By Dianna Douglas

The public health threats in Chicago aren’t just diabetes, asthma and hypertension—about 500 lives are lost every year in the city by homicide.

The University of Chicago Medicine fights the root causes of deadly violence in various ways. One recent attempt is through a partnership with CeaseFire, a group in Chicago that uses public health techniques to identify and interrupt outbreaks of violence with the same intensity as an outbreak of malaria or AIDS.

The work of CeaseFire, documented in the acclaimed 2011 film, The Interrupters, has had mixed results in lowering Chicago’s crime rate. The CeaseFire foot soldiers, called “violence interrupters,” mediate fights to try to keep them from escalating. They are hoping to change the societal norms among people who view violence as an acceptable way to solve conflict. But homicides wax and wane in the city, and the violence interrupters have had a frustrating 2012 so far, with the murder rate 60% higher than the same period last year.

The University of Chicago Medicine will host a total of 6 screenings of The Interrupters around the city this spring. Each is followed by a community discussion. The goal is to give the public some ideas on how to stop violence. Rather than seeing violence as a problem that should be addressed with crime control (more police, more incarceration), they hope that the community can view violence as a disease. The people infected by the disease need treatment and programs rather than judgment.

Below are scenes from one of these screenings and a discussion at the Rainbow PUSH coalition on April 10. Eric Whitaker, MD, MPH, executive vice president of strategic affiliations and associate dean of community-based research at the University of Chicago Medicine, served as the facilitator for the panel.

By Matt Wood

Family medicine physicians try to stay current in their fields by reading the latest medical journals and research literature, but the volume of new research can be overwhelming. To deal with this flood of information, the Family Physicians Inquiries Network created a system called Priority Updates from the Research Literature, or PURLs, in 2007 that is published in the Journal of Family Practice.

The PURLs series has covered a broad range of topics, such as when to expose children to radiation by CT examination after a fall, what medications can treat an infection in a pregnant woman without increasing the risk of birth defects and how best to control atrial fibrillation to prevent a stroke. Each month a network of physicians surveys the relevant literature for articles that might be useful in the typical family medicine setting. An editor then assigns a physician to write an article for the journal that puts the new research into context and examines its impact for family practitioners.

Nina Rogers, MD, and clinical assistant professor in the University of Chicago Department of Family Medicine, participates in this program and has written articles spanning a range of maladies, from appropriate treatment for persistent asthma to, more recently, a home remedy for a common problem that could save time and money for both patients and physicians: removing excess ear wax.

Rogers and a colleague from the University of Missouri wrote about a study published in the Annals of Family Medicine in which physicians from England found that patients can safely and effectively remove excess ear wax on their own. Patients who were given ear drops, a bulb syringe and instructions had on average 50 percent fewer office visits to remove ear wax than patients who were not encouraged to do it at home.

The relative success of home remedies like removing ear wax with a bulb syringe or treating athlete’s foot with corn starch depends on what Rogers calls “patient buy-in.” This is where close relationships earned by treating multiple generations in a family medicine practice comes in handy.

“There’s the component of physician-patient relationship, how much they trust you and how much they’ll take your advice,” Rogers said. “A lot of it is knowing your patients, what’s going to help them. Sometimes saying ’studies show that this is beneficial’ is good, whereas to others you say, ‘I recommend this to a lot of patients.’ Knowing how to present information to them definitely helps buy-in.”

Research on home remedies might seem mundane, but fewer office visits for procedures that patients can perform safely on their own can save time and money for both patients and community facilities that are often strapped for resources.

“We have barriers to how much patients can spend for medicine, so sometimes we have to come up with creative or inexpensive ways to treat an ailment,” Rogers said. “The exciting feature about this study is that there is now an evidence-based non-pharmacologic treatment we can recommend confidently.”

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Rogers N, & Stevermer JJ (2011). PURLs: Ear wax removal: help patients help themselves. The Journal of family practice, 60 (11), 671-3 PMID: 22049350

By Dianna Douglas

Imagine your doctor says he plans to increase your oral medication to control your diabetes. You do not like taking pills. Should you:
A. Not rock the boat with your doctor and agree to take the increased dosage?
B. Agree, but keep taking the same number of pills?
C. Try to discuss another option with your doctor?

Monica Peek, MD, assistant professor of internal medicine at the University of Chicago, believes the best answer for long-term health and happiness is C. But she knows that low-income African Americans with diabetes will often, for a variety of reasons, agree with the doctor and then ignore the advice. Peek has spent hours leading classes with patients from this vulnerable group. They role-play talking to their doctor, critique each other as they practice, and give a debriefing on whether they could ever truly feel comfortable taking an active approach with a physician.

The classes are part of a new program to chip away at the disparities in diabetes among low-income African Americans. The gap is huge. The prevalence of diabetes on the South Side is 19.3 percent, compared with an average prevalence in Chicago of about 7 percent. African American neighborhoods in Chicago have five times the rate of diabetes-related leg amputations as primarily white neighborhoods do.

Three years ago, about 40 people at the University of Chicago Medical Center with expertise in nutrition, cultural tailoring, communication, quality improvement, and even community organizing launched an effort to close this gap. They were prepared to tackle multiple factors that exacerbate diabetes outcomes on the South Side. Among them are unhealthy eating habits, limited safe places to exercise, food insecurity and less access to health care.

Their first move was to get out of the hospital.

The group created teams at six community health clinics to focus on improving diabetes care. They led patients on field trips to local grocery stores to practice making smart food choices. The physicians were constantly on the radio, at health fairs, in churches and high school gymnasiums, educating South Siders about diabetes. Still, the Medical Center team ran into challenges from all sides.

“The economic factors of people choosing between food and medications don’t account for all of the disparities,” Peek said. “There is racial and cultural baggage that creeps into clinical encounters between doctors and poor African American patients.” As an example of this long history of bias, Peek cites a famous 1999 study from Georgetown University in which cardiologists were found to offer better care to men over women who complained of heart problems, and to white patients over black patients.

“People who have had bad interactions with the health care system may delay treatment until their condition is dire,” Peek said. Some say they are afraid of being experimented on, that they don’t trust doctors to do right by them, or that they dislike the perceived power imbalance of being in a doctor’s office.

Peek said she was surprised to learn how some low-income African Americans view the doctor-patient relationship. A woman told her that she gets agitated when she goes to a doctor’s office and hears, “What brings you here today?” — she thinks the doctor is saying, “Why are you sitting in front of me when I’m so busy?” read more

By Dianna Douglas

The goal of World AIDS Day 2011 is not to make the public aware of the disease. That was the goal in 1988, back when the international health threat was still new, infections were rising every year, and there was no hope of a treatment in sight. This year, World AIDS Day marks the sunset of the public panic about the virus. The stated goal this year is “getting to zero” — or bringing the number of AIDS-related deaths and new HIV infections down to zero and ending all discrimination against people living with the virus.

The University of Chicago has various ways of reaching that goal here in Chicago. There’s the STI/HIV Intervention Network (SHINE) based at the School of Social Service Administration, which brings interventions to neglected groups such as men who have sex with men, people in the criminal justice system, minority youth, and young couples. There’s also the Medical Center’s Living Positively program, in which HIV-positive young people act as advocates to their peers who are at risk.

Now, in honor of World AIDS Day, the Medical Center is trying an innovative approach to this public health issue. Instead of doing what he calls the “typical academic thing for World AIDS Day” — a panel of researchers talking about AIDS in Africa in an auditorium full of other researchers — John Schneider, MD, MPH, has organized a ball. “This year, we want to collaborate and fully engage with the community,” he said. In gay culture, a ball is where people dress in drag to show off their moves, a lot like a fashion show. The community he hopes to reach with this ball is the young GLBTQ (gay, lesbian, bisexual, transgender, and queer) minorities who have the highest HIV infection rates in the city.

While the tide may have turned in the AIDS epidemic, the infection rates of several groups remain stubbornly high. Around 22,000 people in Chicago live with HIV or AIDS, and the infection rates among African Americans and gay men are particularly sobering. Since 2005, 57 percent of new HIV infections in men have been a result of men having sex with infected men. Among African Americans, the HIV infection rate since 2005 is more than double the general population’s infection rate.

A partnership with the young people striking a pose at underground balls may seem unusual, but it may also be the best way to reach Chicago’s most vulnerable populations. “We know where the epidemic is, and we have the tools to take care of it. What is needed now is hard work using traditional case-finding methods to reach these vulnerable groups with health services,” Schneider said.

The ball tradition, subject of the award-winning documentary Paris is Burning, has long been a safe place for young black gay and transgendered people to express their creativity and build communities. The World AIDS Day mini-ball will celebrate the support that the members of this subculture offered each other during the worst days of the AIDS epidemic in the 1980s and ’90s.

“These are the people most impacted by AIDS in the United States,” said Keith Green, MSW, co-director for the Chicago Black Gay Men’s Caucus and a co-sponsor for the event.

Everyone at the ball will see their peers promoting safe sex and healthy behavior.

Contestants — many of whom are gay, transgender or bisexual — will compete against one another in the lobby of the School of Social Service Administration this Friday night. Participants will display their dance skills, costumes and attitude in a variety of events, similar to a runway show. In some events, they will be judged on the “realness” of their drag. In others, on the beauty of their clothing and overall style. Each of the seven walk competition categories has a cash prize for the winner.

“Every category requires the creative integration of the AIDS ribbon, the color red, or latex,” said Matt Richards, outreach program manager for pediatric infectious diseases at the University of Chicago Medical Center.

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It has been a couple months since the end of the spring quarter, and the with it the end of many of the Medical Center’s weekly lecture series. But a recent batch of videos posted to the website of the MacLean Center for Medical Ethics brought a whiff of the school year to the dog days of summer. The videos feature a selection of the lectures from the third and final segment of the 2010-2011 theme, “Health Disparities: Local, National, Global,” [pdf] and run the gamut of expert perspectives from libertarian law and the insurance industry to black history and medical education. If you are going through lecture withdrawal or want to get excited for next year’s MacLean Center series (“Medical Professionalism and the Future of American Medicine” [pdf]) beginning in late September, enjoy these videos.

The Case for Health Disparities - Richard Epstein, University of Chicago

Richard Epstein’s annual contribution to the seminar series is always a combustible reaction, where the classically conservative law professor’s market economics conflict with the more liberal lean of the regular audience. This year’s topic was especially flammable - after a couple dozen lectures on the struggle to reduce the health care gap in the United States and around the world, here was Epstein arguing for preserving those very same inequities. Beyond the deliberately provocative title, Epstein’s characteristically off-the-cuff speech recommended that health care reformers should choose a different target - instead of minimizing the health care differences between top and bottom, push policies that support growth and innovation for all patients, rich or poor, while encouraging charity instead of coercive giving.

Future Directions for Health Equity - Anne Beal, Aetna Foundation

The Aetna Corporation is in the business of providing health insurance to Americans. The Aetna Foundation is the charitable arm of that company, dispensing grants and funds to research ways of improving the health care system and reducing costs. Researcher and author Anne Beal is the current president of the Aetna Foundation, and focused her talk on reducing costs and inequalities via improving the quality of health care in America. “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,” Beal said. [Original Article]

“Without Health and Long Life All Else Fails”: African-Americans and the History of the Elimination of Racial Disparities in Health and Health Care - Vanessa Northington Gamble, George Washington University

Obviously, racial disparities in health care are not a new phenomenon. Efforts to improve the health of African-Americans also didn’t begin with the civil rights movement, though the strategies employed by the disparity-fighters of the segregation era were very different from today.

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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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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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