The final question of the MacLean Center for Clinical Medical Ethics seminar series on health disparities was a seemingly obvious query that had gone unasked and unanswered the entire year: who is responsible for fixing the problem? For the self-selecting audience that had attended the lectures all year, the question may have seemed irrelevant - many in attendance are already working on research and interventions to reduce disparities at home and abroad. But for Dan Brock, the director of medical ethics at Harvard Medical School, the question was worth approaching from a philosophical perspective, if only for the purpose of preaching beyond the choir assembled each week at the seminar series.

The statistics about disparities between developed and undeveloped countries are not in question: the threefold difference in life expectancy, the millions of children who die each year from preventable disease and malnutrition, the large discrepancies in health care spending. But who has the moral responsibility to try and remedy these enormous global health gaps? Is it the obligation of rich individuals, or organizations and institutions, or governments, or (as a libertarian might say) of nobody at all? Brock said that philosophical theories of global justice are too new to offer answers for such questions. Arguments have been made for centuries about helping the unfortunate you can see, or even the unfortunate of your own tribe, city, state, or country. But stretched to a global scale, these theories have not yet matured, on issues such as how to take care of a nation’s own needy while still assisting the “foreign” needy thousands of miles away.

To address this shortcoming, Brock suggested three other scaffolds upon which an argument for fighting global disparities could be argued. The first was an economic proposition: as he stated, “if you can prevent great harms at little risk, you are obligated to do so.” Fifteen cents worth of rehydration salts can save a child from dying of dehydrating diarrhea, ten dollars (the cost of a movie) given to a charity can buy minimum essential medicines and more - an argument for sacrifice.

“One can’t make a plausible case that more good comes from me going to a movie then would be done in the world if I had gave that money to OxFam instead,” Brock said.

One obstacle to these small acts of charity is the “out of sight, out of mind” phenomenon - as Brock said, almost everyone would give part of their sandwich to a starving African child sitting next to them, but the concept of millions of starving African children is more abstract. But in a time of increased connectivity, where news organizations and social media can instantaneously spread images around the world from even the most remote locales, this detachment will no longer be an excuse, he said.

Brock’ s second argument that the well-off are obligated to help the needy was a harder pill to swallow: Guilt. The prosperity of the developed world is not independent from the poverty of the undeveloped, Brock argued; it was built upon a history of slavery and colonialism that has continued to handicap Africa and Asia long after such policies (officially) ceased. Even today, the exportation of natural resources such as oil from Africa and the Middle East to the developed world perpetuates oppressive governments, inequalities, and poverty in those countries. That complicity in the suffering of others gives the developed world a special responsibility to help, Brock said.

“Our failure to act isn’t just a failure of beneficence, a failure to help others that are needy, because we are in significant respects causally responsible for their need and in turn morally responsible for their suffering,” Brock said. “If I was the one who drove into your car and wrecked it, then I have a special obligation to help you, because I caused your need.”

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Reducing health disparities in the United States has been a top priority for our health care system in these early years of the 21st century. But efforts to narrow the health gap between black and white patients go much farther back, to the start of the previous century when the first African-Americans were graduating from medical schools and Ph.D. programs around the United States. Those early black professionals looked at the state of African-American health at the turn of the 20th century and were appalled, said Vanessa Northington Gamble, professor of medical humanities and history at George Washington University, at her MacLean Center for Clinical Medical Ethics seminar in late April. No less a figure than Booker T. Washington spoke out about the direct link between African-American health and civil rights in the early 1900’s, saying:

“Without health … it will be impossible for us to have permanent success in business, in property getting, [and] in acquiring education …. Without health and long life all else fails.”

The solutions those black intellectuals chose to improve the health of their race, in a time of national segregation, were very different from the options under consideration today. But Gamble said that discussion of those efforts is missing from the conversation about health disparities interventions in today’s society.

“We don’t talk about the history of these disparities - what are some of the programs that came in the past to address these disparities,” Gamble said. “I do think that many people think it’s only been in the past 20 to 25 years… but I want to talk about what the black community did to take care of itself.”

At the time, black patients faced segregated hospitals and racist theories, such as those put forth by statistician Frederick L. Hoffman in his book, “Race Traits and Tendencies of the American Negro.” Hoffman, an actuary for Prudential insurance, argued that the company should not cover African-Americans because they were destined to die out due to unchangeable biological factors of their race. To refute those claims, W.E.B. Du Bois published his 1906 study, “The Health and Physique of the Negro American,” which pinpointed socioeconomic factors, rather than biology, as the cause of poor health in the black community.

“Du Bois agreed that the health status of African-Americans was worse than that of white Americans,” Gamble said. “Where there was disagreement was on what were the causes of what we would now call health disparities or inequities…for example, he said the high infant mortality rate in Philadelphia was not a ‘Negro affair,’ but an index of social conditions.”

In the wake of that research, black professionals united to try to beat back higher rates of infant mortality, pneumonia, and tuberculosis - the latter of which Du Bois called “the greatest enemy of black people.” One of the best strategies, in the face of segregated hospitals and discrimination from white physicians, was to establish black hospitals to improve access to health care. One example on the South Side of Chicago was Provident Hospital, founded in 1891 by Emma Reynolds and Daniel Hale Williams, who would go on to perform the first successful open-heart surgery there. Similarly, black doctors formed the National Medical Association in 1895, because of their difficulties in joining the American Medical Association. Playing along with segregation wasn’t unanimously popular in the black population of the time; in fact, Gamble said one minister prayed Provident would burn to the ground because it catered to racism.

“You have to look at [black hospitals] in the context of segregation,” Gamble said. “Many black physicians said we wish we didn’t have to start black hospitals, but if we wait for integration, the health of the race would suffer.”

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In the Norman Rockwell past, patients had one doctor who followed them from home to clinic to hospital, managing their health care over a significant portion of their lives. That sort of doctor-patient relationship in today’s medical world seems about as outdated as a family gathered around the fireplace listening to the radio. Now, patients are growing used to unfamiliar people in white coats, seeing multiple doctors at their clinic and a parade of physicians from their hospital bed.

Part of this shift has been the move toward medical specialization, with more medical students choosing careers in surgery, cardiology, neurology or other specialties. The coincident decrease in primary care or family medicine doctors has reduced the ability of those who remain to visit their patients when they are hospitalized and monitor their care. Into this void has rushed the hospitalist, a physician who spends more than a quarter of their time on inpatient service.

Since the mid-90s, hospitals have increasingly relied on this new class of doctor to handle the work of the wards, and David Meltzer, associate professor of medicine, economics, and public policy, has studied the impact of this cultural change. In his talk for the MacLean Center for Clinical Medical Ethics seminar series, Meltzer detailed the impact of an increased role for hospitalists, for both patient health and the hospital’s bottom line. But with the Affordable Care Act rewriting the rules about how Americans receive and pay for their health care, a new kind of hands-on hospitalist may be a key player in the medical landscape of the future.

Meltzer started his research by looking in his own backyard: at the Medical Center’s hospitalist program that he himself directs. From 1997 to 1999, one of the four general medicine services at the Medical Center was run by two hospitalists rather than the rotating house staff and general internists who normally take in new patients. Time revealed the benefits of the more consistent care provided by the hospitalists - by the second year, patient stays were a half-day shorter in the hospitalist service, survival 30 and 60 days after discharge was higher, and costs per patient were nearly $800 lower.

Why would hospitalists show such a profound advantage? The answer may come down to repetition and experience with commonly encountered conditions, Meltzer said. He compared the improvements on the hospitalist service to the growing efficiency of shipbuilders during World War II as they built more ships.

“The total effect was explained by disease-specific experience,” Meltzer said. “Hospitalists seemed to have shorter length of stay and lower costs not because they spend so much time in the hospital, per se, or have so much more experience overall, but because they actually saw these diseases again and again.”

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The University of Chicago is the birthplace of nuclear energy. So like proud but concerned parents, UChicago has kept a close eye on the benefits and challenges of nuclear power over the years since the first self-sustained nuclear reaction under Stagg Field. Thus, the battle to manage the consequences of the damaged reactors at the Fukushima I Nuclear Power Plant in Japan has drawn the University’s interest, and the short-term and long-term effects of that ongoing situation were the subject of a unique panel held on campus yesterday, “Lessons from Fukushima.”

Though nuclear power was created by scientists, discussing its use requires input from political and economic spheres as well. So the panel, assembled by the University of Chicago Alumni Association, brought together nuclear technologists (Hussein Khalil, director of the nuclear energy division at Argonne National Laboratory, and Mark Peters, deputy director of Argonne), nuclear policy watchdogs (Kennette Benedict, executive director of the UChicago-based Bulletin of Atomic Scientists), and energy economics experts (Robert Topel, director of the University of Chicago Energy Initiative). With such different perspectives, it didn’t take long for the panelists to find points of debate, reflecting the tug-of-war over nuclear power that has gone on for several decades.

Nobody disputed the magnitude of the Fukushima incident, with workers at the plant still struggling to limit core meltdown in at least three of the reactors as well as re-cooling spent fuel rods at the site. As well, the panelists agreed that the incident was very relevant to nuclear power in the United States, where roughly one-fifth of electricity is provided by nuclear plants, many of which use the same model as the Fukushima reactors. But opinions differed on what those consequences would be.

Khalil pointed out that this was the first natural disaster to cause “grave damage” to a nuclear power plant in nearly 60 years of their use, and that a similar occurrence was very unlikely in the United States. But Benedict argued that “very unlikely” wasn’t good enough for “the most dangerous technology on Earth,” and that not every safety precaution possible had been taken at Fukushima. Topel agreed with the latter point - “why build generators on the ocean side in a country that coined the term ‘tsunami’?” he asked - and noted that the renewed attention to the long-term dangers of nuclear power would only make it more difficult to build new reactors.

In fact, no new nuclear reactor has come online in the United States in 32 years, Khalil said. So while Argonne continues to research new designs for nuclear plants and new strategies for containing nuclear waste, the economic (and possibly now public opinion) barriers are too large. The most likely rescue for nuclear power may come from an unlikely source: climate change.

“If other technologies turn out to be a bust, and if we really are serious about reducing our carbon footprint and carbon pricing becomes important, then there is a technology we have that can produce a lot of energy at relatively low cost compared to the alternatives,” Topel said. “Then, nuclear energy will prosper.”

By the end of the 90-minute discussion, the panelists came back to common ground on a hopeful note. If a thin silver lining could be found on a disaster that hasn’t yet been completely averted, it’s that the events at Fukushima have re-opened the international dialogue on nuclear power - its immense benefits and equally immense costs.

“One of the positive externalities of the Fukushima accident is that many more people are interested in nuclear energy, and I think that’s terrific,” Benedict said. “It’s unfortunate that it takes an accident to do it.”

Elsewhere…

The conversation about cancer is changing, from a single disease classified by the organ where it appears to multiple diseases grouped by genetic and biological similarities. As ScienceLife has written before, the Chicago Cancer Genome Project is our local contribution to this strategic shift against “the emperor of all maladies.” This week the Los Angeles Times examined that research effort and others like it, speaking with project leader Kevin White and many of the Medical Center’s cancer experts collaborating on this new vision of how to classify and battle cancer.

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There are many different stakeholders in fixing the runaway costs of the U.S. health care system, including patients, doctors, hospitals, and the federal government. Another interested party, heavily involved in recent debates over health care reform, is the health insurance industry. As the Patient Protection and Affordable Care Act rolls out in the coming years, insurance companies will need to adapt to many new rules and regulations on matters such as pre-existing conditions and insurance exchanges. But they also have their own ideas about how to reduce health care costs, focusing on two key components of PPACA: health disparities and quality improvement.

Aetna is the third largest insurance provider in the United States, providing medical insurance for more than 17 million people. The Aetna Foundation, their charity and grant-dispensing arm, is focused on promoting wellness, health, and access to high-quality health care. Addressing those goals will also make progress in reducing health disparities, said Anne Beal, president of the Aetna Foundation, in her presentation to the MacLean Center for Clinical Medical Ethics. The strategy she outlined showed how parties who have sometimes been at odds in the health care reform debate can find common ground for the benefit of patients.

Beal, formerly a faculty researcher at Massachusetts General Hospital and the co-author of a best-selling parenting book, made a case for health equity to the seminar series, which this year is themed “Health Disparities: Local, National, Global.” Beal presented now-familiar statistics about higher rates of infant mortality, diabetes, and more in minority communities, but added a new voice to the mix - the words of Martin Luther King, spoken in Chicago in 1966: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

But aside from social justice, there’s also a bottom-line argument to be made for reducing health disparities, Beal said. If you think of disparities as a form of inefficiency in the health care system, billions of dollars could be saved by narrowing those gaps.

“When you talk about health disparities, it is an important opportunity for us to really try to bend the cost curve,” Beal said. “Giving people the right care at the right time and preventing disease is an amazing way for us to really rein back a lot of these health care costs.”

Ensuring that people receive appropriate care falls under the domain of quality improvement (QI), the idea that health outcomes can benefit from fewer mistakes and more efficient delivery of care. Beal admitted that quality improvement was just one of many possible causes of health disparities, but argued that QI was a way to improve care for all patients and reduce health disparities at the same time - a win-win situation, if done right. Simple interventions such as making sure patients receive the right hemodialysis dose or even basic vaccination programs can help overall population health while narrowing the gap between white populations and minorities.

“This is not to say we shouldn’t do special interventions and targeted population efforts and things like that, but we need to stick to the basics,” Beal said. “If you can’t look at a population of children and say that they’re 100 percent vaccinated against measles, then any other intervention you do is just trying to put a band-aid on a bad situation. I would argue that we really need to focus on high quality care as the first step for addressing population health in communities of color.”

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In taking care of sick patients, clinicians have two goals: treating the disease and treating the symptoms. In the case of an infection or a chronic illness, accomplishing this dual purpose is relatively straightforward. But what about when the symptom is something more complicated than pain or nausea? Some genetic disorders carry the consequence of short height, a condition that may have more serious social effects than medical. But clinicians are nevertheless finding new ways to “treat” short height, helping children approach, if not fully reach, the size of their peers.

One genetic syndrome that carries the symptom of short stature is Turner syndrome, the result of a missing or incomplete X chromosome that occurs in 1 in 2,000 female births. In addition to some physical and reproductive abnormalities, Turner patients grow to an average of about 4-foot-7, several inches below the typical height for an adult female. Since 1996, the FDA has approved the use of growth hormone to help Turner patients achieve a closer-to-normal height, and the treatment, while very expensive, has achieved some success. But a new study finds that a second hormone, once thought to stunt growth rather than promote it, might be a useful additive in the treatment of short stature.

Estrogen is prescribed for a variety of medical uses, such as birth control, hormone replacement during menopause, but also as a suppressor of growth in teenage girls. However, the doses of estrogen given via pills or patches are much higher than what the body normally releases into the bloodstream. Some clinicians, including Robert Rosenfield, professor emeritus of adult and pediatric endocrinology, believe that these lower doses of estrogen may actually promote growth, particularly in Turner girls who have a deficiency of the hormone. But many doctors have shied away from giving Turner girls estrogen, he said.

“It’s obvious that normal girls have a growth spurt, and it turns out to be due to estrogen,” Rosenfield said. “But because of this long history of estrogen being seen as a growth inhibitor, people have delayed given estrogen in Turner syndrome until girls were maybe 14 or 15 years old because they didn’t want to rob girls of the growth-promoting benefits of hormone treatment.”

That theory was put to the test in a long-running and controversial study published last week in the New England Journal of Medicine. Nearly 150 girls with Turner syndrome were divided into different height-treatment groups: growth hormone alone, estrogen alone, growth hormone and estrogen, or placebo (this fourth group created some of the controversy, as the girls were not aware that they were receiving no treatment). The treatments were started when the girls were as young as 5 years old until their growth slowed in their teens, signaling that they had reached their adult height.

Between 1987, when the study began, and today, when the study was finally completed and published, the use of growth hormone in Turner girls has become accepted and approved. In fact, as far as growth hormone use goes, the good news of this study was no news, as the effect of GH alone on height was right in line with other, less rigorous studies conducted in Turner girls. The average size of that effect was not staggering: about 5 centimeters, or 2 inches, over the 7 years of treatment.

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There’s no denying that preventive medical screens do save lives, whether through mammograms, colonoscopies, or prostate exams. But for all the benefits, screening is not a one-size-fits-all practice. In the case of prostate cancer, mortality rates have declined by more than 30 percent in the last 20 years as testing levels of prostate-specific antigen (PSA) became a common clinical screen in older men. But other studies of the benefits of PSA screening have been less decisive, including a large 2009 study that found no difference in cancer-specific mortality over the last 10 years. Why the discrepancy?

One answer is that the benefit of PSA screening changes with age - and the reduced life expectancy that comes with age. Though 1 in 6 men will be diagnosed with prostate cancer at some point in their lives, many older men diagnosed with prostate cancer die of something other than the disease. Screening elderly men who already have serious health problems can therefore do more harm than good, paving the way for invasive procedures, risky treatment, anxiety, and health care costs that may have been unnecessary. As a result, many clinical panels have recommended that PSA screening should only be conducted in men younger than 75 or men with at least 10 years of estimated life expectancy due to old age or health problems.

But recommendations do not always match up with practice. To measure the true screening patterns in the clinical setting, a team including Scott Eggener, assistant professor of surgery at the Medical Center, broke down the numbers from a huge national health survey. The data , published this week in the Journal of Clinical Oncology, showed a quite different shape than many would hope: rather than a bell curve with the highest screening rates appearing in men 55-69 who benefit the most, the curve is an uphill climb to a plateau, with men in their 70s receiving the most tests. Men aged 70 to 79 were screened for PSA at almost twice the rate of men aged 50 to 54.

“Our findings show a high rate of elderly and sometimes ill men being inappropriately screened for prostate cancer,” Eggener told John Easton. “We’re concerned these screenings may prompt cancer treatment among elderly men that ultimately has a very low likelihood of benefiting the patient and paradoxically can cause more harm than good.”

When measured according to life expectancy, the results were not much better. Roughly 750,000 men with an estimated life expectancy of 5 years - half of the recommended 10 years - received PSA screening in the previous year.

“The men most likely to benefit from PSA screening are paradoxically being screened at markedly lower rates than men highly unlikely to benefit,” the authors wrote.

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Like the rest of campus, the MacLean Center for Clinical Medical Ethics seminar series is on spring break, resuming in early April with a talk from provocative economist Richard Epstein. So now’s a good chance to get caught up on the previous quarter’s seminars, covering topics under the umbrella of health disparities from the biological factors of breast cancer to the relationship between crime and public health to some of the exciting projects from the Urban Health Initiative. Hopefully, the ScienceLife coverage has kept interested readers informed about the valuable contents of this unique seminar series, but if you prefer a more visual experience, the MacLean Center website has posted several of the lectures in video form. Here’s a recap of the Winter Quarter sessions that are currently available for viewing.

Eliminating Global Disparities in Breast Cancer - Olufunmilayo Olopade Jim Fackenthal, University of Chicago

Unfortunately, Dr. Olopade was unable to deliver her talk due to a last-minute conflict, but Jim Fackenthal, research associate assistant professor in her laboratory, was able to provide emergency relief. The disparity in the survival rates of white women and black women in the United States with breast cancer remains wide, and while some of this gap can be explained by socioeconomic factors, biology also plays a role. Fackenthal talks about the evidence for more aggressive and harder to treat forms of breast cancer in women of West African origin here and abroad. The group’s research projects span from laboratory experiments on genetics and epigenetics to blood testing and screening in Nigeria.

Births to Arab-American Women Before and After 9/11: Evidence of Stress Effects - Diane Lauderdale, University of Chicago

The terrorist attacks of September 11, 2001 were stressful for all Americans, but possibly most challenging for Arab-Americans who experienced discrimination in the wake of the events. Lauderdale, a professor of epidemiology, wanted to look at whether one could measure a negative health impact of this discrete period of stress, choosing premature or underweight births as a health outcome potentially sensitive to discrimination. It wasn’t an easy task, as Lauderdale and her collaborators first had to develop an algorithm to find names in California’s birth registry that are likely of Arab origin. But the results of the study were striking, as Lauderdale was able to measure a spike in babies born underweight to Arab-American mothers in the months after 9/11, without any significant changes among other ethnicities.

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Alien Life & Scientific Skepticism: The Sequel

In a bit of deja vu this week, a new paper stirred up fevered online debate about the existence of aliens among us - and the traditions of scientific publications. This time, ground zero for the debate was not the bacteria of arsenic-laced Mono Lake, but microscopic filaments on a rare group of meteorites collected in Antarctica in the 80’s and 90’s. In a paper published last Friday by the Journal of Cosmology, NASA scientist Richard Hoover argued that these filaments are bacterial fossils, of species that fell to Earth with the meteorite - a conclusion that was breathlessly reported by Fox News with the lede “We are not alone in the universe.”

Panspermia, the idea that life on Earth may have been seeded by alien organisms that arrived on the backs of meteorites, is a seductive idea. But as the old saying goes: once bitten by reports of alien bacteria, twice shy. Far fewer science reporters fell for the meteorite alien bacteria as they had on the arsenic-based bacteria story of last December, perhaps because of a lesson learned or merely because of the lower-profile journal in which the new paper appeared. And while the criticisms over the arsenic study took a few days to seep from science blogs to mainstream media, the travel time was much shorter this time around - Phil Plait’s skepticism on his Bad Astronomer blog was quickly trailed by an AP story that carried a chorus of criticism. Questions about the qualifications and objectivity of the author and the journal soon followed, as the Columbia Journalism Review recaps.

As with the arsenic story, the meteorite episode was almost more fascinating for what it says about modern scientific communication than what it said about science itself. On the surface, the Journal of Cosmology appeared to take some progressive steps for publishing research, including making the article free and open access and soliciting commentaries from “100 experts” on the findings, 24 of which were published soon after the original article. That move would appear to address one of the critiques of the team that published the arsenic bacteria paper, regarding their attitude that criticism was only valid through traditional (and slow) peer-reviewed channels, instead of online discussion that is able to react more immediately.

However, a very thorough, critical commentary by microbiologist Rosie Redfield (who also sounded the first alarm about the arsenic bacteria research) has not been published by the journal, while some very odd commentaries have, such as one concluding “Hoover’s findings are incompatible with the creationist model of life based on biblical Genesis and Aristotelian philosophy.” The journal has also reacted petulantly to criticism, posting an editorial called “Have the terrorists won?” that claims “Only a few crackpots and charlatans have denounced the Hoover study.” So while the latest alien bacterial invasion of Earth’s media is showing some steps in the right direction, it also signals that the growing pains of adapting scientific discussion to a faster media age are still present.

Elsewhere…

Last week, the Medical Center was part of a four-way kidney swap that spanned the country, from the Bronx to California (we should have a video of the event posted next week). Coincidentally, in a New York Times editorial published Sunday, the Medical Center’s Lainie Ross argued that such swaps or “donor chains” were a better option than proposed revisions to the current organ allocation system that would prioritize younger recipients.

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Cooking indoors over firewood and dung is a tough habit to break for billions of poor people around the world. But Sola Olopade, MD, professor of medicine and family medicine, found a way. He wanted to stop women from hunching for hours over open fires inside their houses, cooking with babies strapped to their backs. The air in such houses quickly becomes filled with toxins, and the women and children have a host of bad health consequences.

“It’s the most unclean combustion you can get,” Olopade said in his seminar earlier this month at the MacLean Center for Clinical Medical Ethics. “The women and children have coughs, headaches, runny noses, chest tightness.”

Those are just the health problems he could measure. “I wonder what kind of cognitive dysfunction people develop in spaces where the carbon monoxide is so high.”

Unfortunately, the billions of poor people who cook their daily meals over firewood and dung have few other options. Without electricity, Olopade said, “energy poverty drives people to use whatever they can get their hands on.” But Olopade was determined to see whether education and a little technology could make it less dangerous for people to breathe inside their houses.

Olopade, who is clinical director of the University of Chicago Global Health Initiative, went to two small villages in his native Nigeria, ready to distribute energy-efficient ceramic stoves. He believed the simple stoves could make an enormous improvement in the community’s health. His team measured the air quality inside 100 homes, and found heavy metals, carbon monoxide, and particulate matter more than twenty times the World Health Organization acceptable standards. The researchers also educated the community about the dangers of exposure to smoke from using firewood to cook indoors and the benefit of using the new stoves, handing out brochures about cooking in their native dialect.

“I told them without medical jargon that this was killing people,” Olopade said.

Three months after giving the stoves to the families in the villages, Olopade returned. He took the same air quality measurements, repeated the survey of symptoms and saw a remarkable improvement. Carbon monoxide and particulate matter levels were dramatically lower, much closer to the WHO standards.

“People were very happy with the stoves. They’re very simple. They’re lined with ceramic which retains a lot of heat and promotes more complete combustion of the firewood or biomass fuel,” Olopade explained.

The women were burning the same fuel - cow dung, agricultural waste, and firewood - but the stoves had kept most of the pollutants from pouring into the homes. With this small change, “you can really improve the indoor environment,” Olopade said.

The health benefits were drastic. Before the intervention, many of the children and most of the mothers suffered from dry cough, runny noses, burning eyes, breathing difficulties, chest tightness, headaches and dizziness. All of these health problems plummeted after they started cooking on the clean stoves.

“Just by engaging the community in partnership, educating them on the dangers of exposure to toxic fumes and giving people efficient stoves, without changing their lives much, the change in symptoms is dramatic,” Olopade concluded.

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Sen. Dick Durbin tours Argonne National Laboratory with Rick Stevens, Professor of Computer Science (photo courtesy of Argonne)

In Washington, the fight over budget cuts is well underway, as a Republican majority in the House and a Democratic majority in the Senate tussle over the best way to reduce a multi-trillion dollar federal deficit. The first bill of the new House, H.R.1, set federal appropriations for the rest of fiscal year 2011 (ending in September) and snipped $61 billion from the budget, predominantly from discretionary domestic spending. One target of those cuts would be the National Institutes of Health budget, which would lose roughly $1.6 billion of its $32 billion budget for funding scientific research in the United States.

As you might expect, this news was not welcomed by Chicago-area researchers, who turned up in lab coats to support a news conference by Sen. Dick Durbin last Sunday at Northwestern University’s downtown campus. Durbin vowed to fight against the cuts as H.R.1 is discussed in the Senate, saying that interrupting the funding would slow progress toward new treatments for diseases such as AIDS, diabetes, and cancer. (video here)

“When you put these research projects on hold, you can’t ask the laboratory mice to take a nap,” Durbin said. “You can’t ask the cultures to stop growing - we’ll get back to you at the end of the fiscal year. And you can’t expect the professional researchers, the men and women who have dedicated their lives to medical research, to have certainty that next year they’ll have a job.”

Researchers from each of the major Chicago academic hospitals appeared at the conference and talked about how the proposed budget cuts could harm their own projects. Michelle Le Beau, director of the University of Chicago Comprehensive Cancer Center, discussed the biomedical research underway at UChicago thanks to the nearly $300 million in NIH funding received this year and last. Le Beau focused in on her own research examining therapy-related acute myeloid leukemia - a “very cruel and ironic” cancer caused by the chemotherapy and radiation treatment of a prior tumor. Any job losses that follow from NIH cuts could break up the expert team she has formed to study causes and treatment of the disease, she said.

“A lapse in funding will result in dismantling our highly specialized research team, and this leads to a loss of capability, because it takes years to assemble these teams again,” Le Beau said. “These are individuals who have trained for years to apply their extraordinarily unique skills. They have families to support and bills to pay.”

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The fickle attention of political pundits has shifted of late from health care reform to budget cuts and labor union protests. But as the Patient Protection Affordable Care Act (known as “Puh-Paca” or the ACA in medical circles) nears its first birthday, much of the real drama is just beginning. Because its changes were designed to roll out slowly over 4 years, many people have not yet directly felt the effects of the ACA in their lives. But the primary players in American health care, including insurance companies, hospitals, and doctors, have been scrambling to guess where they will find their footing in the new medical landscape. That isn’t easy,  Jeff Goldsmith warned in his MacLean Center for Medical Ethics seminar, as the future landscape remains in unpredictable flux.

In the late 70’s and early 80’s, Goldsmith worked at the Medical Center as Director of Planning and Government Affairs and Special Assistant to the Dean of the Pritzker School of Medicine. Now he runs Health Futures, a health care consulting firm, and frequently writes and speaks on the changing world of health care. As you might expect, Goldsmith is pretty well-versed in the gritty details of the ACA, having read the entire 2900 pages of the legislation twice, he said.

“The depths of my masochism now stands revealed to you all here in public,” Goldsmith joked. “I’ve become a Talmudic scholar of this legislation.”

Now that he is well informed about the content of the act, Goldsmith’s critical assessment was a pretty firm thumb’s down - not as a partisan, but as a policy analyst. Goldsmith criticized the delayed activation of many of the act’s effects, arguing that spacing them out over two election cycles made it vulnerable to repeal if power shifted in Washington (as it started to in 2010). Though reducing medical costs was touted as a priority of the bill, the legislation does “nothing meaningful” along those lines, he said. And by expanding Medicaid and placing additional financial burden upon already struggling state budgets, the reforms may threaten the bottom line of hospitals who depend upon government reimbursement for treating patients on public insurance.

“We’ve taken an enormous fiscal risk, and it could turn out great, or it could turn out terrible,” Goldsmith said.

But many of these worst case scenarios are dependent upon how the legislation is implemented and whether new models of care and payment can be designed - quickly. The act gives the Centers for Medicare and Medicaid Services $1 billion a year (up from $30 million a year) to evaluate new ideas for delivering health care more efficiently and at lower cost. That’s one area where academic medical centers have the power to step up and steer the future of health care through programs like Healthcare Innovation Zones, Goldsmith said. The emphasis on cutting-edge research and the integration of clinics and hospitals at academic centers should also be an asset as the healthcare rules begin to shift.

“I think academic institutions have numerous strengths that give you a capability to respond that doesn’t exist in non-academic places,” Goldsmith said. “I think both the meritocracy and the reverence for science that pervades these places are a plus in environments where you have to begin making choices about what care people receive.”

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In a famous 1999 study, 700 physicians were given a simple case-study task. Each watched a video of a patient-actor describing chest pain and were given basic test results for that patient. Each doctor was then asked whether they would recommend the patient for cardiac catheterization, an additional diagnostic procedure. The patient cases varied in terms of type of chest pain, stress test results, and heart history, influencing the physician’s eventual decision. But when all of those clinical factors were controlled for, two other factors remained: race and sex. With everything else equal, black patients and female patients were 40 percent less likely to be recommended for catheterization; black, female patients were 60 percent less likely to be sent to advanced care.

“People assume that when physicians take the Hippocratic oath that somehow there is a miraculous, magic process that makes us free from any inherent stereotypes or biases that we may have had through our whole lives,” said Monica Peek, assistant professor of medicine in her MacLean Center for Clinical Medical Ethics seminar. “We want to be good physicians and give good care and be unbiased in our assumptions. But there’s not really any magic that happens just because you get a medical degree.”

Many studies of the health effects of discrimination focus on the world outside the doctor’s office, where the cumulative effects of sexism and racism negatively affect clinical measures such as hypertension and cardiovascular disease. Less attention is paid to discrimination within the healthcare system, Peek said, the often subconscious biases that physicians and other caregivers may use to make snap judgments about patients. Discrimination in this setting might directly affect preventative measures such as vaccination or screening, lower adherence to prescribed medications, and decrease patient satisfaction.

One way to combat discrimination within healthcare is to elevate the patient’s role in their treatment, creating a patient-centered and shared decision-making model. Research suggests that when the patient is an active participant in their care rather than a passive recipient of doctor’s orders, measures of trust, understanding, and satisfaction improve - and chronic disease measures such as glucose levels and blood pressure are better controlled. But for many African-Americans, shared decision-making in a healthcare setting is a foreign concept.

A 2008 focus group study led by Peek found that many African-American patients wanted to be involved in the decision-making process with their doctor, but many told stories that showed a less than equal relationship:

• “We make decisions together and she gives me what I’m suppose to take and she knows what I’m suppose to take.”
• “She told me I need to go to the dermatologist … Now the lady up there at the check out desk. I told her that I didn’t want to go.”
• “See, when the doctor tells me what to do, then I can make up my mind whether or not to do [it].”

“Basically African-Americans…wanted shared decision-making as much as their non-hispanic white counterparts when we adjusted for class and education - and maybe a little more so,” Peek said.

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When health disparities in urban populations are discussed at the University of Chicago Medical Center, it’s not an abstract, far-away concept. Only a few blocks west and south of the hospital campus are some of the poorest neighborhoods in Chicago, where nearly every health statistic one finds is shocking. Pick any measure - diabetes, heart disease, obesity, infant mortality, or violence - and the numbers in some South Side neighborhoods are closer to those found in developing countries than they are to more affluent North Side neighborhoods mere miles away. The problem is exacerbated by a decline in health services on the South Side of Chicago, from losing more than 2,000 hospital beds in the last decade to a sparse density of grocery stores and exercise facilities.

In response to this health crisis, the Medical Center launched the Urban Health Initiative to execute a multi-faceted campaign of patient care, education, and research. But an important first step in fixing the health disparities on the South Side of Chicago is measurement, obtaining updated and accurate statistics on the healthcare needs of the region and cataloging the resources already available. At the MacLean Center for Clinical Medical Ethics seminar series earlier last week, associate professor of obstetrics/gynecology and medicine Stacy Lindau updated the progress of the UHI’s measurement arm, the South Side Health and Vitality Studies.

The first aim of the SSHVS is to build a map - not of transportation routes, but of neighborhood assets. Recently, organizations such as the World Health Organization and the Robert Wood Johnson Foundation have started to define an area’s health system as “intersectoral,” stretching beyond direct medical care to other aspects of the community that impact the population’s health. For the last two years, the Community Asset Mapping project of the SSHVS has sent out college and high school volunteers to measure assets such as grocery stores, gyms, daycare centers, government services, churches, and more on the South Side of Chicago. The fruits of those efforts are twofold: both a resource for the community and a baseline for UHI research on improving the broader infrastructure of the region, Lindau said.

“Has anyone ever described anywhere all the components of an intersectoral health system and how they’re working together? Has it ever been empirically evaluated or studied? The answer is no,” Lindau said. “But where are we starting to this? Here on the South Side of Chicago, where we’re mapping every single built asset in the primary service area of the University of Chicago…and trying to understand: if everybody’s in the health system, then what’s everybody’s role?”

So far, 11 of the 34 community areas that make up Chicago’s South Side have been mapped, and the information is already proving its value as the “highest-quality asset list for this region,” Lindau said. Compared to the most recent commercially-available resource guide, the mapping project found 4o percent more assets…and found that 30 percent of the resources listed in the commercial guide were no longer in existence. Unlike that flawed information, the mapping project’s data is available for free through a customizable map program on southsidehealth.org (one of many website domains the program has wisely snapped up for community outreach purposes) that allows visitors to search by asset-type and location for 16 different categories. Lindau also hopes to someday incorporate the information into electronic medical records, so that patients can take home a printout of their nearby health resources after a doctor’s appointment.

“You can’t do this on Yelp or Google,” Lindau said. “You can’t map places by disease or by need. I think we have something really special here.”

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Photo by "BankingBum" - Wikimedia Commons

The leading cause of death for American black men between the ages of 15 and 34 isn’t cancer, AIDS, heart disease, or even accidents. It’s homicide, which accounted for more than half of the deaths of black 15 to 24-year-olds and more than a third of those aged 25 to 34. In Chicago, African-American males aged 15-24 are 10 times more likely to be killed in a homicide than white males, and in 2004, more African-Americans died from homicide than diabetes, HIV, or stroke. Genetic predisposition, access to health care, diet and exercise - all pale in comparison to bullets and knives.

Those numbers clearly argue that any discussion of health disparities between white and black populations in the United States can’t be limited to disease, said Harold Pollack in his MacLean Center for Clinical Medical Ethics seminar in late January. Urban, minority populations bear the brunt of the consequences of crime, he demonstrated, including not only homicides but also non-fatal injuries, incarcerations, economic damage, and stress. So while a project like the University of Chicago Crime Lab, for which Pollack serves as co-director, is rooted in the social sciences, the success or failure of its mission will surely have an impact upon medicine and community health.

“If you actually count up the number of dead bodies and in particular the number of life-years lost, homicide is a significant public health threat and it requires a systematic, determined response,” Pollack said.

The most shocking graph Pollack showed during his talk had nothing to do with cancer rates or disease mortality, but instead with incarceration. While the proportion of Americans behind bars remained stable from 1920 to 1970 at roughly 1 in 1,000, from there the numbers took an upward spike to make the climate change “hockey stick” graph jealous, increasing fivefold to today’s rate. As the numbers of jailed Americans skyrocketed, the prison population also became significantly less white, Pollack said, with the white incarcerated population dropping from 60 percent to 30 percent of the whole.

The “incarceration epidemic” causes significant public health ripples, both direct (through violence, HIV transmission, and drug addiction) and indirect. Disparities of incarceration have strained relations between minority communities and police, Pollack argued, making crime prevention in dangerous neighborhoods more difficult. Hiring biases against applicants with criminal records make it hard for convicted felons to find jobs (not to mention health insurance) after their release, steering them back toward illegal activity. For those jailed as juveniles, the lost time in school only intensifies the struggle to find legit work.

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