “How do we set up a social support system and infrastructure to help old people get services at home and keep them out of nursing homes.”

Finding solutions will not easy and tend to run up against a cohort of powerful lobbyists that run the gamut from pharmaceutical companies to the insurance behemoths. On the other hand, the political power of seniors has grown over the past decade, and local and state governments, not to mention the medical establishment, are coming under increasing pressure to respond to demands to improve elder care.

At least the outlines of a solution are out there.

One is to end health disparity. “Everything links back to growing income inequality,” says Brunner, and Satariano agrees: “The issue of disparity is critical.”

Kay McVey, RN, and President Emeritus of the California Nurses Association, says income is directly related to the quality of elder care. If patients don’t have the money, they can “end up tied to a gurney or strapped in a wheelchair and stuck in the back of a facility.”

Two is to create a nation-wide health care system that coordinates care. “Single payer health care would end the idea that you can make big profits off of old people. It establishes one standard of care for everyone, whether you are in an acute care facility or a long term care facility,” says McVay. The only criteria should be: “What does the patient need?”

Three is to improve training. “ Medical schools must train students to treat older Americans,” says Brunner. “We have a right to make demands on our institutions, says Satariano. “You have to teach geriatrics,” says Landau bluntly.

Four is designing communities and programs that take into account the “ecology” of aging. “When you are elderly you need not just medical attention and medications,” says McVay, “you need good nutrition and exercise and things that challenge your mind. Otherwise it is just warehousing. It shouldn’t be that way and needn’t be that way.”

Mobilizing the medical profession, lobbying federal, state and local governments to stop turning a blind eye to the problem, and neutralizing the lobbying power of the “medical-industrial complex” will be a formidable task, and yet given the size of the constituencies involved, one that may not be as difficult as it initially looks.

In the end, it will also take a sea change in our attitude about elders, “Who are not exactly revered,” as Landau points out.

I know it sounds sort of corny, but you have to have love and empathy. Aging is about loss—loss of independence, loss of mobility, eyesight, hearing, cognition—you need an approach that allows people to deal with loss in a collective, supporting way,” she says.

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Turning up the Heat: Global Warming & Human Health

Turning up the Heat: Global Warming & Human Health


By Carl Bloice and Conn Hallinan

On July 21, farmworker Constantino Cruz put in a nine-hour day. It was the third week of 100 degree plus weather in Shafter, a town in California’s fertile Central Valley. At the end of his shift the 24-year old fieldworker collapsed. He died 10 days later. Record heat killed three other farmworkers that same month.

Ninety-degree water temperatures in the Gulf of Mexico transformed Hurricane Katrina from a troublesome storm to a city killer. July is early in the season for a hurricane, and Katrina was not the first. Hurricane Dennis, the earliest recorded hurricane in history, had already pummeled Florida.

Public health officials in Colombia are worried because malaria-carrying mosquitoes, normally restricted to the wet lowlands, are appearing well above 5,000 feet. Researchers have also noticed an increase of ticks bearing Lyme disease in coastal areas of Massachusetts and Scandinavia.

Asthma has shown a worrisome jump worldwide, with a disturbing trend toward increased lethality. U.S. asthma death rates have risen from 8.2 per 100,000 in 1979 to 18 per 100,000 in 1995, with the heaviest burden, according to the National Institute of Allergy and Infectious Diseases, falling on “poor, inner-city African Americans.”

Heat waves, violent weather, and disease epidemics sound almost Biblical, but a broad consensus of scientists says all this has less to do with the sacred than the profane: human activity is heating the world at a dramatic pace, and the health care issues of a substantially warmer world are profound.

There are a handful of scientists who still resist the idea of global warming, but they constitute, “maybe a half a dozen in the world,” according to Susanne Moser. “Ninety-nine point nine percent of scientists are convinced global warming is underway.”

Moser is with the National Center for Atmospheric Research in Boulder, Co. and one of the authors of “Rising Heat and Risks to Human Health,” a Union of Concerned Scientists’ (UCS) study of the potential impact of climate change on the state of California.

According to the United Nation’s Intergovernmental Panel on Climate Change (IPCC), global warming “is projected to increase threats to human health, particularly among lower-income populations, predominantly within tropical/subtropical countries.”

Tracking the health implications of climate change is a little like that old spiritual: “The knee bone’s connected to the thigh bone, the thigh bone’s connected to the hip bone…” It is enormously complex, intricately inter-related, and embraces a staggeringly wide number of phenomena. It is also subtle, which makes getting people to take notice difficult.

“Climate change is big,” says Moser, “but you can’t see global warming in the same sense that you can see a dirty stream.”

Experts generally break down the health implications of global warming into three broad categories: heat, disease, and extreme weather events, like floods, droughts, and storms. While all are different, there is a nexus between them that sometimes comes out looking like some enormous environmental rubix cube.

Heat is a case in point. The heat that killed four farmworkers this past July was hardly the first heat wave to strike California, but if UCS’s predictions are accurate, such heat waves will be higher and far more frequent in the future.

According to a study of the effects of climate change on health by Laurence Kalkstein and Kathleen Valimont of the Environmental Protection Agency’s (EPA) Science and Advisory Committee, temperature studies dating back to the early 1960s demonstrate there is a link between heat and such health problems as heart failure, cerebrovascular complications, peptic ulcers, glaucoma, goiter and eczema.

The heat wave that enveloped Europe in the summer of 2003 killed over 35,000 people, 15,000 in France alone, an event that Pulitzer Prize-winning investigative journalist and author Ross Gelbspan says had global warming written all over it. “That heat wave had a very specific signature of human induced heating.”

Gelbspan has worked for the Washington Post, Philadelphia Bulletin, and Boston Globe, and is author of two books, The Heat is On, and Boiling Point.

One of the characteristics of global warming is the buildup of carbon dioxide (CO2), one of the so-called “greenhouse gases.” Increasing CO2 levels, says Gelbspan, causes “night time temperature levels to rise, so that there is no cooling off period when the sun goes down. It means there is no recuperation time for people caught in it.”

CO2 has risen from 280 parts per million in the 18th century, to 375 parts per million today. The gas is very stable, lasting upwards of 100 years.

According to the UCS study, while the greatest temperature rises will be in the California’s Central Valley, it is coastal cities like San Francisco that are predicted to have the highest mortality. Residents in San Francisco, says the report, are unaccustomed to hot weather and housing is not designed to moderate its effects.

That mortality will largely fall, according to an EPA study of past U.S. heat waves, on “poor inner-city residents who have little access to cooler environments.” Indeed, the overwhelming majority of those who died in the European heat wave were old and poor.

The UCS report urges “significant efforts” to provide early warning systems–most states do not have any ability to predict heat waves–cooling centers, education and community support systems.

But for cash-strapped public health officials trying to hold the gates against HIV and antibiotic-resistant tuberculosis, killer heat waves and disease-bearing mosquitoes are a bit of an abstraction.

“It’s a matter of priorities,” says Contra Costa Public Health Director, Dr. Wendell Brunner. He points to West Nile fever as an example. While he is all for getting rid of mosquitoes, he says the County is spending more on mosquito abatement than on HIV. “We have one case of West Nile, we have thousands infected with HIV, almost all of whom will die.”

San Francisco, according to Dr. Rajiv Bhatia, Director of Occupational and Environmental Health for the city’s Public Health Department, has chosen to focus on long range solutions rather than short range programs.

“I think it is important to think in terms of whole world not just our portion of it. It would be a wrong use of energy and resources to direct our efforts toward dealing with the effects of climate change rather than efforts to prevent it,” he says.

He compares the problem to the proliferation of atomic weapons. “We should not be preparing for a nuclear attack–building bomb shelters–but banning and destroying nuclear weapons.”

Kay McVay, a Registered Nurse, California Nurses Association (CNA) Liaison Coordinator and former president of CAN, strongly believes that “Health care professionals and health care workers should be in the forefront of efforts to educate the public and to support strong measure to head off global warming.”

But she worries that “Nobody is being taught how to respond, there is no plan.”

“Our public health system has been decimated,” she says. “Hospitals have been closed by the hundreds, and RNs have been moved away from the bedside, and there is a shortage of public health nurses. We just don’t have the structure in place to handle it (climate change).”

One thing seems clear: given the inadequate finances of public health, people in the field are wrestling with hard choices of where to bullet their efforts.

Like the knee bone to the thighbone, higher temperatures have a cascading effect on a number of environmental factors. Severe drought is presently affecting one in six countries and has already created a continent-wide crisis in Africa. “Southern Africa is definitely becoming drier and everyone there agrees the climate is changing,” Wulf Killman of the UN’s Food and Agriculture Organization’s Climate Change Group, told the British Guardian.

Some 34 African countries, with upwards of 30 million people, are experiencing drought and consequent food shortages. “Drought affects people’s ability to feed themselves. A lack of food means a weakened population, one that is more susceptible to disease,” says Moser, ” and if you are stressed to the max, you don’t need much of an extreme event to push you over the edge.”

When people do go over that edge, there is virtually no net to catch them. A 2003 study by the World Health Organization (WHO) found that while developing countries carry 90 percent of the disease burden, they have only 10 percent of the world’s health resources. WHO estimates that 23,000 of Africa’s best trained health workers emigrate to Europe and the west each year, leaving only 800,000 doctors and nurses for the entire continent.

While aid can mitigate some of that burden, according to “Africa-Up in Smoke?” by the Working Group on Climate Change and Development—a coalition of organizations ranging from Oxfam to Greenpeace—aid is not enough. “All the aid we pour into Africa will be inconsequential if we don’t tackle climate change,” says Nicola Saltman of the World Wide Fund for Nature, a member of the Group told the Independent.

Climate change does not mean that the world gets drier everywhere. “Global warming means some places are going to get wetter, which is perfect for mosquitoes,” says Dr. Don Francis of Global Solutions. Francis, a former epidemiologist for the Center for Disease Control and an expert on diseases like smallpox, HIV and Ebola, predicts that “Infectious diseases, particularly those with vectors like mosquitoes, will move north. And with warmer temperatures and milder winters there will be longer transmission periods for diseases like malaria and encephalitis.”

That process is already underway. According to Dr. Jonathan Patz of the University of Michigan, malaria has surged since the 1970s, and expanded into areas–like the Colombian highlands–that were formally off limits to its vector, the Anopheles mosquito.

Malaria kills between one and two million people, and generates some 300 million to 500 million new cases a year. The malaria plasmodium is also increasingly resistant to standard treatment with chloroquine, although a new palette of drugs based on artemisinin extracted from the sweet wormwood bush has been effective.

However, while chloroquine costs 10 cents a dose, the new drug from the pharmacology giant, Novartis, runs $2.50 a pop. Artenisinin should also be taken with fatty meals, not normally a part of the developing world’s menu.

While malaria is the most dangerous of these mosquito borne diseases, there are other unpleasant beasts out there, including dengue, or “break-bone fever,” which infects 20 million people a year and kills more than 24,000.

Yellow fever could also spread, as might more exotic diseases like chagus, a trypanosoma that damages the heart and is spread by the nocturnal assassin bug. chagus, which takes about 50,000 lives a year, is endemic in Latin America, and closely associated with poverty and sub-standard housing, which gives the carrier places to hide during the day.

There is a close link between vector-borne diseases and unstable weather, the latter a major consequence of global warming. According to a 2003 World Health Organization study, “Climate Change and Human Health-Risks and Responses,” dengue epidemics are closely associated with El Nino events, when the surface of Pacific Ocean heats up and brings on warm and wet conditions. Malaria epidemics increase five-fold as well.

The same study found similar patterns with malaria in India when monsoon rains are heavy and humidity high.

In a 40-year study of Bangladeshi medical records, Mercedes Pascual of the University of Michigan found that climate change increases the incidence of cholera by spreading the disease through either floods or droughts. In the latter case, restricted water supplies are more vulnerable to disease causing organisms.

Recent heavy rains in West Africa have seen cholera rates more than double. More than 31,000 have been stricken since June. Flooding and drought also spread water borne diarrheal diseases like shigella, dysentery and typhoid, which kill over two million people each year, the majority of them children. Flooding also helps rodents disseminate diseases like hantavirus, tularemia, and bubonic plague.

Melting continental ice, coupled with the expansion of the oceans through warming, is projected to raise sea levels anywhere from three and a half inches to three feet by 2100. This will not only inundate lowlands where hundreds of millions of people presently live, it will generate more powerful storms.

According to the Massachusetts Institute of Technology study, tropical storms have increased in intensity by 50 percent in both the Atlantic and the Pacific over the past 30 years. “Future warming may lead to an upward trend in tropical cyclones’ destructive potential, and, taking into account an increasing coastal population,” says the MIT’s Kerry Emanuel, and “lead to a substantial increase in hurricane-related losses in the 21st century.”

Tropical storms all draw their power from warm water. The hotter the water temperature, the stronger the storm. Hurricane Katrina was a case in point.

Hurricanes, heat waves and vector-borne diseases are the most obvious effects of global warming. Other outcomes, like asthma, are hidden in a web of interconnecting events.

U.S. asthma rates have increased 40 percent in the last 10 years, afflicting 25 million Americans, nine million of those children. It is the number one cause for school absenteeism, and between lost work days and medical care, costs the country about $11 billion a year. Hospitalization for asthma is at record levels, particularly for African American children

This latter figure, however, may have more to do with social policy than asthma rates among certain populations. “African-American kids are hospitalized at four times the rate as Euro-American kids in Contra Costa County,” says Brunner, but says that is because they don’t have quality care. “Kids in Walnut Creek and Danville (affluent areas of the County) don’t end up in hospitals because they do.”

There are, however, asthma “triggers” which global warming is accelerating. A major component of air pollution is ozone, and “ozone is definitely a proven asthma trigger,” Brunner says.

Pollen, which can cause allergies and asthma, is likely to increase with climate change . Studies by Dr. Paul Epstein found that ragweed pollen, a major cause of allergies, will soar 64 percent if CO2 levels double, as predicted by the year 2050. Studies of Loblolly pines in North Carolina reached the same conclusion.

As daunting as problems like asthma seem, a little effort can make a major difference. A Canadian Public Health Association study of the 1996 Atlantic Olympics found that when the city restricted auto traffic for the 17 days of the games, ozone levels fell 30 percent, and emergencies and hospitalizations for asthma dropped 40 percent.

Because of the Bush Administration refusal to touch the subject of global warming or impose mandatory controls on greenhouse gases, a number of states and cities have begun to take action on their own. Nine northeastern states have signed on to their own version of the Kyoto Treaty, agreeing to reduce CO2 levels by 10 percent over the next 15 years. Hundreds of cities across the country have signed on.

Seattle has built a monorail, streetcars, and offers residents free city-owned hybrid gas cars, runs municipal vehicles on bio-diesel fuel, and has restored 2500 acres of urban forest. As a result, the city cut greenhouse gases by 48 percent from 1990 to 2000.

“There is much that is doable,” says San Francisco’s Bhatia. “The effects of global warming being projected are not inevitable. We can do much to prevent it.”

He cites a California EPA study which found that 58 percent of CO2 is produced by transportation, a figure that will increase as the State’s population grows. Only five percent of the city’s residents use public transportation exclusively. We can double that number soon.”

“Can we do something about global warming?” asks Moser. “Hell, yes!”

She points to the recommendations of the CUS report: increased disease surveillance, temperature warnings, cooling stations, and education. And better health care. “Many people don’t have health care, but that is the system that will have to deal with the consequences of climate change. We haven’t had that conversation in this country yet,” she says.

Americans, she argues, are willing to tackle the problem. “People want to do something positive, to leave a legacy. You have to appeal to that part of them. People understand you have to go though a little pain for long term benefits. They put money away for their kids to go to college, they buy insurance.”

The Program on International Policy Attitudes found that 56 percent of Americans would be willing to incur significant economic costs to address global warming, and 73 percent said the U.S. should join the Kyoto Accords.

But Moser says the involvement by the federal government is essential. “You can’t give up driving your car if there are no buses, or no bus shelters, or they cost too much.”

Francis concurs. “Government could have a tremendous impact on this. Remember seat belts? We got the data, passed laws, and people started wearing seat belts.”

Gelbspan even sees a certain silver lining in all this. “We live in a deeply fractured world. Here is an opportunity to bring all the nations of the world together. We can move beyond stale nationalism, create jobs, and undermine the economics of poverty and desperation.”

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Healthcare Provider Migration: a Global Crisis

Healthcare Provider Migration: a Global Crisis

April, 2007

Carl Bloice

Conn Hallinan

Chad, according to the World Health Organization (WHO), has the worst public health infrastructure of any country in Sub-Saharan Africa – maybe in the world. Life expectancy is estimated to be 45, and over a third of Chadians are malnourished. The population is plagued by infectious and parasitic diseases, respiratory afflictions and nervous disorders, mainly from poor sanitation and limited access to potable water. In 2001, the country’s HIV infection rate was 3.6 percent of the sexually active population. To make matters worse, the country must deal with over 200,000 refugees from the ongoing civil conflict in neighboring Sudan, many of whom arrive afflicted with chronic diarrhea, fever, and respiratory infections.

With a population of more than 8 million, Chad has around 3,600 health workers: 50 percent of these are unskilled, and 35 percent are nurses and midwives. And yet one recent survey revealed that over 10 percent of the Chadian-trained nurses were working outside the country – mostly in France, some in the United States.

Chadian healthcare figures are replicated throughout Sub-Saharan Africa, which has 25 percent of the world’s disease burden, and only 1.3 percent of the world’s healthcare workers.

Nor is the problem confined to Africa. World wide there is a shortage of trained healthcare personnel in the places most desperately in need.

According to the United Nation’s International Migration and Millennium Development Goal, “Poor countries, many of them with the fewest healthcare workers, but the highest infectious disease burdens are ‘subsidising’ the health care systems of wealthier countries.”

Billions of dollars have been invested in efforts to prevent the spread of HIV and other diseases in the world’s poorest countries. Yet at the same time, qualified health workers are leaving the same areas to work in the world’s richest countries.

The situation is particularly acute in Africa. More Malawian doctors are said to be practicing in Manchester, England than in the whole of Malawi. And only 50 of the 600 doctors trained since independence are still practicing in Zambia. In Central African Republic, Liberia and Uganda, there are fewer than 10 nurses per 100,000 people, compared with more than 2,000 per 100,000 in countries such as Finland and Norway.

Experts say there is a global shortage of at least four million healthcare workers. Health system weaknesses mean that death rates are rising and life expectancy is falling in the poorest countries, despite the global health advances of recent years. Healthcare workers hold the key to tackling these challenges. But urgent action is needed to improve the supply, capacity and distribution of the global health workforce.

The Joint Learning Initiative, an enterprise involving over 100 global health leaders, list three major factors as exacerbating the problem faced by healthcare workers in the most understaffed areas of the developing world:

  • HIV – which increases their workloads, exposes them to infection and lowers their morale.
  • Labor migration that is accelerating from countries that can least afford the brain drain.
  • Two decades of health sector “reform” that has lead to chronic underinvestment in human resources.

The problem of the migration of nurses and other healthcare providers has become an issue not only in the countries negatively affected but in the nations receiving the immigrants. Increasingly, governments and the healthcare industry in major industrial countries are turning to immigration as a way to solve – or avoid solving – shortages that have resulted largely from the “reforms.”

Vicky Lovell of the Institute for Women’s Policy Research, told Registered Nurse “It is immoral of the United States to ignore the impact of it [immigration of healthcare workers] on the countries where these nurses come from.”

Writing in the “American Journal of Nursing,” Diana Mason argues that the issue is a “primary moral” one of “draining these countries of their much-needed nursing resources and further undermining their healthcare infrastructure and the health of their people (and thus the health of their economies).”

World public health specialists acknowledge the problem, but a major stumbling block, they say, is providing sufficient motivation for healthcare providers to remain within their countries. It’s a problem faced by scores of other countries, particularly in Asia, Africa and Latin America.

South Africa, for instance says it has spent $1 billion educating health workers who emigrated – the equivalent of a third of all development aid it received from foreign agencies between 1994 and 2000. At the same time public health experts say the countries of sub-Saharan Africa should double their nursing work forces, adding at least 620,000 nurses to deal with the spread of Aids, tuberculosis and malaria.

“The massive outflow of nurses, midwives and doctors from poorer to wealthier countries is one of the most difficult challenges posed by international migration,” according to the U.N. Population Fund’s (UNFPA) latest annual report released September 6, 2006. The group said countries losing healthcare providers are facing a healthcare crisis “unprecedented in the modern world.”

The UNFPA “State of World Population” report, UNFPA said nowhere is the effect of the “brain drain” more acutely felt than in the already fragile health systems of developing nations.

“The problem with the brain drain is that health systems are already collapsing in poor countries that face massive health care needs. The outflow of doctors and nurses aggravates this situation,” Maria Jose Alcala, the report’s principal author, told Inter Press Service (IPS). She pointed out that while nursing is one of the few occupations that offer migrant women decent work with decent pay, “In their countries of origin, nurses face poor working conditions, while richer countries become appealing destinations for them because of higher wages.”

For instance, a surgical nurse in South Africa makes about $13,000 a year. The same nurse can earn $66,000 a year in Britain.

The exodus of nurses from poor to rich countries has strained health systems in parts of the developing world, which are already facing severe shortages of their own. In May 2004, African countries at the annual assembly of the World Health Organization urged developed nations to compensate them for their lost investment in training nurses, and won a pledge to study ways to reduce the damage from the emigration of nurses.

Two years ago, the international organization, Physicians for Human Rights, called on industrial nations to reimburse African countries for the loss of health professionals educated at African expense and to try harder to meet their own worker shortages by training more people domestically rather than recruiting abroad.

The group pointed to a trade off between the rights of African health professionals to seek a better life and the rights of people in their home countries to decent health care. It did not recommend that African governments try to prevent the emigration of health care workers, but did recommend that industrial countries not recruit actively in Africa.

In 2001, in response to such calls, the British National Healthcare System (NHS) promised not to engage in “aggressive recruitment” of African nurses. However, the National Health Service policy does not cover private facilities and private British hospitals. Over 12,000 African nurses have registered to work in Britain over the past seven years.

Percy Mahlati, a high official of the South African Department of Health told the British medical magazine, The Lancet, that the NHS were using private agencies to do their recruiting, “so that rather than doing it directly, they (the NHS) is doing it indirectly.”

A Lancet study found that many nurses from Africa who are recruited by private agencies start off working at nursing homes and private hospitals, but quickly move on to the higher paying NHS jobs.

Despite having the resources to do so, the United States and other developed countries have simply failed to produce enough medical and nursing staff to meet their healthcare demands. A study by the Guardian found that Britain only trains 70 percent of the doctors it needs, and that the U.S. trains 50 percent of the nurses it will need.

Instead they actively recruit them from already depleted developing country health workforces, thus contributing to the healthcare personnel crisis elsewhere, particularly in parts of Asia and Africa.

The increasing migration of healthcare providers represents another faucet of the globalization of the healthcare industry.

This past summer Senator Sam Brownback, (R- Kansas), inserted a proposal into immigration legislation that would facilitate increased immigration of nurses into the U.S. The measure was intended to deal with what he described as a nursing shortage in the country. Accoding to the New York Times, public health experts in poor countries, “reacted with dismay and outrage, coupled with doubts that their nurses would resist the magnetic pull of the United States, which sits at the pinnacle of the global labor market for nurses.”

Smita Baruah, Senior Government Affairs Advisor for Physicians for Human Rights, told Registered Nurse that, “Kansas is facing a nursing shortage and the Senator saw this would be of great economic benefit to his own state. He was looking for a fast and easy solution.”

Senator Brownback, who has been an advocate for programs to combat AIDS and malaria in Africa, has suggested that relaxing nurse immigration rules would have little impact on Africa because of the absence of major recruiting efforts there and the fact that arriving African nurses would not have a big community there to plug into.

However, Eric Buch, the top health adviser to the New Partnership for Africa’s Development, an Africa-wide undertaking initiated by the continent’s heads of state, said he expected that recruiting agencies would set up in African countries where nurses were trained in English and that they would advertise the change in the American law. “You’ll see that emerge, that’s my guess,” said Professor Buch, who teaches health policy at the University of Pretoria, in South Africa, said in a telephone interview. “The United States could become a place where we bleed our healthcare workers.”

Holly Burkhalter, with Physicians for Human Rights, said the nurse proposal could undermine the United States’ multibillion-dollar effort to combat Aids and malaria by potentially worsening the shortage of health workers in poor countries. “We’re pouring water in a bucket with a hole in it, and we drilled the hole,” she said.

The nurse proposal has strong backing from the American Hospital Association. “There is no reason to cap the number of nurses coming in when there’s a nationwide shortage, because you need people immediately,” said Bruce Morrison, a lobbyist for the hospital association and a former Democratic congressperson.

Cited as justification for the Brownback measure and the continuing effort to lure nurses from abroad is the contention that there is an accelerating shortfall of nurses in the country, which will increase to over 800,000 by 2020. The hospital industry has employed such statistics in its effort to fend off drive for mandatory standardized nurse-to-patient staffing ratios.

However, nurse union leaders say just how much of nurse shortage exists is open to question. They say changes brought about by healthcare industry restructuring over the past 20 years have resulted in many nurses working in non-hospital settings or out of the field altogether.

There is the continuing problem of the absence of RNs working at the bedside,” said Deborah Burger, president of the California Nurses Association. “This is particularly true in states that, unlike California, do not have adequate staffing ratios and where wages are substandard and working conditions deficient. All sorts of non-healthcare business are actively recruiting nurses away from healthcare. This is true of things like legal consultancies and insurance firms that are anxious to hire nurses because of their knowledge and their respect by the public. It’s tempting because in these other arenas you probably would be treated better and do better financially.”

According to Berger, “There would be no need to lure nurses from abroad if we were willing to spend the necessary resources to attract and educate a sufficient nurse workforce and provide the compensation and working conditions to retain it.”

The question nurse compensation and working conditions has been raised strongly by Lovell, principle author of “Solving the Nursing Shortage through Higher Wages.” Lovell says, “The issue of wages, she said, has been kept under the surface for a long time.”

There are “a lot of players in healthcare” that don’t want to see higher wages as an avenue out of the current situation and propose other means such as more nursing schools and immigration, she said, “But these other avenues won’t be effective.”

“I think the public would really be shocked if they knew about the working conditions for nurses,” said Lovell, citing things like inadequate staffing and mandatory overtime, and “the fact that many nurses work without breaks.” “If the public knew they would really care about” it but “a lot of these conditions are hidden from the public. It isn’t what people see when they go to visit someone in a hospital.”

Lovell said she sees increased recruiting from abroad as way to essentially avoid dealing with the central problem of wages and working conditions, but is careful to say that no one can object to someone coming from another country and getting a better standard of living. It is just that immigration is not the solution to the nursing shortage. Still, “It is immoral of the United States to ignore the impact of it on the countries where these nurses come from,” she said. “Labor supply is a problem in other nations as well.”

Immigration is not the only way we can get more nurses,” said Lovell, “Raising wages is easier and more effective.” The aim, she said, should be to work toward raising nurse wages in other countries.

The key to raising wage levels and improving on the job conditions in the U.S., said Lovell, is collective bargaining. A stumbling block is that “labor laws are so weak on protecting workers and unionization.”

Yes, more nurses will be needed in the coming years, said Burger, but the response to the challenge should be to improve the well-being of nurses employed in hospitals and stepped up efforts to provide more access to nurse education. “When CNA developed its position in nurse migration a central element was our conclusion that at present the U.S. is not really interested in providing the kind of healthcare workforce that is needed. The same can be said for other industries as well. Our thinking is that we should be educating sufficient nurses for the future. But we are not doing so. There are three to four times more applicants for positions in nursing schools than there are slots available. What we are essentially doing is splitting the cost of training healthcare personnel with other, poorer countries.”

Some limited steps have been taken to deal with the education problem. Fourteen nursing schools have launched doctoral programs to prepare nurses to teach or work as supervisors in hospitals, and an additional 190 programs are said to be in development. In addition, 31 nursing schools since 2000 have launched fast-track programs that reduce the time required to earn a doctorate by at least one year, and an additional 13 programs are in development.

However, there are now many more Americans seeking to be nurses than places to educate them. In 2005, American nursing schools rejected almost 150,000 applications from qualified people, according to the National League for Nursing. One of the most important factors limiting the number of students, said the group, is a dearth of faculty. Professors of nursing earn less than practicing nurses, damping demand for teaching positions.

According to the American Association of Colleges of Nursing, nursing schools nationwide rejected more than 41,000 qualified applicants last year compared with 33,000 in 2004 and 18,000 in 2003. The group’s annual survey, released in October, revealed that three out of four schools attributed the increased rejections in large part to an insufficient number of faculty members. At present, the report said, 7.9 percent nursing school faculty slots are vacant.

“We have increased interest in the profession at exactly the time when we need to ratchet up our preparation of staff nurses, but we have too few faculty, and the ones that we have are gray and contemplating retirement in droves over the next few years,” Sally Lundeen, dean of the University of Wisconsin-Milwaukee School of Nursing told USA Today October 4.

Based on past trends, healthcare industry lobbyist Morrison predicts that lifting the restrictions on immigration would incresase the number of nurses coming by 5 to 10 percent a year. Recruiters would focus on countries with large numbers of well-trained nurses, mainly the Philippines, India and China,” he said. “But it’s certainly true that the longer the United States puts off investing in training nurses, the more pressure there will be to find nurses abroad,” he adds.

Opponents of the plan say it would hit the Philippines particularly hard. That Asian country sends more nurses to the United States than any other country, at least several thousand a year. As a result, Philippine healthcare has deteriorated in recent years as tens of thousands of nurses have moved abroad. Thousands of ill-paid doctors have even abandoned their profession to become migrant-ready nurses themselves, Filipino researchers say.

“The Filipino people will suffer because the U.S. will get all our trained nurses,” said George Cordero, president of the Philippine Nurse Association. “But what can we do?”

Cortez, who has worked with Philippine-trained doctors who became RNs in order to emigrate to the U.S. said, they, like the nurses who have left, did so “for the very simple reason: to get away from a situation of relatively low wages and poor working conditions.”

A lot of young Filipinos are going into nursing as preparation for leaving the country is search of a better life. As a result of the emigration a lot of hospitals – especially in rural areas – have been forced to close because a shortage of both doctors and nurses,” said Cortez. “In more urban areas the hospitals are able to avoid being closed because people there are more affluent and able to afford preventive care.”

He says , “The problem is that the government cannot offer the compensation levels that would attract healthcare providers to stay in the country because most of the money there is being spent on business rather than things like healthcare.”

A nurse in the Philippines would earn a starting salary of less than $2,000 a year compared with at least $36,000 a year in the United States, said Dr. Jaime Galvez Tan, a medical professor at the University of the Philippines who led the country’s National Institutes of Health. He said the flight of nurses had had a corrosive effect on health care. Most Filipinos died without medical attention in 2003, just as they had three decades earlier.

Based on surveys, Dr. Tan estimates that 80 percent of the country’s government doctors have become nurses or are enrolled in nursing programs, hoping for an American green card. “I plead for justice,” he told Registered Nurse “There has to be give and take, not just take, take, take by the United States.”

Cortez tells of a recent flight home from the East Coast during which she encountered an in-flight attendant who had graduated from nursing school and subsequently decided her present job was more attractive. The woman related a number of reasons for her career decision, including better wages and working conditions, the opportunity to travel and avoidance of the stresses of working with critically ill people. “One of the things she said was that a lot of the good thing about her job was a result of have the protection of belonging to a union.”

In order to deal with the problems confront nursing,” says Cortez, “Congress should be concentrating on strengthening the country’s healthcare infrastructure and improving the wage and bettering the working conditions for nurses. And they should step in and undo the recent decision by the National Labor Relations Board making it harder for nurses and others to join unionize. If they could have union protection I think many of the nurses not working in hospitals could be convinced to do so.”

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Fighting For Air

Fighting For Air


June, 2006

By Conn Hallinan and Carl Bloice

In a world beset by AIDS, the threat of a global flu pandemic, and the worrisome expansion of mega-killers like malaria, asthma hardly figures very high on anyone’s watch list. But while it cannot match the lethality of HIV or exotic viruses like Ebola and Marburg, it is, according to Dr. Wendel Brunner, Director of Public Health in California’s Contra Costa County, “a seriously disruptive disease.”

Indeed it is. Asthma is the number one cause of school absenteeism, and the number one occupational lung disease. While it strikes rich and poor alike, the burden on the latter is profoundly heavier, particularly if the victims are African-American.

And, by any measure, it is on the increase both in the U.S. and worldwide.

There are about 150 million asthma sufferers in the world, almost 31 million of them in the U.S. From 1980 to 1996, the number of Americans with the disease more than doubled, with the largest increase among children under five. Western Europe doubled its asthma sufferers in the last decade.

The disease has also become deadlier. The number of deaths in the U.S.—between 4,000 and 5,000 a year—has increased almost four-fold from 1977, and worldwide, 25,000 children die each year.

No matter who you are or where you live, asthma is a debilitating and scary disease. By inflaming the air passages in the lungs, causing them to swell, it reduces airflow, leaving a victim wheezing and gasping for breath. In severe episodes it kills. Left untreated, it causes irreversible changes in the structure of the lungs, or “airway remodeling.”

There is no cure.

It is also expensive, costing Americans about $16.5 billion annually in health care and lost workdays. Each year it leads to nine million visits to health providers, 1.8 million trips to the emergency room (ER)—one third of all pediatric ER vists are for asthma—and 460,000 hospitalizations. According to the World Health Organization, the worldwide impact of asthma exceeds that of tuberculosis and HIV/AIDs combined

While asthma is clearly associated with a number of “triggers,” ranging from industrial pollution to mouse droppings and pollen, it has an idiosyncratic quality that makes identifying causes a complex and at times bewildering endeavor.

Why do Puerto Ricans in the U.S. have four times the asthma rate of African Americans, who have, overall, the highest rate in the country? And why do Puerto Ricans have such high rates, when Hispanics generally have low rates? Why do Hawaiians have four times the rate of other Asian-Pacific Islanders? How come nearly 50 percent of the children in the Caroline Islands have asthma, while the disease is virtually absent in Papua New Guinea, just south of the Carolines? No one has a clear answer to any of these questions.

Winnowing out the reasons for this differential is a journey through a labyrinth of inadequate health care, sub-standard housing, the interrelationship between industry, transportation, and communities, and some serious educational deficiencies about how to control the disease.

Take the enormous differential in ER visits and hospitalization. “Hospitalizing is a reflection of poverty,” says Brunner. “If a community has a higher hospitalization rate, it doesn’t mean that community has a higher incidence of asthma, but it does mean they are poor.”

Studies have found that asthma sufferers who have access to primary care physicians, as well as adequate resources for medicine, have fewer ER visits and fewer hospitalizations.

Asthma is a socio-economic disease,” says Kay McVay, RN, and former president of the California Nurses Assn., that is getting worse because, “We are moving backwards in terms of eliminating poverty and the unhealthy circumstances in which people live.”

Asthma can strike down the affluent as well as those on the economic margins, but where you live, and what you do at work, has a lot to do with whether you develop asthma.

According to the Environmental Protection Agency (EPA), 133 million Americans live in areas where pollution reaches unhealthy levels.

African Americans are more than twice as likely to live in those polluted neighborhoods as whites, and the average income in these neighborhoods is about 15 percent lower than for the rest of the nation. African-Americans had five times the number of asthma-related ER visits than whites and over three times the hospitalization rate. African Americans also had a death rate 200 percent higher than whites, and 160 percent higher than Hispanics.

Poor communities, frequently communities of color but not exclusively, suffer disproportionably,” Carol Browner, EPA head during the Clinton Administration, told the Associated Press (AP) “If you look at where our industrial facilities are located, they are not in middle-class neighborhoods.”

Dr. John Brofman, director of respiratory intensive care at MacNeal Hospital in Berwyn, a suburb of Chicago, says air pollution makes asthma worse. “Not only do people get hospitalized, but they die at higher rates with significant air pollution,” Brofman told AP.

One reason why asthma rates are going up may be the policies of the Bush Administration. According to a recent Associated Press story, “The Government Accountability Office concluded that the EPA devoted little attention to environmental quality when developing rules for the Clean Air Act between 2000 and 2004.”

EPA scientists recently charged that the White House proposes weakening sections of the Clean Air Act that regulate the release of diesel particulates, sulfur dioxide and nitrogen dioxide, all asthma triggers. In the name of “streamlining” environmental regulations, the Bush Administration will permit some 4,000 companies in 922 communities—most of them poor, many of them predominantly minority— to increase toxic admissions from 500 pounds a year to 5,000 pounds.

The White House’s refusal to sign the 1997 Kyoto Accords or to reduce U.S. production of greenhouse gases that are warming the planet plays a role in rising asthma rates as well.

During the past two decades, the prevalence of asthma in the United States has quadrupled, in part become of climate-related factors,” concludes Paul Epstein, MD, MPH, is his New England Journal of Medicine study on the impact of global warming on health.

Environmental triggers, or allergens, are not restricted to what comes out of smokestacks and tailpipes, however. Some of the most insidious are the ones people live among: dust mites, rodent and cockroach droppings, mold, animal dander, and nitrogen dioxide from poorly vented stoves and heaters. While these triggers can be found anywhere, they tend to be more prevalent in substandard housing.

There is even a psychological dimension to asthma. An Ohio State University study of 338 Chicago neighborhoods found that asthma rates went up or down depending on how secure people felt in their neighborhoods. People in areas with elevated crime rates—which were generally poorer areas with high numbers of minorities—tended to lock themselves into their apartments.

“If residents feel uncomfortable about walking outside or leaving windows open for fresh air, they may be continually exposed to higher levels of indoor allergens such as dust mites and cockroaches,” writes Christopher Browing, co-author of the study and assistant professor of sociology at Ohio State University. “This may be particularly bad in poor neighborhoods where housing is substandard and there are more allergens such as mold that could trigger asthma.”

Health professionals say the stress that goes along with poverty can play a role. “Many of my patients live very chaotic and stress-filled lives trying to survive in school, work, and foster healthy relationships with their peers,” says Nancy Lewis, RN, MSN, a family nurse practitioner at the Department of Health in San Francisco. “Add to this asthma triggers and a lack of regular checkups with primary health providers, and it sets up patients to end up hospitalized or worse—dead.”

Brunner also points out that the disease itself creates stress. “It is very disruptive of family life. Parents have to keep getting up in the middle of the night, and everyone has to go to school or work the next day.”

The pattern the Ohio State University study uncovered, and its link to income, is repeated across the nation. New York City has twice the national hospitalization rate for asthma as the rest of the country, but East Harlem has nine times the national rate. The depressed community of Bedford Stuyvesant has five times the rate of more affluent Park Slope. The average per capita gross income in the former is $7,406, for the latter, $18,666. Both are in Brooklyn.

The Heilbrunn Center for Population and Family at Columbia University even found that exposure to asthma-causing antigens “occurred before the child was born.” The study discovered, “a significant exposure to cockroaches and mouse antigens and in-utero sensitization to multiple indoor antigens.”

Where you are employed makes a difference as well. According to the American Lung Association, more than one in three adults who suffer from adult-onset asthma can trace their disease to the over 400 substances in the workplace that can trigger asthma. Nursing, food preparation and clerical work tend to be among the most common asthma-linked jobs.

However, according to Dr. Anne Krantz, MPH, and toxicology division chief of occupational medicine at John H. Stroger Jr. Hospital, Cook County, Il, the most common problem is “when someone takes a pre-existing asthma condition into a job and the job makes it worse.”

Krantz says avoiding jobs that either trigger asthma or exacerbate it may be difficult because “income disparity sometimes forces people to take jobs or stay on them in spite of the fact the job gives them asthma or makes it worse,” adding, people in poor communities “don’t have the economic or social mobility of other populations.”

Some industries, like ports, are a particular problem.

“Diesel pollution is omnipresent on the docks,” says Steve Stallone, a spokesperson for the West Coast International Longshore and Warehouse Union (ILWU), “It covers all the equipment, the containers, the men’s clothes, so you know what they are breathing in.” According to Stallone, “Most longshoremen will tell you they have respiratory problems. They are always short of breath.”

Diesel particulates stimulate the production of IaE antibodies, which according to a study by the Department of Health and Human Services, enhances an individual’s response to allergens.

You don’t have to live in a huge city or work in industry to join the asthma fraternity, however. Fresno, in the heart of California’s agricultural-centered Central Valley, would hardly seem ground zero for an asthma crisis. But fully 30 percent of the city’s school children have asthma.

Figures show Fresno has a worse ozone problem than Los Angeles. Ozone is considered an asthma trigger. From 1999 to 2004, Fresno failed federal air standards 38 percent of the time, but a Federal Appeals Court recently allowed the county to put off meeting federal standards until 2010

Fresno residents are pressuring local air quality officials to confront the problem, but they are finding it an uphill battle against powerful interests. “It’s DOA—development, oil and agriculture,” says Medical Advocates for Health (MAH) lawyer, Susan Britton, “those are the primary economic drivers in the Valley.”

MAH lobbies local officials to improve air quality standards.

Last year the Bush Administration exempted agriculture from pollution controls, even though the industry is responsible for 25 percent of Fresno’s problem.

If asthma is a complex disease, what to do about it is equally complex.

Education makes a difference, as programs in New York City and Los Angeles have demonstrated.

The National Asthma Education and Prevention Program in Los Angeles found that 67 percent of inner-city children with asthma got control of their disease if they were educated and treated by the organization’s “breathmobile.” Only 10 percent in a control group without access to the breathmobile managed to do so.

New York City’s Department of Health’s intensive, community-based asthma management program found that education and treatment had a dramatic impact in reducing the seriousness of the disease. Hospitalizations were reduced 28.3 percent in the South Bronx; 42.8 percent in Washington Heights; 38.6 percent in Fordham; 36.3 percent in Williamsburg-Bushwick; and 25.8 percent in central Harlem.

Access to health care is clearly a major variable. Many children in these communities are on Medicaid, which studies show means they will have worse asthma and use fewer preventative medicines than children on private health plans.

De Calvert, RN, MSN, and a Kaiser Permanente staff nurse in pediatric asthma, is careful not to over generalize about the access issue, but agrees, “There are more disease management problems with people on welfare or Medical.”

The number of Americans without health coverage—46 million at last count—is growing, and more and more employers are either refusing to offer health care or forcing employees to contribute more to their plans. A study by the Financial Times found that between 1998 and 2003, the number of employers with fully paid health plans dropped from 35 percent to 28 percent.

A good health plan is no armor against the triggers that induce asthma, however. Communities aiming to reduce those triggers are increasingly trying to pressure the federal government to enforce EPA guidelines on “environmental justice.”

According to the guidelines, “No group of people, including racial, ethnic, or socioeconomic group, should bear a disproportionate share of the negative environmental consequences resulting from industrial, municipal, or commercial operations or the execution of federal, state, local, and tribal environmental programs.”

But both the EPA General Inspector and U.S. Civil Rights Commission found that the government has done virtually nothing to implement the guidelines. From 1993 to 2005, the EPA received 164 complaints alleging civil rights violations in environmental decisions. It rejected 117 of them, accepted 47, but dismissed 28 of the 47. A decision is still pending on the other 19.

In spite of indifference on the federal level, local communities, public health agencies and politicians have cobbled together coalitions, which have made significant progress in reducing asthma triggers. Such a coalition in Contra Costa County won the first agreement in the nation on reducing oil refinery “flare offs.”

Volatile gases that accumulate during the refinery process are routinely ignited into controlled fireballs, or “flare offs.” But many of the gases involved are potential asthma triggers.

Similar coalitions have formed around the issue of diesel pollution at West Coast ports. Under the slogan “Saving Lives,” the ILWU has joined with local communities and Los Angeles Mayor, Antonia Villaraigosa, to reduce diesel pollution by 20 percent at the ports of Los Angeles and Long Beach over the next four years. Between them, the two ports emit 1,760 tons of diesel particulates each year. West Coast ports handle 49 percent of all U.S. cargo.

“The thousands of men and women I represent and work for raise their families under a cloud of port pollution,” says ILWU International President James Spinosa. “They have made a simple demand of their union: while they want a good living, they do not want to pay with their lives for a stronger economy.”

The ILWU is making reducing diesel pollution part of its bargaining strategy for the next West Coast contract, and plans to try and spread the issue to other places. “The ILWU is going to enforce this coastwise, and we’re taking it to the East Coast through the ILA (International Longshoremen’s Assn.). We are also raising this internationally,” says Stallone, “so that pollution will not have a homeport anywhere.”

Stallone says the Union is also working with communities in West Oakland, Ca. that are concerned about diesel emissions from freeways. “We are concerned because our people come out of those communities. We work in it and we live in it.”

According to the EPA, a $100 million retrofit of pollution generating diesel engines could save $2 billion in health costs.

None of this will be easy, and part of the problem is how public health is constructed and financed in the U.S.

“It is very difficult for local health programs to address these problems,” says Brunner. He points out that the average size of a health department in the U.S. is 16 employees, “which includes everyone from the director to the janitor.” The system, he says, “is just too fragmented.”

It is also under-funded. Brunner is in the process of cutting $3.5 million out of his $16 million budget, and trying to rustle up foundation grants, while juggling country, state and federal money. In the end, something gets cut.

Lewis sees the impact of such cuts everyday. “Primary care in San Francisco, like other counties throughout California, has suffered gradual cutbacks annually. Our public health nursing staff has been cut repeatedly over the years.”

While money may be short, the dedication to do something about asthma is strong.

“This is a condition we can influence, if not the incidence, at least the amount of hospitalization,” argues Brunner, ticking off his department’s program for beating back the beast:

*Insuring access to primary health care

*Helping families reduce asthma triggers in their homes and apartments

*Improving the quality of medical care, including educating doctors.

The Contra Costa County Health Department also holds classes to educate community members on how to interpret local and state air quality regulations, as well as EPA rules, including their rights under environmental justice guidelines. It also brings together community members and the staffs of regulating bodies in town hall meetings. The Department is presently working closely with schools and Kaiser Permanente to try and figure out a formula for on-site treatment of asthma attacks.

Kaiser RN De Calvert is optimistic about making progress against the disease. “Asthma does not have to be debilitating. It doesn’t have to mean lost time at school and work. The means to control it are available.”

One of those means is education, although as Lewis, who works with teens and young adults, points out, “It is a very labor intensive process involving patient teaching.”

Ultimately it is a problem bigger than a city or county or even a state, and goes to the heart of the present crisis in health care.

“I think these deaths and hospitalizations reflect a public health and primary care system in decline throughout our nation,” says Lewis. “The sad truth is that these deaths are preventable. How advanced is our health care system if our patients are dying from treatable and preventable diseases?”

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Race & Health: Code Gray?

Race & Health: Code Gray?


By Carl Bloice and Conn M. Hallinan

The February press conference at the annual meeting of the American Association for the Advancement of Science drew media from all over the world. The biotech company, Perlegam Sciences, was making a dramatic announcement that it had successfully associated the “genetic determinants” of many diseases with specific racial groups.

San Jose Mercury science writers Lisa Kreiger and Esther Landhuis wrote that the “discovery” suggests that “the idea of race-based medicine has new respectability” and “could help reduce health disparities among the races,” including “hypertension [that] affects black Americans at a higher rate than white Americans.”

Perlegen’s proclamation came on the heels of similar announcements about so-called “race-tailored” or pharmacogenomic drugs, including a glaucoma drug, travatan, and the heart drug, BiDil. This focus on race and medicine even includes an examination of the Pima Indian genome aimed at ferreting out the reason why Native Americans suffer adult-onset diabetes at a rate three times that of whites.

Certainly the disparity in terms of health and morbidity between European whites on one hand, and African Americans, Native Americans, and Hispanics, on the other, is a sobering one.

Heart disease deaths among African Americans are 40 percent higher than for whites, and deaths from cancer are 30 percent higher. Hispanics die from diabetes at twice the rate of non-Hispanic whites, and infant mortality for African Americans and Native Americans is almost twice what it is for whites.

But are health disparities between populations the result of genetic differences, or do they reflect something about the way those populations live? And would “race targeted” drugs improve the health of these groups, or might they end up masking the underlying causes of such disparities?

Race,” says researcher and internist Dr. Peter Groeneveld, is an “ephemeral concept and poorly correlated with disease. It is not the most useful way to think about the human genome.”

Groeneveld is an Assistant Professor of Medicine at the University of Pennsylvania and the lead author of a recent study in the Journal of American Cardiology on racial disparity in access to heart defibrillators.

This sudden concern with race has opened up some sharp debates among researchers. There are some who are openly suspicious that the medical profession, according to University of California at Santa Cruz sociologist Andrew Szasz, is looking “for that ‘magic bullet’ that means we don’t have to deal with the issue at the heart of this matter: inequality.”

Unequal access to health care is a long-standing problem. Almost 40 years ago the National Advisory Commission of Civil Disorder, the so-called “Kerner Commission,” concluded that “The residents of the racial ghetto are significantly less healthy than most other Americans. They suffer from higher mortality rates, higher incidents of major diseases, and lower availability and utilization of medical services.”

The Commission went on to argue that in everything from medicine to education and housing, “Our nation is moving toward two societies, one black, one white—separate and unequal.”

Almost three decades later, a “Report on Racial and Ethnic Disparities in Health Care” by the American Medical Association found that little has been done to bridge the gap and that “in too many aspects of our society the movement toward two societies continues.”

The most recent study of this gulf, by the Center for Disease Control (CDC), found that African Americans die at a higher rate than whites from nearly every cause, including HIV, stroke, high blood pressure and many infectious diseases.

We’ve been talking about this problem,” says Dr. Ben Truman, Associate Director of the CDC’s Office of Minority Health, “but we haven’t done enough in terms of resources and making sure interventions known to be effective are used widely in both populations.”

Some in the medical profession argue that drugs targeting specific genetic groups are an effective way to deliver better health. That is certainly the idea behind the heart drug BiDil, which trials suggest is more effective for African Americans than whites.

The company that makes the drug, NitroMed, argues that aiming the drug at the African American community makes sense, because “African Americans between the ages of 45 and 64 are 2.5 times more likely to die from heart failure than Caucasians in the same age range.”

But sociologist Troy Duster, Director of New York University’s Institute for the History of the Production of Knowledge, says the figures are more complex and nuanced than NitroMed would have people believe. According to Duster, the 45 to 64 age group only accounts for about 6 percent of heart attack deaths and the statistical disparity between the two groups after age 65 “nearly completely disappears.”

Jonathan Kahn of the Center for Bioethics at the University of Minnesota, even disputes the claim that African Americans suffer heart failure at twice the rate of whites.

“The most current available data,” he writes in his seminal study of heart attack statistics, indicate the rate “is 1 to 1:1″ He adds, Uncritical acceptance and promulgation of inaccurate date mbe be distorting current efforts to address the real health problems associated with heart failure and also lends credence to those who argue that race can and should be used as a biological category.”

Hypertension is indeed a problem for African Americans, but the black-white disparity is “significantly smaller,” says Duster, among black populations in Brazil, Trinidad, and Cuba, suggesting the condition is more about the social experiences of these populations than problems in their genetic structure.

A recent study in Puerto Rico by anthropologists Clarence C. Gravlee and William W. Dressler concluded that there was “no association between skin pigmentation and blood pressure.”

Medical researchers are presently examining the genome of Pima Indians trying to identify a gene that might be related to diabetes. But biological anthropologist Jonathan Marks of the University of North Carolina thinks researchers are looking in the wrong place.

“The Pima are the fattest people on earth, with lots of diabetes,” he says, “but that is only since World War II. If you look at pictures of Pima before that, they look like everyone else.”

Marks says that instead of searching for some kind of “genetic” explanation for the diabetes plague, researchers should be examining the “enormous changes in life style the Pima have gone through,” changes that include not only an increase in fatty, high carbohydrate foods—“the same food that is making all Americans fat”—but also alcohol use. “They drink because reservation life sucks,” he says.

Critics of those who correlate disease with race have come under fire recently for sacrificing science in the name of “political correctness.” In “Medicine’s Race Problem,” Dr. Sally Satel of the conservative American Enterprise Institute (AEI) argues that attacks on race-based medicines are engaging in the “censorship of inquiry.”

Satel points to the new heart drug BiDil as an example of how race can be associated with both disease and treatment. Tests indicates that many African Americans have less nitric oxide (NO) in their cells than European Americans and, therefore, usual heart medicines are not as effective for them as they are for whites. BiDil appears to replenish NO supplies.

But do African Americans have lower NO levels in their cells because of some genetic anomaly? Or, as David Goldstein and Huntington Willard of the Duke University Institute of Genome Science and Policy ask, might it be a side effect of the higher levels of lead and pesticides among African Americans?

Certainly the idea of using genetics to deliver drugs “holds promise,” says sociologist Duster, but he warns against using “phenotype”—how people appear,as opposed to their actual gene markers, as a basis for treatment.

Hubbard says that the rub comes when you start associating gene frequencies with certain populations. “The job of medicine is to treat an individual, not a group. By looking at a group you are lible to overlook the individual’s particulars.” She also points out that simply treating the condition could end up diverting researchers from its real source.

Satel argues as well that higher cancer mortality rates among African American women are race related. African American women have a 50 percent higher incidence of breast cancer before the age of 35.

But as Harvard’s Hubbard argues, figures like these do not indicate “inherent, biological differences” between blacks and whites.

The problem, she says, is that U.S. health statistics are presented without reference to employment, income, housing, and healthy living. And not taking social class into account can skew results.

Epidemiologist Nancy Krieger, for instance, found that when social class is taken into consideration, the breast cancer mortality differential between whites and blacks drops from 1.35 to 1.10.

When we use science to investigate subjects like race and sex, which are suffused with cultural meanings and embedded in power relationships, we need to be wary of scientific descriptions and interpretations that support, or even enhance, the prevailing political realities,” Kreiger and New York Department of Health Deputy Commissioner Mary Bassett, conclude in their study.

It is not just who you are, but also where you live.

The Bayview Hunter’s Point neighborhood on San Francisco’s northern edge is a case in point. The 34,800 residents of the 3 1/2 mile section of the city live amidst a federal Superfund site, two power plants, the city’s main sewage treatment plant, almost 200 leaking underground fuel tanks, 124 hazardous waste handlers, and a recycling plant.

Forty-eight percent of its residents are African-American, 17 percent Hispanics, 23 percent Asian Pacific Islanders, and 10 percent are European whites. Nearly 40 percent of its residents earn less than $15,000 annually, almost double that percentage for the rest of the city. Unemployment rates are twice those of the surrounding city.

The neighborhood is a public health disaster. Rates of cervical and breast cancer are twice that of the rest of the Bay Area, and hospitalization for congestive heart failure, hypertension, diabetes and emphysema are three times the statewide average. The “Point” and neighboring Potrero Hill account for more than half of the all infant mortality in San Francisco.

Environmental justice community organizer and Green Action board member Marie Harrison says what is happening in Hunter’s Point-Bayview is “common across the country.” She says an expert told her, “‘You take me to any city in the country and show me the highest point, tell me where the factories are, and tell me which way the wind blows and I can tell you about the environmental conditions and who lives there.'” She adds, “Where you have the greatest pollution, that is where the poor folks live.”

Sociologist Szasz, who has studied “environmental racism” extensively, agrees: “No one sends a brown or black baby home with a bag of industrial waste, but that is the effect of living where most of these people live.”

The transcription of the human genome has been not only a windfall for geneticists, it has created new markets for drug companies. But many medical researchers and health providers question the priority of looking for new drugs rather than concentrating on improving health care for under served populations.

For instance, a recent study in the American Journal of Public Health indicates that ending the disparities in health care would be a far more effective way to improve health for African Americans than new drugs. “Five times as many lives can be saved by correcting the disparities [in health care between blacks and whites] than in developing new treatments,” says Dr. Steven H. Woolf, lead author of the study, and Director of Research at Virginia Commonwealth University’s Department of Family Medicine.

The study showed that from 1991 to 2000, some 886,000 deaths could have been prevented by ending disparities in care, while only 176,633 were averted because of improvements in medicine. The authors conclude, “The prudence of investing billions in the development of new drugs and technologies while investing only a fraction of that amount in the correction of disparities deserves reconsideration.”

Pennsylvania internist Groeneveld is also worried that thinking about medicine in terms of race could produce a dangerous side effect. “Equality is what concerns me here,” he says, “If more and more therapies are devised for racial groups, it is inevitable that they will benefit Caucasians—because they are the larger group—at the expense of other populations. I am concerned that such therapies will focus on the main population, which is where the money is.”

Duster strongly agrees. “Do you actually think high end molecular medicine will be for black people?” he asks, adding “This was always for people of privilage.”

Many biologists are leery of trying to define race, not just because of the social implications, but because it not very good science. “We don’t have the tools to use this information predicatively,” says Hubbard.

Does the term “race” have a place in medical care? As a biological category, the majority consensus seems to be “no.” But many social scientists argue that as long as racism is an aspect of our world, the term has real value, and the reason why so many oppose efforts like that of former University of California Regent Ward Connerly to abolish the use of race-based data.

“In health care, we are convinced it is legitimate to use traditional categories of racial differences when engaging in studies of the pernicious effects of racism itself,” writes Koenig, Lee and Mountain. Koenig argues that an undue emphasis on genetics at the expense of social factors derails a real solution. “If you look at the history of improvements in life expectations in the industrial west, the things that make the most difference in terms of overall health status were not medical intervention, but those in the social domain.”

Groeneveld suggests that there has to be “a turn around” on how hospitals are reimbursed for providing health care and for upgrading technology. “There are ways to make hospitals better. There needs to be reimbursement for quality care. Medical hospitals that take care of the indigent and poor should be better reimbursed.”

The recent assault on employer provided health care is adding to the growing numbers of Americans with reduced benefits or without health coverage at all. According to the Kaiser Family Foundation, while employee costs were rising 9.3 percent in 2003, benefits were being reduced. Some 8 percent of large private employers cut health benefits for retirees in 2004 and 11 percent plan to do so in 2005.

At the same time as private health plans are becoming more costly and covering less, 34 states have either cut or tightened Medicaid for the poor, among whom minorities are historically over represented. An estimated 15.6 percent of the population, or 45 million people, were without health insurance coverage in 2003, up from 15.2 percent and 43.6 million people in 2002.

Minorities are more likely to be uninsured than the population as whole. More than a third of Hispanics and over a quarter of Native Americans are uninsured compared to 13 percent of whites. The uninsured rate for African Americans stands at 21 percent and for Asian Americans at 20 percent.

Ludmilla F. Wikkeling-Scott, MPH, a legislative assistant to Rep. John Conyers, (D-Mi) and former public health specialist with the Department of Health and Human Services, notes that the problem of race-based health disparities has been the subject of discussion for many years. “We have gone from Healthy People 2000 to Healthy People 2010, from “decreasing the gap” to “eliminating the gap” of health disparities,” she says. “Yet, we are still struggling to address these issues in minority communities most affected by such disparities.”

Wikkeling-Scott points to Dr. W.E.B. DuBois’s 1899 study “The Philadelphia Negro,” calling it a sophisticated “needs assessment” of the status of health in the black community and notes “Now, more than a century later, the most sophisticated state of the art medical solutions cannot provide us with answers to the dilemma. The same disparities brought to our attention then are still profound today.”

Racial disparities in health care are clearly multi-faceted, the issues surrounding race-based therapies complex. However there is widespread agreement that the key to improving the health indicators in minority communities lies in leveling the field in health care access and delivery.

When we return to communities to take care of our people, not for the money but for the simple fact that everyone deserves care, this will bring us one step forward to eliminating health disparities in minority communities, says Wikkeling-Scott. “Without access, we have nothing.”

That is also an assumption behind the effort in Congress to move toward a universal system. Pointing to legislation introduced by Representative Conyers (D-Mi), Joel Segal, a spokesman for the Congressman says, “The only way to eliminate economic and racial disparities is to through universal healthcare. Right now it is the way to get rid of a system that it inherently separate and unequal. We must end the situation of a large number of people uninsured.” Conyers’ bill, he says, “would essentially mean Medicare for all.”

Deborah Burger, RN, president of the California Nurses Association, says, “Some of the problem of racial health disparities is the differences in economic status but when you think it about it there is surely also a connection with where people live – how much pollution there is and how much access to healthcare facilities. In the end it all has to come down to the need for universal access to one standard of care. The big questions are: Can you afford adequate healthcare? Does you job provide for insurance and, if so, what kind?

You cannot eliminate the disparities until you address the inequities in the current system. We in CNA see this as another important reasoning for pressing ahead toward a universal healthcare system.”

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