public health


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. Continue reading


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. Continue reading

Zika And Ebola Grab Headlines, But Lingering TB Worries Many In Public Health More

(Lefteris Pitarakis/AP)

(Lefteris Pitarakis/AP)

For public health nurse Meredith Hurley, the discovery that her town had an active case of tuberculosis threatened an infectious disease nightmare that couldn’t have come at a worse time.

The tuberculosis patient was a young man from Saudi Arabia, living in the Boston area to learn English. He’d been coughing up blood for five days while he traveled on buses and subways, went to class, visited the New England Aquarium, shared a hookah, and hung out with seven roommates who jointly rented a house in the densely populated seaside town of Winthrop, Massachusetts. They hailed from China, Italy, Taiwan, Germany and Turkey and spoke six different languages — but little English.

To make matters worse, the Saudi man’s case occurred at a time when the Massachusetts Department of Public Health had abruptly lost two of its four TB control nurses, reportedly due to budget-driven early retirement. “These retirements were not planned for and a contingency plan was not established,” Hurley says.

The episode is a stark reminder that the ancient scourge of TB is still with us, even though many people think the disease was vanquished in this country long ago. It can pop up anytime. The case also underscores how critical it is for front-line public health workers who understand how to control TB to be available when needed.

The sudden appearance of TB in Winthrop is a tiny piece of a big mosaic. A new report from the Centers for Disease Control and Prevention reveals the number of TB cases in the United States rose in 2015, to almost 10,000 reported cases, after nearly 25 years of steady decline.

In Massachusetts, progress against TB appears to have stalled, after declines in the first decade of the millennium. One in five reported cases involves drug-resistant strains of TB, which are far more time-consuming to treat with expensive drugs that carry burdensome side effects.

In its annual TB update last month, state health officials reported 192 active cases in 2015. Though the number appears small, the stakes involved in each case are high — for the affected individual and for public health. “Challenges include high rates of drug resistance, delays in diagnosis and complex medical and social needs of persons diagnosed with TB,” the state report says.

“I was thinking there were seven more people walking around the community with active tuberculosis, and they were probably going to be spreading it to seven more and then 14 more and then 49.”

– Meredith Hurley,
Winthrop public health nurse

As soon as she heard about the Winthrop case, Hurley — the town’s one-woman public health department — imagined the worst.

She discovered the TB patient had visited clinics three times before getting a proper diagnosis, exposing caregivers and patients each time. That’s not unusual with TB, which is not near the top of many doctors’ list of possible diagnoses.

Hurley began to envision how many people the TB patient exposed in Winthrop, a town of 20,000 residents packed into two square miles.

“We don’t have a lot of space between our neighbors, and for a disease that’s airborne, that can be challenging,” Hurley says. “I was thinking there were seven more people walking around the community with active tuberculosis, and they were probably going to be spreading it to seven more and then 14 more and then 49. It’s a cascading effect.”

Hurley says she badly needed help to figure out how big a problem she was dealing with. Because of the sudden short-staffing at the state health department’s TB control program, she had to enlist the help of a public health nurse in western Massachusetts. Continue reading

Yes, We’re Mammals, But Is It Wise These Days To Promote Breast-Feeding As ‘Natural’?

Public health officials should think twice about the unintended consequences of calling breast-feeding 'natural,' the authors of a new paper argue. (Michael Sawyer/AP)

Public health officials should think twice about the unintended consequences of calling breast-feeding ‘natural,’ the authors of a new paper argue. (Michael Sawyer/AP)

Hippos do it. So do orangutans. There’s no question that for us mammals, nursing is one of those defining behaviors in nature. The question is whether public health officials, in promoting breast-feeding among human mothers, should deploy the term “natural.”

Two academics pondering these and other linguistically charged questions sparked an online frenzy recently with a paper on the unintended consequences of promoting breast-feeding as a “natural” practice — and relating it to the anti-vaccine movement.

University of Pennsylvania ethicist Anne Barnhill and medical historian Jessica Martucci, writing last month in the journal Pediatrics, suggest that by using the word “natural” in campaigns endorsing breast-feeding, public health officials and medical professionals may be inadvertently fueling other groups that reject public health efforts — like anti-vaxxers. Continue reading

Narrating Medicine: How Cultural Differences Challenge Doctors

By Dr. Marjorie S. Rosenthal
Guest Contributor

The pediatric resident was frustrated.

On the exam table was a 6-month-old baby — quite overweight. In fact, the child was heavier than an average 1-year-old. But his mother just laughed when the resident asked how she was feeding the baby.

When the resident and I looked at the medical record, we saw that for months residents had been discussing feeding with the mother. Telling her that she should stop formula feeding because her breast milk was more than sufficient. Telling her not to give solid foods because her breast milk was enough. And telling her that if she was going to give the baby formula or solid food, she should try to pay attention to when the baby’s cry means hunger and when it means a wet diaper or a need for attention.

Over one-third of adults and about 17 percent of children in the United States are obese. And since people who are obese have more high blood pressure, diabetes and heart disease than their peers, it’s not surprising that there are 11 million office visits per year for adults with obesity.

Yet according to a new CDC report, only 40 percent of these 11 million visits for obesity include a discussion of diet and exercise.

Dr. Marjorie Rosenthal (Courtesy)

Dr. Marjorie Rosenthal (Courtesy)

Many health care providers don’t want to talk to their patients about diet and exercise because they think the patients may feel judged. And sometimes doctors don’t talk about fitness and nutrition because they actually think talking won’t change anything. Which makes it safe to assume that office visits for obesity rarely include a discussion about the life experiences of the patients and the parents of patients. This suggests that a critical issue — and a key part of any treatment plan — is never addressed.

Parents’ medical history has always been an important aspect of a child’s medical care. But the central importance of all this has only recently emerged: New research has shown how life experiences affect brain development and hormone responses and how that affects parenting behavior and the health of the child in the next generation.

It’s hard enough to do this with families who speak English and come to the doctor’s appointment ready to talk about themselves. With this overweight 6-month-old, it was even harder: The resident was using a Swahili phone interpreter and the mother was a refugee.  Continue reading

U.S. Health Care Is Less Private, More ‘Socialist’ Than You Might Think

The extent of the government's role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17 in Charleston, S.C. (Mic Smith/AP)

The extent of the government’s role in health care has become a key issue in the Democratic presidential primary. Here, candidates Hillary Clinton and Bernie Sanders are seen in a debate on Jan. 17. (Mic Smith/AP)

By Richard Knox

Readers, a pop quiz:

The proportion of U.S. health care paid by tax funds is (a) less than 30 percent, (b) about half or (c) more than 60 percent.

If you picked “more than 60 percent,” you’re right — but you’re also pretty unusual.

“Many perceive that the U.S. health care financing system is predominantly private, in contrast to the universal tax-funded health care systems in nations such as Canada, France or the United Kingdom,” David Himmelstein and Steffie Woolhandler write in a new analysis of U.S. health spending in the American Journal of Public Health.

They find that 64.3 percent of U.S. health expenditures are government-financed. And they project the tax-supported proportion will rise to 67.1 percent over the coming decade as the baby boom generation ages and retires — nearly as high as Canada’s 70 percent.

“We are actually paying for a national health program, we’re just not getting it,” Woolhandler says.

tax dollars for U.S. health spending

Now, Himmelstein and Woolhandler have an agenda. For decades, they’ve been perhaps the leading researchers promoting the kind of single-payer health system that Socialist and Democratic presidential candidate Bernie Sanders has put on the debate agenda. One recent poll suggests more than half of Americans (and 30 percent of Republicans) support the idea.

But even if you disagree with the Himmelstein-Woolhandler ideology, their research is generally regarded as sound, and their method is straightforward.

They added up what federal and state governments spend on health through Medicare, Medicaid, the Veterans Health Administration, government employees’ health care premiums, tax subsidies and other programs. They argue that accounting by government agencies (the Center for Medicare and Medicaid) undercounts the real tax burden because it leaves out major pieces of the pie — such as government employees’ care ($156 billion a year) and tax subsidies for private, employer-sponsored coverage (nearly $300 billion).

And whatever you think about Medicare-for-all, it’s a good idea to see the present U.S. health care system for what it is — an increasingly government-funded financing scheme. Continue reading

Rare Common Ground: Gun Dealers And Public Health Workers Unite To Cut Suicides

(Image taken, with permission, from a New Hampshire Firearm Safety Coalition poster)

(Image taken, with permission, from a New Hampshire Firearm Safety Coalition poster)

By Richard Knox

The elegantly dressed woman looked out of place at Riley’s Sport Shop, the largest gun dealer in New Hampshire. Owner Ralph Demicco was behind the counter. He noticed she didn’t make eye contact.

“I’d like to buy a gun,” she said. “Could I see that one?”

Demicco sensed something was amiss. “Should you really be buying a gun?” he asked.

She immediately broke into tears. “I took her into the backroom,” Demicco recalls. “She confided that she’d been released from the state mental hospital in Concord that morning. She said she told her doctor she wasn’t ready to go and if he discharged her she was going to take her life. Apparently he didn’t put any stock in that.”

Demicco asked the name of her psychiatrist, then told her to go home and wait for the doctor to call. Then he called the doctor, who intervened. It was a suicide that didn’t happen.

The incident stuck with Demicco. But it wasn’t until later that he realized that gun dealers could take more concerted action to prevent gun suicides — by far the nation’s leading cause of firearm fatalities. That came after a Dartmouth Medical School injury prevention researcher alerted him that three different customers had killed themselves in a single week within hours or days of buying their guns at Riley’s.

The partnership is a rare instance of common cause between gun enthusiasts and public health proponents, amid increasingly polarized public views.

“That was stunning,” Demicco says. He started meeting with the Dartmouth researcher and other gun retailers and health workers. They decided to create a group called the New Hampshire Firearms Safety Coalition. Their idea is catching on — in Massachusetts, Vermont, Maryland, New York, Virginia, Tennessee, Texas, Colorado, Utah, Nevada and California, according to Elaine Frank, chair of the New Hampshire coalition.

Frank is the Dartmouth injury-prevention specialist who alerted Demicco to the problem. Early on in the coalition’s work, a public health worker came to a meeting after talking to gun shop owners around the state. She expressed surprise they were so positive.

One of the gun dealers in the group said, “I could be insulted by that,” Frank recalls. “He said, ‘Why would you think we’d be less interested in suicide prevention than you are?’ It was absolutely an ‘aha!’ moment.”

The partnership is a rare instance of common cause between gun enthusiasts and public health proponents, amid increasingly polarized public views on how to reduce the nation’s death toll from firearms. It’s not embraced by all gun proponents; some fear it’s a stalking horse for more gun controls.

But it’s a real-life example of what President Obama and others are calling for: a public health approach to the nation’s gun violence crisis.

“The concept of collaboration, which is often lost, is very much alive in this area of suicide prevention,” says Bill Brassard, spokesman for the National Sport Shooting Foundation, which represents gun dealers.

A prominent gun control advocate at the Harvard H.T. Chan School of Public Health agrees. “What you want to do are the things that are easiest to do — the low-hanging fruit — and show we can work together,” says David Hemenway, author of “Private Guns, Public Health.” “It takes a long time to build trust. But this is happening.”

The payoff could be large — potentially bigger than gun control measures proposed to stem homicides.  Continue reading


Bad Odors And Brain Fog: 5 Things Nobody Tells You About Quitting Cigarettes

On a break from his midday hosting duties, WBUR's Jack Lepiarz lights up outside the station. (Robin Lubbock/WBUR)

On a break from his hosting duties, WBUR’s Jack Lepiarz lights up outside the station. (Robin Lubbock/WBUR)

WBUR’s Jack Lepiarz is no wimp. He not only braves live air multiple times a day as the station’s midday anchor, he also performs around the country as a circus whip-master, and even recently attempted to break the Guinness world record for whip strokes per minute.

But Jack has yet to defeat the most insidious physical and psychological challenge many of us ever face: his smoking habit.

He has plenty of company: Almost 1 in 5 Americans smoke, the CDC says. He writes here about some of the unexpected obstacles involved, in hopes of helping other would-be quitters and their supporters. And he’ll document his fight periodically this year. Please stay tuned. — Carey

I’m about to try again. This weekend will mark my fourth attempt to quit smoking over the last 10 weeks or so. At age 27, I’ve been smoking for a little more than seven years, with multiple attempts to quit every year since three months after I started. When they tell you that nicotine is as addictive as heroin, they’re not kidding.

I’m at the point where I’ve started and stopped so many times that I know what I’m getting into, but every time, I seem to notice a new symptom or side effect of nicotine withdrawal. Almost always, I’m surprised. We hear about cigarette cravings, irritability and other symptoms of withdrawal — but the process of quitting also carries with it some other, lesser known symptoms.

1. The Mental Fog

By far my least favorite side effect, and one that I find the hardest to explain. You know that feeling you have right after you wake up? Half present, half in another world? This is your brain — not on drugs. I’ve described it as similar to going a day without coffee — except worse. (Believe me, I’ve tried.) Or being in a state of constantly having just had two beers. You can’t focus, you can’t sit still, you can’t formulate any thoughts that last in your brain for more than 30 seconds.

Except for how much you want a cigarette.

2. The Smell

This is one that sneaks up on you. Most people know that smoking dulls your sense of taste and smell, but it’s such a gradual process when you start smoking that you don’t notice it. For me, it rarely takes more than 36 hours to get those senses back strongly — and never in a good way.

The first time I really noticed it was last winter, when after a day of not smoking I drank a soda and nearly spat it out. I never knew it was that sweet.

The smell aspect hit me when I tried to quit on a hot, humid day in July. Long story short, we all need to wear more deodorant. Also brush our teeth more. Also, cities just smell awful in general. Also, yes, I recognize the irony of a smoker complaining about bad smells. You notice just how bad cigarettes smell, too.

3. The Constant Hunger Continue reading

Analysis: Controversy Over CDC’s Proposed Opioid Prescribing Guidelines

OxyContin pills are arranged at a pharmacy in Montpelier, Vt. in this 2013 file photo. Opioid drugs include OxyContin. (Toby Talbot/AP)

OxyContin pills are arranged at a pharmacy in Montpelier, Vt. in this 2013 file photo. Opioid drugs include OxyContin. (Toby Talbot/AP)

Updated at 3 p.m.

By Judy Foreman

The U.S. Centers for Disease Control and Prevention recently came out with controversial proposed guidelines for opioid prescribing through a process that critics say may harm pain patients and is based on relatively low-grade evidence.

One of those critics is Cindy Steinberg, national director of policy and advocacy for the U.S. Pain Foundation, a patient advocacy group which receives funding from opioid manufacturers. Steinberg said in an interview and in emails that she’s worried the guidelines may negatively impact patients suffering with severe pain. “I am concerned that if these guidelines go forward as they are now written, they will lead to further restrictions on access to opioids for people with unremitting pain who truly need them and take them responsibly,” she said.

Dr. Jane Ballantyne, president of the non-profit Physicians for Responsible Opioid Prescribing (PROP), which is part of a larger group involved in the guidelines process, said in a telephone interview that the worry about limited access to opioids for chronic pain patients is a “very legitimate fear.” But, she added: “We don’t want to reduce access for people already dependent on opioids. The guidelines are designed to not have so many people dependent on opioids in the future…”

Ballantyne said that the new guidelines are similar to previous guidelines with two key exceptions: lower dose limitations and the recommendation that, for acute pain not related to major surgery or trauma, opioids should be prescribed for only three days.

The month-long period for public comment on the proposed guidelines will be over Jan. 13.

A major concern of some critics is the lack of solid evidence backing up the guidelines, which give recommendations on prescribing practices; they include when to start opioids, how to establish treatment goals, how to discuss risks and benefits, recommended limitations on drug doses, duration of treatment and other issues. Continue reading

Harvard Researchers: Make Police Killings A Matter Of Public Health

In this Oct. 20, 2014, frame from dash-cam video provided by the Chicago Police Department, Laquan McDonald, right, walks down the street moments before being shot by officer Jason Van Dyke in Chicago. Van Dyke has now been charged with murder. (Chicago Police Department via AP)

In this Oct. 20, 2014, frame from dash-cam video provided by the Chicago Police Department, Laquan McDonald, right, walks down the street moments before being shot by officer Jason Van Dyke in Chicago. Van Dyke has now been charged with murder. (Chicago Police Department via AP)

By Richard Knox

Every week, it seems, a new police killing enters the news stream, sparking outrage, breeding cynicism, fraying still further the social compact between police and communities.

The issue reached a new peak just this week, when the Justice Department announced a probe of the Chicago Police Department, the nation’s second-largest, to determine if there has been “systematic misconduct.” The investigation comes in the wake of social unrest and the recent firing of the police commissioner, after two police killings there.

In fact, police killings happen in America far more often than once a week.

The best available data come from news organizations, such as a website launched earlier this year, ironically enough, by the British newspaper The Guardian. They show that U.S. civilians die at the hands of police nearly three times a day. So far this year, 1,055 Americans have been killed by police, by The Guardian count. The Washington Post has tallied up 913 people “shot dead by police this year.”

About 120 law enforcement officers were killed in the line of duty last year, according to the National Law Enforcement Officers Memorial Fund.

Run through the Guardian’s website of civilian police-related deaths, called “The Counted,” and you’ll see that many of these everyday police killings involve suspects who were armed and menacing. The 14 people killed in the past week include the San Bernardino shooters and others who reportedly were threatening police officers. These are not the kind of cases that generate Black Lives Matter protests, although they shouldn’t necessarily be classified as justifiable use-of-force without careful investigation, either.

“No act of Congress is needed,” they write. “No police departments need to be involved. Public health agencies can do the job.”

The typical investigation focuses on the circumstances and actions in a specific case. But larger forces may be driving the phenomenon as well, forces that don’t get identified in case-by-case investigations. And that’s just the point of a new proposal, out Tuesday, that makes a strong case for collecting data on law enforcement-related deaths a matter of public health.

The authors, from the Harvard School of Public Health, assert that these killings — both by and of police — should be “notifiable” to public health agencies, just like homicides, suicides, many infectious disease deaths, work-related fatalities and injuries, and death by poisoning, fire and spinal cord injuries. That means they should as a matter of law be reported to health departments; currently police-related deaths are reportedly voluntarily (or not).

The Harvard researchers write, in the journal PLoS/Medicine, that death and injury due to police encounters are “a matter of public health, not just criminal justice, as is the occupational health of law-enforcement officials.”

“Deaths are part of our bailiwick,” lead author Nancy Krieger says.

She argues that only by compiling data on a national basis (but with details specific to local jurisdictions) can public health scientists identify time trends, racial-ethnic and geographical disparities, and other relevant indicators. And only then can they put these events in context with, say, the racial makeup of communities and police forces.

Such data now are fragmentary and delayed. Using what’s available, the researchers charted arrest-related deaths in eight U.S. cities at the top of The Guardian’s rankings, along with some recent hotspots such as Ferguson, Missouri.

“We show enormous variability over time among the eight cities,” Krieger says.

Take, for instance, the critical issue of black-white differences in who dies as the result of a police encounter. Continue reading