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Health Disparities

Addiction, Health Disparities, In the News, Public Health

Menthol cigarettes: How they’re being used by and marketed towards African Americans

Menthol pic - smallHere’s a scary statistic, included in a recently published Newsweek article: “Each year, smoking-related illnesses kill more black Americans than AIDS, car crashes, murders and drug and alcohol abuse combined, according to the Centers for Disease Control and Prevention (CDC).” And then there’s this: “More than four in five black smokers choose menthol cigarettes, a far higher proportion than for other groups… By mitigating the harshness of cigarettes and numbing the throat, menthol makes smoking more palatable, easier to start – and harder to quit.”

The article discusses advocates’ call for a ban on menthol cigarettes (all other flavored cigarettes were banned in 2009) before going on to describe the history of African Americans and menthol-cigarette use, and tobacco companies’ aggressive marketing tactics. (“The tobacco industry… positioned itself as an ally of the very community it was seducing,” writes Abigail Jones.) It also quotes Stanford’s Robert Jackler, MD, founder of Stanford Research into the Impact of Tobacco Advertising, who expresses his concerns with ads that appear in a prominent African-American publication:

…[Jackler] has analyzed Ebony magazines since the 1940s and discovered it ran 59 cigarette ads in 1990, 10 in 2011 and 19 last year.

Ebony published 21 articles about breast cancer and 11 about prostate cancer between 1999 and 2013 but did not publish a single full-length story on lung cancer in that 15-year period. “Tobacco advertising is a huge revenue stream,” says Jackler. “Ebony professes itself to be the so-called ‘heart and soul and voice of the African-American community,’ and it completely neglects smoking.”

Previously: E-Cigarettes: The explosion of vaping is about to be regulated, What’s being done about the way tobacco companies market and manufacture products, Menthol “sweetens the poison,” attracts more young smokers, Menthol cigarette marketing aimed at young African Americans and NPR’s Picture Show highlights Stanford collection of cigarette ads
Photo by Classic Film

Health and Fitness, Health Disparities, Stanford News, Videos

AAMC’s Health Equity Research Snapshot features Stanford project on virtual health advisers

AAMC's Health Equity Research Snapshot features Stanford project on virtual health advisers

To improve public health, Stanford and academic medical centers around the country conduct research to identify solutions to systematic and preventable inequities in medicine and health care. A selection of these projects – including research led by Abby King, PhD, professor of health research and policy and of medicine – have been highlighted in the 2014 Health Equity Research Snapshot developed by the Association of American Medical Colleges (AAMC).

King and colleague Timothy Bickmore, PhD, with Northeastern University, are conducting ongoing research examining how virtual advisers can promote physical activity regardless of individuals’ level of education or language. Findings  published last August demonstrated how individuals who participated in an exercise program guided by the online coach had an eight-fold increase in walking compared with those who did not. In the above video, King explains how virtual advisers can be as effective as their human counter parts in promoting regular physical activity and can reach far larger groups of people in a more cost effective way.

In addition to King’s video, the snapshot features six others produced by health-equity researchers and their teams that represent work on a wide array of health outcomes and populations. The AAMC initiative is intended to demonstrate how research at every stage – from basic discovery to community-based participatory research – can contribute to closing or narrowing gaps in heath and health care.

Previously: Help from a virtual friend goes a long way in boosting older adults’ physical activity
Video still in featured-entry box by Relational Agents Group, Northeastern University

Chronic Disease, Health Disparities, Health Policy, Patient Care, Research, Stanford News

Study shows higher Medicaid coverage leads to lower kidney failure rates

Study shows higher Medicaid coverage leads to lower kidney failure rates

Years ago, nephrologist Manjula Tamara, MD, treated a 23-year-old uninsured patient whose kidneys were failing. The patient’s medical options, at that point, were life-long dialysis or a hoped-for kidney transplant – bleak options for such a young person, and ones that adequate preventive care could have been avoided.

That memory, along with the federal government’s recent expansion of Medicaid spurred Tamura as a scientific researcher to pose the question: Does expanded Medicaid coverage translate into better care for low-income patients with chronic diseases, such as kidney disease?

According to the Stanford study published today in the Journal of the American Society of Nephrology, the answer is yes. Using data from national registries, Tamura, who is lead author of the research, and colleagues collected data on the more than 400,000 American adults who developed end-stage renal disease (or ESRD) between 2001 and 2008. As I explained in a release:

Medicaid coverage during those years among low-income, nonelderly adults ranged from 12.2 to 66 percent, depending on the state, with California averaging between 30 and 35 percent. For each additional 10 percent of the low-income, nonelderly population covered by Medicaid, the study found there was a 1.8 percent decrease in ESRD incidence.

The study is particularly timely because states are in the process of deciding whether to adopt the recent changes to Medicaid, which came with the passage of the Affordable Care Act. So far, only about half of the states have. The study discusses these recent changes and what the expansion in Medicaid coverage could mean to low-income Americans with kidney disease, along with patients with other chronic diseases:

Before the Affordable Care Act, only low-income Americans who were pregnant, had a disability or were parents of minors could receive Medicaid coverage if they met their state’s income eligibility levels. States now have the option to increase Medicaid coverage to all adults under the age of 65 with incomes below 133 percent of the poverty level regardless of whether they are pregnant, disabled or parents of minors.

“The care of patients approaching kidney failure or end-stage renal disease is a useful model to study the potential effects of Medicaid expansion on chronic disease care because ESRD care is costly and the quality of pre-ESRD care is tracked nationally,” Tamura said.

What the study did not look at was whether this expansion could ultimately result in financial savings. In the United States, 75 percent of health care dollars goes into the treatment of chronic diseases and these conditions – which include heart disease, diabetes, hypertension, and kidney disease – are all on the rise. In an interview, Tamura suggested that future research on this topic is needed.

Previously: Study shows higher rates of untreated kidney failure among older adults and Geography may determine kidney failure treatment level

Global Health, Health Disparities

In Uganda, offering support for those born with indeterminate sex

Kaggwa - smallWhen most adolescent boys in his Ugandan village were lobbing soccer balls, Julius Kaggwa was sidelined by an unusual phenomenon: He began to develop the breasts of a girl. His mother took this as a sign from the spirits that young Julius was intended to be female and she began to send him to school in girls’ dresses. The boy was mortified and became afraid to show his face in public. Life became so unbearable that he contemplated suicide.

Today, Kaggwa, 44, is the founder and director of Support Initiative for People with Congenital Disorders, the first group of its kind in East Africa to serve the intersex population. Intersex individuals are those born with indeterminate sex because of hormonal, physiologic or other medical anomalies.

In Uganda, where children are cherished and celebrated by the community in the month after birth, he said the arrival of an intersex child is a mother’s “nightmare.”

“Our work starts in the delivery ward where children are mutilated or their lives are terminated,” he said. The mother may be reviled by the community: “There are people who will say, ‘What is the use of this woman?’ So the mother will kill that child to avoid the stigma.”

I met Kaggwa in February at the group’s headquarters in Kampala, Uganda’s bustling capital city. I had traveled to the East African country as a Global Justice Fellow with the American Jewish World Service, an international organization that aims to end poverty and support human rights in the developing world. Fifteen of us fellows spent nine days in Uganda last month meeting with organizations that support women, girls and members of the LGBTI community.

We headed down a long dirt road to the headquarters for SIPD, located in a building that remained unidentified for security reasons. Since the Ugandan Parliament passed a harsh anti-gay law in December, there had been a rise in arrests, beatings and public assaults on members of the LGBTI community, and there were concerns that the anti-gay sentiment would spill over into the organization.

The group focuses on changing cultural attitudes so that intersex children are more accepted in the community. SIPD also facilitates referrals to a hospital in Kampala where they can receive appropriate medical treatment, the only site in Uganda where physicians are equipped to deal with their specialized medical problems, Kaggwa said.

The group also does educational outreach in schools so that intersex youngsters don’t experience the kind of stigma and emotional trauma that he did.

“So they don’t have to kill themselves, drop out of school or sell their souls to seek asylum in other countries,” he said.

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Emergency Medicine, Health Disparities, Research, Stanford News

Insurance status might perversely affect the kind of trauma care you get: Stanford study

Insurance status might perversely affect the kind of trauma care you get: Stanford study

trauma centerGiven how much my health insurance checks eat into my income, I shouldn’t need to worry about the kind of trauma care I’d get if I were ever in a car accident (knock on wood). But should I?

A new School of Medicine study reveals that even insured patients might be at risk for getting poor trauma care for severe injuries – possibly at greater risk than uninsured patients.

Why? Simply because emergency doctors at hospitals lacking a trauma center decide to keep them there instead of sending them to a hospital with more expertise.

Ironically, insured trauma patients are admitted at non-trauma hospitals at higher rates than uninsured patients are, researchers find. Ergo, insured patients may end up missing out on critical resources that trauma centers are equipped with for severe injuries.

Our press release on the study published online today reports on the researchers’ findings from analyzing more than 4,500 nationwide reported trauma cases.

Why would non-trauma hospitals want to hold on to insured patients? One possible reason is that sometimes emergency doctors fail to recognize conditions that need extra care, lead author M. Kit Delgado, MD, suggests. Hospitals may also be used to taking care of certain severe injuries on their own.

But there might also be other reasons. As Delgado elaborates in the release:

Doctors working in the trenches most often strive to do what’s best for patients. But these findings are concerning and suggest that non-trauma centers are considering admitting some patients with life-threatening injuries based on whether or not they can be paid, when research has shown these patients fare better if transferred to a trauma center.

Delgado carried out the research when he was an emergency medicine instructor at Stanford. He is currently an emergency care research scholar at University of Pennsylvania.

Calling the finding “very disturbing,” Nancy Wang, MD, senior author – and an emergency physician herself – says researchers must call attention to such disparities in trauma care. She and colleagues previously discovered disparities in access to trauma care at California hospitals between children with and without insurance.

“I believe in health care as a right,” Wang wrote to me. “I never believed that there would be disparities in access to emergency trauma care based on insurance status.”

The authors suggest closer monitoring of emergency room encounters and splitting costs between hospitals and trauma centers as potential ways to curb such practices.

In follow-up studies, they also hope to figure out how much patients know about their options, and whether their preferences are being taken into account. As Delgado says in the press release, “People who have insurance may not realize that they could do better if they are transferred.”

Previously: Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims
Photo by Seattle Municipal Archives

Health Disparities, Medical Education, Public Health, SMS Unplugged

In between: Learning medicine beyond the hospital

In between: Learning medicine beyond the hospital

Gallegos image - smallSMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

My upbringing and career goals can be summarized as a collection of “in betweens.” I was middle child in a family that was first generation in the United States, and I grew up bridging my parents’ history in Mexico and the American Dream they hoped for. I was raised in Pasadena, Calif., enjoying the perks of an affluent suburbia but witnessing the challenges my parents faced as low-to-middle-income laborers. I had little dental or medical care as a child, as health insurance was inaccessible and my parents were unable to pay out of pocket. I grew up in between socioeconomic lines, blessed by my parents’ sacrifices to support me as the first person in my family to pursue higher education, but aware of the struggles that poverty creates.

One of the reasons I decided to pursue medicine is a desire to serve as a connection between the underserved poor and health care. I wanted to translate my experiences growing up in a Hispanic household without health insurance and with little knowledge of the health-care system into a career meant to empower underserved populations and improve their overall health. However, the image of the health provider I desired to be was at one time very narrow.

Initially, I was focused on making my way into the hospital, unaware of the health impacts that come from other fields. But through a series of undergraduate courses and extracurricular programs, I discovered the impact that public-health interventions, policy and ideology can make. I came to realize that in order to address health-care needs, it’s important to understand the circumstances creating them. It’s not just about dealing with high blood pressure, obesity and mental health – it’s about drawing awareness to their causes and coming up with ways to prevent them. My career goal became to position myself between providing direct patient care and defining health prevention and maintenance practices.

When I was deciding where to go to medical school, I initially dismissed Stanford. I felt its lack of a public health school would hinder my goal of becoming both a health-care provider and a health-care promoter. Second Look Weekend not only dispelled this false vision of Stanford, but also introduced me to the Stanford that I’ve come to value highly: a center of excellence that positions itself between academic medicine and community outreach, and between scientific advancement and public health empowerment. From learning about social determinants of health in the Community Health scholarly concentration, to providing services such as health education through free clinics, Stanford creates an environment to learn about and participate in numerous public-health approaches. In doing so, it exemplifies what I believe is important in defining what the future of medicine is: caring for people and communities before and beyond the hospital.

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Health Disparities, Medical Education, Stanford News

Med students awarded Schweitzer Fellowships lead health-care programs for underserved youth

Med students awarded Schweitzer Fellowships lead health-care programs for underserved youth

Fu2Two Stanford School of Medicine students are among the 11 recipients of this year’s Albert Schweitzer Fellowship – San Francisco Bay Area Chapter. Founded in 2006, the fellowship supports health-focused graduate students in year-long projects working with vulnerable communities to address health disparities locally. Michael Fu and Karen Hong, both second-year med students, chose projects that align with their personal values of providing community service and working with youth. Fu’s project provides a seventh-grade class with weekly, thirty-minute mindfulness-based stress reduction sessions over 10 weeks. He described his work in an e-mail:

Our project has two goals. First, through our mindfulness-based stress reduction (MBSR) program, we hope to positively impact students’ abilities to perceive and cope with stress. Second, we hope to build a self-sustainable curriculum that can be implemented by the entire Ravenswood City School District as a behavioral intervention tool. … Each session is structured around one of four central themes (paying attention to the present moment, paying attention with kindness, paying attention with curiosity, and responding vs. reacting) and involves a combination of formal mindfulness practices and reflection.

Hong is working with Prevent Blindness Northern California and told me:

They are a community based non-profit that screen preschool children using a high-tech screening device called the Retinomax. It is quick and extremely effective in detecting possible vision problems. Vision problems in this age group are important to detect and treat, as more emphasis is placed on using these years to ensure school readiness for kindergarten. Vision problems can result in permanent vision loss, or children being mislabeled as inattentive or behavior problems. … [Our project] will be piloted primarily in low-income schools, with great attention given to connecting those who fail the screening with appropriate vision care for full exams and treatment, if indicated. This is an expansion of a current program currently using paid staff and will be the first time it will be implemented by volunteer screeners.

Fu and Hong both said that service will continue to be part of their careers beyond the scope of their projects and their terms as medical students. Fu noted that a collaborative component of the Schweitzer Fellowship – previous fellows providing mentorship and consulting help to the current ones, and monthly meetings of the 2013 class – underscored the importance of team work in any service project.

Previously: Getting back to the basics: A student’s experience working with the Indian Health Service, Sowing the seeds of change: Medical students pen book on leadership, action and social innovation, What I did this summer: Stanford medical student works to improve pediatric surgical care in Tanzania and Stanford team provides healthcare in rural Guatemala
Photo by Michael Fu

FDA, Health Disparities, Sexual Health, Women's Health

Female sexual health expert responds to delay in approval for “Viagra for women”

Female sexual health expert responds to delay in approval for "Viagra for women"

As announced yesterday, Sprout Pharmaceuticals, manufacturer of flibanserin, dubbed a “female Viagra,” is appealing the Food and Drug Administration‘s decision requesting more information on the drug before approving it for use in the U.S. Leah Millheiser, MD, director of Stanford’s Female Sexual Medicine Program, writes an appeal of her own on her blog,, in response to the FDA’s delay.

From the post:

Many of us in the field of female sexual medicine felt that Flibanserin had the best shot at being the first FDA-approved “Viagra for Women” – the holy grail for women with persistent low sexual desire in whom other treatments have failed (relationship therapy, sex therapy, off-label medications,etc). With this latest rejection, I ask you to consider the following: 43% of women in the US compared to 31% of men suffer from a sexual function complaint. There are currently 2 drugs that are FDA-approved for female sexual dysfunction (both for the treatment of postmenopausal painful intercourse due to vaginal dryness) compared to over 10 FDA-approved treatments available to men.

Previously: Speaking up about female sexual dysfunctionYoung, single, dating – and a breast-cancer survivorAsk Stanford Med: Director of Female Sexual Medicine Program responds to questions on sexual health and Shining the spotlight on women’s sexual health

Health Disparities, HIV/AIDS, In the News, Patient Care, Public Health, Women's Health

Photography and storytelling may help poor women with HIV cope with their illness

Photography and storytelling may help poor women with HIV cope with their illness

cameraI can’t tell you how many times I’ve heard a song, read a poem, or seen a photo that transformed my point of view. But the viewing or listening audience may not be the only ones who benefit from art: Sometimes the act of creating can be therapeutic for the artist, too. So I was interested to read about a study that looked at photography as a means to facilitate empowerment among women with HIV.

Scientists at the University of Missouri partnered with the charity PhotoVoice in a project called Picturing New Possibilities. Thirty women with HIV who were poor and members of a racial or ethnic minority group were given cameras to capture and document their daily lives. They discussed their images in small-group settings and had the option to display them in public exhibits. Then the women were interviewed about their experience with the project.

From a release:

“When the women got the cameras in their hands, they chose to focus on their strengths – not just their challenging circumstances,” [first author  Michelle Teti, DrPH] said. “They were able to reflect on what they had overcome in their lives despite illness. Many women said such opportunities for reflection were few amid their other life responsibilities. The photovoice project really enabled these women to stop, reflect and think about their HIV and their lives in new and often positive ways.”

The results of the study, which was funded in part by the National Institutes of Health, were published in the Journal of Nurses in AIDS Care (subscription required).

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Dramatic art depicts triumph over HIVWHO’s new recommendations on contraceptive use and HIVEngagement in arts or sports linked with greater well-being, Scottish report shows and Research suggests art lovers may fare better after a stroke
Photo by Sasha D Butler

Chronic Disease, Health Disparities, Medicine and Society, Mental Health, Stanford News

Responses to Rosebud Indian Reservation story: “Nobody cares because nobody realizes these people exist”

Rosebud imageAs I blogged about here last week, I recently wrote a Stanford Medicine magazine story on the catastrophic health statistics from the Rosebud Indian Reservation in South Dakota. My piece came after following a group of Stanford students who travel there each year to volunteer and learn about health disparities in the United States.

While heart wrenching and difficult to read at times, the article has generated an encouraging response from both residents of the reservation and people who want to help change the situation. The story, which was picked up by and, has been read by bureaucrats, health-care workers, activists, educators and many who suffer first hand from the shockingly high rates of diabetes, alcoholism, and suicide rates in a community where life expectancy in the high 40s rivals many developing countries.

After reading the story, Rebecca Foster, PhD, a psychologist who I wrote about as dealing with suicide on the reservation daily in her job at the Rosebud Indian Health Service Hospital, paused to reflect:

I spent some time thinking about your story and was touched by the despair, sadness and fatigue of all those you interviewed. Working in the trenches everyday I forget how our lives appear to others. It was heartbreaking to see everything in black and white. I keep thinking that we keep working, living, laughing and crying and doing our best because the other choice is to give up and to do that is to dishonor and forget all those who have gone before us, the sacrifices that were made so we could be here and have a good life. By our actions to help our people in need now, we allow those that come after us, like my grandchildren to have a chance at a good life to continue to walk the red road in happiness, to sing the songs of our grandfathers and grandmothers with joy. So I rise everyday with the hope to help my people live through another day and hopefully find a sense of purpose again.

Foster would also be touched by the outpouring of e-mails I’ve received – including ones from an anesthesiologist who wants to volunteer her time on the reservation, a nurse in San Francisco who plans to write her Congressional representatives to ask for help, and teachers at the local tribal college, Sinte Gleska University, who are sharing the story with their students.

But what has most affected me is the gratefulness of many members of the tribe themselves for our exposing the situation on the reservation, where they’ve often felt isolated and forgotten. Josh Cossett, who has friends in their twenties who have died from suicide and alcohol-related accidents on the reservation, wrote to me:

There needs to be nation wide awareness to this problem. I get the sense that nobody cares because nobody realizes that these people exist… This is not a racial issue. It is a human rights issue. It has been going on for a century. The U.S. Government created this problem… Now, we ignore it like it doesn’t exist while holding on to our precious logos and memories of when Indians fought bravely against cowboy cavalries. People wonder why more Native Americans don’t stand up against the use of their image as mascots… Maybe that is something reserved for privileged white Americans. For Natives such as those on Rosebud, the debate over Indian nicknames is the last of their worries.

Previously: Broken Promises: the state of health care on Native American reservations, Finding hope on the Rosebud Indian Reservation and Getting back to the basics: A student’s experience working with the Indian Health Service
Illustration by Jeffrey Decoster

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