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Health Disparities, Mental Health, Pediatrics, Public Health

Stanford study of mental illness in incarcerated teens raises policy questions

Stanford study of mental illness in incarcerated teens raises policy questions

depressionMental illness is an even bigger problem for jailed teenagers than experts previously realized.

That’s the take-away message from a Stanford study, publishing today in the Journal of Adolescent Health, which compared 15 years’ worth of hospital stays for adolescents in California’s juvenile justice system with hospitalizations of other California kids and teens. Experts already knew that juvenile inmates are more likely than other young people to have mental health problems, but the new study gives fresh perspective on the scope of the issue.

The research team, led by Arash Anoshiravani, MD, an adolescent medicine specialist at Lucile Packard Children’s Hospital Stanford, looked at 15 years of hospital-stay data for California’s 11- to 18-year-olds. From a total of almost 2 million hospitalizations, about 11,000 were for incarcerated youth.

Of these 11,000 hospital stays, 63 percent were due to mental-health diagnoses. In contrast, just under 20 percent of the hospital stays by adolescents from the general population were prompted by mental illness. Hospital stays were also longer for the incarcerated teens, suggesting more severe illness.

However, the kinds of diagnoses were pretty similar between the two groups, with depression and substance abuse the most common. From our press release about the new study:

The types of diagnoses suggest that many incarcerated teens’ mental health problems developed in response to stressful and traumatic childhood experiences, such as being abused or witnessing violence, Anoshiravani said.

“They’re regular kids who have had really, really horrible childhoods,” he said, adding that he hopes the new data will motivate social change around the problem.

“We are arresting kids who have mental health problems probably related to their experiences as children,” he said. “Is that the way we should be dealing with this, or should we be getting them into treatment earlier, before they start getting caught up in the justice system?”

Previously: Online health records could help high-risk teens, study finds, Lucile Packard Children’s Hospital partners with high schools on student mental health programs and Increasing awareness and advocacy of emotional disorders with mental health first-aid programs
Photo by ryan melaugh

Chronic Disease, Genetics, Health Disparities, Pediatrics, Research, Stanford News

Cystic fibrosis is deadlier for Hispanic patients, Stanford study finds

Cystic fibrosis is deadlier for Hispanic patients, Stanford study finds

Lungs-embroideryHow do physician-scientists select research projects? Sometimes, they’re prompted by the niggling feeling that something is not right.

That’s what happened to cystic fibrosis doctor MyMy Buu, MD, the lead author on a new paper that uncovers an important health disparity, a higher mortality rate for CF patients of Hispanic ethnicity. Buu, a pediatric pulmonologist who takes care of CF kids at Lucile Packard Children’s Hospital Stanford, launched the research because she noticed something worrying: It seemed to her that a lot of Hispanic children with CF were not doing well.

“…I didn’t know if this was just because we have more Hispanic patients in California, or if they were actually, really, sicker,” Buu said. CF is a genetic disease that causes serious breathing and digestive problems; Buu’s job is a mixture of trying to help her patients stay relatively healthy and dealing with complications of the disease.

“Because I’m interested in health disparities, I wanted to see if there were any differences in outcomes in the Hispanic group,” she said.

She turned to the Cystic Fibrosis Foundation‘s patient registry, focusing on 20 years of data that encompass every California child diagnosed with CF from the beginning of 1991 to the end of 2010. Of the children studied, Hispanic CF patients were almost three times as likely to die as their non-Hispanic counterparts.

Buu and her colleagues were able to use the data to eliminate several possible explanations for the disparity. Hispanic children were not being diagnosed later than non-Hispanic kids and did not have less access to health care, for instance. Our press release about the study describes the factors that may contribute to the disparity:

However, the researchers did find important clinical and social differences between the groups. At age 6, the earliest that lung function is routinely and reliably measured for patients with CF, Hispanic children with CF had worse lung function than non-Hispanic kids with the disease. The gap in lung function persisted as the children aged, although it did not widen. And although the same proportion of patients in both groups eventually developed CF complications, the complications struck Hispanic patients earlier in life. Hispanic patients lived in poorer neighborhoods and were more likely to be covered by public health insurance than their non-Hispanic counterparts.

The research also showed that, between the two groups, different mutations prevailed in the disease-causing gene, which is called the CF transmembrane conductance regulator gene. Hispanic patients tended to have rare and poorly characterized mutations in their CFTR gene, whereas non-Hispanic patients had more common mutations that have been more extensively researched.

The next steps, Buu said, are to make others aware of the increased risk for Hispanic CF patients and to figure out how the risk can be reduced.

Previously: Cystic fibrosis patient on her 20+ years of care, New Stanford-developed sweat test may aid in development of cystic fibrosis treatments and Film about twin sisters’ double lung transplants and battle against cystic fibrosis available online
Image by Hey Paul Studios

Global Health, Health Disparities, Health Policy, Stanford News

Rosenkranz Prize winners devoted to innovative health care in developing countries

Rosenkranz Prize winners devoted to innovative health care in developing countries

African girls studyingMarcella Alsan, MD, PhD, knows that the division of labor among men and women starts at a young age in the developing world.

“Anecdotally, girls must sacrifice their education to help out with domestic tasks, including taking care of children, a job that becomes more onerous if their younger siblings are ill,” Alsan, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR) within the Freeman Spogli Institute of International Studies, recently told me.

More than 100 million girls worldwide fail to complete secondary school, despite research that shows a mother’s literacy is the most robust predictor of child survival. So Alsan is analyzing whether medical interventions in children under 5 tend to lead their older sisters back to school. She’ll compile data from more than 100 Demographic and Health Surveys covering nearly 4 million children living in low- and middle-income countries. The surveys ask about episodes of diarrhea, pneumonia and fever in children under 5 and record data on literacy and school enrollment for every child in the household.

“My proposed work lays the foundation for a more comprehensive understanding of how illness in households and early child health interventions impact a critical determinant of human development: an older girl’s education,” Alsan, the only infectious-disease trained economist in the United States, said.

Alsan is one of two winners of this year’s Rosenkranz Prize for Health Care Research in Developing Countries, awarded by CHP/PCOR. Her Department of Medicine colleague, Jason Andrews, MD, is the other recipient of the $100,000 prize, which is given to young Stanford researchers to investigate ways to improve access to health care in developing countries.

In the current scientific climate, most National Institutes of Health grants go to established researchers. The Rosenkranz Prize aims to stimulate the work of Stanford’s bright young stars – researchers who have the desire to improve health care in the developing world, but lack the resources.

While Alsan is researching how older girls in poorer countries are impacted by the health of their younger siblings, Andrews is focusing his attention on cheap, effective diagnostic tools for infectious diseases.

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Big data, Health Disparities, Medicine and Society, Men's Health, Research, Stanford News

To live longer, men need to embrace their femininity, new research suggests

To live longer, men need to embrace their femininity, new research suggests

13938506188_faea591a9b_z (1)Scores of scholars have examined a fundamental truth of our time: Women live longer than men. But why?

After poring over data spanning centuries and continents, a team of Stanford researchers has discovered an overlooked aspect of that disparity. When there’s plenty to go around, the gap between men and women shrinks. But when adversity strikes, men die young.

And in cultures where women excel — racking up academic, professional and extracurricular accomplishments equalling or topping men — men live longer too, said Mark Cullen, MD, the first author of the recently published study that also appears in an abridged, reader-friendly form on Vox.

“The punchline is feminism is good for men too,” Cullen said.

The team posits that women are hard-wired to protect each other, an ingrained trait that goes beyond hormones and isn’t culturally dependent.

The researcher’s primary conclusion — that socio-economic stress hits men harder than women — is solid. Cullen and team looked at societies worldwide, finding that in poorer nations women live about 10 years longer than men, while in the United States the gap is closer to five years. When a social safety net is pulled out suddenly, such as following the fall of the Berlin Wall in Eastern Europe, the lifespan of men dropped nearly 15 years, Cullen said.

“Men were just dropping like flies. But that didn’t happen to women,” he said.

The team posits that women are hard-wired to protect each other, an ingrained trait that goes beyond hormones and isn’t culturally dependent.

“Women live differently,” Cullen said. “They seek each other, invest heavily in family and nurturing, which men do much less of. That’s the secret sauce — women have each other and this incredible support network.”

As women enter the workforce, and men invest in family relationships and social networks, the lifespan gap begins to lessen. “It’s the feminization of the way that men live that helps men,” he said.

As evidence, the team points to Alaska and highly developed Asian nations such as Japan and Korea. There, female lifespans far surpass male’s, probably because despite their economic success, their cultures embrace traditional gender roles. “These are places where men are men, and they die like men,” Cullen said.

Next, the team plans to continue their inquiry by investigating the hypothesis that equality helps men and search for policy programs that also boost men’s lifespans.

Cullen directs the Stanford Center for Population Health Sciences. His co-authors include Michael Baiocchi, PhD, assistant professor in the Stanford Center for Population Health Sciences; Karen Eggleston, PhD, director of the Asia Health Policy Program; Victor Fuchs, PhD, Henry J. Kaiser Professor, emeritus, of economics and of health research and policy; and statistician Pooja Loftus, MS.

Previously: “Are we there yet?” Exploring the promise, and the hype, of longevity research, Living loooooooonger: A conversation on longevity and Social factors better indicators of premature mortality than skin color or geography
Photo by DVIDSHUB

Health Disparities, Health Policy, In the News, Medicine and Society, Women's Health

Report: Health-care industry needs to focus on women

Report: Health-care industry needs to focus on women

16755600997_ca15a76fcf_zThe health-care industry needs to pay much more attention to women. That’s the argument laid out in a recent piece on MedCity News, which shared findings of a survey (.pdf) from the Center for Talent Innovation. That report shows that women make the majority of health-care decisions but are inadequately equipped to do so, and it calls on health-care companies, which are increasingly oriented towards consumers, to bridge that gap.

According to the survey, which included more than 9,200 respondents from the U.S., U.K., Germany, Japan, and Brazil, 94 percent of women make decisions for themselves and 59 percent make decisions for others; when working moms are considered separately, 94 percent make decisions for others. And yet, 58 percent of these decision makers lack confidence in their decision making.

The report says this is due to “three profound famines”: lack of time, lack of knowledge, and lack of trust. Seventy-seven percent of women don’t know what they need to do to stay healthy; 62 percent lack the time. Only 38 percent of working mothers passed a “health literacy quiz,” and the report showed that women are unlikely to trust online information (31 percent), their insurance companies (22 percent), or pharmaceutical companies (17 percent).

The report suggests that health-care companies need to understand women in the context of their family and career responsibilities, which is quite different from standard male-based “life stage analysis.” Moreover, they need to understand that women think about health more broadly than freedom from illness and health risks. Fully 79 percent said that health means “having spiritual and emotional wellbeing,” while 77 percent called it “being physically fit and well rested.”

An excellent place to start change is the management structure of health-care companies, the report suggests. Despite being the “CMOs” (Chief Medical Officers) for their families, women are underrepresented in other “C-level” roles in these companies:

We find that, while the health-care industry employs a large number of female professionals, their ideas, insights, and capabilities haven’t been fully supported, endorsed, and promoted. Without women in power, women’s ideas don’t get the audience they deserve, because… leaders only see value in ideas they personally relate to or see a need for.

MedCity news writer Nina Ruhe sums up another area for improvement. “Doctors, insurance companies and pharmaceutical companies can start instilling trust in women again by letting them know exactly what they should know in regards to their personal health and the health of their families,” she writes.

Health Disparities, In the News, NIH, Research, Science, Women's Health

Research for All: Congressional bill aims to bring gender equality to medical research

Research for All: Congressional bill aims to bring gender equality to medical research

Gender matters in medical research. That’s the reasoning behind the Research for All Act (.pdf), a recently introduced Congressional bill that would require scientists conducting NIH-funded research to look at male and female animals and cells. The legislation would also require the FDA “to guarantee that clinical drug trials for expedited drug products are sufficient to determine safety and effectiveness for both men and women.”

As noted in a press release on the bill from U.S. Rep. Jim Cooper (D-Tenn.):

Women compose more than half the U.S. population, but most medical research focuses exclusively on men…

For example, the unique way women metabolize drugs was ignored when researchers determined the dosage for Ambien sleeping pills; as a result, the initial recommended dosage was double what it should have been for women.

Additionally, cardiovascular disease is the leading killer of all Americans, but only one-third of subjects in cardiac clinical trials are women.

In a Nature piece published last spring, Londa Schiebinger, PhD, director of Stanford’s Gendered Innovations in Science, Health & Medicine, Engineering, and Environment, highlighted the “male default” in science and outlined the benefits of taking gender into account during research:

Including gender analysis in research can save us from life-threatening errors… and can lead to new discoveries. Gender analysis has led to better treatments for heart disease in women. Identifying the genetic mechanisms of ovarian determination has enhanced knowledge about testis development. Analysing how sex affects donor–recipient matching is improving stem-cell therapies. And exploring how sex-specific biological factors and gender-specific behaviours interact has helped researchers to understand how nutrients trigger cell functions, and may assist in the fight against obesity.

Previously: Stanford professor encourages researchers to take gender into account, A look at NIH’s new rules for gender balance in biomedical studies, Why it’s critical to study the impact of gender differences on diseases and treatments, Stanford Gendered Innovations program offers tools for improving scientific research and Women underrepresented in heart studies
Via The Hill
Photo by Benita Denny/Wellcome Images

Global Health, Health Disparities, Health Policy, In the News, Medicine and Society

Why millions lack access to surgery: A conversation with Stanford surgeon Thomas Weiser

Why millions lack access to surgery: A conversation with Stanford surgeon Thomas Weiser

surgery-688380_1280

In the United States, many routine surgeries are just that: routine. They may or may not correct the condition, but the likelihood of death or of life-changing complications are minimal.

But if you live in a poorer nation, surgery — even a cesarean birth — is quite risky and hard to procure. For as many as 5 billion people, these basic procedures are out of reach, according to a recent report by the Lancet Commission, the focus of a recent Scope post and many other news articles.

There are numerous reasons for this surgical gap, as Stanford surgeon Thomas Weiser, MD, who contributed to the report, explains in an Inside Stanford Medicine Q&A.

First, surgery “requires a strong and continuous supply chain, highly technical skills and ongoing training, and intensive management to organize such services,” Weiser said. In addition, most aid programs focus on a specific disease, while surgery is a therapy, leaving it outside the bounds of most international development programs, he said.

So what does the future hold? Weiser is optimistic:

I hope that these findings and the new data presented in the commission report will increase attention and awareness of the vital role surgical care plays in a health system. Ideally, we will see increased leadership from organizations like the WHO and the World Bank in the form of attempts to standardize data collection, identify high-performing health systems, publicize successful programs and promote their adoption and replication in other health settings, and support improved investments in surgical capacity and quality improvement as a way to strengthen the health system more generally.

Previously: Billions lack surgical care; report calls for change, Stanford Medicine magazine opens up the world of surgery and Global health expert: Economic growth provides opportunity to close the “global health gap”
Photo by skeeze

Global Health, Health Disparities, Health Policy, Patient Care, Public Health, Surgery

Billions lack surgical care; report calls for change

Billions lack surgical care; report calls for change

In this country, we take it for granted that we will have access to needed surgeries, whether it’s the repair of a broken leg or an operation to remove an infected appendix or a malignant tumor. But for as many as 5 billion people – or two-thirds of the world’s population – these basic procedures are out of reach.

A major new report by the Lancet Commission sheds light on this enormous surgery gap and argues that building surgical infrastructure in low- and middle-income countries is critical both from an economic, as well as a human, perspective.

“Surgery hasn’t been part of the dialogue with respect to health system strengthening. It’s been a hugely neglected item,” said Stanford trauma surgeon Thomas Weiser, MD, who contributed to the 58-page report. The commission includes 25 leading experts from the fields of surgery and anesthesia, with contributions from more than 110 countries.

In its report, the commission notes that in 2010, nearly one-third of all deaths (16.9 million) were attributable to conditions readily treated by surgery, such as appendicitis, hernia, fractures, obstructed labor, congenital abnormalities and breast and cervical cancer. That is more than the number of deaths from HIV/AIDS, tuberculosis and malaria combined. And although there have been many gains in global health in the last 25 years, the quality and availability of surgical services in many regions have stagnated or declined, while the demand for surgery continues to rise.

“The global community cannot continue to ignore this problem – millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease and road accidents,” said Lars Hagander, MD, of Lund University in Sweden and one of the lead authors.

Weiser and his colleagues provide new estimates of the global shortfall, calculating that some 143 million additional surgeries are needed to save lives and prevent disability, with the largest number of neglected patients living in South Asia (57.8 million), East Asia (27.9 million) and southern sub-Saharan Africa (18.9 million).

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Events, Health Disparities, Medical Education, Medicine and Society, Public Health

An ounce of action is worth a ton of theory: Med student encourages community engagement

An ounce of action is worth a ton of theory: Med student encourages community engagement

IMG_0775Right after graduating from Stanford, Steve (Suk) Ko moved to East Palo Alto with some friends who were also recent graduates. They put all their effort into becoming engaged in their new community, starting and running a tutoring program out of their apartment – which could get really crowded, judging by the pictures he showed last week while speaking to undergraduates interested in public health.

Soon after making East Palo Alto his new home, Ko started medical school at Stanford and continued his service work throughout. “We at Stanford are good at thinking and debating, but less good at action,” Ko said during this talk. “I felt some guilt about indulging in socioeconomic affluence when there was this community right next door.”

Ko’s talk was part of the Primary Care, Public Health, and Health Disparities Lecture Series sponsored by Stanford’s Center of Excellence in Diversity in Medical Education, which aims to produce leaders who can eliminate national-health inequities. Ko shared his personal experience and offered three points of advice:

1). Never lose what makes you special. 

If you’re thinking about how to improve public or global health, “don’t fake it – do what you’re passionate about.” This will lead you in the right direction. As for medical school applications, there are all kinds of ways to have a “research background,” he said.

For Ko, a Korean ethic of hard work and his Christian faith enabled his interest, experiences, and goals in public health. During an undergraduate service learning trip to Oaxaca, Mexico, he shadowed an OB/GYN at a public hospital and was moved both by the beauty of birth and the limited opportunities these newborns faced. Born resource poor and in a society with high gender inequality, “this baby girl had not made a single choice, but 99 percent of her life was already decided,” Ko said. He wanted to think about health in a broader context.

2). An ounce of action is worth a ton of theory.

Last summer, Ko implemented a 5-week summer meal program in East Palo Alto that served kids and their families. The suggestion to focus on food insecurity came from Stanford pediatrician Lisa Chamberlain, MD, Ko’s mentor. The YMCA, Stanford Medicine, and Revolution Foods supported the project, which served 270-370 kids and 4-30 adults every day, and provided a total of 2,525 take-home meals. Ko said it’s “like pulling teeth” to get kids to eat healthy food, but shaping tastes early is key to forming long-term habits. The team ran both quantitative and qualitative analyses of the program, gathering insights like that families are hungrier in bad weather because those who work outdoors or in construction cannot earn money, and that libraries could be great food distribution points.

One of Ko’s most rewarding recent memories was when several of the high-school students he works with made a documentary film about East Palo Alto. They wanted to challenge its unfair portrayal in the news media – although it had the highest homicide rate in the country in 1992, gentrification is now starting to be a bigger problem than crime. “The 90’s were a long time ago,” the students pointed out.

3). Community engagement is difficult, and therefore a privilege.

It was very hard for Ko to gain the trust of his adult neighbors (he says kids are easy: just smile at them). After living there for years, he felt gratified last week when he was ill and a neighbor brought him soup. Trust comes slowly; you have to prove you’re there for the long haul. Even so, circumstances are just hard – what do you do when a student tells you a family member just died from gang violence? Ko coped with the emotional and physical difficulty through his faith and by finding joy in the process, not the outcomes.

One of the audience members asked a question about “white knight syndrome” – the problematic idea that someone from a different community is able (and welcome) to storm in and fix everything. Ko agreed that good intentions can hurt vulnerable people. Temporary involvement doesn’t require accountability and invites the community to be jaded and skeptical, focusing on the impact of the last person/organization. For this reason, it can be much better to join an existing project than to start a new one, he said. But above all, Ko favors humility and a sense of wonder, not just going in and”fixing it”.

Previously: A quiz on the social determinants of health, Stanford researchers use yoga to help underserved youth manage stress and gain focus, Med students awarded Schweitzer Fellowships lead health-care programs for underserved youth, Nutrition and fitness programs help East Palo Alto turn the tide on childhood obesity and Doctors tackling child hunger during the summer
Photo, of Steve Ko (right) and Marcella Anthony of Stanford Medicine’s Community Outreach, by Andrea Ford

 

Events, Global Health, Health Disparities, Pediatrics, Stanford News

Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival

Countdown to Childx: Global health expert Gary Darmstadt on improving newborn survival

newborn-IndiaEach year, around the world, almost 3 million babies die in the first month of life. But it doesn’t have to be that way: For many newborns, simple changes in their care could make the difference between life and death.

I spoke about this conundrum recently with global health expert Gary Darmstadt, MD, who will be among the panelists at this week’s Childx conference at Stanford. Darmstadt, who recently arrived at Stanford from the Bill & Melinda Gates Foundation, has focused much of his career on improving newborn health in developing countries. The key, he says, is engaging community members as full partners in creating the solutions for how to care for newborns. Excerpts of our conversation appear below.

Registration for the Childx conference is still open, and those who can’t attend in person can watch the conference’s live stream at the Childx website.

Preterm birth has just passed pneumonia as the No.1 cause of death, worldwide, for children under age 5, and yet many deaths from prematurity could be prevented with simple, low-tech interventions. What needs to change?

We’ve known since the late 1970s that kangaroo mother care, in which the mother keeps the infant on her chest next to her skin, is very effective. But the rate of adoption has been very poor, about 5 percent globally in 35 years.

It was originally conceived as a substitute for an incubator: By holding babies skin-to-skin you provide a constant source of warmth. What I think happened was that, by making kangaroo mother care a medical intervention rather than a natural behavior, we’ve stigmatized it. Mothers may think, “If I was a rich person, my baby would be in an incubator. Being a provider of kangaroo mother care tells me something about me and my baby: We’re second class.”

We need to communicate that kangaroo mother care is for every baby, everywhere. It’s not just something that poor people get if there aren’t enough incubators. Yes, there are situations where an incubator is helpful, but in many ways kangaroo mother care is superior. An incubator can’t provide a mother’s heartbeat or the feel of her breathing, her voice and her touch. It can’t provide breast milk. It’s not something you form a bond with that lasts for a lifetime. People have picked up the message that the medical device is superior, and they may feel like “I’m an inferior version of a medical device” rather than understanding that the medical device is, for many babies, an inferior attempt to produce what the mother or other family members can provide.

What are some key examples from your research of how social and environmental approaches can help improve infants’ health and survival?

I’m part of a team that worked closely with communities in India to understand how they perceive newborns’ needs and their issues in dealing with them. From there, we developed a simple package of preventive care. It consisted of things like holding babies skin-to-skin, breastfeeding, keeping infants warm, and basic hygiene. Once it was implemented, we saw a 50 percent reduction in neonatal mortality over a 16 month period.

We found, for example, that these communities had no real concept that hypothermia was bad for babies. They had a term for fever and understood that fever was a danger signal, but didn’t have a word that brought the connotation of harm or danger together with cold for babies. When we realized that, the community ended up coming up with a term – they called hypothermia “cold fever.” It created a whole new dialogue around hypothermia, and new openness to trying things that might be helpful to your baby, particularly skin-to-skin care.

What we really sought to do was to bring the science into language that was simple and related to their everyday experience. So the messaging became, “In the same way that when you bathe in the river, when you come out, you feel cold and wrap yourself in a sari, when a baby is born, it’s wet and feels cold, and we need to wrap up the baby for the baby’s protection.” Without understanding the social construct, the environment, we couldn’t come up with those simple messages that would become part of the social fabric.

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