Public Health

The World Heath Organization today issued revised recommendations for women who are at high risk for HIV/AIDS and who are using injectable hormonal contraceptives. The new recommendations come on the heels of a study published last October in The Lancet Infectious Diseases, which found that women using these contraceptives, which are particularly popular in eastern and southern Africa, were at twice the risk of contracting HIV, although the absolute rate of infection was relatively low. HIV-positive women using the contraceptives also were found to be more likely to infect their partners.

The widely publicized study generated considerable concern, as millions of women are using these progesterone-only contraceptives in Africa, where HIV rates are among the highest in the world. The results prompted the WHO in January to convene a group of 75 experts from around the world to review the issue. The group found that the evidence wasn’t conclusive – as some studies didn’t find the same association and many of the studies were limited in their design.

The panel concluded that there should continue to be no restrictions on use of these contraceptives but it added a clarification to these recommendations, strongly advising HIV-positive women or those at risk of HIV to use condoms and other forms of protection.

Paul Blumenthal, MD, a professor of obstetrics and gynecology at Stanford who served on the panel, said the group sought to re-emphasize the importance of dual protection to minimize the risk of HIV transmission. He told me today:

It is also important to note that decreases in use of hormonal contraceptives, perhaps as a result of concern about HIV risk, may result in increased rates of unintended pregnancy, which, especially in areas where HIV risk is high, also carries increased risks associated with unsafe abortion and high maternal mortality. Thus, the revised recommendations represent an important balancing of the complex relationships between contraception, HIV risks and pregnancy-related risks.

Updated 4:15 pm: In his ongoing effort to push for a public health campaign to battle our country’s pain epidemic, Philip Pizzo, MD, dean of the School of Medicine, traveled to Washington D.C. to speak before the U.S. Senate Committee on Health, Education, Labor & Pensions today.

During the hearing, Pizzo highlighted the results of last June’s Institute of Medicine Committee report on pain, which concluded that the effective treatment of pain demands a “cultural transformation” on the part of patients, physicians and researchers. Pizzo chaired the committee that issued the report.

The total costs of treating pain are higher than the costs of cancer, cardiovascular diseases and diabetes put together, while the treatments still leave many patients suffering needlessly. In order to battle this epidemic, the government needs to support a public health campaign that includes improving education of providers, patients and communities, Pizzo and his co-authors concluded.

“The magnitude is simply astounding,” Pizzo told the committee. While the report focused on the public health implications of this epidemic and recommendations for change, the authors also understood that “it’s the individual human impact of pain that underscores why this is such an important issue…”

The effect on the individual was brought into stark focus by speaker Christen Veasley, an advocate for pain research who had a near-fatal accident 15 years ago and has suffered from residual back and neck pain ever since.

“For many of us, we wake up and the first thing we feel is pain,” she said. “It feels like you live with a veil over your face. As patients, we’ve been left completely disillusioned… This report has brought us renewed hope.”

Also testifying were John Sarno, MD, professor at New York University School of Medicine and William Maixner, PhD, director of the Center for Neurosensory Disorders at the University of North Carolina at Chapel Hill.

Previously: A call to fight chronic-pain epidemic and Relieving Pain in America: A new report from the Institute of Medicine

Although home births account for fewer than 1 percent of births in the United States, the percentage of women choosing to deliver at home has increased notably since 2004, according to the most recent data (.pdf) from the National Center for Health Statistics.

Now new research from UC San Francisco shows that babies delivered at home may be at higher risk of complications after birth including low Apgar scores and seizures. In the study, researchers examined birth certificate data on nearly 2.3 million singleton U.S. births in 2008. Health Day reports that researchers found:

Babies born at home were more than twice as likely to have an Apgar score of under 7 as children born in a hospital or at a birthing center, and also had double the chances of having a seizure.

The Apgar score is a test used to measure a child’s skin color, pulse and overall vigor in the moments after birth.

The overall number of kids who had seizures was low — less than 1 percent at any location.

However, researchers say that some of these risks were reduced if a certified nurse midwife was present at the home birth.

Further down in the story, Mary Norton, MD, professor of obstetrics and gynecology at Stanford, comments on the findings and advises women considering a home birth to recognize that it involves certain risks. She says:

Even in a normal-health woman with a normal pregnancy, there will always be unanticipated things that can happen and unanticipated emergencies.

…

This data does indicate there is a higher level of risk to the baby when delivering at home. If someone is carefully monitored, is in close proximity to the hospital and willing to go to the hospital if needed, then the risks are lower.

Previously: Tensions high in debate over safety of home births and Should midwives take on risky deliveries?
Photo by David Roseborough

Having farmers markets on medical center campuses could prove useful in boosting wellness in surrounding communities, according to researchers with the Pennsylvania State College of Medicine.

In a case study (subscription required) published in the American Journal of Public Health, the researchers describe the process of creating a seasonal market at the Penn State Milton S. Hershey Medical Center. The market, as described in a university release:

… is held once a week and aims for at least 80 percent organic items for sale, including fruits, vegetables, dairy products, meats, baked goods, coffee and specialty items such as spices, honey, sauces, flowers and prepared foods. Community wellness programming through medical professional-led activities that promote public health education is a major strategic focus that differentiates [this farmers market] from other markets. Three rent-free booths are reserved each week for community health outreach.

The researchers outline the goals of the market – one of which is to increase community access to healthy locally grown foods – and explain how such markets can help promote healthful lifestyle changes:

For example, medical center markets can enable nursing and medical students and residents to develop their health screening and program management skills, researchers and graduate students interested in evaluating market-based initiatives, and volunteer staff committed to improving community health. In addition, market vendors can contribute to this sustainability through health-related programming such as healthy food demonstrations, distributing healthy recipes and participating in federal nutrition supplementation programs…

More than 100 of the 7,175 known farmers markets in the United States are located on medical campuses, and these researchers call for more analysis on how such markets are impacting public health.

Previously: Should the lack of access to good food be blamed for America’s poor eating habits?, When it comes to nutritional value, debating “organic” vs. “conventionally grown” may be beyond the point, Living near fast food restaurants influences California teens’ eating habits, CDC calls for improving kids’ access to healthy food and Mapping out our country’s “food deserts”
Photo by Corey Templeton

Anthrax toxin is a deadly poison. But it doesn’t affect all people the same way. Research published today by Stanford geneticists Mikhail Martchenko, PhD; Sophie Candille, PhD; Hua Tang, PhD; and Stanley N. Cohen, MD, has shown that susceptibility is a genetic trait that is passed from parents to children. According to our release:

Among 234 people studied, the cells of three people were virtually insensitive to the toxin, while the cells of some people were hundreds of times more sensitive than those of others. The findings may have important implications for national security, as people known to be more resistant to anthrax exposure could be effective first-line responders in times of crises.

…

In the new study, Cohen and his colleagues found that variation in the level of expression of a gene that produces a cell-surface protein called CMG2 affects the success of the anthrax toxin in gaining entry into human cells. The research suggests that analogous effects may occur in people exposed to anthrax bacteria. The authors suggest that the investigational approach they used may be broadly applicable for learning about individual susceptibility to various pathogens in human populations.

The research is published in the Proceedings of the National Academy of Sciences and was funded by the Defense Threat Reduction Agency of the United States Department of Defense. According to Alan Rudolph, PhD, the director of DTRA’s Chemical and Biological Technologies Directorate:

This paper is an important contribution to our understanding of the mechanisms of host susceptibility to anthrax. We are committed to supporting outstanding science in this field and will seek opportunities to translate key discoveries such as this into useful applications in diagnostics and medical countermeasures for enhanced preparedness for the department of defense and global health security.

Previously: Human immune system has developed elegant self-defense against anthrax infection, Report questions whether U.S. is adequately prepared for future public health threats and Show explores scientific questions surrounding 2001 anthrax attacks
Photo of Martchenko by Steve Fisch

In the 1920s, tobacco companies began a campaign to engage throat doctors into helping calm the public’s growing fears about the harmful effects of tobacco. Yep. You’ve read that right. Throat doctors actually pushed cigarettes as remedies for throat irritation. But are you really surprised? Think about it. The tobacco industry is the most brilliant marketing machine ever. Still today, decades after telling Americans about the vast array of harm caused by cigarette smoking, millions of Americans light up. (Hollywood still loves cigarettes. I saw the film The Girl with the Dragon Tatoo this past weekend and almost every character had a cigarette in their hand.)

Robert Jackler, MD, has tracked the pernicious way in which the tobacco industry joined arms with the medical community to sell cigarettes. In his latest study, the Stanford professor of otolaryngology chronicles the intricate advertising campaign of the last century that attempted to sway American public opinion with slogans such as, “Not one single case of throat irritation with Camels.”

Using internal tobacco company documents made available by the Tobacco Master Settlement Agreement between industry and attorneys general of 46 states, Jackler and his co-authors reviewed a treasure trove of correspondence, contracts, marketing plans and payment receipts that expose the industry’s highly effective campaign. Jackler’s ongoing research into the history of tobacco company advertising has resulted in several published studies, sparked in part by his collection of thousands of historical cigarette ads exhibited online.

I sat down with Jackler to discuss his work, and the relationship between doctors and cigarette companies, during my latest 1:2:1 podcast.

Previously: The smoking gun of the Iron Lady: Margaret Thatcher’s relationship with the tobacco industry, Throat doctors manipulated by Big Tobacco and NPR’s Picture Show highlights Stanford collection of cigarette ads

We wrote yesterday about a UC San Francisco paper calling for the regulation of sugar. So what does Stanford nutrition consultant Jo Ann Hattner, RD, think about villianizing the sweet stuff? Her thoughts were included in today’s San Francisco Chronicle:

…Not all scientists agree that sugar should shoulder the entire burden for the chronic diseases afflicting modern Americans.

The inability of a congressional “super committee” to deliver a budget proposal has endangered the U.S. medical research enterprise and the potential discovery of future treatments, warns School of Medicine Dean Philip Pizzo, MD, in a commentary published in today’s San Jose Mercury News.

In the piece, Pizzo discusses how the committee’s inaction is forcing lawmakers to make considerable cuts to domestic programs, including research sponsored by the National Institutes of Health, and how reducing this investment will likely slow advancements in medical research that ultimately improve Americans’ health. He writes:

Consider the evidence: The death rates for heart disease and stroke have fallen by 60 percent and 70 percent, respectively, since World War II. Over the past 15 years, the incidence of cancer is down by 11.4 percent among women and 19.2 percent among men because of better detection methods and more effective treatments. Today, individuals diagnosed in their 20s with HIV — once considered a death sentence — may receive antiretroviral therapy and live to age 70 or beyond. These and other advances in our health have been built on basic scientific research — work that may not have had a clear application when it was conducted but which opened the way to a better understanding of human biology. This knowledge then was translated into new tools or devices to diagnose, treat and prevent disease.

For instance, today’s lifesaving treatments for HIV were built upon advances in a basic understanding of how the immune system works. I witnessed this personally when I began my own work in pediatric AIDS, which would not have been possible without the basic science discoveries about retroviruses that took place more than a decade before HIV was even known. Similarly, at Stanford, work aimed at understanding how immune cells recognize antibodies ultimately led to a groundbreaking treatment for non-Hodgkin’s lymphoma, as well as other debilitating conditions.

As Pizzo goes on to say, the improvements to human health are only part of the equation. Medical innovation and discovery are also vital to jobs and economic recovery.

Previously: The economic benefits of publicly funded medical research, Report: NIH investments created $68 billion in economic activity last year, Academic medical centers bring billions to the economy and New initiatives show how federal stimulus dollars advance scientific and medical research

In a new paper in Nature, UC San Francisco researchers argue that sugar, with its “potential for abuse, coupled with its toxicity and pervasiveness in the Western diet,” is helping contribute to 35 million deaths annually worldwide from non-communicable diseases like diabetes, heart disease and cancer. The authors, as you’ll hear in the video above, believe that sugar consumption in America should be considered a public health issue, and that sugar should be controlled like alcohol and tobacco products.

Schmidt further explains the researchers’ position in a release:

We’re not talking prohibition. We’re not advocating a major imposition of the government into people’s lives. We’re talking about gentle ways to make sugar consumption slightly less convenient, thereby moving people away from the concentrated dose. What we want is to actually increase people’s choices by making foods that aren’t loaded with sugar comparatively easier and cheaper to get.

This work follows a study recently published in Health Affairs showing that adding a penny-per-ounce tax onto sweetened beverages purchases would prevent nearly 100,000 cases of heart disease, 8,000 strokes and 26,000 deaths over the next decade.

Previously: Denmark’s “fat tax” aims at life expectancy – not just waistlines, Poll finds majority of Californians’ support policies to promote healthy eating, fitness among children and Food stamps and sodas: Stanford pediatrician weighs in

If you’re not a woman, I bet you know a few who you love. Heart disease, although typically viewed as a man’s disease, happens to be the number one killer of women. The disease affects women of all backgrounds and ages and, because symptoms show themselves differently in women than men, women are often misdiagnosed.

It became clear to us that most women don’t think that heart disease will affect them, but the statistics show otherwise. Women’s Heart Health at Stanford graciously collaborated with Liat Kobza, my colleague, and me to create this video.

We hope the video will spread far and wide, so please share this with all the women you love and help save lives.

Previously: A focus on women’s heart health, Understanding and preventing women’s heart disease and Gap exists in women’s knowledge of heart disease

I’ve mentioned before that I rarely wear flat shoes. Even two pregnancies couldn’t get me to abandon my heels: I pulled on a pair of Skechers before heading to the hospital to deliver my daughters, but I can’t remember reaching for them before that. (I considered this a sort of badge of honor at the time; in retrospect it was probably pretty foolish.)

A few studies have shown that wearing high heels may lead to pain and knee and joint problems, but as Gretchen Reynolds writes on Well today, whether these shoes “affect the wearer’s biomechanics and injury risk has received scant scientific attention.” In her piece, she discusses a new Australian study that found wearing heels “may compromise muscle efficiency in walking” and may increase the likelihood of strain injuries. And she offers advice from Neil J. Cronin, PhD, the researcher who led the work, for readers who can’t kick (sorry, couldn’t resist) their heel habit:

So, if you do wear heels and are at all concerned about muscle and joint strains, his advice is simple. Try, if possible, to ease back a bit on the towering footwear, he says. Wear high heels maybe “once or twice a week,” he says. And if that’s not practical or desirable, “try to remove the heels whenever possible, such as when you’re sitting at your desk.” The shoes can remain alluring, even nestled beside your feet.

Previously: Do pretty shoes lead to ugly problems?, Study links high heels to osteoarthritis and joint problems and Ouch! How high heels can shrink leg muscle, cause pain
Photo by NessieNoodle

“Am I contagious?” Doctors hear this question all the time. Patients want to know if they can go back to work or school. Parents wonder if going to a birthday party will mean inflicting pink eye on 30 kids. Airlines are concerned their flight attendants could be handing out gastroenteritis with the ginger ale.

When people keep their buggy selves quarantined, other people benefit. The problem is, it’s often hard to keep track of how long different viruses or bacteria can be transmitted to others. According to the National Institute of Allergy and Infectious Diseases, the likely reason that wintertime brings on more coughs and colds is that we are spending more time indoors at work and school – putting ourselves within reach of viruses hanging out on other people.

Armed with a little knowledge, you can minimize the transmission of your germs or your kids’ to other people. Here’s a list of common contagious diseases:

• Conjunctivitis (pinkeye) is a notorious kid-hopper, and long-enduring too. Plan on about 10 days until the eyes are no longer red – your signal that the virus is done.

• Colds are common for a reason: cold viruses are hardy enough to keep infecting 5 days after you get sick (10 days for children). Remember, too, that cold viruses hang out on inanimate objects (doorknobs, computer mice) for several hours, so you may want to chase your sick child’s path around the home with some disinfectant.

• The dreaded strep throat is luckily a complete wimp against the most simple of antibiotics, but you should quarantine for 24 hours after the first dose if your doctor says it’s definitely strep.

• I hope you’ve already been vaccinated against whooping cough (especially since the vaccine wears off in adulthood and needs a booster), but for those unlucky souls who get it, assume 2-3 weeks of contagiousness. And, considering how scary this cough sounds, you might want to hide in your house anyway.

• Influenza (real flu, with fevers and serious muscle pain) is a significant cause of mortality in the elderly and young. Do us all a favor, and stay at home until there has been no fever for 24 hours.

• Sexually-transmitted diseases (in this case, chlamydia and gonorrhea) mean no sexual activity until antibiotics are completely finished, and there are no more symptoms.

• Chickenpox shows you that it’s done infecting. If the spots are crusted over, you’re good to go. This is true for shingles also. Note that shingles can cause chickenpox in people who haven’t had it before. So avoid schools and babies if you’re an adult with shingles. If you are going back to work before the crusting happens, make sure that everyone in your office has already had chickenpox first.

While I hope you find this information useful in making sure you don’t infect unsuspecting others (and perhaps knowing how long to avoid that coughing woman in sales), it’s not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Monya De, ’00, MD, MPH, manages social media for MD Delivered, Inc. of Los Angeles and Orange County. She received her BA from Stanford in human biology.

Previously: Guest post: Healthy traveling is happy traveling
Photo by eyesogreen

For half a century beginning in the 1920s, tobacco companies continued a campaign to manipulate throat doctors – primarily with money – into helping calm the public’s growing fears that smoking might not be good for you.

Most shocking about this was that many of the most well-respected leaders in the field of otolaryngology got on board with this campaign – testifying before Congress, recommending certain brands of cigarettees to their patients – into the 1970s when the scientific evidence pointing to the hazards of smoking had become overwhelming.

In a story I wrote for Inside Stanford Medicine today, Robert Jackler, MD, professor and chair of otolaryngology at Stanford, discussed his latest study on the manipulation of doctors by Big Tobacco. The paper appears in this month’s issue of Laryngoscope. An otolaryngologist himself, Jackler found the results of his research particularly disheartening:

Tobacco companies dreamed up slogans such as, ‘Not one single case of throat irritation with Camels;’ then, to justify their advertising claims, marketing departments sought out pliant doctors to conduct well-compensated, pseudoscientific’research,’ which invariably found the sponsoring company’s cigarettes to be safe.

Previously:  A conversation about the FDA’s new graphic health warnings for cigarettes, Early anti-smoking advocate: King James I of England? and NPR’s  Picture Show highlights Stanford collection of cigarette ads

During my years working as a health writer, I’ve interviewed a wide variety of frustrated – and often depressed – chronic pain sufferers who, after years of searching, were at a complete loss as to where to find help. The causes of the pain were many and varied – from ongoing back problems to autoimmune disorders to accident injuries – but the frustrations were similar.

You could see the pain etched into these patients’ faces, reflected in their movements. Often, they felt misunderstood or not believed or condemned for not “sucking it up” and complaining too much. Living with ongoing pain had become a way of life.

The number of these pain sufferers, who often go ontreated and suffer needlessly, has reached epidemic proportions in the the United States, and now the dean of Stanford’s School of Medicine is calling for a public health campaign to fight the problem. In a New England Journal of Medicine perspective piece published today, Philip Pizzo, MD, and co-author Noreen Clark, PhD, write:

We recommend expanding and redesigning education programs to transform the understanding of pain, improving education for clinicians, and increasing the number of health professionals with advanced expertise in pain care.

The co-authors describe both the “astounding” magnitude of pain – up to 116 million Americans suffer – and the need to better educate health care practitioners and the public as a whole about the problem:

Sadly, many physicians are viewed as poor listeners by people living with chronic pain. Some physicians over-prescribe medications including opioids, while others refuse to prescribe them at all for fear of violating local or state regulations… Often, an initially supportive community becomes intolerant or inattentive as the pain persists, which leads many people with chronic pain to give up, resulting in depression.

Last June, an Institute of Medicine report concluded that the effective treatment of pain demands a cultural transformation on the part of patients, physicians and researchers; Pizzo chaired the committee that issued that report.

Previously: No pain, no gain. Not!, Relieving Pain in America: A new report from the Institute of Medicine, Elliot Krane discusses the mystery of chronic pain, Researching ways to “heal the hurt”, Stanford’s Sean Mackey discusses recent advances in pain research and treatment and Oh what a pain
Photo by SashaW

A post today on CommonHealth takes a closer look at the effectiveness of hand sanitizers when it comes to killing germs. In a thorough discussion of the science behind sanitizers, contributor Aayesha Siddiqui notes:

Alcohol-based sanitizers, at the concentrations commercially available, work best against bacteria (like E. coli or salmonella), fungi, and certain types of viruses (enveloped viruses–viruses that have a coat around them, like the influenza virus and HIV). Check, check, and check.

But what about non-enveloped viruses (like norovirus or rotavirus)? Alcohol-based hand sanitizers have been shown to have some effect–with ethanol doing better than isopropanol–but their killing prowess here isn’t as strong as against the other germs. Sanitizers also won’t do much good against protozoa (like what causes malaria) or bacterial spores (like those of C. difficile). (If you want to geek out on the scientific literature, take a look at the World Health Organization Guidelines on Hand Hygiene in Health Care, starting on page 32.)

Take home lesson: It doesn’t hurt to use hand sanitizers, just know that you’re not fully protected.

Overall, Siddiqui concludes that hand sanitizers are convenient and effective in many circumstances but aren’t a cure-all. So perhaps consider using them to supplement regular hand-washing practices rather than as a substitute.

Previously: Survey outlines barriers to handwashing in schools, Examining hand hygiene in the emergency department, Good advice from Washyourhandsington, Hey, health workers: Washing your hands is good for your patients, Clean hands save lives and Everything you ever wanted to know about hand hygiene
Photo by John Kannenberg