By Matt Wood

Video conferencing has crossed the threshold from corporate boardroom to the household in the last few years. Anyone with a Skype account or an iPhone can host their own video chats. Now, a group at the University of Chicago Medicine is using video conferencing as a way to train primary care providers in clinics throughout the South Side of Chicago.

Daniel Johnson, MD, associate professor and chief of the Section of Academic Pediatrics, has taken a telemedicine system called Project ECHO and applied it to an urban environment. Project ECHO (Extension for Community Healthcare Outcomes) was a model originally developed at the University of New Mexico to train health care providers in rural clinics using video-conferencing equipment.

“Providers in urban areas, generally speaking, work their tails off, particularly if they’re working with an under-served or under-insured population,” Johnson said. “They quite simply don’t have the time to take advantage of some of the learning opportunities that are around them. So they end up being academically isolated, intellectually isolated and in some cases socially isolated. This system provides a forum for them.”

Johnson, along with colleagues at the University of Chicago and in the community, developed a pilot program for the ECHO system to train primary care providers on resistant hypertension management. They set up the video conferencing systems at six Federally Qualified Health Centers (FQHCs) affiliated with the South Side Healthcare Collaborative and conducted 12 sessions scheduled every other week over six months.

Each session began with a 20-minute lecture by George Bakris, MD, professor of medicine and director of the University of Chicago Medicine Hypertension Center, on topics such as how and when to take blood pressure, how to make sure patients take medications properly and how to treat hypertension in the elderly. Following the lecture, medical staff from the participating clinics presented cases of patients with resistant hypertension and discussed them with the group.

At the end of the 12 sessions, the providers who participated in the ECHO training sessions scored significantly better on a knowledge test about resistant hypertension than at the beginning of the project, and better than a control group that did not participate. They also said they were much more confident in their ability to treat resistant hypertension than before they started. The results of this study were published in The Journal of Clinical Hypertension.

Johnson says this method has a number of advantages over other remote training formats such as webinars or standard video presentations. “The video conferencing has the value over most other remote formats of making you feel like you’re almost in the room with other people,” he said. The cost to equip a site with video cameras, monitors and network equipment runs from $1,500 to 3,000. While this is a high initial investment for a small clinic, it’s more cost-effective than sending a physician to a training course and losing their services for a full day or more.

The format also mimics traditional case-based rounds in which most clinicians in academic medical institutions learn. “The subject matter expert isn’t the only person providing value to the activity because the other people in the room all have experience that is valuable to each other,” Johnson said. “So there is value in the shared experience that comes from people’s sitting around learning together.”

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By Dianna Douglas

Maybe you’re the type of person to see a tiny nonsensical phrase in the credits of a movie and actually dig into it online. Be careful—you might find yourself sucked into a mystery story. Over the course of a week, you get a text message from someone you’ve been mindlessly Googling, you get an email with a riddle, and you find a chatroom with hundreds of people asking questions about clues they’ve found. You pick up more hints in this puzzle—on your phone, from YouTube, in your inbox, on a major website like Amazon. By the time you have solved the mystery, you know that the entire cloak-and-dagger game was orchestrated by the movie studio to create buzz. And it worked.

Instead of marketing the next summer blockbuster, Melissa Gilliam, MD, professor of obstetrics and gynecology and pediatrics at the University of Chicago Medicine, wants to deploy these tools to keep urban kids from getting pregnant or contracting infections. If this goal hardly distinguishes her from a million other people working with disadvantaged youth, her methodology certainly does: she is inviting them to play a secretive, science-fiction transmedia game on their computers to get them to rethink contraception, STIs and the cycle of poverty.

“Playing games can shape social attitudes and transform behaviors,” Gilliam said. “But I am not certain if anyone has tried to use a transmedia game in this context with urban youth.”

First, an explanation: A transmedia game is a story that unfolds across multiple digital technologies. It is usually designed by a video game, movie, or television show creator for that subset of the audience who wants to take the experience out of the screen and into everyday life.

This transmedia game is being orchestrated by Gilliam and her colleague Patrick Jagoda, PhD, Mellon Postdoctoral Fellow of New Media in the Department of English at the University of Chicago. It will launch on March 12th, and will be live for two weeks. They and their team of game developers will drop clues online and in the real world during that time, leading young players on a scavenger hunt for health and science knowledge and letting the players create content for each other.

The first hint in the game is already being planted at various places across Chicago. The developers are also drawing players into the game with Facebook and Google advertisements. The ads will direct these curious people to a website. Right now, the website is just a countdown clock to March 12. When the game starts, it will be a hub of clues.

(The plot and characters are under wraps until it’s over, so don’t look here for spoilers.)

“We don’t know who will play the game,” said Ainsley Sutherland, the research coordinator for the project. “But it was designed by 14 to 17 year olds, for their friends and peers.”

The research group plans to collect demographic information, to survey the people who play, and to monitor the online forum to see what they learn by playing. Gilliam is hopeful that the game will reach the target audience of poor, urban young people of color.

“I hope they realize that their course doesn’t have to be determined for them,” Gilliam said. By helping the young players think critically about health disparities and increase their health literacy in an augmented reality game, Gilliam hopes they’ll feel empowered to choose their sexual path in real life.

“Sexual and reproductive health is about your sense of relationships, and where you fit in the world. Young people who reach their full potential know what dangers they face and what hinders them. And they learn to reach beyond it.”

Will they play? Will they run away at the faintest whiff of being educated by an academic medical center? Will they think more critically about their social and cultural pressures to make poor reproductive choices?

And the million dollar question: Will their sexual behaviors change? read more

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

As another year comes to a close we’d like to look back at the fascinating research breakthroughs and inspiring patient stories from 2011. ScienceLife ran 168 posts this year, and while we wish we could highlight all of them, here are a handful of our favorites from each month.

January

Patrick Wilson found out that the H1N1 virus could end up helping us fight all types of flu. Stephen Pruett-Jones studied how some male birds mimic the sounds of predators to pick up the ladies (with an audio clip). We interviewed David Gozal about his study on the link between childhood obesity and lack of sleep, and took a look at NCAA regulations mandating sickle cell testing for athletes.

February

Harold Pollack gave a lecture on why violent crime in urban, minority communities should be considered a public health epidemic. Siri Atma Greeley studied the actual medical benefit of widespread genetic testing. Stacy Lindau wanted to know why so few women get help for sexual problems after surviving cancer. We talked to Bana Jabri about the causes of celiac disease, and Sliman Bensmaïa showed us how the brain processes the basic elements of touch very much like it handles visual information.

March

Sola Olopade educated women in Nigeria about using clean-burning stoves to prevent indoor pollution. Stefano Allesina and Jonathan Levine looked at how rock-paper-scissors helps explain evolution. Joshua Miller went to Yellowstone Park to see what stories the ghostly bones of animals can tell, and Scott Eggener questioned the wisdom of indiscriminate prostate cancer screening.

Photo by Gerald Waddell

Andrea King studied the wide range of responses to drinking alcohol, and why it can be fun for some people and a bummer for others. Cheryl Reed took a ride in a helicopter with our UCAN nurses. Kamal Sharma looked at the genes that control animals’ gait, and Ningqi Hou studied how urban environments can dictate how much exercise people get.

May

Daniel McGehee looked at the long-term effects of nicotine on the brain. Habibul Ahsan went to Bangladesh to study the health impacts of accidental exposure to arsenic in drinking water. The brain’s overlooked supporting cells got their due at a conference on neuroscience, and we remembered a landmark discovery about a once popular drug taken during pregnancy that we now know can cause cancer.

June

As we headed into summer, Diana Lauderdale used Google to track MRSA. We learned about an extraordinary transplant where a man received a new heart, liver AND kidney. Daniel Geynisman gave us the rundown on whether or not cell phones are killing us (they’re not, as long as you don’t use them in the car), and some UChicago undergrads studied what happens to gorillas on the birth control pill.

July

We spoke to Donald Jensen and Andrew Aronsohn about the new outlook for patients with hepatitis C. Igor Schneider made a time machine to find the genetic switch for limb development. Farr Curlin led a study about the benefits of addressing spiritual needs alongside medical care, and Adam Cifu looked at the phenomenon of scientific study reversals.

August

Stefano Allesina dug into the long, shady history of nepotism in academia in Italy. John Schneider talked about his work addressing sexual health and stigma in India. Michael Becker discovered a new treatment for the Royal Disease, and we had the rare chance to name check a Spiderman villain in a post.

September

Martha McClintock and Suzanne Conzen studied the connection between social isolation, stress and breast cancer. Gallego Romero traveled to India to search for the origins of lactose intolerance. Stephanie Dulawa developed a mouse model for OCD, and Paul Vezina looked at a different kind of obsession, compulsive gambling.

October

Arshiya Baig started a pilot project to help people learn about life with diabetes through pictures. Manyuan Long found that some of the youngest genes are in the brain. Jens Ludwig and Stacy Lindau published a landmark study about the connection between neighborhood poverty and health, and Issam Awad studied a rare brain disease that soon could be treated with a drug instead of surgery.

November

Cathy Pfister and Tim Wootton figured out how to use seashells to track climate change over the years. Lianne Kurina found a link between loneliness and sleep quality. Shantanu Nundy, Monica Peek and Marshall Chin developed a program to send text message reminders to people with diabetes, and Pan Chen looked at the links between childhood abuse and aggressive behavior in adults.

December

Inbal Ben-Ami Bartal, Jean Decety and Peggy Mason discovered that rats can show empathy for their fellow rats in distress. Maciej Lesniak performed a scary but amazing brain surgery on a patient who was awake. Cathryn Nagler searched for the source of food allergies within our bodies, while Stafano Guandalini uncovered the challenges in educating doctors about one of those allergies, celiac disease.

Whew. Hope you were able to click through at least a few of those. We look forward to another great year of research in 2012. We’re taking a break next week, but we’ll be back on January 5. Happy holidays!

Texting has grown from technological fad to a primary route of communication popular around the world. With cell phones in the pockets of people of all incomes and ages, the quick, no-frills conversations enabled by texting have made almost everyone more proficient with their thumbs. Due to such impressive ubiquity, people in health care are starting to ask whether text-messaging can be harnessed as a cheap and user-friendly tool for communicating with patients outside of the clinic - particularly hard-to-reach patients in urban and low income areas.

“People are ignoring that unlike every other technology, mobile phones reverse the digital divide,” said Shantanu Nundy, clinical instructor of medicine at the University of Chicago Medical Center. “More low income patients are using phones for text messaging and internet than other groups. So shouldn’t we then be developing technology for this type of population?”

Nundy and Jonathan Dick, a Pritzker graduate now in residency at Columbia University Medical Center, arrived independently at this same idea after separate trips overseas, where they saw clinics in Uganda and India using text messages as part of their operation. With texts, physicians could follow up with patients with chronic diseases, making sure they were taking medications and doing the types of self-examinations necessary to manage diabetes or HIV - tasks that are just as challenging at home as they are abroad. In some areas of Chicago the diabetes rate is as high as 25 percent, and African-American populations have much higher rates of diabetes complications such as blindness and amputation.

“It seemed to me that we had a lot of the same problems on the South Side of Chicago, so why not try it there?,” Dick said.

To test this premise, Nundy and Dick joined efforts with Medical Center faculty Monica Peek and Marshall Chin, who recently received grants from the Alliance to Reduce Disparities in Diabetes and the National Institutes of Health to look for new ways to improve outcomes in South Side neighborhoods. For a pilot study published last month in the Journal of Diabetes, Science, and Technology, the team recruited 18 African-American diabetes patients to try out a new automated text-messaging communication system that they programmed.

The study participants were not your typical teenage texters, instead reflecting an age range (38-72) more commonly afflicted with diabetes.

“If this is going to work, we needed to look at middle aged people and people in their 60s and 70s. I’m less interested in having this as a hip thing for teenagers with diabetes,” said Peek, assistant professor of medicine. “It needs to be able to work in people I see in clinic. A 55-year-old black woman with diabetes, if it works for her, I’m interested.”

Each participant was asked at the beginning of the study what kinds of text message they would like to receive, with candidates including reminders to take diabetes medications, check blood sugar, or conduct self-examinations to detect potential complications. Participants could also customize when they received the message, and how often they came in over the one-month pilot.

Some were purely notifications (i.e. “Please take your medications now.”) while others required a text response (”How many times did you check your feet this week?”). In one early sign that the messages were reaching their targets, participants often texted back whether a response was required or not, sending an “OK” or a “Thank you” message to what they knew was an automated system. The study reports, “Many participants found that they began anticipating the text messages and readying themselves to answer the questions in an affirmative way, such as preparing the insulin syringe ahead of the expected message.” That enthusiasm was reflected in surveys of the patients after the study period ended, where all but one participant said they were very satisfied with the text reminders.

“In the context of a population that typically has very few interactions with the health care system and may have experiences that are negative or bad or fearful, it was very fulfilling for them to have positive reinforcing messages where they really felt cared for by the system in a way they hadn’t in the past,” Peek said.

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By John Easton

Location, location, location. The three most important words in real estate turn out to be significant for health as well.

In today’s issue of the New England Journal of Medicine, a research team based at the University of Chicago show that low-income women with children who moved from high-poverty to lower-poverty neighborhoods experienced notable long-term reductions in diabetes and extreme obesity.

The research was the first to employ a randomized experimental design on a large scale to learn about the connections between neighborhood poverty and health.

For the study, Jens Ludwig and Stacy Lindau from the University of Chicago, and a team of scholars from around the country, studied 4,498 poor women and children, who from 1994 to 1998, enrolled in a residential mobility program called Moving to Opportunity.

The U.S. Department of Housing and Urban Development (HUD) operated MTO in five United States cities - Baltimore, Boston, Chicago, Los Angeles and New York.

MTO was based on the Chicago Gautreaux program, established in the late 1970s as part of a court-imposed public housing desegregation remedy. It was designed to study the effect of neighborhoods on employment, income and education in families with children living in cities with a 40% or greater poverty rate. It wasn’t originally focused on health, but Ludwig and his team were curious about how poverty in the U.S. correlated with health issues such as obesity and diabetes and they persuaded HUD to add the public health research component.

Moving to Opportunity enrolled low-income families with children living in distressed public housing. Families volunteered for the experiment, and based on the results of a random lottery, were offered the chance to use a housing voucher subsidy to move into a lower-poverty community. Other families were randomly assigned to a control group that received no special assistance under the program.

According to HUD: The four Chicago census tracts targeted for MTO had an average poverty rate of 67 percent and contained six public and assisted housing developments, which housed a total of 2,197 households. The average income among residents of the six targeted projects was $7,114, and over 75 percent of residents received some form of public assistance. Virtually all of these households were African American (99.4) and 70 percent were female-headed.

The NEJM study collected information during 2008-10 on families who had enrolled in the program 10 to 15 years before. The research team directly measured the heights and weights of MTO participants, and it also collected blood samples to test for diabetes.

At the time of follow-up, 17 percent of the women in the study’s control group were morbidly obese (body mass index at or above 40), and 20 percent had diabetes. However, in the group of women who were offered housing vouchers to move to lower-poverty neighborhoods, the rates of morbid obesity and diabetes were both about one fifth lower than in the control group.

“The initial aim of the study was to help families be safer, but it turns out there’s an effect on these really important health outcomes that’s in the ballpark of lifestyle and medical interventions,” Ludwig said. “That’s pretty striking,”

“This is one of the first studies to show that where you live - the circumstances of your neighborhood, the social characteristics of the people around you - all these things may play a role in your own health,” said Harlan Krumholz, a cardiologist at the Yale School of Medicine who was not involved in the study, during an interview with the Los Angeles Times. “Your health is not just what happens to you, but is influenced by all of those around you and the environment. … Some environments are toxic to health.”

“Giving a low-income woman the opportunity to move with her children to a less impoverished neighborhood appears to lower her risk of … two of the biggest health problems facing our country,” said Lindau, associate professor in obstetrics and gynecology, and an expert in urban health.

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Almost everyone has experienced the boredom of sitting through someone’s vacation photos, forcing a wan smile as a friend hands you picture after picture of beaches, museums, and old buildings. But if you’ve been to the same destination as your friend, there’s an allure to seeing how their experience of a particular place compares to your own. Discussing a gelato stand you both visited outside the Uffizi gallery in Florence or debating the merits of ocean-side vs. sound-side in the Outer Banks can bring a friendship closer. But can that communal photo-sharing power be captured and channeled into improving people’s health?

That concept is a novel component of assistant professor of medicine Arshiya Baig’s pilot project to improve diabetes outcomes in the Chicago Latino community, Picture Good Health/Imagínate una Buena Salud. Designed in cooperation with churches in the predominantly Mexican neighborhood of Little Village, Baig’s program offers focus group classes with Latinos diagnosed with diabetes, seeking to improve their diet, exercise, and disease control. At each of the eight weekly sessions, participants go through education, counseling, and activities to help manage their diabetes. But each meeting begins with a novel concept, called “photovoice,” that puts the storytelling potential of photography to use as a stimulant of healthy discussion.

“We thought we would do something fun, so we are giving disposable cameras to everyone in the intervention group, and they get to take photos of their life with diabetes,” Baig said. “Then each class starts off with a conversation around those photos. People can share stories, they can problem solve, and our class leader is trained to facilitate a conversation. It’s probably the most innovative part of the study.”

The concept of photovoice was not created by Baig, but it is typically used by researchers for different purposes. Typically, the idea of giving subjects cameras and asking them to document their situation is used as a “needs assessment” to help design an intervention. For example, one project asked teenagers in an urban area to photograph negative elements in their daily life and community. Researchers or policy makers could then look at those photos to find places where an intervention could make the largest impact, such as cleaning up abandoned buildings or providing more supervision during walks to school.

However, in Picture Good Health, the photovoice method is the intervention. Participants are told only to document things in their life that are relevant to living with diabetes. After the photos are developed, they can choose which ones to share with the group during the first half-hour of each week’s session. The photographer explains what the photo means to him or her, and then the group discusses from there.

Second-year Pritzker medical student Matthew Stutz joined Baig’s project this summer to start analyzing the photovoice component of the focus groups. He found that the participant’s photos covered a wide range of topics, from the obvious (food, diabetes medications) to more general influences such as their home, workplace, neighborhood, and family. A photo of loaves of white and wheat bread might kick off a group discussion of health grocery choices, or a picture of an ashtray could trigger participants to talk about the methods they have used to try and quit smoking. One man shared a picture of a park and said it reminded him of his deceased daughter, inspiring the other participants to talk about family members they had lost - a topic that wouldn’t typically be on the agenda for a diabetes intervention.

“I think of photovoice as an easy mechanism for someone to convey emotions, experiences, losses, gains, without having to verbalize it,” Stutz said. “By having a prop or a mechanism to share, I feel we can gain a lot more ground and depth and conversation.”

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By Dianna Douglas

The Affordable Care Act is nearly one and a half years old, but the complexity of its reforms and their gradual roll-out have made it difficult to grade. Different disciplines are still parsing the legislation, attempting to figure out how it will change the future of their field. Experts in the field of Family Planning and Contraceptive Research has been puzzling over an enormous and perhaps unanswerable question: How will health care reform affect the reproductive lives of women and girls?

That was the primary question at the section’s spring conference, “Reproductive Justice and Health Care Reform: the Impact of Reform on the Reproductive Health of Underserved Women and Youth.” The phrase “reproductive justice” connotes the activism to give women and girls of all races and incomes the access to the same choices and education for controlling their reproduction. Panelists argued that some aspects of the bill, particularly the expansion of insurance coverage, would benefit this cause. But there were also warnings about the political resistance, exemplified by Representative John Boehner’s statement that he doesn’t think reproductive health care services are the business of the federal government: “How can you spend hundreds of millions of dollars on contraceptives? How does that stimulate the economy?” he asked in 2009.

Speakers at the conference, which was co-sponsored by UChicago’s Center for the Study of Race, Politics and Culture, posed many unanswered questions about how the Affordable Care Act will affect women and girls in America. Some expressed hope that it could close the gap between black and white and rich and poor in all areas of maternal health, unintended pregnancy, intimate partner violence, and infant mortality.

But Harold Pollack, PhD, professor at the School of Social Service Administration, gave both sides of the story. He argued that the Affordable Care Act is not only health care policy, but it is the defining document of America’s public policy on reproductive health care.

“Near-universal health insurance coverage will reduce disparities in health,” Pollack said. One of the goals of the Affordable Care Act, passed by Congress and enacted by President Obama in 2010, was to stop people from skimping on health care when they couldn’t afford it. If enacted properly, the health care plan would extend reproductive health care to millions of women.

Under the law, Pollack said, insurers can no longer require a referral to see an obstetrician or gynecologist, and must offer women direct access to these specialists. They are required to pay for some preventative services, like screenings for breast and cervical cancers and sexually transmitted infections. Insurers are required to pay for certain vaccines for women. They have to pay for preventive care for children and adolescents, including screenings for pregnancy. And, insurers may be required to pay for contraception and other family planning services.

All of these requirements were designed to improve women’s health across income levels, but basic access to physicians is the key. “When you visit a doctor because your knee hurts, the truth is that she probably won’t do very much for your knee. But you’ll get your blood pressure taken. She’ll ask you about your diet. And she’ll recommend you for other screenings and lifestyle adjustments,” he said. Oregon recently found that poor people with health insurance were healthier than poor people without it.

Pollack’s keynote address was not uniformly cheerful, however. “The bill is vulnerable, and reform is a risk,” he said. The politics around health care reform have become poisonous, he said, and some of the best public policies in the bill are the most under attack.

Pollack lamented that the great benefits of health care reform won’t be enacted for a few years, during which time public opinion on health care reform could sour more dramatically. “Backloading was the sin of this bill,” Pollack said. It takes time for reforms to embed in society, he said and the legal challenges to the bill may stop the process before it can begin.

To keep the Affordable Care Act on track and make the reforms sustainable, Pollack suggested that the people who support the bill should put a human face on it. “Americans are deeply ambivalent about sexuality and reproductive health,” he said. “But even people who disagree with abortion are uncomfortable with making a poor woman carry a baby to term after a rape or if the pregnancy will seriously damage her health.”  The more human and less theoretical the reforms can become, the more likely they are to survive the next few years of budget cutting.

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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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Countless campaigns have been launched to steer schoolchildren toward healthy habits, and yet rates of childhood obesity and diabetes continue to soar. Celebrity endorsements, catchy catchphrases, and food pyramid redesigns have struggled to combat the allure of fast food and television in the battle for child health in the United States. But with childhood obesity rates tripling in the last 30 years and type 2 diabetes showing up earlier in life, there’s an urgent need for more effective programs to promote nutrition and exercise in kids. One strategy is to create more relevant programs, locally focused and tailored to the culture of the children the program is trying to help.

That approach inspired not one but two child diabetes prevention programs created by Medical Center researchers and tested with our neighbors on Chicago’s South Side. The two programs - called Reach-Out and Power-Up - are siblings, with similar designs, goals, and measures, but in slightly different populations and venues. The pilot studies, both published in recent months, demonstrate the challenges faced by researchers in creating effective, reproducible programs with a local focus…and also offer hope that a successful intervention is possible.

Before the programs could be designed, the first step was to listen. The research team, led by Deborah Burnet, professor of medicine and pediatrics, organized focus groups with overweight children and their parents to learn about their specific obstacles to improving health and gather ideas about the types of physical activity and classes that would appeal to them. For example, the African-American children said they would like to try martial arts and yoga, so instructors for those activities were recruited. The conversations laid the groundwork for programs that would take the unique circumstances of families on the South Side of Chicago into account.

“Nutrition and exercise are both behaviors we do in a social context; in a place, in a neighborhood, in the context of certain social mores and expectations and cultural factors,” Burnet said. “Food, especially - who cooks, where we learn how to cook, how do our tastes get shaped in what we like to eat - those occur in social and cultural contexts.”

While both programs were designed to improve the health and behavior of children, the targets were both the kids and their parents. In Reach-Out, families gathered at a local YMCA for 14 weeks, splitting into separate parent and child groups for the first part of each session and then reconvening for a combined activity. Sessions included grocery store tours, exercise training, cooking classes, and even a family basketball game. Scavenger hunts, relay races, and Family Feud-style review quizzes were used to keep the kids and their parents engaged. But addressing the family’s cooking and eating habits could also be a sensitive topic.

“Feeding is all bound up with caring and love, so it’s very complicated - if you tell grandma she’s not cooking for her grandchildren right, her feelings get hurt,” Burnet said. “So how do you do that in a constructive way so that grandma is valued, but also moves in this healthy direction?”

At the end of the Reach-Out pilot study, published in the Journal of the National Medical Association, the program earned glowing reviews from participants, who said that it helped reduce food intake, steered them toward new fruits and vegetables, and encouraged increased physical activity. However, the clinical improvements were modest, including slight dips in BMI z-score (which scales the measure to child age) and glucose-to-insulin ratio. The incremental changes might mean that very heavy kids need more help to get back to healthy habits, Burnet said: “Kids who are this big probably need a more intensive treatment and intervention than a weekly community-based program.”

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Over the year-long discussion of health disparities in the MacLean Center for Clinical Medical Ethics seminar series, the health gaps presented between American whites and blacks have been predominantly a one-way street. On nearly every health measure - from infant mortality to diabetes to cardiovascular disease - higher rates are observed for African-Americans. But there’s one health gap where the racial positions are surprisingly flipped, said James Jackson of the University of Michigan in his visit to the series in early May. Over the course of a provocative talk, Jackson demonstrated how this strange reverse disparity in mental health could be hiding a model explaining the physical health gaps that continue to resist reduction efforts.

In a 2007 study, a survey project led by Jackson measured the lifetime prevalence of major depressive disorder in African-Americans, Caribbean blacks, and white Americans. An almost complete reversal from the normal health disparity was observed, with roughly 18% of whites diagnosed with major depression at some point in their lives, compared to only 10.4% of African-Americans. The data, though replicated several times, was initially greeted with skepticism by observers who were mostly familiar with biased data based on hospital admissions, Jackson said.

“When people noticed this, they really began to contort  the data,” said Jackson, a psychologist and director of the Institute for Social Research at the U. of M. “The argument was that there must be something wrong with the way it was assessed, because everybody knows that African-Americans have to have higher rates of psychiatric disorders than whites.”

But now that the reverse disparity has been verified in many different populations, Jackson has started to ask why these differences exist. His working theory hinges on two other observations: the delayed appearance of physical health disparities over the course of life, and cultural differences in the way people cope with stress. When well-known health disparities on measures such as diabetes or hypertension are broken down by age, there is not a consistent gap between blacks and whites, but a gap that emerges and rapidly grows in middle age (45-64 years old). Putting aside differences in infant mortality rates, some evidence actually suggests that black children are healthier than white children on many measures, Jackson said.

The growing gap in health measures over the life course is paralleled by another growing gap - in the frequency of poor health behaviors. In white populations, smoking rates peak in young adulthood and then decline, while the rate in black populations accelerates with age. The same pattern holds true for heavy alcohol use and drug use, Jackson said, while frequency of vigorous physical activity declines with age faster for black females than white females. Obesity is more complex - it is the only black-white difference observed early in life, at least for females - but this gap also widens over life course, regardless of socioeconomic status.

The core of Jackson’s theory was to cast those physically unhealthy behaviors not as mere vices, but as methods people use to self-medicate themselves against the stress of daily living.

“If you’re having a bad day…you know it. At the end of the day, your stomach is upset, you have a headache. There are palpable things that are present with regard to the stress reaction to the circumstances,” Jackson said. “But if you are growing a tumor for cancer, you don’t know it, until it reaches a certain stage.”

“If you know you’re having these stress-related kinds of problems, this awareness motivates you to action - you are motivated to do something about the physiological and psychological consequences of stressors in your life. And what do you want to do? People eat comfort food to reduce stress, the activity in the chronic stress response network,” Jackson said. “If I’m stressed, a Twinkie makes me feel better.”

Self-regulating stress can also go beyond junk food, Jackson said, to severe drug and alcohol use. All of these coping strategies may help dampen the stress response and protect mental health, but only at the cost of exacerbating physical health problems.

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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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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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It’s no big secret that one of the keys to good health is getting regular exercise. Yet good intentions are often thwarted by factors outside of one’s control. A person might decide to jog or bike several times a week, but if the neighborhood outside their door is not conducive to physical activity, it can be easier said than done. Whether you live out in the country or deep in the heart of the city, the design of the neighborhood around you can have an effect on your ability to exercise out of doors.

To clarify that relationship between neighborhood streets and physical activity, epidemiologist Ningqi Hou used data from one of the largest longitudinal studies of cardiovascular health in the United States, the CARDIA study. As a graduate student at the University of North Carolina, Hou and her colleagues analyzed the frequency of physical activity in over 5,000 CARDIA participants alongside characteristics of the “street networks” where they live. Hou, now a postdoctoral researcher in the Department of Health Studies at the Medical Center, looked at the density of intersections, the connectivity of streets, and the type of roads in each participant’s neighborhood.

Their hypothesis was that the “built environment,” the infrastructure surrounding a person’s home, has an invisible influence on their behavior that could conflict with their exercise plans.

“Although there are a lot of physical activity interventions, a lot of them don’t actually work. For example, you have an education program to tell people how beneficial physical activity could be, but over time, that effect is going to fade,” Hou said. “However, your built environment is really just existing there for you, and you are passively receiving its influences. To build a sustainable intervention, you need to know what works in that environment.”

The results of the analysis, published in December in Health & Place, were more complex than just “more roads, more exercise.” In areas of low urbanicity - rural and exurb regions with small, spread out populations - more connected street networks did indeed promote walking, jogging, and bicycling. Specifically, a higher density of intersections was associated with more outdoor exercise, suggesting that long, country roads are better suited to physical activity when they are connected instead of remote. That information could be valuable for civic planners looking to build “exurban” neighborhoods that promote health, instead of sprawling suburbs filled with meandering drives and cul de sacs.

“For the ongoing projects we can still influence that process and hopefully help planners to build a more physical activity-friendly environment,” Hou said. “Sometimes when I see the cookie-cutter communities, they have a very suburban style of being spread out, and it kind of worries me. But I think our result may do some good in informing policymakers to change the design for new communities.”

But in more densely packed areas of high urbanicity, the street network effect reversed for women. The higher the density of local roads, the less often female residents biked, jogged, or walked on average (men were unaffected). This unexpected result suggested that other factors associated with high population and street density - such as crime, or socioeconomics - could counteract the exercise benefits of a more connected neighborhood, Hou said. It also suggests that changing urban neighborhoods to promote physical activity may be more complex than adding intersections.

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