End of life care

End of life, or palliative, care is a touchy subject. And I seem to be on a roll with touchy subjects lately like suicide and "unsexy" health threats, so let's keep rolling with this one!

An organization called Engage with Grace is encouraging families to discuss end of life care during this holiday season. Engage with Grace has a one-slide quiz to help get the conversation started to discuss family members' wishes at the end of their lives. This NPR blog discusses this initiative a bit more. The American Academy of Hospice and Palliative Medicine has more information as well.

It can be incredibly difficult to think about these issues inside one's own head, much less with one's family. Death is a hard subject, and no one enjoys thinking about it. But a little conversation ahead of time can prepare your loved ones for when the time comes. This article in the NYTimes discusses palliative care physicians and their role in the conversation. This video shows more of what is in this article.

".. As an aging population wrangles with how to gracefully face the certainty of death, the moral and economic questions presented by palliative care are unavoidable: How much do we want, and need, to know about the inevitable? Is the withholding of heroic treatment a blessing, a rationing of medical care or a step toward euthanasia?"

The article discusses, amongst other things, the growing subspecialty of palliative care and its importance with an aging population. It notes that an enormous amount of a person's healthcare spending is spent during the last 6 months to 2 years of one's life, and much of the time this is Medicare and/or Medicaid spending.

But, most importantly, it's vital to be comfortable with the concept of end of life care. It is a subject that this country is scared to talk about, but one that is incredibly crucial. It's not about "death panels" but rather about caring for your loved ones at the end of their inevitably finite lives. There is honor in dying with dignity and grace and in discussing one's wishes to do so.

An interesting story on NPR this morning about how the media cover teen suicide. Worth a listen!

Once again - some links for you

1. I wrote a few weeks ago about unsexy health threats, and chronic disease could probably fit under that category. Certainly the Global Alliance for Chronic Disease thinks so. This organization, founded in June, is trying to increase awareness of the prevalence of chronic disease around the world, even in developing countries. This article details more about this organization and this issue.
2. Food safety legislation has been given the next push forward in the Senate. This article says that the full Senate won't take up the legislation until 2010, but Congress is certainly looking to move on food safety legislation of some sort this session. "The Senate bill would expand U.S. Food and Drug Administration (FDA) oversight of the food supply and shift its focus toward preventing, rather than reacting, to foodborne outbreaks. FDA would have the power to order recalls, increase inspection rates and require all facilities to have a food safety plan."
3. I have briefly mentioned the economy's effect on public health, and this article repeats that message - the economy has affected the public's health and well-being. Respondents to a recent survey indicated that they were more likely to overeat and less likely to exercise due to stress about the economy. Respondents were also less likely to take care of health problems in a timely manner. And, last but certainly not least, emotional health was adversely affected by the economy.
4. And finally, our favorite topic du jour - the recent change in the U.S. Preventive Services Task Force's recommendations on breast cancer screenings.
   
   This article provides a good, solid perspective on the recommendation change, explaining a bit about why the public has a hard time accepting the fact that screenings are not always in our best interests: "Statisticians and epidemiologists know this for a fact. The problem is, there's no way to tell which of the tumors are dangerous and need to be treated and which are harmless and would be best left alone. So all of them get treated, often aggressively. The medical establishment calls this overdiagnosis."
   
   This article's title, "New mammogram guidelines are confusing, but here's why they make sense," says it all. The article notes that the new guidelines are in line with international recommendations and goes through the recommendation in a detailed manner, explaining each point. The potential harms from widespread mammogram screening include radiation exposure, false-positives, and the incorrect notion that early detection is always a good thing. It's a good article.
   
   This NY Times op-ed piece by Robert Aronowitz has an interesting premise: "Why do we keep coming around to the same advice — but never comfortably follow it?" The column details some of the history of cancer screening and treatment and how increased diagnoses of cancer led to increased pressure to screen earlier and diagnose earlier and more often. He makes a very good point:
   

   "You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much."

   
   And, finally, "What watching ESPN could teach us about mammograms" - this title immediately caught my eye. Basically, this article says that statistical data are presented in the sports world every day and understood - why can't the same thing be done in public health? Why is the message clouded? Great question! The answer is that we have messaging problems, we public health professionals. It's true. It also gives a link to the National Cancer Institute's breast cancer assessment tool - interesting.
   

Gobble gobble

Before you down your share of turkey this Thanksgiving, keep part of your brain on food safety. First of all, thaw your bird properly. Second, cook your bird to the proper temperature. Third, don't let food sit out too long after it's cooked - the bugs will love breeding to their hearts' content while you chat around the dining room table.

Here is an article that has a bunch of helpful links.

Enjoy and happy Turkey Day!

Some links for you

1. Massachusetts public health officials explain the dissemination of their H1N1 vaccine allotment. Patience, all you patients out there!
2. The WHO has discovered new data that show that 1.2 million people over the age of 5 die of foodborne illness each year in Southeast Asia and Africa. That number is significantly higher than previously estimated, providing new reason to address this issue in the developing world.
3. In case you're one who needs everything, check out these iPhone apps about H1N1.
4. There is a new tool to show where AIDS treatment and care in San Francisco is lacking. Click here for the map itself.
5. Obesity is an alarming public health issue, and this latest article has alarming numbers. If trends stay as they are now, 43% of adults will be obese in 2018. Wow.
6. This article highlights that many public health professionals around the country are being reassigned from their normal job duties to work on H1N1 assignments. This is disrupting usual public health activities that address ongoing problems that are not going away simply because this pesky flu virus has shown up. It's a problem, but it doesn't appear it will be solved.
7. Representative David Camp says in this article about the breast cancer screening recommendations: "I mean, let the rationing begin. This is what happens when bureaucrats make your health care decisions." Right, the U.S. Preventive Services Task Force is bureaucrats. They're not experienced physicians and trained professionals. Sure.
8. Lots of money is being poured into fighting healthcare-associated infections. This article details the stimulus funding being given to the issue.
   

Cancer screenings, Part 2

Since my last posting about cancer screenings (conveniently linked for a little refresher), new information has come out about breast cancer screening.

The U.S. Preventive Services Task Force, the panel in charge of determining preventive services standards, has deemed that mammograms should begin at age 50 instead of the previous recommendation of 40. It also recommends that screenings be conducted every 2 years instead of every year; the harms are greatly reduced while the benefits remain the same.

Here is a link to the USPSTF recommendations.
NPR had a big story this morning about this topic.
The Annals of Internal Medicine outlines the data that went into this decision.

The basis for this updated recommendation is that screening too often and too early can lead to unnecessary testing of any abnormal result, which can cause physical and psychological harm. The risk of false positives also pose psychological harm. The New York Times writes, "while many women do not think a screening test can be harmful, medical experts say the risks are real. A test can trigger unnecessary further tests, like biopsies, that can create extreme anxiety. And mammograms can find cancers that grow so slowly that they never would be noticed in a woman’s lifetime, resulting in unnecessary treatment."

The interesting thing is the reaction to this new recommendation. The National Cancer Institute will investigate revising its guidelines in light of this report, but the American Cancer Society and the American College of Radiology are both sticking with their previous guidelines of starting screening at age 40.

While some will bristle at the idea of pushing back a cancer screening, looking at the population's overall health and benefits of these screenings is important. Overall, it is more beneficial to delay screening until age 50 unless a woman has an increased risk of breast cancer. It may be hard to stomach for some individuals, but the cost-effectiveness is overwhelming.

An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All

An interesting article about Paul Offit and vaccines.

An Epidemic of Fear: How Panicked Parents Skipping Shots Endangers Us All

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Unsexy health threats

There are lots of sexy-sounding health problems. Some of the topics du jour include HIV, malaria, and, currently, influenza. But what are the actual leading causes of death, in the U.S. and internationally?

In the U.S., the leading causes of death are heart disease, cancer, and stroke - all chronic conditions. While pandemic influenza may be causing a lot of morbidity these days, it is chronic disease - caused by obesity, mostly - that cause the greatest number of deaths in the U.S.

Abroad, it's a different story. According to the Global Health Council, the leading causes of death among children are pneumonia and diarrhea, both preventable diseases. Maternal health is also a huge issue; it is the second leading cause of death among women worldwide. These tables from the WHO outline leading causes of death by the country's income level, revealing interesting disparities between low-income countries and high-income countries.

Nicholas Kristof has done a great job reporting about deaths due to pregnancy or childbirth; he quotes the U.N. in a July column, saying " in Pakistan, a woman dies every 35 minutes because of problems from pregnancy or childbirth." He also spoke out about pneumonia: "pneumonia gets very little attention from donors or the public health community, yet it kills more than two million children a year, according to Unicef and the World Health Organization."

This article in the NY Times on October 29 compelled me to blog about this. After all, this blog is devoted to domestic public health issues. But this article was too important to ignore. "Diarrhea kills 1.5 million young children a year in developing countries — more than AIDS, malaria and meaasles combined — but only 4 in 10 of those who need the oral rehydration solution that can prevent death for pennies get it." Diarrhea is, most certainly, not a sexy topic, but it is one that is vital to discuss.

While AIDS continues to be a huge problem that needs attention, especially in certain parts of the world like Africa, these smaller diseases also need equal attention, especially because they are treatable.

Weekend links

1. There have been several teen suicides in California, prompting public outcry against suicide, which is the 3rd leading cause of death among teens, according to CDC. Actions are being taken to curb suicide in California, including counseling, suicide hotlines, and other measures. "These poor kids died from an untreated psychiatric illness, or undertreated. It's not as if it's a mysterious thing and it's not as if it's not preventable," says Madeline Gould, a psychiatrist. Once again, and I reference another suicide posting I've done, suicide is preventable, and it's important to treat mental illness and reach out to people.
   
   
2. Not surprisingly, H1N1 is hindering health departments' ability to conduct other activities. Dr. David Fleming, health officer in Seattle, says, "we're being held hostage by a national shortage of the vaccine."
   
   
3. The Infectious Diseases Society of America conference brought a lot of discussion of various infectious diseases this weekend. Antibiotic resistance is still a concern, according to this article in the Atlanta Journal-Constitution. There is also a virulent strain of MRSA going around, posing another infection-related problem in hospitals.
   
   
4. At the IDSA conference, Dr. Paul Offit, a frequent vaccine spokesperson, spoke out for the H1N1 vaccine. Another article about the speech can be found here.
   

   "... Now the seasonal flu vaccine and H1N1 flu vaccine are being skipped by millions of people who somehow distrust the science that went into making them, even though the illnesses they cause can be fatal.

   But hey, it’s a free country. Paul Offit just throws up his hands: “Is it your right to catch and transmit a potentially fatal infection? The answer is ‘yes,’” he says."

   The article continues:
   

   "So despite vaccines’ overwhelming safety profile when compared to the risks run by exposure to the diseases they prevent, and despite the exhortations of the CDC and World Health Organization, some people just gravitate toward other sources of information they deem more reliable."

5. In food safety news, the Produce Safety Project put out results of a survey showing that there are significant gaps in foodborne illness response. The survey asked about types of questionnaires administered, the time frame in which they were completed, types of questions asked, and how the data collected were used. They found that state health departments don't ask about fresh produce initially, use a mixed questionnaire with open- and closed-ended questions, and are more likely to interview an individual linked with an outbreak. This survey did not assess staffing or funding levels, which will be discussed in a forthcoming assessment by CSTE about foodborne illness epidemiology capacity. They did report, however, that "the decisions of the responding states appear to be driven by available resources." Very true.