Where does your food come from and how did it get to you?

I subscribe to Community Sponsored Agriculture (CSA) , Mattawoman Creek Farms, a local certified organic farm on the Eastern Shore of Virginia. CSA connects local farmers with local consumers. The subscriber purchases a share of the the harvest and in return receives a large bag of fresh local produce weekly during the growing season. In addition to supporting local farmers, CSA provides a direct link between the growing and the consumption of food. I now know how, where, and by whom my food was grown.

CSA gives me the opportunity to try many new local foods such as mizuna, bok choi, and tatsoi. I eagerly look forward to my weekly supply of fresh produce delivered directly from the farm. The iceberg lettuce wrapped in cellophane at the supermarket will have to wait until winter.

Flu Vaccine – Who gives the shot?

According to CIDRAP, the recent National Influenza Vaccine Summit led to some heated discussion over where patients receive their flu vaccine – public health clinics, personal physician, or alternative vaccination sites such as grocery stores, workplaces, pharmacies. Some physicians argue that alternative sites leads to fragmentation of health care and steers patients away from their “medical home”

One of the basic problems is who gets vaccine early and who has vaccine left when flu peaks late in the season. Primary care physicians argue that the alternative sites get vaccine first and their patients are tempted to go elsewhere for vaccination. In 15 of the past 25 flu seasons in the U.S. flu peaked in February or March and it is hard to locate providers with vaccine late in the season.

The summit was attended by many participants in the vaccination process such as manufacturers, clinicians, and public health. Hopefully this type of discussion can lead to innovative methods to improve vaccination rates.

Drugs – Country of Origin and Safety

Are the pills you take as safe as the food you eat? I can peel my imported fruit but I must swallow my pills without washing or peeling.

There was an interesting article in the Wall Street Journal about the country of origin of pharmaceutical ingredients.

“Indeed, the FDA requires drug companies to disclose only the name and place of business of the manufacturer, packer or distributor of prescription medications. Active and inactive ingredients must be listed on the label, but not the raw materials or their origins, which are considered “commercial confidential.”

Since the FDA does not have the resources to inspect all overseas facilities that manufacture ingredients, it is up to the pharmaceutical companies to ensure good manufacturing practices. The recent contamination found in the blood thinner heparin supplied by China shows that this system does not always work.

According to a recent article in the New England Journal of Medicine (NEJM) Trying Times at the FDA – The Challenge of Ensuring the Safety of Imported Pharmaceuticals by Stuart O Schweitezer, Ph.D

“This sort of problem should theoretically have been prevented by the FDA, which inspects foreign factories producing drugs and chemical components that are intended for export to the United States. Investigations are continuing, but preliminary information shows that the FDA did not inspect the plant, though it had intended to do so. The FDA’s program for inspecting foreign drug manufacturers has been swamped by a rapid increase in overseas manufacturing of both finished drugs and chemical components. The FDA has a mandate to inspect producers of both drugs and chemicals used to manufacture drugs (active pharmaceutical ingredients, or APIs) in order to certify that plants meet the current Good Manufacturing Practice (GMP) standards. Data on the number of foreign drug and API manufacturers are difficult to obtain. The FDA uses two databases listing foreign plants that are subject to inspection. According to a 2007 report by the Government Accountability Office (GAO), one database lists approximately 3200 establishments, whereas the other lists 6800.³ Even if the smaller number is accurate, the agency inspects only approximately 7% of foreign establishments in a given year, meaning that it could take at least 13 years to inspect them all — once. The FDA cannot say how many foreign plants have never been inspected.”

The pharmaceutical industry is increasingly using foreign plants and ingredients. The burden on the FDA to ensure that the drugs we take are are safe and pure is daunting. So what is the solution to this problem?

In a recent NEJM article Allastair J.J.Wood M.D. has a very reasonable suggestion.

“We need to acknowledge that ensuring the safety and integrity of our food, drugs, cosmetics, and medical devices is primarily the responsibility of manufacturers, with the FDA providing a regulatory framework and oversight. It is also critical that legislators recognize their responsibility to provide the agency with funding that is adequate for it to perform its important functions.”

“No longer should manufacturers be able to imply that inadequate FDA inspection is an excuse for adulteration of their product during manufacture. We must stop allowing the game of “kick the FDA” to be risk-free to participants. The public’s health is at stake, and the time for adequate federal funding of the FDA is now.”

Climate Change and Health

Dr. Margaret Chan, Director-General of the World Health Organization (WHO) has made some interesting statements on the impact of climate change on human health.

Almost everyone acknowledges climate change and that humans are the principal cause of this effect. Global warming has the potential to cause extreme weather events such as storms, floods, droughts, and heat waves. These have profound consequences on human health.

According to WHO the five major health consequences of climate change are:

1. Agriculture is sensitive to climate variability which can compromise the food supply. This will cause malnutrition particularly in countries that rely on rain-fed subsistence farming.
2. Extreme weather events can cause storms and flooding. In addition to injuries, floods are followed by outbreaks of diseases when water and sanitation services are compromised
3. Lack of water necessary for hygiene and excess water from more frequent and torrential rainfall can increase diarrheal disease from contaminated food and water. Diarrheal disease is already a leading cause of mortality in children.
4. Heatwaves are dangerous for the elderly with compromised cardiovascular and respiratory systems and higher temperatures increase ground ozone.
5. Changing temperatures and patterns of rainfall could alter the geographical distribution of insect vectors of diseases such as dengue and malaria.

“The reality of climate change is no longer in doubt, but there’s still time to reduce the consequences for human health,” Chan said. WHO is hoping that political leaders can move with more urgency when they understand the profound health effects of climate change .

Cooperation in the Healthcare Industry

After being grounded in Atlanta during the recent safety inspection of Delta’s MD88 planes, I asked the ticket agent if she could book me on a different airline. She told me that Delta had no arrangement with competing airlines for such situations.

In my area all hospitals have signed a memorandum of understanding (MOU) to assist each other in a medical disaster. They all sit at the table and develop cooperative disaster plans. Despite the fact that there are several competing health organizations, they realize that no one wants their ” market share” during an emergency.

Perhaps the airline industry could learn a lesson from the health care industry.

Bike Helmet Safety

Dave Love has written an excellent review of bicycle helmet safety. Unintentional injury is the leading cause of death in the 1-44 year age group and in 2005, cycling accidents claimed 93 lives. However, there is no data on whether these cyclists were wearing a helmet. According to a recent CDC publication on traumatic brain injury (TBI) in the US, this is a leading cause of morbidity and mortality with cyclists (non motor vehicle) accounting for 3% of the the 1.4 million cases/year and presumably many more involved in motor vehicle crashes. Again there is no mention in the data about helmet use.

CDC recommends wearing a helmet for the following activities

• Riding a bike, motorcycle, snowmobile, scooter, or all-terrain vehicle;
• Playing a contact sport, such as football, ice hockey, or boxing;
• Using in-line skates or riding a skateboard;
• Batting and running bases in baseball or softball;
• Riding a horse; or
• Skiing or snowboarding.

“Head injury is the most common cause of death and serious injury in a bicycle crashes”

and bicycle helmets are the most effective means of reducing bicycle related head injuries. Many cities passed legislation mandating the use of bicycle helmets. Enforced legislation is the most effective method to increase helmet use.

Patients Rate Hospital Care

After my last post, Compare Your Hospital, I was asked about patient input on the care they received in a hospital. Several hospitals collect information on patient satisfaction but it was difficult to compare data since previously there was no standard questionnaire. The same organizations that developed Hospital Compare have also developed a hospital survey for measuring patients’ perspectives of hospital care. It is composed of twenty questions about aspects of the patients’ hospital experience such as:

• communication with doctors
• communication with nurses
• responsiveness of hospital staff
• cleanliness and quietness of hospital environment
• pain management
• communication about medicines
• discharge information

In addition patients are asked to rate the hospital from 1-10 and if they would recommend the hospital to friends and family.

The survey should provide a meaningful comparison of hospitals from the patients’ perspective and public reporting should be an incentive for hospitals to improve.   Results of the survey should appear on the Hospital Compare website in March 2008.

Compare Your Hospital

My friend sent me an interesting public web page created by the Centers for Medicare & Medicaid Services (CMS) and the Hospital Quality Alliance (HQA) called Hospital Compare. They report on hospital quality of care based on how often these hospitals provide certain recommended care for adult patients being treated for heart attack, heart failure, pneumonia, or adult patients having surgery.

Participating acute care and critical access hospitals voluntarily submit their data on treatment from medical records. Information is not gathered on children’s, rehabilitation, or long-term care facilities.

The information is useful to patients anticipating hospital care and also encourages hospitals to improve their quality of care. Transparency in health care is important and I applaud the effort of the HQA and CMS for making this informative website available to the public.

Obama, Clinton on Prevention and Public Health Policy

I wanted to write about the Democratic candidates’ health plans. I will focus on what their plans say about prevention and public health rather than the broader topic of universal health care.

Obama’s plan

“Lowering health care costs and ensuring affordable, high quality health care for all”.

“Less that 4 cents of every health care dollar is spent on prevention and public health. Our health care system has become a disease care system, and the time for change is well overdo.”

“Covering the uninsured and modernizing America’ s health care system are urgent priorities but they are not enough. Simply put, in the absence of a radical shift towards prevention and public health, we will not be successful in containing medical costs or improving the health of the American people.”

“Protecting and promoting health and wellness in this nation is a shared responsibility among individuals and families, school systems, employers, the medical and public health workforce, and federal and state and local governments.” His plan then describes how each of these can contribute to encourage Americans to adopt healthy lifestyles.

Clinton’s plan

“Quality Affordable Health Care for Every American”

“Prioritize prevention to reduce the incidence of disease that impose huge human and financial burdens.”

“our back-ended coverage of health care that gives short-shift to prevention“

Her plan proposes “A Groundbreaking National Prevention Initiative to Reduce the Incidence of Such Diseases as Diabetes and Cancer that Impose Huge Human and Financial Costs ” This initiative would:

• require all insurers participating in federal programs to cover prevention priorities.
• Coordinate public spending on prevention across federal programs in the Department of Health and Human Services to maximize high-priority prevention and push prevention outside of the boundaries of the health care system and into schools, workplace, supermarkets and communities through free provision of preventive benefits.

Her plan acknowledges the fact that our current physician payment system does not value prevention and that insurance reimbursements are higher for procedures than for counseling and patient management.

My Conclusion

Obama’s discussion on promoting prevention and strengthening public health shows that he or his health advisers understand the value of public health practitioners and how they are strained to perform their traditional functions as well as participate in chronic disease prevention and disaster preparedness. He recognizes that health is a shared responsibility which involves medical and public health workforce as well as the individual, families, schools, employers, and government.

So after reading the Democratic candidates’ plans, I believe that the Obama plan is superior with respect to prevention and public health policy because he recognizes that covering the uninsured is not enough to improve the health of Americans. The current health care system needs a change that includes a strong emphasis on public health and prevention.

His plan comes closest to recognizing the WHO definition of health.

” A state of complete physical, mental, and social well being and not merely the absence of disease or infirmity.”

Flu Shots for Children

The CDC Advisory Committee on Immunization Practices made a broad new recommendation that all school age children receive influenza vaccine. This would increase vaccination coverage from the current recommendation of 6 months to 59 months and children with chronic medical conditions to cover all children from 6 months to 18 years. Another 30 million children would be included in this recommendation.

It is thought that children have a significant burden of disease and carry their illness to their household contacts to include parents and grandparents.

Last year the influenza associated pediatric mortality was 68. Influenza associated pediatric hospitalizations are also significant. In addition childhood influenza means lost school days and parent work days.

It will be interesting to see how this new recommendation changes the influenza statistics when fully implemented.