Sex, Drugs, and Public Health

July 10, 2016

Public Health and the N R A

Filed under: Uncategorized — cbmosher @ 10:07 am

Well, they did it again.

Thursday (July 7) some Democratic and Independent congresspeople tried to get the Dickey amendment language removed from the 2017 Health spending budget. This would have allowed the CDC to fund research on firearm injury and death, so that we could have solid facts on this Public Health epidemic.

Dickey himself has reversed his position on his own eponymous amendment of 1996 and recommends that we allow the CDC to study this Public Health issue (see previous BLOG of June 19). But NRA-influenced congresspersons killed that effort. And, as more Americans are also killed, accurate data – also known as the truth – will be withheld from us all.

The horrific killings in Baton Rouge, Falcon Heights and Dallas this week scream from the headlines, skewing – again – our picture of gun violence. These high-profile killings, which are a symptom of something badly diseased in the body of our society, are not the only killings from guns that we suffer.

There are also incidents like Texas mom Christy Sheats gunning down her own daughters. Sheats is alleged to have written on her Facebook page: “it would be horribly tragic if my ability to protect myself or my family were to be taken away, but that’s exactly what Democrats are determined to do by banning semi-automatic handguns.”

This pre-Dallas (Houston area) tragedy is a stark example reinforcing the findings of the now-classic 1993 Public Health study which showed that households with firearms actually experience MORE homicides than gun-free households (see previous BLOG and original article for details).

That was the study that triggered the Dickey amendment.

Aside from the death statistics related to guns (mortality rates), there’s the issue of non-fatal serious injury (morbidity). In the absence of CDC compiled data, we still have some idea of the scope of this issue. From 2010 through 2013, an average of 76,164 people went to hospitals annually for treatment of gunshot injuries. That’s 208 seriously injured people each day, more than eight every hour.

That, folks, is an epidemic.

If killings and injuries are the SYMPTOMS of this disease in the body of our society, how is the body’s “immune system” responding? Of course, our individual bodies’ immune systems are defenseless against bullets, but society’s body has responded:

1. congressfolks who profit from lobbying by the NRA have responded by maintaining the Dickey amendment, in hopes of keeping us in the dark about this epidemic;

2. investors in gun manufacturing have responded by profiting from the value of firearm stocks. In the few hours between stock market close on Thursday and the opening bell on Friday, the Dallas shooting occurred. Friday morning, Smith and Wesson stock and Ruger stock both INCREASED by 3 to 5%.

If that’s society’s immune system at work, we need a new immune system.

Skewed impressions about gun violence – which are produced in this data void of the Dickey amendment – lead us to react with overheated emotion, anger, and finger-pointing. Almost always, in my experience, fingers point away from the true cause of the disease under these circumstances.

If we want to do something that may actually work (because it’s based on logic and reason, not emotion), we need to utilize the same problem-solving process we use in Medicine every time we see a patient:

1. Examine the patient (in Public Health, we need accurate data to do this)

2. Diagnose the disease (for P.H., it’s a community-wide disease, not just one individual)

3. Treat the disease (P.H.’s main treatment is Prevention).

But we’re not doing that. So, on the day that headlines scream “First Death from Zika in the U.S. !!!” there were (an estimated) 208 serious injuries and 82 deaths from firearms.

You know what to do.

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References: Agency for Healthcare Research and Quality, CDC, New England Journal of Medicine, Daily Kos, New York Daily News.

June 19, 2016

Public Health and the Second Amendment

Filed under: Uncategorized — cbmosher @ 4:04 pm

The CDC was originally the “Communicable Disease Center.” It focused on microbial diseases like TB, Influenza, Malaria etc. which could spread from one person to another. It is now called the “Centers for Disease Control” and investigates many other society-wide maladies like Cancer, heart attack, and death from injuries.

As with other branches of medicine, we in Public Health make the Diagnosis, search for the Cause of the problem, and decide on a Treatment (in Public Health, that’s Prevention).

In addition to investigating these conditions with their own staff, the CDC also funds research and prevention of disease by many other agencies and universities. The following data reflects a small sample of accomplishments from such efforts, measured between 2000 and 2010:

1. TB: case rate down 30%; Cause – the Mycobacterium; Treatment – drugs, isolation, investigation of contacts
2. H1N1 Pandemic Flu: prevented 30,000 hospitalizations and 1500 deaths; Cause – a virus; Treatment – vaccine, drugs, isolation
3. Cancer: colorectal, breast and cervical down 2.2 to 2.8 % each year; Cause – various; Treatment – screening, early intervention, vaccine
4. Heart Disease: down from 195 cases per 100,000 persons to 126; Cause – the major one is smoking; Treatment – smoking in youth down from 35% to 19.5%.
5. Motor Vehicle Accidents: death rate down from 15 per 100,000 to 11; Cause – inadequate safety devices; Treatment – belts, air bags, better design.

In 1993, the New England Journal of Medicine, America’s most prestigious Medical Journal, published a research paper from the University of Tennessee entitled “Gun Ownership as Risk Factor for Homicide in the Home.” The study showed that homes where guns were kept were significantly more likely to experience a homicide as homes with no guns.

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Funding for the study came from the CDC’s Center for Injury Prevention.

Congress, under pressure from the NRA, produced the Dickey amendment to a budget bill, prohibiting the CDC from funding such research. Congress, no doubt parroting NRA catch phrases, accused the CDC of “promoting gun control.” The amendment was named for a congressman from Arkansas.

Over the years, with repeated affirmations of the Dickey amendment (and related budget cuts), CDC funding into firearm injury and death dried up.

As I’m sure you know, the NRA repeatedly envokes the second constitutional amendment to bolster its position. I encourage you to read it. Even though it was written in the vernacular of 225 years ago, it’s only one sentence and is quite clear:

“A well regulated Militia, being necessary to the security of a free State,
the right of the people to keep and bear Arms, shall not be infringed.”

You should probably ask yourself this question: What does a “well regulated militia” mean in 2016?

While you’re at it, ask where the NRA’s money comes from (hint: membership dues is only about 50% of its more than $300 million annual revenue).

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In the absence of solid “official” data from the CDC (collected from emergency rooms, physicians, death records etc.) a number of organizations have nevertheless provided us with some sense of this epidemic of injury and death. Numbers vary, due to lack of centralized, fact-checked analysis, but here are some samples:

1. every year in the U.S., between 27,000 and 33,000 people die of Gun Shot Wounds. At least 750 of them are children, and the number may be as high as 2600.
2. Compared with other “developed” countries (Europe, Canada, Australia, New Zealand, Japan, Korea) our GSW homicide rates are 25 times higher, and suicide rates 8 times higher. If people did not have a gun handy (recall the NEJM article discussed above), they’d either use a less lethal tool, or have a little more time to think about it.
3. 60% of all homicides in the U.S. are committed using guns, a much higher percentage than in the U.K., Australia or Canada.
4. Of those 30,000 deaths a year, what percentage involve a mass shooting? Only 2%.
5. Of those 30,000, how many deaths were due to Terrorism between 2005 and 2015? Just 71.

Thus, the vast bulk of GSW deaths never make the national press. Due to this skewed reporting (focusing on mass shootings and those where the shooter was called a “Terrorist” by someone) most of us are unaware of the scope of this epidemic.

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If the CDC were allowed to study this issue, it would most likely approach it as it has communicable infectious diseases, cancer, heart disease, and deaths from other injuries. First, it would compile nation-wide data. Next, it would look for patterns in the data which might identify where risk is highest. In certain geographical areas? Are there differences by gender or age in injury and death?

Then we could use that information to formulate a RATIONAL approach (as opposed to the current EMOTIONAL reactions).

Hopefully – very likely, I believe – using such an approach, we’d begin to show improvement in death and injury rates, just as we have with TB, Pandemic Influenza, Cancer, heart disease, and motor vehicle accidents.

This quote has been attributed to the former director of CDC’s Injury Prevention Center: “The scientific community has been terrorized by the NRA.”

An even more interesting quote comes from former congressman Dickey, written jointly with the former CDC director for Injury Prevention in a Washington Post Op-Ed: “We are in strong agreement now that scientific research should be conducted into preventing firearm injuries and that ways to prevent firearm deaths can be found without encroaching on the rights of legitimate gun owners.”

Why not obtain the facts about gun related morbidity and mortality? We wanted it with Pandemic Flu. We want it with Cancer. We have it available from the CDC for dozens of other diseases, including non-gun related injuries. What are we afraid of finding? More to the point, what is the NRA afraid we’ll find out?

* * *

References: CDC, New England Journal of Medicine, American Psychological Association, BBC, CNN, CBS, Forbes, Washington Post, Daily Kos Gun Fail, Brady Center, Business Insider.

May 3, 2016

Dog Food Medicine

Filed under: Uncategorized — cbmosher @ 10:21 am

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Pierre calls 911 for an ambulance every week or two during the warm months when he still pans for gold. More often during the lonely winter.

“Chest pain,” he’ll wheeze the magic words. “Like a fart turned sideways.”

Just to seal it, he’ll often add “I can’t drive.”

We wouldn’t want him to. Not any time after eleven A.M. anyway. There are enough drunks on the roads during the night hours causing accidents; we don’t want the steel mining contraptions crammed into his rusty Datsun clanging into each other and shifting the wreck’s momentum as it staggers between the right lane and its usual trajectory directly into oncoming daytime traffic.

“We’re coming, Pierre,” we always reassure him.

It’s my job to bring the dog food.

Red lights plinking off the pine trees astride the road, siren wailing to warn any meandering deer, Joe, the hospital janitor, weaves around the hills and swoops us down, then up the gullies. Like a needle embroidering the landscape.

As the ambulance struggles up the final grade to Pierre’s shack on the hill, transmission slipping, medical equipment sliding to the back of the vehicle, I pull an opener from the Trauma Kit and start opening the first can. I’ve ruined a few pairs of pants from that splattered grease.

The instant we pull into the junkyard surrounding his shack, the ambulance is accosted by a half dozen raucous canines, no two of which look to be even the same species, let alone the same breed, but all of which are seriously mean and, we’re pretty sure, unvaccinated.

I roll down the window. A big black-and-brown with stinking breath and thistle-matted fur lunges his front paws onto the door, almost reaching the window. His snarling makes my ears ring.

“Ready?” I yell to Joe.

“Ready.”

I wind up, like back in Little League, and heave the can as far as possible from both ambulance and front door of the shack.

The howling, yelping, baying cacophony streaks after the can. We jump out, run to the back of the ambulance, yank out the gurney, and run for the shack.

“Got the Trauma Kit?” he asks me.

I streak back to the ambulance, grab the kit, then race toward the shack again. The black-and-brown sees me, and comes charging. We burst in, hauling the gurney and Trauma Kit, and slam the door behind us.

“What took ya so long?” he growls from somewhere within his indoor junkyard. “My friends are saying nice things about me – I must be ready to die.”

The din of dogs is a muffled tornado beyond the thin walls. We can slow down now, and be methodical.

I check his blood pressure.

“Never mind that,” his tobacco breath gargles. “Check my eyes. I don’t wanna go blind from that Immaculate Degeneration, like my brother.”

“I thought you had chest pain,” I retort.

“Yeah. It’s prob’ly from the cigars the doctor said I had.”

I’m surprised.

“You smoke? I thought you just chewed,” I try hard – in vain – not to look at the permanent brown streak of stained skin at the right corner of his mouth.

“Don’t smoke,” he mumbles. “Doctor said the X-ray showed I have cigars in my lungs.”

I listen to him breathe, stretching the stethoscope to its full distance. That close to him, I don’t want to inhale too deeply.

“There’s some mucus in your lungs. You coughing it out?”

“Can’t. I can get down to my cough, but I can’t get under it. It’s stuck. Take me to the hospital.”

We will, of course. But by the time he’s strapped securely into the gurney and we’re ready, a dozen paws scrape furiously at the door. The incessant caterwauling envelopes us.

I pull the second can from the Trauma Kit, open it, crack the door just enough, and heave again.

They all wheel and run after it. All but the black-and-brown. He stands there, snarling at me, saliva drooling from his black lips like tobacco juice from an old miner’s mouth. But then he, too, turns to chase the pack, sure of himself that he’ll get the biggest share.

We run for the ambulance, wheels bumping over the irregular earth and the scattered trash.

“Hey, slow down,” Pierre complains. “It feels like you done throwed me in the ore tumbler.”

We shove him in the back and lock the gurney in place. We just make it to our seats before the dogs come back, snarling for more.

“Don’t you feed your dogs?” Joe shouts back to Pierre once we’re safe inside.

I shiver at the sound of claws scraping down the vehicle like fingernails on my grade school blackboard.

“Sure I feed ‘em,” he yells up to the driver. “I feed ‘em ambulance guys.”

And he chuckles all the way down the hill as our red light strums the pines that straddle the road.

March 9, 2016

Filed under: Uncategorized — cbmosher @ 5:44 am

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So, I’m standing in line at the local 24 hour Stop-and-Rob, waiting behind some gum-snapping teenager to pay for my food-like products. Stuff not recommended by any Public Health officials. But I figure, if anyone asks, I can say they’re not for me and go to confession later.

Then I feel someone behind me. Not that he touches me or breathes on me, but he’s giving off a very strong – – – presence.

“Hey, Bobbie,” yells the check-out clerk over the teen-ager’s head and mine. “How you been?”

“Still alive,” the guy responds with a voice like an animal’s growl.

I’m about to turn around and be friendly, trapped as I am between the trajectories of their words. Until he finishes his thought: “no thanks to the damn DOCTORS.” He spits the last word.

He starts moving toward the counter, coming alongside me, talking directly to the counter clerk. “Doctors don’t know SHIT.”

I see him with my peripheral vision. Scruffy three-days’ beard, saliva still glistening on his lips from the words he’s spitting, his eyes narrow and predatory.

Like a snake’s.

A fog of alcohol fumes moves with him.

“DOCTORS gave my mother pills,” he seethes thru clenched teeth.

Ah. That’s what I felt when he was behind me: violence, barely contained.

“Take them pills, they said. You’ll be fine, they said.” His lips stretched out the “f” in “fine” until it sounded like a burning fuse.

It’s clear that his words and his hatred are aimed at me, but his eyes, like mine, remain fixed on the check-out clerk.

Who is his mother? Is she my patient? Or, was she?

The teenager in front is taking forever to fish out and count her nickels and pennies.

“Doctors HURT people,” the alcohol cloud blasts me again. I don’t even allow him into my peripheral vision anymore.

Maybe I should just go.

“Doctors should be KILLED.”

The teenager finally turns to leave.

“Just this,” I hold up the candy bar and can of Cheese-Whiz. I don’t want to put them on the counter, prolonging the process.

Wonder if Cheese-Whiz could function like Mace?

I give the clerk three bills and leave without my change. All the way to the door, I feel a laser boring a smoldering hole into the back of my cranium.

The door swings closed behind me, and I’m back in the community again. The community where almost everyone knows me. The community I serve. Trying to do well for everyone who comes for help. And I succeed most of the time.

But, in this business, most of the time isn’t good enuf.

January 27, 2016

The Next Big Public Health Epidemic

Filed under: Uncategorized — cbmosher @ 11:00 am

Among the on-going challenges of contaminated water, cases of communicable disease, and various Public Health emergencies, I’ve noticed a larger pattern. Almost every decade, some major Public Health problem grows into an epidemic that plagues us for years. So, what’s coming next?

 

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                                                                                                                   (photo by Sarah Mosher)

 

In the early 1980’s after I’d returned from South America, a patient walked into a doctor’s office, terrified that he had melanoma. He was young – too young for a fatal disease, he told his doctor – just 27. But these spots on my skin – – –

The doctor, after examining him, was reassuring. Doesn’t look like melanoma. A biopsy will tell us.

It turned out to be Kaposi’s sarcoma. A disease I’d heard of – once – in Med School, but never seen. Not even in towering teaching hospitals in New York City or Los Angeles. My 2400 page textbook of Medicine mentioned it just once, in only eighteen words, within a table of multiple other obscure skin conditions. It was endemic to Africa, but exceedingly rare in the U.S.

Or had been, up until the 1980’s.

AIDS soon erupted into the number one Public Health epidemic in the U.S. and, quickly, in much of the rest of the world. Jet travel accelerated this disease’s spread, unlike the inevitable but slower spread of Tuberculosis or Syphilis – both major Public Health epidemics in prior centuries.

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It’s not much in the news anymore. The non-journalistic reasons include discovery of some very good suppressant drugs and an impressively effective Public Health education effort.

So what is the most likely candidate as the next major epidemic which Public Health physicians and other professionals will be combatting for a decade or two?

Just as AIDS was the underlying condition which spawned outbreaks of Kaposi’s, of unusual lymphomas, and of uncontrolled invasion by microbes previously classified as “benign,” Climate Change will spawn multiple Public Health outbreaks.

Think of Climate Change as the growing epidemic of the 2016 – 2036 decades. What health problems will spring from it?

1. As the planet warms, mosquitoes, ticks and other insect vectors can expand their territories to the north (2015 was the hottest year, planet-wide, since we began keeping records 136 years ago. It quickly surpassed what is now the second-hottest year – 2014).

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As the vectors move north, and travellers to tropical vacation spots return home during some virus’ infectious period, the potential for spread of seldom or never seen diseases increases at these latitudes.

For example, Lyme-infected ticks have been increasing in numbers and have been found further north in Canada. Species of the Aedes mosquito which can carry Yellow Fever, Dengue, Chikengunya and now, Zika viruses have been found in the southern U.S. Some species of Aedes have been found as far west as California and as far north as New York.

*Chikengunya, originally of Africa, spread to the Caribbean, right next door, in 2013. Within a year, it had hit the U.S.

*Dengue, originally of the Caribbean, showed up in Texas in 2004 and Florida in 2009.

*Zika virus, originally of Africa and Brazil, is already in northern Mexico. As of January 20, there have been a dozen imported cases of Zika in the U.S..

Are all these diseases certain to become established in the U.S.? Nothing is certain in Medicine. But now, because of Climate Change, it is very possible.

2. Other than these arthropod-borne diseases, other Climate Change triggered Public Health problems will be Emergencies caused by Extreme Weather events (earlier and more powerful hurricanes, floods, heat waves, fires, drought).

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                                       (drought and beetle-killed trees in Mariposa, Calif)

 

3. Also, we anticipate more frequent and severe Air Pollution emergencies from increased smog, more pollen allergens, and smoke from fires.

 

What can you do?

1 Start acclimating and adapting. Stop hiding in the AC on a daily basis. Use the AC only when really necessary (the hottest summer days), and set it higher than 68 – like 80.

2 Install Solar panels and house batteries to run the house and you don’t have to worry about power outages.

3 Start conserving water. Catch rain water and reuse greywater.

4 Eliminate mosquito breeding areas around your home including old tires, birdbaths, pails and other containers and flower pots outside your home.

 

And for the Visionaries and Leaders among you, do what is necessary to get us all off fossil-fuels and on renewable sources as quickly as possible.

The Health of the Public (which includes you and your children) depends on us taking action.

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