Despite what Donald Trump says, climate change is real and it is related to human activities. It is also killing us NOW. Even though he buried his own administration’s climate change report because he didn’t like the findings, all of the rest of us can look around and see what is happening:

I could go on and on, but what I really want to focus on in this story is the evidence that health consequences to us humans are not something that may happen in 2050 – they are already happening now. Here is a summary of what we know based on what I learned at the February 2017 Climate Change and Health Conference.

Related story: Enviromedics: How Climate Change is Killing Us Now

The Climate Change and Health Conference

The Climate Change and Health conference was held at the Carter Center in Atlanta in 2017. It hosted by former Vice President Al Gore and the American Public Health Association.

The goal of the conference was to lay out the scientific evidence that directly links climate change to adverse health events, such as infectious diseases, heat-related deaths, increases in asthma and allergies, and much, much more. The main takeaway of the conference was that the impact of climate change is not just bad weather, melting polar ice caps, and increases in sea level, rather,

it is clear that the environmental consequences of climate change are killing humans right now.

This is a Goldilocks planet

Former Vice President Al Gore opened his keynote address at the conference by reminding us what the late Carl Sagan said about our planet:

“This is a Goldilocks planet, not too hot like Venus, not too cold like Mars, but just right.”

He went on to say “Now that human beings have become the most powerful force of nature in affecting planetary conditions, we are pushing many people outside of the envelope in which we have evolved and in which we thrive.” There are places on earth now that are seeing increases in temperatures no longer compatible with human life.

Here is how we are doing it:

“We are using our atmosphere as an open sewer, dumping 110 million tons of man-made global warming pollution into it every 24 hours. The cumulative amount now traps as much heat every single day as would be released by 400,000 Hiroshima-class atomic bombs exploding every day.”

Climate change we can see

We are all experiencing what has been a profound change in climate in our lifetimes. I live in Northern California. Several years ago, I first noticed my tulip tree blooming in December after 30 years of blooming in February. And the harbinger of autumn in my yard, the fragrance of honeysuckle, now tickles my nose in July instead of late September. But that is the subtle stuff and it is not dangerous to humans.

This summer, ferocious wildfires burned across California wiping out neighborhoods, killing people in their homes, and leaving many thousands homeless. Just a few weeks ago, the worst fire in California history burned down the town of Paradise killing 88 with 203 still missing.

Paradise house burned 675 x 506

The remains of my friend’s house after the Paradise, California fire

A good friend got out with his dogs and a few photos, but his home burned to the ground. Many in the town were burned to death trying to escape in their cars or on foot. Others died in their homes. The skies around the San Francisco Bay Area filled with smoke that turned the skies an eerie yellow-grey and forced people to wear N95 masks or stay indoors for most of Thanksgiving week. It is unknown whether there will be long term health consequences as a result of the exposure to this toxic smoke.

The magnitude of global warming

What is alarming is the magnitude of global warming that has already happened. We were told at the conference that sixteen of the seventeen hottest years ever measured have occurred since 2001—the hottest year of all was 2016 – that was the third year in a row that we had an all-time record hot year. Climate change also affects humidity.

For some people, these statistics are a big yawn. They laughingly say global warming will bring them better weather or the accompanying sea level rise will change their landlocked home into a seaside property. Who cares? Some think this is only about plants, penguins, and polar bears…it’s a sacrifice we should make so that we can have cheap energy, more jobs, and a robust economy.

Each of those misunderstandings will be dealt with in later posts. But it is not what I want to focus on here because each of those consequences has elements of uncertainty; they may or may not take place in the future. Rather, I want to focus on harm to human health because it is happening right now. Climate change is already killing us.

Climate change and human health

I learned at the conference that there are many ways in which climate change is impacting human health. Here are some of the most important:

  1. Infectious diseases. Many of the microbes that cause human disease thrive in hot, humid climates. This is why they are more common in the tropics. What we are seeing now is that higher temperatures are driving some of the vectors of infectious diseases, such as mosquitoes that transmit diseases such as Zika and dengue, into new territories, including parts of the U.S. where they have not been seen before. Warmer climates also increase their reproduction rates and the frequency of them biting humans for their blood meals. There are a number of other ways in which climate change increases infectious disease outbreaks that you can learn about here. But suffice it to say that even if the spread of infectious disease was the only impact on human health, it would be bad enough. Just think back to how you felt when you first learned that Zika was now in the United States.
  1. Extreme-weather related events. Extreme weather, such as wild storms and severe droughts Northern California and heat waves in Australia, Pakistan, India, and even the U.S., are not just an inconvenience, they are deadly. According to conference presenter, Dr. Kim Knowlton from the Natural Resources Defense Council and Mailman School of Public Health at Columbia University,

    “Heat waves…are the #1 cause of U.S. weather fatalities on average over the last 30 years, causing more deaths than tornadoes, floods, and lightening.”

    She went on to say that there are between 670-1,300 heat-related deaths annually in recent years, and 65,000 heat-related emergency department visits in the U.S./year. Over 700 people died in the 1995 Chicago heat wave; a 2003 European heat wave led to 70,000 excess deaths; and a 2006 California heat wave saw ~16,000 more ER visits than expected.

    Mark Keim, MD, MBA, Founder of DisasterDoc, also a speaker, showed evidence that the annual incidence of natural disasters appears to be rising worldwide. One category of natural disaster—those related to extreme weather events, such as hurricanes, tornadoes, and heat waves—have accounted for 41% of all disaster-related deaths between 1964-2013, exceeded only by geologic disasters (e.g., earthquakes). Although we usually think of floods as a major cause of disaster-related deaths, in fact, extreme drought accounts for about 60% of climate-related deaths compared to 35% for floods. Storms account for about 5% of these deaths.

  2. Failures of nutrition. In the U.S. and other “lands of plenty,” we rarely think about crop failures anymore unless they lead to big jumps in prices that catch our attention, like the recent jump in the price of olive oil. But, Dr. Sam Myers, Senior Research Scientist at Harvard T.H. Chan School of Public Health, points out that failures of nutrition drive more deaths and disability around the world than any other risk factor. And, climate change is threatening the quantities and quality of food we produce as well as the locations of where it is produced. Changes in CO2 levels, temperature, precipitation, pests, pathogens and pollinators (e.g., bees), and heat-related labor issues are all threatening crop yields and even nutritional value of those plant-based foods, particularly iron, zinc, and protein. As Dr. Myers pointed out, ten years ago when the conversation about the impacts of climate change first got serious, we weren’t anticipating that changes in the nutritional value of food would be one of them. How many other unanticipated effects are going to surprise us as climate change progresses?

I have purposely tried to focus on health impacts that we are seeing today instead of sharing projections into the future for two reasons:

  1. The future projections, as it is true of all projections, are as yet uncertain
  2. It would scare the bejeezus out of you

Climate change is real. Climate change is harming human health right now. Our politicians are letting ideology get in the way of needed action. We can’t let that happen.

******

Be sure to listen to my American Journal of Managed Care Interview with Georges Benjamin, Executive Director of the American Public Health Association, co-sponsor of the Climate Change and Health meeting.


This post was first published Febuary 21, 2017. It has been reviewed and updated by the author.

As a rule, doctors don’t scare easily.

But when a bacterial strain becomes so advanced that it can resist most or all available antibiotics, doctors and public health officials get nervous – and we should too.

When that infection is sexually transmitted, known as a sexually transmitted disease or STD) and has mutated into a so-called superbug at a time when young people are reportedly less concerned about STDs, it might be appropriate to bypass “frightened and nervous” and head straight to full-blown panic.

It’s being dubbed “Super Gonorrhea” and it may be a looming public health crisis.

It was predictable

Health officials acknowledge that in some ways this was predictable. Antibiotics are designed to destroy the bacteria that causes the disease but over time the bacteria evolve resistance mechanisms such that the antibiotics are rendered ineffective.

Scientists have long observed bacteria becoming resistant to one or more of the antibiotics on the market, but the outbreak reported in the U.K. this year marked the first time the disease has seemingly found a way to overcome all of the available antibiotics. Doctors were ultimately able to treat the infection with an experimental combination of potent antibiotics, but, alarmingly, new cases of the same superbug have been reported in Australia.

All of that almost seems fascinating in an academic sense, but the repercussions of this scientific wonder are pretty bleak.

Related Content: What You Need to Know About Hepatitis

Gonorrhea is quite common

Gonorrhea is already the most frequently sexually transmitted infection; according to the World Health Organization (WHO), almost 80 million new cases are reported each year. For decades, those who caught the bacterial infection could generally count on aggressive dosing of antibiotics to quickly abate the symptoms that infects the genitals, rectum, and throat. But in a world where the most of the effective antibiotics known are rendered ineffective, the consequences of an outbreak could be catastrophic, particularly in the most vulnerable communities.

Unless it is effectively treated, gonorrhea presents a host of complications to those afflicted, particularly to women as untreated gonorrhea leads to an increased risk of infertility and ectopic pregnancies.

It gets worse. Gonorrhea significantly increases the risk of contracting HIV and infections can be passed to babies during birth, in extreme cases causing blindness to the newborn. Typical symptoms can be very uncomfortable: urethritis, a burning discharge during urination caused by inflammation in the urethra can afflict men and women alike.

More troublesome than these painfully obvious symptoms are the many cases of gonorrhea that occur without any symptoms; health experts speculate that the infection is frequently passed to partners from sources who were completely unaware of their affliction.

 

There’s an uptick in STDs

The outbreak of Super Gonorrhea comes at a time when health organizations are already sounding the warning sirens over a dramatic uptick of sexually transmitted diseases and infections; it was recently reported that a record number of California residents contracted an STD in 2017.

In some ways, experts suggest, the effectiveness of previous antibiotics that halted the spread of diseases such as gonorrhea, syphilis and chlamydia has led to a more lax attitude towards using protection, especially when compared to the peak of the HIV scare in the 1990s.

A recent CDC study found that sexually active individuals aged 15 to 24 are increasingly eschewing condom use; one survey found that almost half of millennials use condoms “never” or “rarely”. Some observers theorize that young people are more concerned with deterring pregnancies than infections, and the ubiquity of hormonal birth control methods leads many to conclude that condom use is an unnecessary nuisance.

While scientists test more powerful antibodies to introduce to the battle, health officials believe that education and prevention will continue to be the biggest way humanity can work to stay one step ahead of the superbugs.

It was a bathmat that did it.

Leaning over my tiny daughter as I bathed her one night, I stared at the broken-in vinyl mat she was sitting on in the tub. For the first time, I wondered if it could be leaching into every night’s bathwater. And into her. When even Google couldn’t give me a clear answer, I knew I had work to do.

Turns out, there’s no clear, credible and concise site for consumers, no place where they can get actionable guidance about how to reduce their exposure to everyday toxic chemicals. Meanwhile, there’s a silent epidemic: A tidal wave of toxicity surrounding us. Most of us remain completely unaware of it – especially pregnant women who are responsible not only for their own health but also for the health of the whole next generation.

I started SafetyNEST to solve this problem.

We are surrounded by toxins

According to the EPA, there are more than 85,000 synthetic chemicals that surround us in everything from our living room couch to our cleaning products.1 Another way to slice it: 30,000 pounds of industrial chemicals are being produced for every single person in the United States, every year.2 Lead, mercury, phthalates, Bisphenol A, flame retardants, Teflon, and pesticides are among the chemicals of concern. Increasing evidence shows widespread exposure and adverse health outcomes as a result.

Here’s the glitch.

Most of us think that if it’s sold in the store, someone must have tested it for toxicity and safety…right?

Not so. Unlike pharmaceuticals, consumer product companies can constantly introduce chemicals into the environment with little to no proof of safety, due to a flawed approval system.3

These chemicals get into us through the air we breath, the food we eat, the water we drink and a host of products we routinely, blithely, benightedly use in our home and workplace. Us, by the way, includes pregnant women. Virtually every pregnant woman in the US, according to a UCSF study, has at least 43 toxic chemicals in her body. 4 These chemicals are also found in the breast milk of nursing mothers and the umbilical cord blood of newborns.

Toxins and pregnancy

We know for sure that exposure to toxic chemicals, even at very low levels, during vulnerable windows of development such as pregnancy and infancy can disrupt the delicate growth process, causing a lifetime of health havoc, even death.5 Prenatal exposure to toxic chemicals is linked to preterm birth, birth defects, childhood cancer, obesity, diabetes, asthma, and lasting harm to the brain.6

Toxic chemicals affect us all. But many toxic chemicals disproportionately impact vulnerable populations, leaving underserved women more susceptible to adverse impacts. These can be exacerbated by other factors, including stress, nutritional status, housing quality, and poverty. It’s notable that immigrant populations often work in occupations associated with hazardous workplace environments.

Related content: Fetal syndromes: Diagnosis, Treatment, and Outcomes

Research continues to prove that we are ignoring this issue – but shouldn’t be. In August 2017, UCSF released a study titled “Higher Exposure to Flame Retardants in Pregnant Women Leads to Lower IQ in Children.” The facts:

For every 10-fold increase in a mom’s levels of PBDE – the compounds used as flame retardants, which are found in couches, electronics, plastics and more – there’s a drop of 3.7 IQ points in her child.

The price tag for all this? In 2008, the price tag was $76 billion every year in the United States. This is for poor childhood health caused by environmental factors, such as air pollution and exposure to toxic chemicals.7 The Lancet published a 2016 study showing exposure to chemicals in pesticides, toys, makeup, food packaging and detergents costs the U.S. more than $340 billion annually, in health care costs and lost wages.8

How can this be something we are willing to ignore?

How can this be something we are willing to ignore? Maybe we’re not. Since SafetyNest started in 2016, a lot has happened:

  • There’s been an acknowledgment of the problem

In the US: The American College of Obstetricians and Gynecologists (ACOG) released a Committee Opinion in 2013 stating:

“The evidence that links exposure to toxic environmental agents and adverse reproductive and developmental health outcomes is sufficiently robust….Harmful chemicals can cross the placenta…ACOG and the American Society for Reproductive Medicine join leading scientists and other clinical practitioners in calling for timely action to identify and reduce toxic environmental agents while addressing the consequences of such exposure.” 9

There has been a call to action

FIGO, the International Federation of Gynecology and Obstetrics, released a call to action in 2015 that stated, categorically, that exposure to toxins before and after birth is a serious threat and

“Preventing exposure to environmental chemicals is a priority for reproductive health professionals everywhere.” 10

  • There has been legal reform

After 40 years of waiting, the Toxic Substances Control Act (TSCA) – our nation’s badly broken chemical safety law – was reformed in June 2016. It still leaves the majority of chemicals untested and only a very small fraction of new chemicals added to the list for assessment.11 But it is a step in the right direction.

SafetyNEST – a trusted source for pregnant women

We can’t just kick back and wait for strong policy to be enacted in the United States. We have to get smart, ourselves. This is why SafetyNEST’s mission is to become the most trusted source for every pregnant woman and her reproductive health provider to safeguard our babies’ health against toxic chemicals.

SafetyNEST transforms prenatal care by equipping both reproductive health providers and the pregnant women they serve with the most accurate, evidence-based, and personalized information about the effects of toxic chemicals on prenatal and early childhood health. Our goal is to reduce the incidence of preventable diseases linked to toxic chemical exposure.

Our priority is developing an engaging, digital health platform to educate women about how to reduce their exposure to toxic chemicals in their daily lives, particularly in their homes. Partners include UCSF Program on Reproductive Health and the Environment, Icahn School of Medicine at Mount Sinai and the American Medical Women’s Association.

Together we’re working to make sure no more mothers have that moment of panic I did, all those years ago, at bath time – or worse. It’s our job, and our mission, to give the next generation the best possible start.

References

1. Children and Environmental Toxins: What Everyone Needs to Know, Philip J. Landrigan and Mary M. Landrigan, Oxford University Press, 2018.
2. We’re Surrounded by Way More Chemicals Than We Thought, Mother Jones, October 2015.
3. Why the Toxic Substance Control Act Needs an Overhaul, and How to Strengthen Oversight of Chemicals in the Interim, SA Vogel and JA Roberts, Health Affairs, 30:898-905, 2011.
4. UCSF Study Identifies Chemicals in Pregnant Women, January 14, 2011.
5. Environmental Chemicals in Pregnant Women in the United States, Tracey Woodruff et al, Program on Reproductive Health and the Environment, Environmental Health Perspectives, June 2011.
6. The Role of Environmental Toxicants in Preterm Birth, National Academy of Sciences, 2007.
7. Environmental Illness In Children Costs $76.6 Billion Annually, Health Affairs, May 20111.
8. Exposure to Endocrine-Disrupting Chemicals in the USA: A Population-Based Disease Burden and Cost Analysis, The Lancet Diabetes and Endocrinology Journal, October 2016.
9. Committee Opinion Number 575, Exposure to Toxic Environmental Agents, ACOG Committee on Health Care for Underserved Women; American Society for Reproductive Medicine Practice Committee; UCSF Program on Reproductive Health and the Environment, October 2013.
10. Opinion on reproductive health impacts of exposure to toxic environmental chemicals, Di Renzo GC, et al, International Federation of Gynecology and Obstetrics, 2015.
11. Assessing and Managing Chemicals Under TSCA: The Frank R. Lautenberg Chemical Safety for the 21st Century Act, United States Environmental Protection Agency, June 2016.

The shrillness of the gun debate is disappointing. And I am particularly disappointed by the way the “Founders” are sometimes invoked as private property libertarians who supported unrestricted gun ownership. In over twenty years of writing about the Revolutionary Era, I’ve reviewed literally thousands of documents—local and state government records and account books, militia returns and orders, veterans’ pension applications and Continental Army papers, court dockets and case papers, estate inventories and personal papers, and hundreds of pages of newspaper. So I feel like I have a pretty good sense for how the founding generation governed—particularly in lower New York and New Jersey. What follows is a short discussion of the governing record of the Founders with respect to regulating firearms.

The sanctity of gun ownership during the revolutionary war

When governing in the region I’ve studied, the Founders showed little sanctity for gun ownership. From its first days as a proto-national government, the Second Continental Congress advised States to disarm individuals suspected of disloyalty and to impound goods, if necessary, for the good of the Army. Local Committees of Safety, acting as de facto county governments prior to the first post-independence elections, assembled militias not to fight the British, but to impound useful war materials—including guns, but also livestock, foodstuffs, liquor, forage, boats, and wagons.

George Washington’s first action of 1776 was a campaign to confiscate the private arms of the citizens in Queens Co., New York. The impoundments occurred without trial, though the Army did provide receipts, which were redeemable for (nearly worthless) Continental currency. Meanwhile, local militias in New Jersey confiscated arms and livestock from people living along the Jersey shoreline. In one county, the militia was called out specifically to confiscate guns from African-Americans, both free and slave. These were not actions taken against a handful of traitors, but large actions against neighborhoods of people.

Guns were confiscated from individuals without due process. Firearms were treated similarly to other kinds of private property impounded for the war effort. In a region under British invasion, the need to win a war trumped individual property rights—including the right to own a gun.

Related Content:  People Should Prove They Have Earned the Right to Have a Gun

The Federalist papers

A decade later, as the Federalists attempted to make the Constitution more attractive to a skeptical public, they added a Bill of Rights (ten amendments to the Constitution) to lessen fears that the Constitution would become “an engine of tyranny”.

The 2nd Amendment to the Constitution, in its entirety, reads:

“A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”

People will argue forever about the construction of this sentence and its meaning, but the opening phrase, “a well-regulated militia,” deserves consideration.

Minute Man Statue, Lexington, Mass (Wikimedia) 272 x 450

Minute Man Statue, Lexington, Mass (Wikimedia)

Drawing from the Revolutionary experience, the Founders believed that a local militia, properly officered by community leaders, was essential to resisting external threats and a potentially oppressive central government. The 2nd Amendment spoke to the Colonial and Revolutionary experience.

The Founders did not make detailed or public arguments regarding private gun ownership as a unique right. The Federalist Papers, written by the Founders to explain the benefits of the Constitution, discuss different rights in great detail: Fair treatment before the law, the right to vote, freedom of religion and the press, etc. To the degree firearms are mentioned, it is nearly always in the context of the right of Americans to organize into local militias to resist political tyranny and protect the nation from external threats.

Federalist #29 declares “it is a matter of the utmost importance that a well-digested plan should be adopted for the proper establishment of the militia“; and Federalist #46 discusses the strength of a militia “with arms in their hands, officered by men chosen from among themselves, fighting for their common liberties.” However, The Federalist Papers—85 essays and 200,000 words, many of which are devoted to articulating the rights of citizens—do not dwell on firearms as a unique property right.

Gun ownership in the early republic

The first president permitted the seizure of private property. Federalized militia—more or less led by Secretary of Treasury Alexander Hamilton—confiscated a wide variety of private property from the “Whiskey rebels” of Pennsylvania (including guns). The federal government was willing to take goods in the name of restoring public order and ask questions later.

In the new nation, families often owned a gun, but it was not ubiquitous. By the late 1700s, long settled parts of the country were fully agrarian and a century removed from the frontier. The farm family estate inventories I’ve seen reveal that many families owned a gun, and many did not. And gun ownership was even less common among the large numbers of poor “cottagers” and landless laborers who drifted between agricultural and maritime pursuits.

To the British, Americans were indeed “a people numerous and armed“—but that statement is relative to the population of Britain. It was hardly an absolute.

The limits of privately-owned weaponry

The common guns of the late 1700s had limited range, limited accuracy, and a cumbersome reloading process. A man with a saber on horseback was more dangerous to a crowd of people. As no public menace was posted by one or a few guns, the Founders saw no need for “gun control”. However, local governments owned the really dangerous stuff. Casks of gunpowder, artillery, and anti-personnel weapons (i.e., grapeshot) were inventoried, secured by commissioned officers, and kept in guarded public magazines. Even the most powerful men of the day did not keep private stores of dangerous weapons. Washington’s estate at Mt. Vernon, for example, had nothing more dangerous than a small number hunting rifles. Leading merchants like John Hancock and Robert Morris purchased large quantities of war materials and then turned them over to state and local governments.

I do not mean to suggest the Founders were anti-gun or anti-private property. I do mean to suggest that they were pragmatic and, with the exception of a few cosmopolitans, locally-focused. Private property rights for guns or nearly anything else was fine unless it threatened the good of the community as they defined it based on the problem of the day. When that happened, private property rights—of all types—were sacrificed.

In a few personal letters, Founders speak glowingly of the importance of an armed citizenry. Washington’s quote about guns being “liberty’s teeth” is frequently cited. These quotes can be interpreted differently, but one read is that they simply affirm the importance of a “well-regulated militia” (led by, of course, the Founders and their kinsmen).

It also must be remembered that the Founders were prodigious writers who tested ideas in their letters, much as we do in emails today. Thomas Jefferson, for example, wrote letters in which he stated that because the Constitution did not give the Executive the power to acquire foreign territory, the Louisiana Purchase was unconstitutional. But he still signed the deal. That is why I focus on governing actions and public documents in this essay, rather than pulling favorite selected quotes from personal letters.

Keep the founders out of it

When it comes to gun control, argue whatever position you want. But maybe we should keep the Founders out of it. It is inconsistent with their governing record to believe that they were supporters of unrestricted private firearms.

P.S. I like skeet shooting with my boys. I don’t hunt, but a couple of my friends do, and it’s a nice part of their lives. School shootings like the recent one in Florida make me sad, but I am against curtailing these long-established activities.


This post was originally published on 11/01/15. It has been reviewed and updated by the author and republished on 02/20/18 because of its unfortunate timeliness.

Otis Webb Brawley, Chief Medical and Scientific Officer and Executive Vice President of the American Cancer Society (ACS) joined me on my bi-monthly podcast for the American Journal of Managed Care to talk about some good news when it comes to cancer. Recent statistics from ACS show that the death rate from cancer has been declining over the last two decades, and dropped another 1.7% last year. There has also been a 2% decline in the rate of new cancer diagnoses in the last decade for men, although not for women.

What follows is a condensed edited version of the transcript of the podcast. You can also listen to the conversation here:

 

The impact of smoking cessation

Pat: Otis, what’s going on? Why are death rates declining? And why are new diagnoses declining for men, but not for women?

Otis: The biggest reason for the decline in the death rate is that people have stopped smoking. Men stopped smoking in the late 1950s and continued to decrease the prevalence of smoking well into the 1980s. There was a leveling off of the decline but it started again in the last 15 years. When men stopped smoking, they stopped stop getting smoking-related cancers.

Women actually continued to increase their smoking rates throughout the 1960s and their declines have been slower than in men. So, we’ve seen less of a decline in cancer death rates in women because their decline in smoking was not nearly as steep as the decline that men had in the 1960s.

Pat: It’s really good news that people have quit smoking. I live in California and I just don’t see smokers anywhere anymore.

Otis: Yes, but there are huge geographical variations in smoking rates. In West Virginia and Kentucky, ~30% of adults still smoke. In Utah and California, it’s down to around 10%. I am a little worried that marijuana is going to increase some of our lung cancer rates because it is carcinogenic.

Pat: What about vaping? Is it safer?

Otis: Vaping is safer than combustible cigarettes but that does not mean that it is safe. There are a lot of things in the vaping solutions that we don’t know about and they have not been tested. So, I’m not an advocate for vaping at all. There is a group of individuals, smoking combustible cigarettes, who find that they can wean off with vaping. I’m fine with them doing that. But I would prefer that they do it by using other nicotine replacement products because vaping still is going to have some health risks that are undefined yet.

There’s also this concern that vaping is a gateway for children toward combustibles. They can vape up in their bedroom so their parents won’t smell it. They get hooked on nicotine and the next thing you know, they’re smoking combustibles when they’re out of the house.

 

Screening for lung cancer

Pat: Can you talk about the impact of advances in diagnostics that facilitate earlier detection of lung cancer?

Otis: There’s a great study that shows that lung CT screening decreases the risk of death by about 20%. That same study showed that it actually has some harms associated with it as well. In fact, for every 5.4 lives saved by lung cancer screening, one life is lost associated with biopsies and bronchoscopy that resulted from screening. So, there is the benefit and there is the risk.

Everyone who is considering getting screened needs to balance the benefit and risk and make a choice for themselves as to whether they want to be screened. Also, they need to be screened at a good place that is capable of evaluating the CTs and treating lung cancer if it’s diagnosed. That being said, in the U.S., very few people (maybe 3% to 4%) who are eligible for lung cancer screening (people in their mid-50s and older who have smoked more than a pack a day for 30 years and are still in good health) are actually getting it.

Pat: I recently spent time at Enlitic, a digital diagnostic startup, that that is using artificial intelligence and machine learning to improve the efficacy of lung-cancer CP screening. They showed me data that suggests it is much more sensitive than regular CT scanning and that it is particularly good at being able to calculate the three-dimensional volume of lesions. Are you familiar with this advance? Do you think that this could change the way we think about lung CT screening?

Otis: I think, first and foremost, we need to discourage smoking. We should consider lung CT screening, particularly for people who have extensive smoking histories. Over time, CT scanning for lung cancer will get better and more hospitals will offer it. We’ve actually done some mathematical modeling on lung CT screening as it exists now. If it was available throughout the entire United States in the way it was offered in the University Hospitals in the trial I described, we could save about 12,000 lives per year. But as it is offered now, it would actually cost us a little over 2,000 lives per year. Keep in mind that well over 150,000 people die every year from smoking-related diseases. So, we really need to focus on the anti-smoking message. But lung cancer screening is going to get better and it will be an option. We should mention that about 20% of lung cancer patients are non-smokers. Right now, unfortunately, we don’t have anything to offer them in terms of screening.

 

Targeted therapies for lung cancer

Pat: But there are new targeted therapies available for non-smokers with metastatic lung cancer, right?

Otis: That is right. This is really good news for someone like me, who is a medical oncologist. But for patients, this can still be somewhat dissatisfying. Many of our lung cancers—I say lung cancers (plural) because when I graduated from medical school, we only had two kinds of lung cancer: small cell and non-small-cell. Now, 30 years later, based on their molecular biology, non-small-cell lung cancer (NSCLC) is thought of as perhaps 80 different types of cancer. For some of those cancers, we have drugs that perform very well. For example, some patients with NSCLC that have the ALK gene rearrangement have been alive with metastatic disease for five and six years right now. This is a disease which 7-8 years ago had a life expectancy of a year or two. Unfortunately, these targeted therapies are only good for about 30% of the people who have non-small-cell lung cancer right now. But they are growing in number and they’re getting better.

 

What’s going on with breast cancer?

Pat: Breast cancer is still a scourge among women even though death rates have declined. How much of the progress that we’ve made in breast cancer is related to being better at diagnosis versus having more treatments including the new targeted therapies or is it a mixture of both?

Otis: We’ve had a 40% decline in breast cancer death rates over the last 30 or so years, much of it due to improvements in treatment. But nearly half of it is due to screening. I’m a big advocate for both because we’ve got a lot of good studies to show that there’s a substantial number of Americans who are diagnosed with breast cancer and then get less than adequate care for that breast cancer. So, we need to work on getting screening to people and making sure the screening is good. But, we also need to make sure that women get good treatment once the disease is diagnosed. We very frequently argue about whether we should start screening at age 50 or at age 40. As one who gets to look at the epidemiology, I know we could save more lives if we just correctly treated everyone that we are diagnosing now. That is not happening.

Pat: That’s a very good point and we’re going to come back to it at end of our conversation. Because this isn’t just a problem with breast cancer. There is a disparity in access to diagnosis and treatment with respect to all cancers. But first, let’s talk about the outcomes of some other common cancers.

 

Prostate cancer

Pat: Let’s start with PSA screening. We’ve been hearing for years that we shouldn’t order this test because there is morbidity associated with the workup that is triggered when a test returns positive. What’s the final word on that?

Otis: There is no final word yet. There’s been a decline in mortality that’s close to 50%. That decline started before we started screening in the United States. So, it’s hard to say that the whole thing is due to screening. That decline exists in 21 countries around the world—18 of which don’t screen, several of them actually have policies against screening that are really very harsh. Some of the decline that we’ve seen since 2000 might be due to screening but the decline that we saw in the 1990s is definitely not due to screening, rather it might be due to treatment. Also, there are some technical issues about changing the way death certificate data are interpreted. In 1991, the World Health Organization changed the algorithm raising questions about why we’ve seen a decline in prostate cancer? Some of the people who are dying are being categorized as having other diseases. Overall, it translates into “we still don’t know” whether we should be screening for prostate cancer with a PSA test.

What we do know is that in the 1990s in this country, every man who was diagnosed was told you need to be treated immediately. Many of them had a radical prostatectomy in the next week. Today, in 2018, more than half of all men who are diagnosed through screening are told we should watch your cancer. Many of those men will never be treated. We’ve gotten a lot better at being able to distinguish the cancers that need to be treated and the ones that can be watched.

The answer to the question of whether a man should be screened for prostate cancer has changed just in the last five to ten years. There’s a group of men who I would encourage to get screened knowing what their concerns are. These are men that I would have encouraged not to get screened just five years ago. I do think it’s still up to the man to decide once he understands the potential benefits and the potential risks of screening. He needs to know that there are harms associated with prostate cancer screening related to both diagnosis and treatment but there also may be benefits. The man needs to decide what he wants to do.

Pat: I think this whole discussion about prostate cancer shows us how very hard it is to get to the “truth”. From a consumer point of view, you want somebody to say, this is what you should do. But prostate cancer has shown us that you can’t always get there. There are still some very difficult decisions that have to be made by patients in conjunction with their family and healthcare providers.

 

Is colorectal cancer another good news story?

Otis: Yes! And there’s less controversy. We have had dramatic declines—well over 40% to 45%—in colorectal cancer death rates throughout the United States. Some of these declines started back in the 1970s. They are linked to screenings (stool blood screening, sigmoidoscopy, colonoscopy) that are all highly effective. Even stool blood testing that triggers a colonoscopy has been shown to find polyps that reduces the risk of colon cancer. So, we’re talking about a screening test that reduces the risk of death and reduces the risk of colon cancer.

Our ability to treat the disease, including stages 3 and 4, have improved dramatically. This, too, is a part of the reason for the decline in mortality. The sad thing is there is geographic variability in outcomes. This is a lot like what we discussed with smoking breast cancer. There are 12 states in the United States that have not had a 10% decline in colorectal cancer death rates even though the United States as a whole has had close to a 45% decline.

Pat: Do we know if that’s due to environmental factors, ability to get insurance coverage, or patient education? Are there any hints to why that disparity exists?

Otis: Yes. The declines are because people got adequate preventive diagnostic and therapeutic care. Preventative care can be related to diet (e.g., five to nine servings of fruits and vegetables per day), not being obese, exercising—all of those things prevent a number of cancers, not just colon cancer. It’s not just screening.

What we have found is the states that have had a very small decline in colorectal cancer death rates are the states that overwhelmingly have the highest proportion of people who have not graduated from high school or not graduated from college. They are some of the poorest states in the United States. They are also the states where people traditionally have difficulty getting healthcare once diagnosed. They also have difficulty with some of the preventative aspects, too. They are some of the states with the highest proportion of the population being obese.

The death rate for college-educated Americans in the United States is considerably different from that of non-college educated Americans for cancer. If all Americans had the death rate of college-educated Americans, 150,000 of the 620,000 people who are going to die from cancer this year would not die. They would have had all the preventative aspects over the last 10, 15, 20 years in terms of diet and exercise. They would have had all of the screening that college-educated Americans tend to have. And, they would have had access to better care. All of those things are important when it comes to lowering death rates. We spend a lot of time talking about race and racial disparities, but most of the racial disparities, are actually due to socioeconomic disparities.

Pat: It is completely unacceptable in a country as wealthy as ours that we have two Americas: an America that gets good healthcare and has good health outcomes and an America that doesn’t. Otis, I hope you will come back soon to talk to us about disparities in cancer outcomes.

Building a healthy workforce is imperative in this climate of healthcare debate and uncertainty. The connections between health, job performance, healthcare costs, and engagement is clear. Healthy employees are more productive, have lower overall healthcare expenses, and are more present on the job. Recently, Willis Towers Watson found that 78% of employers encourage employees to stay healthy by using telemedicine services. However, the National Business Group on Health found that just 3% of eligible employees currently use this method to stay healthy.

The reason for the deep divide between the promise of telemedicine and its actual usage by consumers is complicated. First, it’s a big change for most—we’re used to seeing a physician in-person, sitting in the exam room, and feeling the cold of the stethoscope on our chests. For some, that lack of a personal touch, especially after years of in-person trips to the doctor, makes them wonder if it’s as effective. Although these services need to comply with HIPAA regulations just like any other medical provider, some also question their privacy and confidentiality.

This begs the question: If telemedicine services have not yet reached their full potential as powerful, immediate solutions for both employers and employees, then what has? Innovative employers who offer worksite healthcare as part of their benefit offerings have seen success in engaging and managing the health of their workforce alongside attracting and retaining talent and returning hard dollar savings to the bottom line.

Managing the health of employees and delivering true value may prove difficult for some employers, but population health risk management delivered through worksite health centers is one of the best strategies for building a healthy workforce. Managing the health of the population and deriving value for the employer can be achieved by following these four steps:

 

1. Find the risk

Healthy workforces begin when employers understand the health risks present among their employee population. This model uses claims and screening data, like health risk assessments and biometric screenings, to help clinicians focus on the patients with the highest health risks and chronic conditions. Using this information gives members of the human resources team a total picture of health of the employee population, from how many people are at risk for heart disease to what percentage of the population are smokers, stressed, have sleep problems, or depression. Knowing the health risks and potential impact provides a roadmap for benefits managers and the health center clinical staff to address the identified risk factors. The clinical staff can then stratify the employee population by those risks, allowing them to focus on the employees that can benefit most by engaging with the health center. At this stage, it’s essential to educate and empower the patient to take control of their health.

Related Content:  Physician Innovators: Empowered to Change Healthcare

2. Mitigate the risk

An engagement program that gets eligible participants into the health center in which a clinical team can then perform a comprehensive health review is key. At this stage, patients are given the tools they need to change their unhealthy behaviors and improve their health. Providing the patient with a personalized wellness score and risk profile to help them begin their journey is a helpful roadmap. Wellness scores can reflect measurements on health risks, including clinical markers such as weight, glucose, blood pressure, cholesterol, as well as health history and risk assessment responses regarding sleep, stress, depression, alcohol use, seatbelt use, and other indicators of overall wellbeing. A health portal displays, which displays the risk measurements and score and shows changes so the patient can monitor results and address health issues over time, can also help mitigate risk and reach patients.

Health coaching is another way to address the areas where they can make the most improvement and better manage their chronic conditions. A personalized approach to the individual patient’s health literacy, values, and goals is key so they can move at their own pace, along a continuum of health improvements. In this process, patients often begin adopting new lifestyle behaviors that are influential for long-term health.

 

3. Change utilization

Through this process, employees begin to make better, smarter healthcare decision for themselves. The result? A healthier workforce. The risk profile identified at the beginning of the process starts to change, moving patients to lower risk categories as health behavior changes are made. In fact, our data shows that 57% of patients across our customer base make progress towards improving their health. We also see a significant reduction in emergency room use, specialist visits, and hospital stays, meaning that employees are not only improving the way they take care of themselves but also how they utilize the entire healthcare system.

 

4. Capture value

The results of the improved health of the workforce? Significant cost savings. We know engaged employees cost less than non-engaged employees. But how much less? According to our data, engaged employees who use the health center cost 34% less than those that do not use the health center. In addition, the savings for employees with chronic conditions are even greater at 44%. One might assume that this is because we are seeing healthier employees, but the opposite is true. Patients who are engaged with the health center are sicker (have a higher illness burden rating) than those who do not.

Engaged Employees Cost Less

Marathon Health Data from 2016

Although telemedicine is a promising solution to improving employee health, employers need a way to engage employees today. Even for the small percentage that is taking advantage of telemedicine offerings, an onsite health center can be an excellent complement to the digital services, especially considering that a telemedicine visit actually spurs more doctor visits. With an onsite health center, employers can achieve the pinnacle of healthcare success: improving patient satisfaction, healthcare outcomes, and lowering the overall cost of care.

Have you ever felt trapped in a predicament in which you thought there was no possible good outcome? I have. I was a successful psychiatrist, married for 18 years with two young daughters, but tormented with a decision about coming out as gay. The more I struggled with the decision, the more anxious I became. Although I never considered suicide, other mature adults—and there are many—confronting the decision to come out attempt suicide at about three times the rate of the general population, sometimes making multiple attempts. My predicament lasted a relatively short time, and once I made the decision to come out, my anxiety disappeared.

 

The transgender suicide predicament

The dominant psychiatric belief has always been that suicide is the result of a mental disorder, and recent adverse life events are known to increase the risk and perhaps form the trigger for suicide. Dr. Saxby Pridmore, an Australian psychiatrist, described “predicament suicide,” which occurs when an individual without a mental disorder completes suicide to escape intolerable circumstances. To some extent, all suicides are a response to a predicament, but the idea of predicament suicide still has some currency when applied in a limited sense to cases where there is no mental disorder.

People who are transgender have a much harder struggle than I did. Many trans children become aware of their predicament long before they understand the concept of gender or are aware that their opposite-sex interests will result in significant disapproval. It doesn’t take long for them to begin to experience strong opposition and violence. Often, a trans individual experiences multiple, daily acts of intolerance or violence, beginning as early as preschool and continuing across a lifetime.

I recently interviewed a middle-aged trans female just beginning her transitioning from male to female. She always wanted to be female. At age four, her alcoholic father caught her dressing in girls’ clothing and in a fit of drunken rage, he threw her against the wall, causing injuries that required her prolonged hospitalization. Because of that violence, she lived a secret life. As an adult, she had a successful career, married, and had children, burying her interest in being a woman except when secrecy could be assured. Her predicament frequently led to thoughts of suicide.

Acts of violence are not single incidents. Mental health issues and experiences of harassment, discrimination, violence, and rejection may interact to produce a marked vulnerability to suicidal behavior in transgender and gender non-conforming individuals.

I work as a psychiatric consultant in a clinic that does gender-reassignment treatments, and stories like this trans woman’s are common. I am often asked to give a psychiatric opinion of whether a person is psychiatrically stable so that gender-reassignment surgery can proceed. In most cases, I find no evidence of a psychiatric disorder or only symptoms related to a lifetime of abuse.

Although at higher risk for anxiety, depression, and suicide, many of these transgender men and women show a remarkable resilience to having been rejected by family and peers, harassed, traumatized, and abused. Many of their psychiatric symptoms disappear once they have accepted that “I am what I am; I don’t care what anyone thinks.” Shame cannot survive in the presence of people who accept these individuals. One person who had lived as a woman for a year after having undergone hormonal treatment requested surgery and said,

“I have no illusions that I will be a beautiful woman. I just want my outsides to match my insides.”

Findings published in a report called “Suicide Attempts among Transgender and Gender Non-Conforming Adults,” indicate that 46% of trans men and 42% of trans women have attempted suicide, a public health crisis for the estimated 150,000 trans teens and 1.4 million trans adults. The prevalence of transgender suicide is highest among the young, the economically disadvantaged, and the less educated and ethnic minorities. It is also higher for those who are thought by others to be gender non-conforming, even if they are not told. For those who have an underlying mental condition, suicide prevalence is even higher.

Related Content: Suicide in America: Understanding the What and Why

Politics and religion

As a candidate for president, Donald Trump said that transgender people should use the bathroom they were more comfortable with. He appeared to support the Obama administration’s decision to inform schools receiving Title IX federal funds that they must allow students to use restrooms and changing rooms consistent with the gender with which they identified. He claimed to be sympathetic to the LGBTQ community and made a commitment to protect us from violence.

President Trump lost credibility when he reversed his position and in a brief letter announced that he was rescinding President Obama’s directives to protect transgender schoolchildren. The decision was couched in terms of deference to the primary role of states and local schools to establish educational policy. An editorial in the Los Angeles Times suggested, however, that Trump’s decision was influenced largely by religious conservatives who provided significant support to Trump and long have stirred up hysteria over the imaginary danger to children posed by policies that allow transgender children to use facilities of the gender they identify with, even if it doesn’t match the one on their birth certificates.

A recent article on the Gospel Coalition website states, “The sexual revolution has so subverted public opinion and Christian-influenced morality that teachings about sex that were previously considered immoral or even unthinkable eventually found their way into the classroom as school policy. But a quicker and more effective route to societal change is to simply reverse the process: force an issue to become school policy and eventually opposition to it will become unthinkable. That is the shift that is being attempted today on the issue of transgenderism in schools.”

This article goes on to say that people might choose “their own sex” to benefit themselves. “But as history has shown, people respond to incentives. If men can gain an advantage by saying they are women, many will do so. To claim otherwise is to be completely unaware of humanity’s sinful nature.”

Although we don’t really know why some people are transgender, the explanations for this complex issue are often found in a combination of genetic, psychological and cultural factors. The statements by the Gospel Coalition ignore the pain that goes into the decision to transition and the violence to which these people are exposed, treating the matter as if transitioning will help gain one admission to a favored college or a peek over the top of a bathroom stall.

The LGBTQ community is in for a bumpy ride. Trump supports the First Amendment Defense Act, which is quite like a law passed by Vice President Mike Pence in 2015 when he was the governor of Indiana. It would allow business owners to deny services to LGBTQ customers based on their belief that marriage is solely between one man and one woman.

That legislation was cosponsored by then Alabama senator and now attorney general Jeff Sessions, who has consistently opposed pro-LGBTQ legislation throughout his twenty years in Congress. He voted in support of a constitutional ban on same-sex marriage, against providing workplace discrimination protections for LGBTQ people, against repealing the military’s “don’t ask, don’t tell” policy, and twice against expanding the definition of hate crimes to include attacks on people because of their sexual orientation and gender identity. He has supported a law that would allow state laws to override federal laws about same-sex marriage. The Human Rights Campaign, in its annual scorecard of how lawmakers fare on LGBTQ issues, year after year has rated Sessions at zero.

Education Secretary Betsy DeVos, a conservative Christian, originally supported President Obama’s policy of protection for trans teens but, apparently, under pressure from the new administration, has reversed her position and now says it is an issue for states and local schools to decide.

On March 28, the Supreme Court will hear oral arguments in a lawsuit filed by Gavin Grimm, a transgender high school student, a boy seeking to use the boys’ restroom at his Virginia high school. In ruling for Grimm, a federal appeals court had relied on the Obama administration’s interpretation of Title IX. With the Trump administration’s change of policy, the justices might send the case back to the appeals court.

 

The bottom line

What some have seen as an epidemic of people seeking to transition from one gender to another is not a real change in incidence but a change in visibility of a hidden population. If recent policy changes by the Trump administration are activated, trans children and adults will be driven back into hiding, where they will once again be faced with a huge predicament. It appears that this is only the beginning for the entire LGBTQ community.

Related content: Older Gay Men and the Risk of Suicide

Instead of wagging their fingers at parents reluctant to vaccinate their children, Vax Northwest, a unique public-private partnership in Washington state that includes Kaiser Permanente Washington Health Research Institute (KPWHRI), the Group Health Foundation, WithinReach, Seattle Children’s Hospital, BestStart Washington, and the Washington State Department of Health, formed an “Immunity Community.” They knew from earlier studies that parents who interact with other parents in a social network trust the opinions of their peers and generally support vaccination if their peers do.

 

Advocating for vaccination…peer-to-peer

The Immunity Community was made up of parents who understand and value childhood vaccination. These parents were mobilized into their communities to serve as advocates and to have positive conversations—in person and through social media—with other parents at their kids’ childcare centers, preschools, and schools.

To assess the effectiveness of the intervention, researchers at KPWHRI surveyed parents in two communities in Washington state before and three years after the implementation of the program. The results of their study were published in the journal Health Promotion Practice on April 11, 2017. They document significant improvements in vaccine-related attitudes:

  • Parents concerned about others not vaccinating their children rose from 81% to 89%.
  • Those who called themselves “vaccine hesitant” fell from 23% to 14%.
  • Fewer parents thought children receive vaccines at too young an age.
  • More parents were confident that vaccinating their children is a good decision.
  • More parents knew the vaccination rates at their children’s childcare or school.

Further, study principal investigator Clarissa Hsu, PhD, at KPWHRI’s Center for Community Health and Evaluation noted that,

“Our evaluation found that the Immunity Community program was successful at empowering parents to communicate positive messages about vaccines in a way that was not confrontational.”

This is a far cry from the demanding, cajoling, belittling, berating, and other heavy-handed approaches health professionals and the media (including ourselves) have used in the past and that led to (no surprise here) parents concerned and confused about the fake news and pseudoscience that surrounds childhood vaccination just digging in their heels.

As Dr. Hsu states,

“Strong negative rhetoric about vaccines can circulate widely on social media. And some parents feel hesitant about early childhood vaccines and may delay or refuse some or all vaccines, which may put others in their community at risk.”

This project was designed to “counterbalance prevalent anti-vaccine messages that do not reflect the fact that most (at least four in five) people vaccinate their kids and are supportive of vaccines.

 

Why this study is important

Addressing vaccine hesitancy among parents is important because vaccines work best when a high proportion of people in a community are immunized against a contagious disease. This phenomenon, known as “community immunity” (also called “herd immunity”), is based on the fact that the viruses that cause many of the common preventable childhood illnesses, such as influenza, measles, mumps, and rotavirus, require a pool of susceptible individuals in order to spread from person-to-person. When a critical portion of the community, somewhere in the range of 80-90%, is immune to the virus—either because of vaccination or because they have had the infection in the past—large outbreaks are not possible. Everyone in the community benefits, including those who are unable to receive vaccines, such as infants, pregnant women, and immunocompromised individuals.

The researchers reported some limitations to the study, including that it had no control group. Rather, information from parents was compared before and after the intervention. This is considered a weaker study design than one in which participants are randomized to an intervention vs. a non-intervention (or control) group. In addition, it was not possible to determine with certainty that the observed improvement in attitudes about immunization were actually due to the Community Immunity intervention and not to other factors, such as outbreaks of vaccine-preventable disease or changes in state laws around school exemption policies, that could have led to increased vaccination during the intervention period.

Not all participating sites are required to report their immunization rates to the Washington Department of Health. But the Immunity Community worked with the Organization of Parent Education Programs to improve the processes for tracking immunization rates and disease outbreaks for the children who attend cooperative preschools across the state of Washington. This policy change could affect thousands of families, according to Schoeppe.

Vaccine Related Article: Yes, Your Teen Needs Vaccines, Too

Applauding innovation

The Immunity Community program is innovative,” said study author Jennie Schoeppe, MPH, MS, also affiliated with KPWHRI’s Center for Community Health and Evaluation. “We are unaware of any other intervention that has used volunteer parent advocates to effect change in their communities.

This study is part of broader efforts by Kaiser Permanente and the Group Health Foundation to promote immunization as the most effective way to protect children from many infectious diseases, including ones that can cause serious disease and even death. The Group Health Foundation’s Childhood Immunization Initiative seeks to promote immunization and also funded the first randomized trial to test an intervention aimed at decreasing hesitancy about early childhood vaccines by working directly with doctors. Pediatrics published those results in 2015.

Kudos to Vax Northwest and Kaiser Permanente’s Washington Health Research Institute for designing such an innovative intervention and then testing whether or not it worked. Being able to break away from traditional approaches with mediocre results and try something new is the hallmark of a learning organization. We could use a whole lot more of this in healthcare.

Unless you work with large mammals, are involved in law enforcement, or consider yourself a narcotics expert, you’ve probably never heard of carfentanil. Consider yourself lucky.

Carfentanil is an unbelievably powerful synthetic opiate, manufactured for use as a tranquilizer for large mammals, like elephants. Basically, it’s man-made heroin on steroids. Ten thousand times more powerful than morphine, a few grains of the substance are considered a lethal dose for humans. Unlike other commonly abused opioids such as oxycodone, fentanyl, and hydromorphone, there is no practical human use for this pharmaceutical. The United States classified carfentanil as a Schedule II Controlled Substance, and it is highly regulated. So how is it responsible for deaths across our country?

Carfentanil is used to increase the strength of heroin

Our nation is in the midst of an opiate crisis. The abuse of narcotics including heroin and prescription painkillers is surging among middle-class, young adults. Just like its cousin fentanyl, carfentanil is being mixed with heroin to increase its strength, thus increasing the profit margin for dealers. Fentanyl made an appearance on the opiate scene in the past few years as another dangerous heroin substitute, but the potency of carfentanil is unprecedented. Dealers love it because it makes sense from a business perspective to mix stronger synthetics into heroin, driving up its potency and increasing sales. But typical drug dealers are far from chemists, so mixing lethal chemicals with drugs is far from an exact science. As pushers experiment to find the right potency, users can never be sure of which substance they are using or in what amounts. Even without the danger of synthetics, opiate addicts are always at risk for overdose. This new danger adds a whole new element of uncertainty to the growing epidemic.

Like fentanyl, carfentanil is a colorless and odorless granule or powder that is undetectable by the daily user. Since dealers often mix carfentanil into heroin along with other ingredients, buyers have no way of knowing how much is in their dose. For example, if a gram of heroin is 10% carfentanil, someone could theoretically consume 1/10th of that gram and only ingest carfentanil. Since a lethal amount can be the size of a poppy seed, the danger here is obvious.

The epidemic’s ravaging the Midwest, especially. In Ohio, public health and advocacy groups have issued warnings in several counties following a string of several overdoses last summer. Confiscated heroin has tested positive for carfentanil in at least six other states, reinforcing fears that the dangerous substance will continue to spread.

But how could a highly regulated veterinary medicine even make it into a street-level heroin dealer’s hands in the first place? Chinese vendors are largely responsible for the influx of spiked heroin in the United States and Canada. Law enforcement believes it is being manufactured in China and imported into Mexico or South American countries, mixed in with Mexican heroin, and then trafficked into the United States.

Single-dose Naloxone is not enough

Another frightening aspect is the fact that Naloxone, the only approved medicine to reverse opioid overdose, is often not powerful enough in regular doses to be effective. Individuals frequently require multiple doses to be revived because of the sheer potency of their narcotics. Naloxone, also known by its trade name Narcan, was developed for a typical heroin or opiate overdose. Unfortunately, the medicine sometimes isn’t enough for this deadly new chemical. Even those who keep Narcan on hand can’t always revive a loved one because the newer synthetic opioids are just too powerful.

There is a glimmer of hope, however. China has classified carfentanil and a few other synthetic opiate analogs as controlled substances, effective March of 2017. This substance will still be extremely hard to regulate because it is usually created in secret laboratories, but the new laws abroad are a beginning for international cooperation.

In the past, trace amounts of this deadly chemical have been undetectable, which is why it is hard to pinpoint its presence when combined with other drugs. It is difficult for law enforcement to affirmatively say that a synthetic opioid caused an overdose rather than the heroin itself. Recently, though, a toxicologist in Franklin County, Ohio has recently developed a test that is capable of detecting minuscule amounts of carfentanil within a sample of heroin. This test is predicted to have a hugely positive influence on the problem. If developed into a field test, it would allow police to detect opiate analogs in confiscated drugs and charge the criminals who possess it accordingly. It would also put an exact number on overdoses that occur from each opioid variety. Having reliable statistics can help convince lawmakers that the problem goes deeper than Mexican cartels and street level dealers in America, but can be traced all the way to secret manufacturing facilities in Asia. Passing legislation and encouraging cooperation between countries and agencies can help to prevent the manufacture and import of these chemicals and save many lives in the process.

There is little doubt that more designer drugs and analogs will be created, imported, and passed around on American street corners. There will need to be more cooperation between government agencies and even countries to classify them as controlled substances to establish consequences for those who import and export them.

Every person struggling with addiction can recover from their disease if given a chance

It is important now more than ever that resources for those struggling with addiction and alcoholism are affordable and readily available. Hospital participation is pivotal to getting those suffering from substance abuse into rehabilitation programs where professionals can treat them.

In addition, people who may encounter overdosing individuals should be trained to spot an overdose and potentially save a life. Even though one treatment of Naloxone is sometimes not enough to reverse a carfentanil overdose, the more individuals who are trained to administer this medicine, the better. In many states, over-the-counter Narcan is available for purchase in pharmacies.

Advocacy, education, and treatment are essential to battling this disease. With no sign of this epidemic slowing down or stopping, it is important to remember that every person struggling with addiction can recover from their disease if given a chance.

Digital Health has experienced a glorious boom in the last decade and is expected to reach $379.3 Billion by 2024 with 25% of the growth occurring between 2016 and 2024. Patient management can now be done on user-friendly platforms; physicians can remotely monitor their patients with mobile devices and telemedicine; and personal trackers and genetic testing are allowing patients easier access to their own health data. Clearly, we understand the kind of power technology has on improving the delivery of care and management of disease.

But what Public Health professionals have known for decades and what Healthcare is now catching onto, is that the real story behind who is healthy and who is not has little or nothing to do with the doctor’s office at all—the real story starts in the place you lay your head (if you have a place to lay it at all). The bigger picture and, therefore, the truly transformative opportunity is in the social, physical, political, and economic situation of each person—the social determinants of health. Leveraging tech for this more comprehensive approach to health is what we are calling Public Health Tech.

 

So what is Public Health Tech exactly?

Public Health Tech, as we define it, is any tech product or tech-enabled service that prevents the onset of disease or addresses the needs of medically vulnerable populations. It is a subset of digital health and sits at the intersection of Public Health and Tech.

Public Health TechIn 2016, my co-founder Vanessa Mason and I founded P2Health Ventures, the first venture fund supporting Public Health Tech companies. We invest in early-stage startups innovating solutions for population and/or preventative health. We also look for companies who are addressing health inequities, are committed to diversity within their teams and among the populations they serve, and who are implementing evidence-based product development. Through our work, three key observations about Public Health Tech convinced us this was the future of healthcare.

 

1. An opportunity for more cost-effective, sustainable healthcare delivery

Public health spending had increased significantly from $39 per capita (inflation adjusted) to $275 per capita from 1960 to 2002, but a recent study has found that it has since been declining. Most of the increase in funding (approximately 80-90%) was a result of federal or local government spending. While the ACA in 2010 had originally committed $15 Billion in public health funding, it reduced that commitment by $6.25 Billion in 2012 and even further via sequestrations in 2013. Now with the new Trump administration, it is unclear how that spending will change, but if recent efforts to repeal the ACA are any indication, it is unlikely public health spending will see any relief in the near future.

We, therefore, find ourselves in a challenging position and simultaneously at an opportune moment. Traditional funding streams for population and preventative health interventions are more difficult to access. As payers seek better methods to manage patient populations without support from the public sector, many of these interventions are finding a home in the commercial market. Omada Health is one startup that has developed such an offering. Prevent, is a digital therapeutic modeled off of the CDC’s National Diabetes Prevention Program—a program that is proven to reduce the risk of developing type 2 diabetes from pre-diabetes by 58%. Its digitization allows for greater scalability and patient monitoring compared to conventional methods, making Prevent a cost-effective program for payers and health systems.

 

2. An opportunity to support a value-based healthcare system

Our healthcare system is changing. The shift toward value-based care has offered glimmers of the benefits of population and preventative health outcomes. However, most of the health technology on the market is still rooted in the fee-for-service model. While organizations like Medicaid ACOs, CBOs, and Medicaid Advantage Plans that serve vulnerable populations search for methods to improve the health of communities, proven population health programs are becoming a top priority.

Healthify, an early stage Public Health Tech startup, tackles population health by addressing the social determinants of health. Healthify enables caseworkers and social workers to refer patients to social services in their neighborhood. For many vulnerable populations, fulfilling a treatment plan can be challenging with unmet non-clinical needs (e.g. access to fresh produce, transportation, emotional and social support). Healthify’s platform connects providers to community resources that were difficult to access with traditional methods and addresses interoperability of health systems by integrating with Epic. More social support means lower readmissions, better treatment outcomes, and greater overall health.

 

3. The opportunity to address the right problems

As with any intervention, ensuring that the right question is being addressed is essential. The inability to identify meaningful problems within a target population’s social, physical, and political environment can render any intervention and its resources useless. Often in tech, the tendency is to develop the technology first and then attempt to fit it to a problem or create a problem altogether.

When wearables debuted on the market, the concept was easy to grasp. Wear the device daily to capture activity data to become more informed about your personal behavior in order to make healthier, more productive decisions. Awesome. Got the data—now what?  Herein lies the problem. What do we do with the data and more importantly, why? How is this better than a $5 pedometer: Why does a user really want his or her personal activity data collected and analyzed in this manner? What is the user’s real psychological itch motivating them to keep wearing the device? How will it significantly impact their everyday life? How does it enable them to make better decisions, and sustain these positive habits over time?

Enter the public health professional, the healthcare professional, the healthcare economist, the clinician, and on and on. Much of the problem within health tech is that the people asking the questions were never trained on HOW to ask the right question. They are former engineers, business development professionals, or consumers turned health enthusiasts. While their skill sets are invaluable to operating a company and breathing fresh air into an industry as slow moving as healthcare, they can lack the behavioral science research training necessary to develop the right theses, or in other words, to define the right problem. What digital health and Public Health Tech needs now more than ever, are more healthcare and public health professionals building their lived experience into the product development process and guiding transformational innovation. Public Health Tech training should be built into academic curricula, professional training, and career development so that professionals feel prepared and empowered to seek new solutions. Tech has so much power to simplify and scale—let’s use it to fix the healthcare system.

 

The number of older people with fractures related to osteoporosis is huge. The National Osteoporosis Foundation (NOF) estimates that 1 of every 2 women and 1 of every 4 men 50 years or older will experience a fracture. Think about it. That’s 50% of women and 25% of men. Many of these fractures will occur as the result of a low trauma event, such as a fall from a standing height. They are considered fragility fractures because our big bones (hip, shoulder, and spine) are not supposed to break when we fall.

According to the NOF,

“the annual number of osteoporotic fractures that occur exceeds the incidence of heart attack, stroke, and breast cancer combined.”

Despite the magnitude of the problem, we have yet to take this disease as seriously as those other conditions. Perhaps, it is because we associate the condition with fragile little old ladies who gradually shrink and bend over. Most of us don’t think of it as a killer or a cause of major disability. But that is not correct.

Second fractures are common, particularly, for individuals who sustain a hip or vertebral fracture. And, the disability after a fragility fracture can be significant. Up to 85% of older adults who have fallen experience a syndrome known as “fear of falling” that causes them to alter their gait and become less active. Hip fracture, in particular, is associated with a significant increase in the first year after the fracture.

So, it is pretty disturbing to read the results of a recent study, “Patterns of Prescription Drug Use Before and After Fragility Fracture” published in the August 22 online issue of JAMA Internal Medicine. It turns out that not only are we failing to reduce the overall use of drugs that are associated with fractures, but only a fraction of the number of people who are eligible for prescriptions for bone-strengthening drugs are actually getting them.

Drugs that increase the risk of fracture

The researchers, led by Jeffrey Munson MD from the Department of Medicine at Dartmouth, looked at 2007-2011 data from Medicare beneficiaries to determine whether their prescriptions for drugs known to increase fracture risk were changed after they sustained their fracture. Here is what they found:

  • Three-fourth of the 168,133 beneficiaries who survived a fragility fracture were using a risky drug at the time of the fracture
  • More than half of the patients were taking at least one drug that increases fall risk prior to their fracture; slightly less than half were taking at least 1 drug that decreases bone density
  • Although some of the drugs were stopped in a small number of people after the fracture, about the same number of risky new drugs were prescribed

Drugs that increase the risk of fracture fall into three categories:

1. Drugs that increase the risk of falls, such as opiates (used by 35% of the cohort), selective serotonin reuptake inhibitors (SSRIs) (by 26%), thiazide diuretics (by 23%), and nonbenzodiazipine sedative hypnotics (by 11%).

2. Drugs that decrease bone density, including proton pump inhibitors (used by 26% of the cohort), anticonvulsants (by 9%), and oral or inhaled glucocorticoids (by 17%).

3. Drugs that are associated with fractures, but the mechanism is unclear. These drugs included loop diuretics and antipsychotics.

A full list of drugs in the study found in the here.

Bone-strengthening drugs

The study also examined whether or not patients were prescribed the most common type of bone-strengthening drug, oral bisphosphonates, once the fracture had occurred. Consistent with other studies about the dismally low use of bisphosphonates after osteoporosis-related fractures, this study found that less than one-quarter of patients had filled a prescription for a bone-strengthening drug either before, or, more egregiously, after their fracture. It is important to note that the study design did not allow the capture of data on the use of IV bisphosphonates, but this probably didn’t dramatically affect the results because only 2.5% of the group were using this type of drug prior to their fracture.

Why aren’t we doing better?

There are a number of reasons why we may not be doing better when it comes to discontinuing drugs that increase the risk of fractures. It may be that the consequence of discontinuing the drug is worse than its continued use.

For example, people with intractable asthma may require glucocorticoids in order to control their symptoms. In other cases, the underlying condition itself may be the real culprit and not the drug—anti-Parkinsons disease drugs come to mind.

In other cases, it may be a matter of optimizing the dose of the drug—for example, diuretics—so that orthostatic hypotension, due to dehydration, does not contribute to falling propensity. But in other cases, such as opiates, substituting less risky drugs could be a key intervention that reduces the risk of fracture.

Similarly, there are many reasons why people with osteoporosis are not taking bisphosphonates. Doctors may not be prescribing them when they are needed or patients may be refusing them because of fear of the uncommon, but serious complications of jaw necrosis and spontaneous femur fractures that have been reported.

I believe that one of the biggest problems related to drugs, falls, and fractures is that no one “owns” osteoporosis management after a fracture. Primary care docs are pretty good about screening women (men, not so much) for low bone density. But some people with low bone density may slip into frank osteoporosis that isn’t discovered until after a fragility fracture occurs. That is what happened in my case.

Further, most people in the United States get their care in a non-integrated, non-system of healthcare. When they fall and sustain a fragility fracture, they almost always end up in an ER with a follow-up from an orthopedist. The ortho takes care of the fracture, but may or may not address the underlying bone pathology. No one thinks to ask WHY you fell or WHY you broke a big bone, like the hip or shoulder, after a fall.

Population health programs for osteoporosis

This is where population health programs for bone health come in. Not to diminish the role of the PCP, but bone health and treatment of osteoporosis is pretty complicated and the consequences of failure to diagnosis and properly treat are huge, not only because of the impact on the person’s life, but also because of the cost of care.

Because there is so much emotion around the current treatment options for osteoporosis, a specialist with a high degree of knowledge about the physiology and pathophysiology of bones and the pharmacology of the various bone-strengthening drugs can be quite valuable in helping a patient make the right choice for her (or him). I spent 45 minutes on the phone with the bone health specialist going over the recent literature before making my treatment decision. Let’s be frank here…what PCP would even have 45 minutes to spend with you to just talk about the science?

Conclusion

If we are going to make a dent in the tsunami of fragility fractures coming down the pike as the population ages, we are going to need to have programs that take the management of populations at risk for osteoporosis as seriously as heart failure, asthma, or diabetes. We must keep in mind that falls are not “just falls” and fragility fractures are not “just fractures.” They are painful, traumatic events that have the potential to alter a person’s life forever. We simply must do better.

As horrible as Zika is, causing severe brain abnormalities in developing fetuses, a new study in mice published in Cell Stem Cell on August 18, 2016 suggests the consequences of infection with this rapidly spreading virus could be much worse than we imagined. It may affect adult brains as well.

The Zika virus wreaks havoc on fetal brains by infecting a type of brain stem cell known as neural progenitor cells. As fetal brains grow and develop, these cells differentiate into the various types of neurons and glia (cells that provide support and protection for neurons) that make up the adult brain. It is believed that these mature types of brain cells are more resistant to Zika explaining why adults seem to be protected from the severe brain damage and resultant microcephaly (small head) that is found in newborns who were infected while they were fetuses.

It turns out that adults don’t lose all of their neural progenitor cells (NPCs). Pockets of them remain in two different areas of the adult brain: the anterior subventricular zone (SVZ) of the forebrain and the subgranular zone (SGZ) of the hippocampal dentate gyrus. These NPCs are the source of neurogenesis (creation of new neurons) in adults. Neurogenesis is important to replace neuronal cells that are lost or damaged throughout adulthood—this is particularly important for learning and memory.

 

The mouse study

In an effort to learn about the impact of the virus on mature brains, scientists from The Rockefeller University and La Jolla Institute for Allergy and Immunology infected the blood of adult mice with Zika virus. When the brains of the infected mice were compared to control mice, the researchers discovered that Zika preferentially infected and killed neural progenitor cells.

According to one of the study authors, Joseph Gleeson, a professor at Rockefeller University,

“Our results are pretty dramatic…the virus wasn’t affecting the whole brain evenly, like people are seeing in the fetus. In the adult, it’s only these two populations that are very specific to the stem cells that are affected by virus. These cells are special, and somehow very susceptible to the infection.”

 

Why haven’t most adults shown symptoms?

Sujan Shresta, a professor at the La Jossa Institute of Allergy and Immunology and one of the study authors, says “the majority of adults who are infected with Zika rarely show detectable symptoms.” Although we don’t know exactly why, scientists have speculated that “healthy humans may be able to mount an effective immune response” not shown in the type of mice used in the experiment. It could also be that clinicians, not expecting neurologic deficits in adults, have not looked closely enough to detect subtle findings. It is also possible that difficulties with learning and memory may only show up over time as healthy neurons die of other causes and fail to be replaced because Zika-related impairment of neurogenesis. Further research, both basic science and clinical studies, are urgently needed.

 

The public health response

This study, although preliminary and in mice, should drastically alter how we think about the public health response to Zika. Currently, beyond mosquito control efforts, public health measures are largely directed at pregnant women and their partners, couples thinking about getting pregnant, and men and women of reproductive age. If it is confirmed that Zika can cause brain damage in older adults as well, we will have to amp up mosquito control and vaccine development efforts far beyond what we are currently doing. It will be impossible to keep everyone out of areas with Zika-infected mosquitoes.

This means Congress will have to stop dallying around and, perhaps, even come back from vacation early so they can pass a serious funding bill. This is not the time to play party politics; the consequences of an unchecked Zika epidemic are enormous. Zika containment should not be a red or blue issue. Mosquitoes don’t really care who they bite as long as they have blood.