jeudi 28 avril 2016

Senate Votes To Increase Smoking Age To 21 In Mass.

Senate Votes To Increase Smoking Age To 21 In Mass.

The Massachusetts Senate voted to raise the minimum age to buy tobacco products from 18 to 21. Signs like this one may need to change if the legislation makes it to the governor's desk. (Joe Difazio for WBUR)

The Massachusetts Senate voted to raise the minimum age to buy tobacco products from 18 to 21. Signs like this one may need to change if the legislation makes it to the governor’s desk. (Joe Difazio for WBUR)

The Massachusetts Senate voted 32 to 2 on Thursday to raise the state’s tobacco purchase age from 18 to 21, passing legislation that supporters said would cut down youth tobacco use and nicotine addiction.

The bill, compiled by the Joint Committee on Public Health based on several separate pieces of legislation, also bans pharmacies and health care institutions from selling tobacco products and prohibits the use of electronic cigarettes in places where smoking is already banned.

Sen. Jason Lewis, who co-chairs the Public Health Committee, said that about half of the state’s population lives in municipalities that have adopted local regulations setting 21 as the minimum age to purchase tobacco.

Lewis, a Winchester Democrat, said the three-year increase will help keep tobacco out of middle- and high-school social networks, making it harder for younger teens to get cigarettes and other tobacco products from their older peers.

The bill would also need approval from the House before heading to Gov. Charlie Baker’s desk. Baker has said he “conceptually” supports the smoking age increase but wants to see the specifics of any legislative proposal.

Weight Gain, Heart Disease, Back Pain: Longer Car Commutes May Harm Your Health

Weight Gain, Heart Disease, Back Pain: Longer Car Commutes May Harm Your Health

The worsening traffic in Boston -- or any metropolitan area -- does not just cost drivers time. It may also cost them health. Here's early afternoon bumper-to-bumper traffic on 93 in Milton (Jesse Costa/WBUR)

The worsening traffic in Boston — or any metropolitan area — does not just cost drivers time. It may also cost them health. Here’s early afternoon bumper-to-bumper traffic on 93 in Milton (Jesse Costa/WBUR)

Four years ago, Barbara Huntress-Rather got a great job, as director of quality improvement for a health care company that serves fragile seniors. Just one problem: She lived in Lawrence, and the new job was in Lynn.

“The first day I drove to work and said, ‘Oh, Lord, what have I done?’ ” she recalls. “After having a short commute for quite a few years, I hadn’t done the commute before in rush hour traffic and I was absolutely stunned at how long it took — it was over an hour.”

A harrowing hour, or more, hunched at the wheel, watching out constantly for aggressive or distracted drivers. In the months that followed, the effects on her health were dramatic: “I gained back 40 pounds that I had lost, developed low back pain and high blood pressure,” she says.

Huntress-Rather didn’t immediately blame her commute; she blamed herself for eating too much and feeling too tired to exercise. But she hit a turning point when her nurse practitioner told her she’d need blood pressure medication.

“I had always prided myself in being in good physical shape and meditating and doing all the things that would keep me from having high blood pressure,” she says. “And I immediately made the connection between not working out, spending endless hours in the car and feeling totally stressed most of the time. I was either commuting or worrying about commuting.”

Barbara Huntress-Rather found that her long commute led to weight gain, high blood pressure and back pain. She aims to retire soon and get her good health back. (Jesse Costa/WBUR)

Barbara Huntress-Rather found that her long commute led to weight gain, high blood pressure and back pain. She plans to retire earlier than she would have otherwise and get her good health back. (Jesse Costa/WBUR)

Huntress-Rather is practically a textbook case of what longer car commutes can do to bodies and minds. The evidence has been mounting in study after study in recent years, adding up to strong reason to believe that the worsening traffic in Boston — or any metropolitan area — does not just cost drivers time. It may also cost them health.

Let’s begin with the No. 1 killer of Americans: heart disease.

“You potentially have a triple whammy, where you’re piling on different cardiovascular stressors all tied back to the same root cause, commuting,” says Dr. Jonathan Levy, a professor of environmental health at the Boston University School of Public Health.

That triple whammy includes two effects of traffic that everybody already knows are bad for the heart: the stress, and the finding that people with longer commutes tend to exercise less.

The third piece is less obvious: “Air pollution has been tied to cardiovascular outcomes and sometimes acute outcomes — things like heart attacks,” Levy says.

Yes, German researchers have found that people who are prone to heart attacks become much likelier to actually have one within an hour of being in heavy traffic. Why isn’t exactly clear, but scientists say that air pollution appears to play a role — in particular, ultra-fine particulates, nano-sized airborne toxins whose levels tend to be highest around highways and in tunnels, especially in heavy traffic.

Professor Doug Brugge of Tufts Medical School, who studies particulates, says that though clean air laws have made heavy smog a thing of the past in the United States, these invisible, odorless particles are still a major health concern, particularly for people who live right near highways.

“Everyone thinks: air pollution — breathing in, lungs, respiratory disease,” he says. “But the particles also affect your circulatory system. They drive inflammation. And the main health outcomes — the largest, most tangible health outcomes — are actually cardiovascular: heart attacks and strokes.”

Tunnels — like Boston’s I-93, put underground by the Big Dig — can be particular hotspots for this localized air pollution. Tufts University researchers have found that by the time a motorist reaches the end of the 93 tunnel, the level of air pollution particulates may be 10 times as high as it is on the highway a couple of miles away. Those two or three minutes in the tunnel are likely to expose you to a higher concentration of air pollution than any other part of your day.

But professor John Durant, who oversaw that Tufts research, offers three simple remedies: Roll up the windows, turn on the air conditioner, and close the vents that bring in outside air.

“Those three measures,” he says, “will reduce exposures by a significant amount, by close to 90 to 95 percent.”

If only it were so simple to offset the other health risks of long car commutes. Here’s a sampling, from the last few years of research: Longer commutes may mean…

• more depression and anxiety;

• more social isolation;

• higher weight;

• lower life satisfaction and happiness;

• less sleep;

• less exercise, lower fitness;

• higher cholesterol;

• higher blood sugar;

• higher blood pressure;

• more back and neck aches.

• One Swedish study even found that people who commute more than 45 minutes each way are 40 percent likelier to get a divorce.

Most of these risks do not rise by very much, and many do have commonsense remedies — deep breathing and other stress relief techniques, for example, or conscious efforts to exercise more when not commuting.

And of course, the ultimate remedy is to drive less and switch to public transportation or “active commuting” — walking or biking. And for everyone to drive less.

But if you feel like you have to drive, you might want to do an informal, personal version of what’s called a Health Impact Assessment. That’s what Levy of BU and his team did in 2012, when the MBTA was planning service cuts and fare hikes aimed at saving about $160 million.

Levy’s team calculated roughly what the cuts would cost in health and time if they made people drive more — everything from added air pollution to less exercise. Their conclusion: Trying to save $160 million could cost $300 or $400 million.

Our commuter, Huntress-Rather, did her own math and made a radical decision. She really likes her job, and had planned to work until she was 70. But instead, she’s taking a financial hit and planning to retire at just 65. She’ll live near the beach, where she can take long walks. The last day of her long commute is coming very soon.

“May 25!” she says with an audible sigh of relief.

She decided that getting home so tired every day that all she can do is numb out by binge-watching brainless reruns is no way to live.

“I just felt like time was slipping away, and I wasn’t enjoying it,” she says. “I don’t enjoy sitting in a car, not moving. I had to do it.”

She’s going to start working out again, she says, and get her good health back.

Tips For A Healthier Commute

It’s become a whole little genre: headlines that warn, “Your commute is killing you!”

Dr. Edward Phillips, director of Harvard Medical School’s Institute of Lifestyle Medicine, says he’d never say that to a patient. But he would tell them that longer car commutes are linked to higher weight and less happiness. “[And] I would tell them to take any other option for a more active commute, including walking, biking, use of mass transit.”

1. Consider a ‘hybrid commute’

“Even if you’re saddled with a long car commute, look for maybe a hybrid commute,” Phillips says. ‘I’m not talking about driving a hybrid. I’m talking about combining driving with mass transit, or parking a little further from your office, maybe in a cheaper spot. Pick up some extra steps in the morning; and you’ve got to get back to your car in the afternoon.

“While you’re at it, add some steps during the workday, break up that continuous sitting, and overcome the deleterious effects of a long commute.”

2. Avoid air pollution

As professors Brugge and Durant explain above, air pollution particles tend to be found in particularly high concentrations in poorly ventilated tunnels and where traffic is high. Durant suggests three preventive measures for tunnels: Close the windows, turn off the vents and turn on the air conditioner.

His other tips: Buy a lighter car that burns less fuel, and hope everyone else does, too. Shorten your commute by driving at a less busy time, or take less crowded roadways (though that may add time.) Avoid spikes of air pollution exposure, such as in tunnels and at busy intersections.

3. Cut stress

Glaringly obvious but so seldom acted upon: If you leave earlier, the trip will be less stressful.

Otherwise, on the mind-body front, this MSNBC post headlined “5 ways to keep your commute from killing you” (See? It’s a whole genre!) offers some tricks of emotional engineering to cope with the lovely gamut of daily commuting emotions, from rage to despair over lost time.

Some sound easier said than done, though. Like: “Reframe your thinking, and instead of letting anger over traffic or aggressive drivers make you act the same way, use this ‘downtime’ in a positive, productive way.”

Bottom line: Fill your commuting time with good content (preferably from your favorite purveyor of public radio, of course.)

4. The new smoking? 

Confession: I knew commuting was often tedious or stressful, but I’m struck by the multitude of health harms that researchers have found. In many cases a longish commute adds only a few percentage points to your risk; for example, a Gallup poll found that 20 percent of people who commute under 10 minutes have high cholesterol, compared with 27 percent of people who commute over 90 minutes. Among those super-short commuters, 24 percent were obese, compared with 30 percent of super-long commuters.

But across the many aspects of mental and physical health affected by commuting, the percentage points add up. Raising the question: Should we see long commuting as a health risk a little like smoking? It’s surely not as harmful, but if “sitting is the new smoking,” couldn’t commuting be as well? And could awareness of those risks help spur even healthier behavior while not in the car?

5. Big picture: Try everything

Ask experts for tips on what you can do at the individual level and the discussion inevitably expands to the big picture.

Brugge of Tufts says that health-conscious commuters might want to support advocacy for more and better public transportation and “active transportation” — biking and walking.

The air pollution from vehicles, he says, is a public health problem on a par with obesity and smoking, “the other major public health problems of our time — but somehow it is not as well recognized,” though it’s estimated to lead to 100,000 American deaths per year.

“I think you have to pursue an issue like this from every direction you can,” he says. “You can encourage public transportation and active transportation. You can encourage cars that are cleaner. You can encourage — as in Somerville — protection in buildings near highways that reduces exposure inside buildings. Even at a very individual level, you can roll up windows and turn off the outside air vents in your car as you go through a tunnel and when you’re in heavy traffic.

“I don’t think you privilege one of those things and say, ‘This is it.’ I think you pursue all of them and over time, you hope some of them –like cleaner vehicles and better public transportation — make some progress. And enough of them make progress that there’s substantial change.”

Readers, reactions? Tips? Did health effects persuade you to change your commute? 


mercredi 27 avril 2016

Buffets One Day, Vomiting The Next — Life With A Rare GI Disease

Buffets One Day, Vomiting The Next — Life With A Rare GI Disease

Melissa Adams Van Houten was diagnosed with a rare GI disorder in 2014. (Courtesy)

Melissa Adams Van Houten was diagnosed with a rare GI disorder in 2014. (Courtesy)

I am going to share some pretty personal information. Not a big deal to some of you, I am sure, but to me, it is huge. I am not the kind of person who does this — or at least I did not used to be. But things have changed.

In February of 2014, I spent a week in the hospital and was eventually diagnosed with gastroparesis, a disorder that slows or stops food from moving from the stomach to the small intestine.

I am guessing most people have never heard of this; I know I had not, prior to being diagnosed.

A Life-Altering Day

My life changed in ways I could not have imagined — overnight.

One day, I was able to eat at buffets, and the next day, I was unable to tolerate all foods and liquids. I was hospitalized with severe pain and vomiting, put through a battery of tests (including one particularly terrible one where they forced a tube down my nose and pumped my stomach). Eventually, I was diagnosed, but was given only a brief explanation of my illness and its treatment before I was sent home.

For the next few weeks, I was on a liquids-only diet, and was told that I had to gradually work my way up to soft foods and (eventually) solids. I am able to eat some soft foods, these days, in tiny amounts, but it is becoming clear to me that I will likely never again be able to eat “normal” foods in “normal” amounts.

Thinking About Food — Always

At first, I told myself that I would not let this stupid disease define or control me — it simply would not be the center of my life. But as time passed, I began to see how foolish this was. Every single day, every second of every day, I think about food. I see it; I smell it; I cook it and feed it to the other members of my household; but I cannot have it myself.

I look in the mirror, and I see a skeleton. I try to eat even small amounts of food, and I am in agony. I am weak and fatigued to levels I did not think were possible. Some mornings, I do not think I have enough energy to get out of bed. I can barely concentrate and function enough to do everyday tasks. And almost every single night, my husband has to help me up the stairs to bed because he is afraid that if he does not, I might fall.

My 11-year-old daughter has seen me vomiting, screaming in pain, lying on the floor crying, and on the verge of passing out. It has frightened her so much that she has asked my husband to get me Life Alert.

What I Miss

I grieve over the fact that I can no longer travel or get out of the house much. I grieve over missing family events and not being able to attend my daughter’s activities. I grieve over not being able to go out to eat, or on a picnic, or to a concert. I worry that I will not get to see my daughter graduate, or get married, or have children. I am not on the verge of death today (at least, I don’t think I am), but when I look in the mirror and think about how tired I am, I realize that people like this do not have long life spans — and it bothers me.

I get frustrated because people do not understand how my life is affected by all of this. If you were to see me on the street, you would likely not realize I am sick. I do not look very sick. And because most people are unaware of the effects of gastroparesis, they ask me all of the time if I am OK now. I can’t seem to convince them that I am never going to be okay again — not in the way they mean it.

I am told that I “just need to eat,” or that if I would only try yogurt, I would be OK. My own doctor accused me of being an anorexic and told my husband to “watch me.” Though I know people mean well and are trying their best to help, it still makes me frustrated.

What You Should Know

Here are a few things I wish people understood about this disorder:

1. It affects people emotionally and mentally, perhaps even more so than physically. This is a lifelong illness that patients have to cope with — always. The resulting lifestyle changes and isolation can be difficult to manage. The seriousness of this condition was not impressed upon me at the time of my release from the hospital, and I could not properly prepare for it mentally.

2. There are very few treatment options available and the few that do exist come with serious risks and side effects.

3. It often takes years to get a diagnosis, and even then, many doctors have never heard of this condition and do not know how to treat it. Specialists are few and far between.

4. Although it can be challenging, there is help available in the form of support groups, non-profits and advocacy groups. Don’t face this alone.

5. The complications resulting from this disease (such as malnutrition, dehydration and infections) are often serious and can and do sometimes lead to death.

6. I wish people living with this disease knew that they had a right to speak up for themselves and should not have to apologize for being ill. Gastroparesis imposes many limitations upon us, but this is not our fault, nor is it something over which we should feel guilt. We should expect and demand that others respect our struggle, and we should forgive ourselves for perceived “failings” over which we have no control.

Still, It Could Be Worse

I am angry because I am a control freak, and I do not like being a slave to this disease. I do not like having to rely on others for help. I have screamed at, smacked and pushed my husband away for simply trying to assist me more times than I can count. I have thrown things (including food) across the room in fits of anger. I have intentionally gone without eating — even though I know I should not — just to “show” this disease who is in control. Crazy, I know! I am angry because I do everything that I am supposed to do — eat the right things, exercise and ingest the known medications — and I am still sick.

I think about the others who have this disease who are so much worse than I am. There are thousands of posts in my Facebook feed every day from people who have had to go to the ER or back in the hospital for dehydration, pain or other such conditions. I know so many people now who have feeding tubes or ports for nutrition. I know many who have developed other serious conditions because of the gastroparesis. I sometimes look at them and think that this will surely be my future, too, and it scares me. There are times when I am in such agony that I can do nothing but cry — lie on the floor and beg God to just let me die. He does not — and I am so thankful that he ignores those moments.

I mostly have a good attitude about my situation and try to make the best of it. I feel blessed that I have been given so many years with the best husband and daughter anyone could imagine. I am truly thankful for each day I get to spend with them.

Sharing The Burden

What I do understand is that it is somehow important to me to let people know what I go through — what all people with this disorder are likely to go through.

I share these personal details because I think it is important for people to better understand this disease. But I think it is equally important to share how much I have been blessed, and to let others know how much they matter and how much of a difference they can make.

I first joined a Facebook support group because I wanted to know what treatments and medications others like me had found helpful — but I hated the idea of support groups. I was there for information only; I just knew I did not need anything like support. Not for me! So foolish! You cannot imagine the blessing these online groups have been.

I have learned much, for sure, but I have received so much more than information. I have received more support, understanding and kindness than I ever could have dreamed. I have made friends that I feel I have known for a lifetime. I tell people all of the time that I hate this disease, but I dearly love all the people I have met because of it.

My neighbors have cooked meals for my husband and daughter; they have watched my child and my pets; and they have offered to transport me to and from appointments. My family has come to visit me, even though I know it is horribly inconvenient for them — and they have also stayed away when I have asked them to.

Do not ever be convinced that you can do nothing to help, that you do not matter. To those who are struggling, your efforts to understand, your cheerful words, your helpful attitude and simply your willingness to contribute and be present, make a difference.

Melissa Adams Van Houten is a wife and mother who was diagnosed with gastroparesis in 2014. She now advocates for others stricken with this life-altering illness. 

A version of this story first appeared at Health Story Collaborative.

mardi 26 avril 2016

At Least 40 Students With Mumps, Harvard Reports

At Least 40 Students With Mumps, Harvard Reports

Harvard University's campus in Cambridge, Mass. Several students have recently been diagnosed with the mumps. (Elise Amendola/AP)

Harvard University’s campus in Cambridge, Mass. Several students have recently been diagnosed with the mumps. (Elise Amendola/AP)

Harvard University officials report 40 cases of mumps at the school.

Lindsey Baker, spokeswoman for Harvard University Health Services, said six of those cases were reported on Friday.

Baker said health officials at the school are worried there could be an even larger outbreak before commencement next month, because the virus lies dormant for two to three weeks after a person is exposed.

Since the illness is quite contagious, students who have tested positive for mumps are put into isolation for five days, she explained.

At least 12 students are in isolation as of Tuesday for suspected or confirmed infections in the wake of the outbreak.

vendredi 22 avril 2016

A Death And A Changed Life: Traumatic Births Take Toll On Health Workers Too

A Death, And A ‘Changed Life’: Traumatic Births Take Toll On Health Workers Too

Sarah Jagger and midwife Stephanie Avila were together when Jagger's son suffered a brain injury during labor that led to his death. Here, about a year later, in 2013, Jagger and Avila share a moment of gratitude after the safe arrival of a healthy baby girl. (Courtesy of Orchard Cove Photography)

Sarah Jagger and midwife Stephanie Avila were together when Jagger’s son suffered a brain injury during labor that led to his death. Here, about a year later, in 2013, Jagger and Avila share a moment of gratitude after the safe arrival of a healthy baby girl. (Courtesy of Orchard Cove Photography)

Everything seemed fine until the little boy was born.

He wasn’t breathing, but his heart was strong, recalled Stephanie Avila, the midwife attending the baby’s birth at a Rhode Island hospital back in 2012. But it soon became clear that the boy had suffered a brain injury during labor.

Eleven days later, after an MRI confirmed the severity of the injury and the family withdrew life-support, the child died. His official diagnosis: hypoxic ischemic encephalopathy, a brain injury caused by oxygen deprivation.

“I was prepared to stand by the family through this trauma,” Avila said in an interview. “But I fully expected I’d get sued — and it was going to get ugly, or uglier.”

Of course, the little boy’s family was devastated. “I just went into my own world,” said his mother, Sarah Jagger, speaking about the loss of her son.

But Avila suffered too. “I was a wreck,” she said.

Immediately after the birth, Avila said, she remained on call overnight at the hospital, Women & Infants, in Providence. “I retreated to the call room and curled up in the fetal position and prayed that no other people in labor would show up. I cried, had the worst headache I’ve ever had in my life, and felt like I’d vomit. For days I felt emotionally and physically terrible. I’d be walking down the street and suddenly could no longer move.”

At the time, Avila had two small children of her own. “And whenever my 2-year-old would do this cute thing, I’d think, their baby will never walk around in his mother’s high-heeled shoes. I’d get these terrible thoughts and I’d never know when it would strike.”

The Psychological Toll

After a traumatic birth — or any traumatic medical event — attention, rightly, turns to the grieving family. But research has been mounting in recent years that health care providers, sometimes called “the second victims,” also sustain long-lasting emotional damage following such a trauma.

A new study published by Danish researchers underscores the phenomena: Midwives and obstetricians who experienced a traumatic birth — one involving severe injuries or death — report that the psychological toll of such an event is deep and long-lasting.

More than one third of those surveyed said that they always would feel some sort of guilt when reflecting on the event, researchers report. Nearly 50 percent agreed that the traumatic birth had made them think more about the meaning of life. “This tells us that health care professionals are affected, not only professionally, but also at a personal and even existential level,” said Katja Schrøder, the study’s first author and a Ph.D. fellow at the University of Southern Denmark.

‘Changed My Life Forever’

This was indeed the case for Avila. “I feel as though that day — even to this day — changed my life forever in many ways,” she said. And while the “acute” nature of the trauma has passed, she said, the enormity of it continued to grip her, sometimes unexpectedly and at random times.

In the Danish study, published in Acta Obstetricia et Gynecologica Scandinavica, a journal of the Nordic Federation of Societies of Obstetrics and Gynecology, more than 1,200 Danish obstetricians and midwives responded to a survey on the aftermath of a traumatic birth. Of those respondents, 14 were selected for a followup interview.

Many of the providers spoke of not being able to shake the trauma, whether they were blamed for the bad outcome or not. “Although blame from patients, peers or official authorities was feared (and sometimes experienced), the inner struggles with guilt and existential considerations were dominant,” researchers report.

From the paper:

One mid-wife explained that even now, 12 years after the event, she would still think about that particular mother and child when passing through their town…

Most participants described having spent many hours agonizing and wondering whether they could have prevented the adverse outcome. One midwife said that her sense of guilt would never disappear because she knew that the parents would have to live with the consequences of her handling of the delivery.

Still, the researchers found that for many providers, “the traumatic childbirth had given rise to personal development opportunities of an emotional and/or spiritual character …for instance by achieving a more humble and profound understanding of both professional roles and of life as a whole.”

A Meaningful Meal

About a month after her infant son’s death, Jagger did something unusual: She asked Avila to meet for lunch. Up until then, the two women had been in touch — Avila had called to check in often, offering to help out and attend followup medical appointments with Jagger.

But the lunch date marked a turning point, the women agreed. First, it became clear that Jagger didn’t blame Avila for the boy’s death, and did not want to focus on the tragedy going forward.

“We had this little boy who had a such a short life,” Jagger said. “I didn’t want his life to be clouded in anger. I wanted his life to be about love…and not focus on the horrible part.”

But the meeting also underscored the growing bond between the women. When it was over, they walked outside and Jagger posed a question: “I said to her, ‘If I have another baby, would you deliver it?’ And I think she was horrified. But I think because I trusted her so completely, through the birth, and his death, and her calls and the followup, I felt like she was there with me, like this was our loss, it wasn’t just my loss.”

The Danish research paper quotes Donald Berwick, a pediatrician who served in the Obama administration and is also a patient safety guru of sorts. In a 2009 interview published in the Journal of Patient Safety, Berwick speaks about those “second victims”:

Health care workers’ egos can be big. But believe me, their superegos are a lot bigger. You carry into work — as a nurse, or doctor, or a technician or pharmacist– the intent to do well. And when something goes wrong, almost always you feel guilty, terribly guilty. The very thing you didn’t want to happen is exactly what happened. And if you don’t understand how things work, you feel like you caused it. That creates a victim. My heart goes out to the injured patient and family, of course. That’s the first and most important victim. But health care workers who get wrapped up in error and injury, as almost all someday will, get seriously hurt too. And if we’re really healers, then we have a job of healing them too. That’s part of the job. It’s not an elective issue, it’s an ethical issue.

In the past decade or so, various institutions and nonprofits have emerged with tools and systems to better support medical professionals who have endured a traumatic event.

One of those groups, MITSS, or Medically Induced Trauma Support Services, based in Massachusetts, provides trauma tool kits used around the country.

Linda Kenney, the founder of MITSS, was herself the victim of an anesthesia error that nearly killed her. She said that for her, connecting with the anesthesiologist who caused her injury (he called her afterwards to express his regrets) and creating the nonprofit to help others, helped her heal.

But for health care providers, sometimes talking to peers at a hospital, or others in the institution, isn’t enough and can actually feel isolating, Avila, the Rhode Island midwife, said. Because of the omnipresent fear of lawsuits, and also due to patient privacy laws, she said, “there are very few environments where we can freely discuss what happened.”

A Second Chance

In 2013, a few days shy of what would have been her son’s first birthday, Jagger went into labor with her second child, and she called on Avila to attend the birth. By that time, Avila was no longer working for the same midwifery group, but the practice arranged for her to have insurance during the birth, and Avila left a family gathering on Block Island to get to Providence on time.

Jagger’s little girl is now a healthy 2-and-a-half-year-old who considers Avlia her “auntie.”

“It was this amazingly cathartic experience for all of us,” Jagger said.

Avila is now a family nurse practitioner and attends births less frequently as part of her work. These days, she and Jagger are extremely close: They’ve vacationed together, bake each other birthday cakes and talk almost daily.

“I never would have expected our relationship to evolve to this point,” Avila said. “But despite how close we are now, I would sacrifice it in a moment if I could change the outcome of that first birth.”


jeudi 21 avril 2016

When Doctors Encounter Human Trafficking: What To Look For

When Doctors Encounter Human Trafficking: What To Look For

(Ira Gelb/Flickr)

(Ira Gelb/Flickr)

It was 2 a.m. on a typically hectic Friday overnight shift in the emergency department.

A young woman, Kelly, checked into triage, accompanied by her older boyfriend Jim, who explained that Kelly had abdominal pain and some vaginal bleeding. Jim wanted her checked out and maybe some pain medicine to help her rest at home.

Kelly had no identification. She appeared younger than her stated age of 18. I also noticed track marks punctuating both of her arms — a sign of IV drug use. She immediately looked to Jim after answering all my questions.

If this sounds suspicious, that’s because it is. While clinicians are trained to address Kelly’s medical ailment, many of us fail to recognize the larger social cues right in front of us. It appears that Jim is in control of the situation. Kelly is young, maybe very young. As a clinician I must consider Kelly’s living situation, and her relationship with Jim.

As emergency care providers, it is standard practice for us to separate patients from their visitors long enough to at least ask about domestic violence. And for most of us, that would likely be the first concern in this case. But Kelly is actually a victim of human trafficking.

By definition, human trafficking, sometimes referred to as modern day slavery, is the recruitment, transportation and harboring of persons by means of force, fraud, coercion or deception. And while many assume trafficking is the movement of people across international borders, in reality many victims never leave their hometowns.

Victims are found in domestic service, nail salons, massage parlors, restaurants, the sex trade, as well as farm and factory work. Few people realize the Northeast is one of the nation’s human trafficking hot spots. We have seen the magnitude of the problem in our region further compounded by the opioid epidemic.

Several studies show that most trafficking victims receive medical care while being trafficked, with the majority showing up in the ER. We expect emergency providers to recognize and address many public health ills, and the time has come to add human trafficking to the list.

Identifying Cases, And The Physical Signs

Unfortunately, most of us on the front lines lack the training to even recognize the signs of trafficking — let alone what to do when a case is confirmed.

Part of the challenge in identifying cases is that they all look different. On Monday, I could see a foreign-born woman or girl being sexually exploited. Tuesday, it could be a man working as a domestic servant who grew up in the area.

Force, fraud, coercion and deception obviously can take a variety of forms, and health care providers must learn to think more broadly than most of us do today. Going back to Kelly’s situation, there were several opportunities to ask questions to get a sense of her daily life.

It could have been something as simple as, “How do you pay for your drugs?” Working in emergency departments around Boston, we encounter patients struggling with heroin addiction often — sometimes several times in a shift. Finding out how they get their drugs may open up a broader conversation about whether this person in your exam room is trapped, forced to do something he or she doesn’t want to do.

We must train ourselves to notice the nuanced clues of exploitation on our patient’s bodies. Signs of trafficking can be subtle, such as track marks from heroin use, or more obvious, such as facial hematomas from being pistol whipped while raped.

In addition to signs of physical violence and STDs, trafficked patients may have chronic infections, dehydration, malnutrition and the stigmata of trauma and psychological stress.

The Response

I have never met a patient who called himself a victim of human trafficking. As with victims of domestic violence, many may not acknowledge the true nature of their situation. The sense of shame they feel is profound. And many decline intervention or services. The goal for us as health care providers is not rescue. First and foremost, we need to communicate that the health care setting is a safe place for them to seek help when they do want it, and to ensure — with the support of our hospitals and departments — that it actually is. Whenever possible, involving our social worker colleagues can help us navigate potential options for these complex patients.

The response to children, it should be noted, is unique. In Massachusetts, and in many other states, suspected child victims of human trafficking must be reported to the Department of Children and Families. In Massachusetts, that report will trigger a multidisciplinary team response to help meet the trafficked child’s needs.

Providers and victims should utilize the National Human Trafficking Resource Center Hotline. This hotline is meant as a resource to both victims themselves, and for health workers and others looking for support in helping potential victims. The hotline can advise providers and their patients on local resources such as shelter, and provide continued guidance through the process.

We encourage our colleagues in health care, particularly in emergency departments around the region, to be vigilant for the trafficking victims that come through our doors. Human trafficking is an egregious form of suffering that health care providers are only starting to grapple with recognizing and addressing. Clinicians should know that support is there, for their victims and for them, as they continue to serve the most vulnerable and exploited people in our society.

More Resources

The National Human Trafficking Resource Center recently published three resources for health care professionals about human trafficking:

Or you can join other public health professionals combating trafficking through HEAL Trafficking, a national network of professionals improving the public health response to trafficking.

Editor’s Note: The names used in this story are not the real names of the individuals involved.

Laura Janneck is an emergency medicine physician at the Cambridge Health Alliance. Hanni Stoklosa is an emergency physician at Brigham and Women’s Hospital, Harvard Medical School and executive director of HEAL Trafficking.


mercredi 20 avril 2016

Narrating Medicine: The Long Lasting Impact Of Child Abuse

Narrating Medicine: The Long Lasting Impact Of Child Abuse

One day when we were in first grade and sitting on a rickety wooden bench under a large oak tree in her backyard, my best friend’s mother called her to come inside.

A few minutes later, I heard wailing like an animal being gutted. Squinting my eyes and looking perplexed, I turned to my friend’s younger sister who was sitting beside me. She whispered, “She’s just getting beat.” Beat? What’s that, I wondered. She explained. Depending on the severity of their perceived wrongdoings, they were administered one of three levels of physical punishment: a stick, a belt or a big slab of wood. Their parents had moved from Ireland to our small suburb in New Jersey.

The Catholic schools the parents had attended as children in Ireland were very strict and the nuns reportedly beat them until their knuckles bled. Here, as parents in New Jersey, they told their daughters to strip naked and mercilessly receive corporal punishment. (I learned this from her sister, and over the years, from my friend.)

This was not a onetime event. These were repeated, deliberate acts.

The occurrences did not seem to have predictable patterns, so my friend, I’ll call her Heather, couldn’t prepare herself for them. And the negative psychological effects for her were deep. Over time, Heather became highly anxious, constantly got in trouble at school, and started a pattern of severe substance misuse that led to even further problems, particularly violations at the hands of men and boys.

Sadly the intentional violence Heather experienced as a child and throughout her adolescence is not an anomaly. Physical abuse is in fact the second most common form of child maltreatment, impacting more than 15 percent of all children living in the U.S. per year.

This despite 40 years of the Child Abuse Prevention and Treatment Act, the first federal child protection legislation to assist in prevention, identification and treatment of child abuse and neglect. This despite another April being another National Child Abuse Prevention Month.

As a trauma psychologist on faculty at Yale, I’m very familiar with the research on and treatment of child abuse. These kinds of repetitive interpersonal damages place a child at greater risk for not only a host of mental health disorders — depression, post-traumatic stress disorder and substance misuse — but also for further abuse in adulthood. Often referred to as re-victimization, this means that people who have already been hurt can get hurt again and again.

There are several hypotheses on why re-victimization happens. Children come to view themselves as “damaged goods” who don’t deserve or shouldn’t expect better. Abused children aren’t able to recognize safe from unsafe people, and if they do, they don’t have the internal or external resources to protect themselves from danger.

In a recently published study, a team of researchers from the University of Washington found that substance misuse, particularly blackout drinking, predicted incapacitated sexual re-victimization.

And that is exactly what happened to Heather.

The phone calls would always come. “Pick me up,” she’d say, and out I would hobble from bed on weekend mornings during high school and go to a local motel to get my best friend. Hi-Ho, Red Roof Inn, Howard Johnson’s — the string of cheap motels lined Highway 1 in Central Jersey.

Heather would party all night, binge drinking alcohol and doing any drug she could get her hands on. Her drug of choice was “boat,” a mixture of pot, embalming fluid and animal tranquilizer. But the relief from the child abuse she was suffering at home was only temporary. The hole within her could not be repaired in this way, though I didn’t tell her that at the time because I didn’t know either. At the time I thought I was being a good friend. Pick her up, take her home, never give a word of advice or caution — just consistency, concern and love.

Heather’s binge drinking and drugging often resulted in blackouts. Attempting to anesthetize herself, she would not remember large stretches of time and would be unaware of her surroundings. During one of these blackouts she was allegedly raped by a group of boys who went to a local public high school. From that point until well into her 40s, her drinking and self-loathing got worse.

The pain reverberated throughout her life. She had difficulties finding and sustaining relationships with men and friendships with women. She never graduated college, married or had children. Although an incredibly smart, kind, quick witted individual, she didn’t get a chance to reach her fullest potential. She was unable to let her light shine. Instead, she struggled with the demons of repeated multiple assaults on her soul. She spent many years in psychotherapy trying to rebuild her self-esteem and decrease her depressed mood. And at for least 20 years she has moved in and out of AA.

But the optimal point of intervention for Heather and the thousands of adults who live with the consequences of severe and prolonged childhood abuse and subsequent re-victimization would have been years before. Early intervention is what’s effective.

It is clear to me, and I hope to you, that we need not just national awareness this April, and every month; we need personal awareness.

Joan M. Cook Ph.D. is an associate professor in the Yale School of Medicine Department of Psychiatry, an Op-Ed Public Voices Fellow and president of the American Psychological Association’s Division of Trauma Psychology.

mardi 19 avril 2016

Study Tracks Yik Yak App To Learn More About College Drinking And Drug Use

Study Tracks Yik Yak App To Learn More About College Drinking And Drug Use

The Yik Yak app, lower left, is seen on an iPhone on Nov. 11, 2015. (Ronald Lizik/AP)

The Yik Yak app, lower left, is seen on an iPhone on Nov. 11, 2015. (Ronald Lizik/AP)

Consider this message, most likely posted by a college student in or around Brandeis University near Boston: “I just remembered I have a 4loko in my minifridge. Guess who’s getting sloppy day drunk tomorrow!”

Good luck finding the Four Loko fanatic. The post is from Yik Yak, an anonymous, free social media platform popular on college campuses.

Even so, a recent study analyzing Yik Yak posts gathered from 120 campuses suggests that tracking these messages does have an upside: Public health experts say it may ultimately help them learn more about issues like alcohol and substance use.

Over the span of one month, researchers at Johns Hopkins University and the University of Colorado at Boulder found 2,047 health-related yaks — the term for posts on Yik Yak — dealing with themes like smoking, drinking and drug use.

“Because it’s anonymous, people disclose things about themselves that they might not publicly post, either on Twitter or even necessarily to their doctors,” said Michael Paul, an assistant professor and founder of the Information Science Department at UC Boulder,  in an interview.

While big data collected from social media has been used to study public health, such as influenza surveillance through Google search queries and Twitter, the field is relatively new and Paul’s study is the first to look at public health using Yik Yak.


After collecting original data from the posts (they are public on the app) and replies within a five-mile radius of university campuses, the researchers used specific word clusters to sift through topics discussed on Yik Yak. Nearly 20 percent of those posts related to health, including alcohol consumption, tobacco smoking and illicit drug use.

To further drill down into the language used when discussing substances, the researchers coded a sample of 500 posts, assigning a category of either substance use, solicitation, social groups, addiction or information-seeking.

Tobacco aggregated the most posts tied to addiction, represented by yaks such as this: “It’s a funny realization when you realize that you’ll just never quit smoking cigarettes.”

The most commonly discussed substance was marijuana (“Anyone want to smoke? I got the weed and now I want some company”), with 117 standalone yaks (posts only about marijuana) and more than nine poly-substance use yaks (posts about marijuana and another drug).

“With Yik Yak, we were looking at patterns in substance use which are in some cases not at all monitored by existing government systems,” Paul said. “There aren’t necessarily large-scale official surveys on, say, attitudes towards tobacco or e-cigarettes, or monitoring for new drugs like bath salts, or if it does happen it can take literally years for official government resources to catch up.”

Studies like this one fill in the gaps. The federal government’s national survey on substance use is expensive and labor-intensive. Responses are collected over  a year from phone calls to landlines and door-to-door visits, and it takes an additional year to analyze and put out the results.

This two-year lag is compounded by the fact that the questions themselves were developed in a health context that has inevitably changed in that time, and inherently reveal less fruitful data on personal information, Paul says. Research using big data is inexpensive, uncovers rich data, and is the most equipped at reporting on the most contemporary trends, such as the use of e-cigarettes, bath salts and synthetic adenoids.

But there are certainly drawbacks to an approach that casts a wide net on social media. Critics point out, for example, that not everyone is on Yik Yak or Twitter, and those that are might not be sharing truthful information.

Paul agrees with these confounding elements.

“There are a lot of factors that can definitely influence the results,” he said. “Sarcasm and joking — that alone is a really big challenge.” Some attention-seeking posters might not have in fact used methamphetamine, even though they’ve Yak’ed about it.

Plus, anonymity prevents confirmation of associations between geographical location and a cohort. For instance, a non-college student’s yak could be included in the mix of posts if the individual is within the five-mile radius of a message location on a college campus. Demographic properties within that cohort, such as gender, also could not consequently be correlated with particular findings.

There are implicit trade-offs when using social media platforms to analyze public health issues.

Clearly, they can’t replace nationwide surveillance efforts by agencies like the Centers for Disease Control and Prevention. “But this may or may not matter,” according to Paul; beyond the notion of new study instruments displacing the old, he says the two schools of thought complement each other and have a symbiotic relationship.

Paul wants to continue peering into real-time conversations on social media platforms such as Twitter and Yik Yak to bolster traditional nationwide studies, standardize analysis of online public health messaging, and perhaps even catch new illicit substances coming onto the scene.

“If our goal is just to identify, say, a new drug, then sure epidemiologists would like to know who is using it,” Paul said. “It’s still useful to know.”

Madeline Rosenberg is a freelance journalist covering science, health, and society, and is graduating in May from Brandeis University with degrees in Public Health and Environmental Studies.


Simmons College Course Prepares Future Social Workers To Address Suicide

Simmons College Course Prepares Future Social Workers To Address Suicide

Justin Marotta, right, takes his oral mid-term exam for his course -- "Understanding Suicide: Prevention, Intervention, and Postvention" -- at the Simmons College School of Social Work. Laura Goodman, left, role-plays as the client, as instructor Kate O'Brien observes. (Jesse Costa/WBUR)

Justin Marotta, right, takes his oral mid-term exam for his course — “Understanding Suicide: Prevention, Intervention, and Postvention” — at the Simmons College School of Social Work. Laura Goodman, left, role-plays as the client, as instructor Kate O’Brien observes. (Jesse Costa/WBUR)

In a conference room at Simmons College, two young adults sit across from each other at a table. One of them is sharing details of a very personal mental health struggle.

“I was on the inpatient unit for like a week or so,” the woman says. “My parents brought me into the emergency room because I was pretty depressed and was, like, cutting myself with a scissor.”

It isn’t a real counseling session. It’s a mid-term exam.

Laura Goodman and Justin Marotta are second-year students working toward master’s degrees in social work at Simmons. They’ve been learning how to determine whether a client is suicidal and how to respond. They found out early in this course to come right out and ask clients whether they’re thinking about suicide or have a suicide plan in place.

The mock therapy sessions allow the students to show their professors how comfortable they are having that conversation.

“So when you were cutting yourself and you were brought to inpatient, was the idea to try and kill yourself?” Marotta, acting as the social worker, asks.

“I think yeah, that time it was,” Goodman, who’s acting as the client, responds. “I cut a lot and I have thoughts of suicide a lot.”

When the 10-minute exam is over, Marotta realizes he didn’t ask his mock client about any access to guns.

“I knew the whole time. I just wanted to find an appropriate way,” he tells assistant professor Kim O’Brien.

O’Brien has taught students it’s crucial to ask that question, because having a gun in the home increases the risk of suicide. But she understands the conversation is nuanced and takes time. She tells Marotta he should have also asked the client about use of alcohol or drugs.

‘There’s A Lot Of Fear And Panic’

When O’Brien received her master’s degree in social work (MSW), she says she didn’t feel adequately trained to work with suicidal clients. She went on to receive training while working at Boston Children’s Hospital. But she wasn’t alone in feeling unprepared.

Surveys have found most MSW students receive four or fewer hours of instruction in suicide prevention and intervention. Most other medical and mental health professionals also don’t receive advanced training.

“I would say it’s a huge problem,” says Joanna Almeida, who’s also an assistant professor of social work at Simmons.

With a doctorate in public health and an MSW, she comes at suicide prevention from both angles.

“I knew that there wasn’t a class dedicated exclusively to suicide here at Simmons, and I thought that was a gap in the curriculum,” Almeida says.

She and O’Brien developed the course, “Understanding Suicide: Prevention, Intervention, and Postvention.” Simmons offered it for the first time last spring. It’s the first course of its kind at any Massachusetts college, and only a handful of schools around the country offer similar courses.

Almeida says students were shocked to learn the epidemiology of suicide. It kills more people than homicide or car crashes. There were more than 42,000 suicides in the United States in 2014. It’s the 10th-leading cause of death overall, but the second-leading cause of death for those 10 to 34 years old, according to the Centers for Disease Control and Prevention.

Research has found lack of expertise among social work faculty is one reason there aren’t more courses nationally to train clinicians in suicide prevention. Almeida believes the failure to teach it also stems from the same stigma that surrounds the issue in general. And there are ramifications.

“It means that there’s a lot of referring to the emergency room because clinicians don’t feel confident in their skills and ability to handle a suicide assessment,” Almeida explains. “There’s a lot of fear and panic that happens when they’re told that they have a client who is suicidal.”

The state Department of Public Health, which also sponsors courses to train clinicians in suicide prevention, notified other social work schools in the state about the Simmons course.

Simmons is sharing the curriculum with any school in the U.S. that wants to offer it. Salem State University will begin offering the class this summer. The University of New Hampshire and the University of Kentucky have adopted the class, and others have expressed interest.

‘Our Goal In Our Work Should Be Zero Suicides’

Justin Marotta, left, role-plays as the client as part of Emily Walcott's mid-term exam for the "Understanding Suicide: Prevention, Intervention and Postvention" course at the Simmons College School of Social Work. (Jesse Costa/WBUR)

Justin Marotta, left, role-plays as the client as part of Emily Walcott’s mid-term exam for the “Understanding Suicide: Prevention, Intervention and Postvention” course at the Simmons College School of Social Work. (Jesse Costa/WBUR)

In one session of the class, visiting instructor Laika Aguinaldo teaches the students specific methods of intervening to prevent suicide.

She tells the students about an experience in which she asked a suicidal client to make a visual art piece highlighting the client’s reasons for living.

A student asks Aguinaldo what tipped her off that she needed to do that kind of intervention.

“My issue with this client in particular was that this is her first time disclosing the suicidality to anybody,” Aguinaldo explains. “When she went to the emergency room, she said she had a panic attack. And they missed the suicidal thoughts.”

Social work student Emily Wolcott says the course has helped her feel more comfortable counseling suicidal adolescents in her internship at a community health center.

But, she acknowledges, it’s stressful.

“I think the challenges are really determining someone’s level of safety and what level of care they need,” Wolcott says. “Feeling that kind of responsibility is, like, very intense.”

It’s especially hard when someone doesn’t readily acknowledge having suicidal thoughts.

A recurring theme throughout the course is empathy — really listening to people who are suicidal without judgment, conveying that you understand how hard things are for them, and not trying to prevent them from having the suicidal thoughts — but instead, finding a way to manage the thoughts.

“If you can bring your real self to the table, I think that’s super important,” student Marotta reflects. “I think that particularly in working with teens, that they can read right through you and whether you’re being genuine and sincere, versus saying a script that you say to everybody.”

Professor O’Brien wants the social-workers-in-training to remember suicide is preventable.

“A lot of our students come in thinking, well, it’s someone’s choice — if they are going to kill themselves then they are going to kill themselves, and there’s nothing I can do about it,” O’Brien says. “The whole thing we want them to come away from this course is saying, ‘That’s false.’ Our goal in our work should be zero suicides. It might happen where we lose a client to suicide. I have. But that doesn’t mean that it couldn’t have been prevented in some way.”

Surveys have found more than 90 percent of social workers encounter a suicidal client in their careers. For these soon-to-be-MSWs armed with advanced knowledge and interest in suicide prevention, that number may end up even higher.


vendredi 15 avril 2016

She Wiped Her Nose, Then Prepped My Biopsy. Still, It's Hard To Ask The Nurse To Wash Her Hands

She Wiped Her Nose, Then Prepped My Biopsy. Still, It's Hard To Ask The Nurse To Wash Her Hands

Hand washing before and after touching a patient is mandatory. And before and after walking into a patient’s room or touching medical equipment. (Arlington County/Flickr)

Hand washing before and after touching a patient is mandatory. And before and after walking into a patient’s room or touching medical equipment. (Arlington County/Flickr)

I was lying on my back on a gurney, getting my abdomen washed by the nurse.

She dipped Q-tip-like sticks into the brown antiseptic and then swirled them on my skin where the physician would make his incision. He would penetrate layers of skin and muscle to get into my liver and extract cells. He would send the cells to the laboratory to assess what kind of cancer I had. Eight days earlier, I had learned I had masses in my abdomen and chest. Three days earlier, I had learned the masses were cancer. That day I was on the gurney getting prepped for a liver biopsy, to find out what kind of cancer it was.

While one nurse washed my incision site, another nurse prepared the room. She was adjusting the lights, surgical equipment and my gown. And she rubbed her nose with her hand. Everyone rubs their nose. Humans unconsciously touch their nose or mouth more than 3.6 times per hour.

When we do this, we spread germs into our body from whatever we were touching before and spread germs from our body onto whatever we touch next.

I laid there and wondered if I should say something to her.

In medical school in the early ’90s, I had learned about the risk of normal nose bacteria infecting surgical sites. While on the gurney that day, I remembered a story about a patient with a massive infection in his surgical wound site. The hospital searched for the source of his Staph aureus. They found it in the surgeon’s nose. This story was told to us to remind us of the dangers of what we were seeing on the wards in medical school — which was still full of old-school clinicians who drew blood without gloves and washed their hands only intermittently.

Today things are supposed to be different. Hand washing before and after touching a patient is mandatory. And before and after walking into a patient’s room or touching medical equipment. The compulsory annual online classes for all clinicians include specific directions on how to wash your hands. There are signs on the walls and screen savers on the hospital computers reminding us to wash our hands.

But there I was, flat on my back, wondering if I should say something to the nurse. I was afraid she’d be upset with me if I said something — I was all but naked, lying on my back and pretty much in her hands. The hands that had just wiped her nose. I didn’t say anything. I tried to get my courage up to say something — but couldn’t. A few minutes passed. I decided it was too late to say anything. But I told myself if she did it again, I would say something to her.

And then she did. She rubbed her nose with her hand and then reached for the equipment table with that same hand. The equipment that would be in my liver in a few minutes.

I called her on it.

“Excuse me, you just wiped your hand on your nose and then touched the equipment.”

“I didn’t touch my nose.”

“You did. Can you please wash your hands?”

“I didn’t touch my nose.” She looked knowingly at the other nurse. She walked over to the sink and washed her hands. I was sure she was doing it begrudgingly and I worried how she would treat me going forward.

There are conflicting recommendations for hand washing. All involve soap or an alcohol-based hand rub and all emphasize the importance of friction between the hands. A new report just found that the World Health Organization’s six-step method is more effective in reducing hand bacteria than the CDC’s three-step method. But not surprisingly compliance with both techniques is limited.

At Yale-New Haven Hospital, where I both work and get my cancer care, the recommendation is that if we are asked by a patient to wash our hands, we should do it without question. Even if we know we have just washed them, the amount of time it takes to wash is well worth the trust and respect it shows for the patient and her sense of control.

After the liver biopsy, I got a bloodstream infection. I had a high fever, chills, a headache and had to stay in the hospital for four days to get IV antibiotics. The bacteria infecting my blood came from my liver: Cancer cells in the liver make a hospitable home for Clostridium septicum, and I learned it’s not uncommon after a liver biopsy for these bacteria to infect the bloodstream. I knew that a bloodstream infection was a risk I was taking by having a liver biopsy. No procedure is without risk.

But while feverish and shaking with the chills in my hospital bed — before I knew which bacteria had infected my blood — I worried that it might have been bacteria from the nurse’s nose.

And perhaps more importantly, I worried that the blood infection was my fault because I didn’t insist the nurse wash her hands as soon as I saw her rub her nose.

It wasn’t her nose bacteria in my bloodstream and it wasn’t my fault.

But do we really want our sick patients to spend any mental energy wondering if speaking up for themselves could have made their outcomes better? And when they do speak up, do we want them worrying that their nurse or doctor might be angry with them for speaking up?

We need to make it easier for patients to speak up, but we also need to make it unnecessary.

The websites of most hospitals and many advocacy groups are full of language encouraging patients to speak up when they note errors — in hand hygiene or otherwise — and hospitals try to teach their staff to respect an assertive patient in improving patient safety.

When patients speak up, we want to know errors will be acknowledged and remedied. And that we will not be treated any differently for having done so. But the truth is, most people don’t want to shame the person who is about to examine them or draw their blood or perform their liver biopsy. The glance I saw one nurse give another as she started to wash her hands was painful for me.

So where does that leave us?

We in health care need to take responsibility. We need to make safety a part of our culture, and that includes focusing on it, rewarding it when appropriate, and giving negative feedback when deserved.

We should no more depend on patients to check up on their clinicians than we should depend on passengers to ask their pilot if she’s gone through a safety checklist. It doesn’t make sense.

When patients are assertive, we need to be respectful and take action. When they don’t seem assertive, it should be because we have carefully and thoughtfully attended to all matters of safety and that includes hygiene.

Marjorie S. Rosenthal, M.D., MPH, is assistant director of the Yale Robert Wood Johnson Clinical Scholars Program, associate research scientist in the Department of Pediatrics at the Yale University School of Medicine and public voices fellow with The OpEd Project.

mardi 12 avril 2016

‘Can’t Imagine Life Without It’: 10 Years After Mass. Health Reform, Residents Speak About Law’s Impact

‘Can’t Imagine Life Without It’: 10 Years After Mass. Health Reform, Residents Speak About Law’s Impact

On this day, 10 years ago, the hottest ticket in town was for a seat in Faneuil Hall, to watch then-Gov. Mitt Romney sign the state’s new health coverage law and describe its goals.

“Every citizen with affordable, comprehensive health insurance, small businesses able to conveniently buy insurance for their employees at a cost that’s competitive with big businesses, medical transparency bringing marketplace dynamics to health care — really for the first time — and finally, beginning to rein in health care inflation,” Romney said in 2006.

Today, we have compiled some facts and figures on the 10th anniversary. There’s also a collection of essays from health care experts of all stripes assessing the law’s first decade.

On Morning Edition today, we hear from a different group: Massachusetts residents, including several who did not have insurance before the state’s first-of-its-kind law.

Dr. Alice Coombs: Mass. Health Law Put State On The Right Road

Dr. Alice Coombs: Mass. Health Law Put State On The Right Road

One of a series of analyses on the 10th anniversary of the 2006 Massachusetts health care overhaul. Dr. Alice Coombs was formerly the president of the Massachusetts Medical Society. She currently practices anesthesiology at South Shore Hospital. 

Before Massachusetts’ health care reform law went into effect, I distinctly remember a patient in the ICU who had difficulty breathing and had been dealing with hoarseness for more than a year. In a raspy voice, she told me she’d been working part-time, couldn’t afford medical care, and was waiting to see a doctor until after she turned 65 – when she’d be eligible for Medicare.

Dr. Alice Coombs (Courtesy)

Dr. Alice Coombs (Courtesy)

Because of this long wait her disease was much more advanced, involving intensive care as well as urgent surgery. My heart ached for what could have happened if only the patient had been able to see a doctor before her condition deteriorated. Instead, she came in with a more advanced stage of her illness and it changed her life trajectory.

With the Massachusetts health law, the key question was: Will patients be better off with universal health coverage? While my answer is unequivocally yes, I have concerns that still need to be addressed.

Early on one study found that African-Americans and Hispanics did not benefit from increased access in all regions of the state. When patients had to wait two to three weeks for an appointment, there was a correlation with increased emergency room visits. These patients were disproportionately vulnerable and minority patients. Other research found that many of those emergency room visits occurred between 9 a.m. and 5 p.m., a time when most clinics and physician offices are open. Nearly half of patients could have been treated in a non-emergency setting.

Today, despite improved access, racial disparities persist. One cannot deny the impact of poverty and social economic factors on health outcomes, however health care access is the absolute bottom line. If you can’t access health care due to finances, then this becomes the rate limiting factor in quality. The patient described above is an example of the impact of costs on health care decisions and outcome.

Here in Massachusetts, the Medicaid acceptance rate is also a barrier for some patients. A person can live in an area with an adequate number of primary care physicians, but those physicians may not be accepting new patients, especially those on Mass Health/Medicaid. It’s like having a check that no one will cash and results in patients having to travel long distances for care.

Insurance plans with co-pays, coinsurance and high-deductibles can also impact access. Patients may postpone or skip care to save money.

We are seeing the unintended consequences of rising costs. Of course this was inevitable, costs were escalating prior to the passage of the state’s health care law. The Health Policy Commission was created to do address this problem and is exploring ways to reduce costs in a transparent way. But there are many areas of cost escalation that need to be addressed, including the price of drugs and medical equipment.

Despite our hurdles, and the work that still needs to be done, I am proud to stand with more than two-thirds of the physicians in the state in supporting the state’s health care law.

Health Law Turns 10: What Analysts Say:

Josh Archambault: Paternalism Undermined Mass Health Reform Law

Josh Archambault: Paternalism Undermined Mass Health Reform Law

One of a series of analyses on the 10th anniversary of the 2006 Massachusetts health care overhaul. Josh Archambault is a senior fellow at the Pioneer Institute and is co-author and editor of “The Great Experiment: The States, The Feds and Your Healthcare,” a comprehensive review of the Massachusetts state law. He also served in the Romney administration.

An honest assessment of the Health Connector reveals an entity quite unlike Gov. Mitt Romney’s original vision. He proposed a statewide health insurance exchange that would offer small businesses a robust selection of plan choices and designs. Instead, a number of the Connector’s early implementation decisions set a trajectory that has failed to attract those who don’t receive a taxpayer-funded subsidy.

Josh Archambault (Courtesy)

Josh Archambault (Courtesy)

Romney’s Original Vision

Romney’s proposal provided for defined employer contributions, meaning an employee would be given a set amount of money to purchase whatever exchange insurance they deemed the best fit. It also envisioned a “premium aggre­gator” function that, for example, tapped into employer contributions from both a couple’s employers. The design was informed by survey data show­ing that over three quarters of the commonwealth’s uninsured were employed – a majority working full-time – but their employers were struggling to afford health insurance coverage.

The proposal was market-oriented and consumer-centered; intended to promote personal choice and ownership of portable health insurance for small business employees.

Such a set up would streamline the administrative burden and limit minimum participation and contribution hurdles that had prevented many businesses from offering coverage. Instead, the Connector set up a program that maintained many of the barriers the Romney administration had identified as problems before the law’s passage.

Early Policy Decisions Moved Connector Toward Costly Paternalism

The original proposal called for benefits that focused on value: preventive and primary care, emergency services, ambulatory patient care, mental health and surgical and hospitalization benefits. But the Connector board approved “minimum creditable cov­erage” that looked more like costly “Cadillac” coverage offered in other states. They then created tiers (Gold, Silver and Bronze) that limited the diversity of offerings. Instead of giving consumers tools to decide which plan was right for them, they simply prohibited most options.

These decisions made the Connector into a health insurance sales channel that is largely indistinguishable from the general marketplace, thereby limiting its appeal to small business owners. This largely remains the case today.

Small business is clearly shopping elsewhere. As of this March, the Connector served just 1,246 groups and 5,741 members. Some of the Connector board’s rhetoric has changed with new appointments by Gov. Charlie Baker, but much more work will be needed for the Connector to live up to the promise set out in the 2006 reform. In the meantime, small business will continue to face crushing premiums.

Health Law Turns 10: What Analysts Say:

JudyAnn Bigby: Better Health After 10 Years of Mass. Health Care Law

JudyAnn Bigby: Better Health After 10 Years of Mass. Health Care Law

One of a series of analyses on the 10th anniversary of the 2006 Massachusetts health care overhaul. Dr. JudyAnn Bigby served as secretary of health and human services for Massachusetts from 2007 to 2013. She’s now a senior fellow at Mathematica Policy Research.

Are people healthier since the implementation of the 2006 Massachusetts health insurance reforms? For the most part, the answer is yes.

JudyAnn Bigby (Courtesy)

JudyAnn Bigby (Courtesy)

Some groups are clearly healthier, especially populations that benefited the most from insurance eligibility expansions — people with low incomes, racial and ethnic minorities, and those with chronic health conditions. The pathway from expanding insurance eligibility to improved health is logical — making eligibility easier leads to increased coverage, better access to care, more effective use of clinical services, and improved or maintained health. Proving coverage leads to better health can take years, but after 10 years, outcomes from Massachusetts suggest promising results.

The evidence includes increased self-reports from residents who say they are in good or excellent health, and who accessed preventive services — such as screening for HIV, cholesterol and colon cancer. People with diabetes report receiving more targeted preventive care — such as eye exams and influenza vaccines.

Another positive consequence of expanded coverage: resolution of disparities – the differences in access and treatment among demographic groups. One study showed that procedures (such as orthopedic surgeries) that require referral to a specialist increased after reform for low- and medium-income non-elderly adults. The same was true for blacks and Latinos.

In another large study of death rates in Massachusetts, researchers found that mortality rates decreased after 2006 by nearly 3 percent compared with rates in comparable populations in other states. Reductions in deaths were nearly twice as large for Latino and racial minorities than for white adults and were largest in lower-income counties. Most of the reduction occurred in deaths due to conditions that are avoidable or treatable if detected early, such as cancer and heart disease.

Some adult women especially benefited from reform. Uninsured rates among women dropped, especially for lower-income women, racial and ethnic minorities, and women without dependent children. Importantly, younger women reported greater access to contraception with fewer costs barriers. The total number of abortions performed in Massachusetts after the 2006 law declined by more than the pre-reform trend, despite more women having new coverage for the procedure.

There are still challenges ahead. Critical access issues continue to pose an obstacle for Massachusetts residents. In the context of an archaic substance abuse treatment system, addiction treatment services did not increase after reform in spite of the mandate to cover these services. Health care affordability is a major barrier to access. Out-of-pocket costs have increased and the delivery system remains a complex maze to navigate. But Massachusetts has moved beyond the debate about whether to strive for universal coverage and is tackling these problems. The rest of the nation still has much to learn from the Massachusetts model.

Health Law Turns 10: What Analysts Say:

Elizabeth Browne: Mass. Law Leaves Many Still Uninsured, Needing Care

Elizabeth Browne: Mass. Law Leaves Many Still Uninsured, Needing Care

One of a series of analyses on the 10th anniversary of the 2006 Massachusetts health care overhaul. Elizabeth Browne is executive director of Charles River Community Health, a nonprofit health center that provides care to people in Allston-Brighton, Waltham and surrounding communities.

At Charles River Community Health, we fully embraced state health care reform in 2006 and federal reform in 2010 because we had some of the highest rates of uninsured in the state. Although health centers do not receive state funding for their outreach and enrollment work, our staff was trained in the new insurance options and our outreach efforts ultimately enrolled tens of thousands of community residents in new health coverage.

Elizabeth Browne (Courtesy)

Elizabeth Browne (Courtesy)

The law has had many positive impacts. Since 2006, the health center has seen a 55 percent increase in insured patients and a 170 percent increase in patients covered by Medicaid. The 2006 law expanded Medicaid coverage for children, provided fully subsidized coverage for low-income adults not eligible for Medicaid, and partially subsidized plans for the working poor through the state’s Health Connector.

Four years later, the Affordable Care Act further expanded Medicaid to a broader range of low-income residents. For example, you previously could not qualify for Medicaid if you were an adult with no children even if you were poor enough to meet income requirements. Having more people insured has also had the significant benefit of connecting them with care, saving the health care system thousands of dollars, and allowing patients to lead healthier lives. A newly insured Charles River patient might have a cancer screening, for example, that detects cancer at an earlier stage, meaning less treatment and a better health outcome.

The law also has its limitations. For some people, even subsidized plans remain unaffordable. This causes them to pay the state penalty or fall behind on premium payments, leaving them without coverage. And in spite of the law’s success in increasing employer-sponsored coverage, some residents struggle to afford their share of increasing premiums and deductibles.

Although we have made great progress, Massachusetts health reform has not yet delivered on its promise of affordable, accessible care for all. This is largely because the health care system has not yet evolved enough to shift care and funding to primary care settings like community health centers. We also face a significant primary care provider shortage. The state must continue to invest in the primary care workforce and other reforms to control costs to make both affordable coverage and access to high quality primary care available to all residents.

Health Law Turns 10: What Analysts Say: