Thursday, December 30, 2010

Orange Things

I just have to say this: I love Nicholas D. Kristoff. I really do. His efforts to raise awareness of crimes against women and girls worldwide have been heroic. And his overall work to shine a light on areas of inequity and poverty are enough to qualify him for, if not a full saint, then at least someone working his way up the rungs of the sainthood ladder. But his Thanksgiving day column that encouraged the development and use of biofortification of certain crops in developing nations gave me pause.

At first glance, one might wonder what's wrong with breeding crops to incorporate iron, zinc, Vitamin A or other important vitamins and minerals into their edible parts. After all, these substances can save vision and lives. As he noted,
"It may turn out that one of the best ways to save children's lives, or to save women in childbirth, doesn't involved doctors, but rather, high-tech seeds." 

Sounds simple, cheap, and easy, right? At the risk of being all wet-blanket-y about it, I think it sounds neither simple nor cheap and also as if it has great potential for unintended consequences.

There are two avenues of research here - conventionally bred crops produced in the public domain, and genetically modified ones developed and owned by corporations. Developing nutrient-dense crops available to anyone is a noble idea and enabling families in Africa to grow vitamin-packed orange sweet potatoes instead of the typical white sweet potatoes that they always have grown is a great idea. However, once it gets more complicated than that scenario, I have concerns.

For one thing, I have long been uncomfortable in rushing science in the name of helping impoverished countries. After all, the United States and Europe are still grappling with the role genetically-modified crops - of which many biofortified crops would be - can play in feeding their citizens, especially in light of the facts that pests are growing resistant to some of those expensive, herbicide-intensive crops and the long-term implications of ingesting those crops are not fully understood even by those who embrace them.  It also seems like bringing back the buggy whip when you consider that some of the crops that are proposed will require pesticides and herbicides, chemicals whose use citizens in the developed world are trying to minimize, due to the mounting evidence of their health and environmental hazards. So why do we think making ever-more complicated plants and encouraging their use in impoverished areas are good ideas - especially when individuals in developed countries are clamoring for simpler, organic, back-to-basics clean food? Is cast-off technology from the developed world the best we can offer to developing countries?

Some may argue that that imperfect solutions are better than nothing when the stakes are as black and white as survival versus death . There is a grain of truth to that argument, which basically falls under the heading of "don't just sit there, do something." However, we already have a perfect solution - vitamins exist in pill and powder forms and some designer waters are already enhanced with some of those vitamins. The problem is that vitamins are too expensive for many developing countries, and the logistics of getting them to every person on a regular basis can be daunting. However.

For-profit companies do just that.

Let's repeat that sentence.

For-profit companies do just that.

They just don't do it with vitamins.

But they do it with cigarettes. And they do it with soft drinks. It no longer surprises me when I see the cheery red and white of Coca-Cola products in the Amazon basin in Brazil or a kid puffing on a Marlboro in Thailand. It seems when the bottom line is at stake, human ingenuity finds ways to source components of products, assemble those products, and then figure out how to market, deliver, and sell them regardless of the challenges presented by the location. For example, by harnessing local ingenuity and providing a profit incentive, Coca Cola has mastered the logistics of getting its, shall I say,  product-of-questionable-nutritive-value into the most remote reaches of Africa. And I believe one of Coke's products is vitamin-enhanced water.

Therefore, for this particular problem, it may be better to practice what Buddhists know: "Don't just do something, sit there." Just sit there and think. Look around. Take a page from Melinda Gates' play book and learn what we can from what Coca-Cola already does.

One of the reasons I would encourage the public health world to look for a simpler solution is firsthand knowledge of how long it can take to create these complicated plants and then figuring out how much of them individuals would have to ingest in order to attain certain levels of the vitamin. Years ago, I used to manage a series of seminars for the American Cancer Society. These seminars were very high-level. The audiences were top-line national medical and scientific reporters. The presenters were the researchers who push the envelope, like the ones who brought you Gleevac, virtual colonoscopies, and basic knowledge about cancer including oncogenes and suppressor genes. The panel chairpersons were directors of national cancer centers, Nobel laureates, and Mary Lasker Award winners. The seminars were three days of intense science and emerging research.

One presentation in 1996 showcased a scientist from Roswell Park Cancer Institute who presented her research on "Transgenic Plants as a New Vaccine Source." The specific project she was working on was inserting hepatitis B antigens into bananas. Once eaten, the theory was that the antigens would effectively vaccinate the banana eaters against hepatitis B,  a leading cause of liver cancer around the world. This edible vaccine would be especially useful, the scientist postulated, in developing countries, where cost and logistics create obstacles to vaccinating the local population.

Sound familiar?

Fourteen years after that presentation, there is still no banana/hepatitis B vaccine. A quick Google search of "hepatitis vaccine banana" returned 27,000 hits, showing that research is still going strong on this concept. But still no edible vaccine.

I'm sure you can see where I'm going with this. We already have vitamins and vaccines against many diseases. What is being proposed - biofortification of existing plants to enable them to carry vitamins - is expensive research. Then, intensive education programs must be carried out so that individuals in countries that need these plants can learn how to grow, harvest, and cook them. And no one has done the research - asked the individuals who will be expected to grow these plants - if they are interested in changing their social norms to eat orange sweet potatoes instead of the white ones, or golden rice instead of white rice. And, last I checked, these plants are still in development.

So, with all due respect to the researchers and to Mr. Kristoff, I'd rather put my money on creating partnerships between the public health world and Coca-Cola or other global brands to oversee the distribution of vitamins that we already have, instead of investing a lot of money into a more complicated situation. The price seems to be a red herring at some level - after all, individuals seem to have the money to purchase Coke products, as evidenced by Mexico's astonishing 665 per capita ingestion of Coke products in 2009. Or, if you want to go further with this concept, Coca-Cola already makes VitaminWater. Couldn't the public health world work with Coke to develop a VitaminWater to deliver the key vitamins lacking in certain parts of the world?

We already have vitamins. Multi-national corporations have distribution systems and perhaps even products that can be tweaked to provide specific nutrients to children, or pregnant women, or the elderly. What seems simple to me is not the creation of complicated seeds that require costly chemicals and unpredictable weather to grow, but a linkage that would combine the best of the knowledge from the public health world and the infrastructures of big corporations in order to get those vitamins where they can do a lot of good.

PS to Mr. Kristoff. I still think you rock.


Tuesday, November 16, 2010

An Unexpected Oasis

Today, instead of pointing out yet another dreary problem that confronts our country, I'd like to offer up some good news. For years, we have been hearing about "food deserts," those urban areas that lack sources of healthy foods, but have unhealthy convenience food in abundance. You can see these food deserts everywhere - in inner cities, in small towns along interstate highways, and even in some suburbs where fast food chains and convenience stores line the streets and grocery stores are few and far between. All the nutrition guidelines in the world will not help individuals and families living in food deserts eat as well as they could.

That's why it is exciting to learn that Walgreens is doing something about this lack of healthy food options.  I remember Walgreens as being a Midwestern old-timey five-and-dime chain, best known for its luncheon counters. In recent years, I have noticed more Walgreens stores opening on corners in my Southern city as the chain successfully expanded to become the largest drug store chain in the United States. And now, Walgreens has taken that revitalization to a new level - that of offering groceries and fresh foods in some of its urban Chicago stores.

Food deserts are a big problem in Chicago. The US Centers for Disease Control and Prevention estimates that about 600,000 Chicago residents live in neighborhoods that are either lacking or too far away from conventional grocery stores. And Walgreens has a large presence in inner-city Chicago, making it an ideal partner to get groceries, such as milk, meat, eggs, fruits, and vegetables, into those areas. Of course, this move isn't entirely altruistic - after all, Walgreens is a publicly traded company (NYSE, NASDAQ: WAG) that has shareholders to consider - but it does carry more than a whiff of civic responsibility. You see, Walgreens was founded in Chicago more than 100 years ago and, according to its press release, was asked by Mayor Richard M. Daley's office to start offering groceries in some neighborhoods where grocery stores were scarce. Taking this concept even further, Walgreens has created a partnership with local medical entities to pilot a program designed to educate residents about the link between healthy food choices and preparation and better management of chronic illnesses like diabetes.

This all sounds like a win-win situation to me, one that combines a basic tenet of capitalism of being the first to enter a niche market, and the do-good-ness of a hometown hero. The short-term outcomes may be that individuals and families living near these Walgreens will have expanded food choices and Walgreens may increase its market share over competitors.  It will take awhile to see the longer-term result of better health due to access to healthy foods, but it's not a leap to envision that those results will occur. Research has already shown that people who live in food deserts are more likely to become ill with conditions like diabetes, high blood pressure, and obesity - all conditions that can be helped or prevented with proper nutrition. So it stands to reason that the availability of appropriate foods could counteract or even prevent those conditions.

If you want to read more about food deserts, especially in Chicago, here is a report by Mari Gallagher and Associates, the firm that coined the term. It has some interesting facts, such as many who live in food deserts have incomes over $100,000, as well as important implications for our built environments.

Northwestern University's Medill School of Journalism pulled together a nice video in which residents of food deserts in Chicago are interviewed. The video highlights the lack of access to real food that many people face and allows us to see the type of establishments that residents must frequent if they are limited to shopping in their neighborhoods.

So kudos to Walgreens, the City of Chicago, Northwestern Medicine, and Near North Health Service Corporation for this innovative partnership. Walgreens is keeping a close eye on the initial 10 stores that are offering groceries. If they work well, meaning if they make money from the groceries, the concept could be expanded to other stores, and other cities. Keep your fingers crossed.


Friday, November 12, 2010

Can This Be True?

Earlier this week, Yale University's Rudd Center for Food Policy and Obesity released a report Evaluating Fast Food Nutrition and Marketing to Youth. Faster than you can say "drive-through window," some startling statistics were racing around the Internet and hitting the mainstream media. The most compelling of those statistics was that 84% of parents taking part in this survey reported feeding their kids fast food in the week prior to their interview.

When I read the 84% statistic, my first thought was, "That can't be true." I thought perhaps it was a sampling error - maybe the researchers asked only parents who lived across the street from a McDonald's, or who didn't know how to cook, or who were employed by Burger King. Or maybe there was some other reason the findings were skewed.

So I dug up the report, certain I would spot some methodological weakness. And, I'm sad to say, I was wrong. It's a whopper (sorry) of a report, but a good, thorough one. The methods section (on page 33 for those who care) convinced me that the sample of parents was, in fact, nationally representative. The researchers took pains to include appropriate racial/ethnic diversity and had a reasonable sample size.

The next thing I wanted to know was why. Why would all those parents take their kids to fast food restaurants so frequently? I thought the answers might be cost and convenience, two factors that could influence any parent's decision on where to eat. This time I was partially correct. A useful bar chart (page 118) shows the main reason parents take their kids to the following restaurants:

  • McDonald's and Burger King: the kids like it
  • Wendy's: convenience
  • Subway: nutrition (as an aside, of the 3,039 food combinations evaluated, Subway had the most choices that met the nutritional criteria for kids. Burger King didn't do so badly, either. But scoring well means choosing milk or juice with the meal, substituting fruit for french fries, and eschewing cheese, among other choices.)

This brought up another question: How did the kids know about the restaurants?

And this time, I got the answer correct. Kids know about these restaurants because of amazingly effective advertising and marketing.

Check this out: In 2009, preschoolers saw an average of 2.8 fast-food television commercials each day, kids aged 6-11 saw an average of 3.5, and teens saw 4.7. And that's just TV, not exposure to radio, billboards, online banner ads or pop-ups, bus ads, airport kiosks, and all the other places that fast food is advertised.

So what's a parent to do?

Even though I'm not a big proponent of TV, especially for small kids, I don't think isolating your kids from popular culture is the answer. Sure, sitting around watching the tube is obviously not exercise, and the exposure to the noxious advertising makes the kids want what they don't have  - clothes, food, and toys included. I also don't think we can sit around and wait for government regulations that would limit marketing to kids. After all, it took almost a decade before Congressional pressure and private lawsuits brought about the retirement of Joe Camel despite his obvious intention of selling cigarettes to kids - intentions that were pointed out by a 1991 article in the Journal of the American Medical Association that showed that 5 and 6-year-old kids could identify him more readily than Mickey Mouse or Fred Flintstone. This wasn't a benign situation. A companion article noted that during Joe Camel's reign, one-third of all cigarettes sold illegally to underage buyers were Camels - up from less than one percent before Joe Camel.  So even though it was clear (and later proven by internal RJR Nabisco documents) that tobacco was being marketing to kids, lawsuits and government action still took years to be effective.

Therefore, I think the most important thing parents can do to counteract the marketing messages targeting our kids is to teach them, from a very young age, that they are being manipulated. Put your kids in the driver's seat and teach them how to make choices. PBS has a "Question the Commercial" guide that is a good start to opening conversations with young kids about commercials.

And don't forget moderation. There is room in a healthy diet for treats: a donut here, couple of cookies there, an outing to a fast food restaurant every once in a while. But when 8 out of 10 parents willingly tell researchers that they took their kids to fast food restaurants in the past week, we know that kids aren't the only ones who need to learn moderation.

The reality is that we live in a world where marketing is everywhere. We can't keep our kids away from it. So we have to teach our kids - and ourselves - how to live with it.


Monday, November 8, 2010

Not Really a Surprise, But Still...

A super shout-out to Michael Moss's excellent investigative reporting on how conflicted the government is when one of its agencies is charged with both promoting business and promoting health. Moss's article, published on the front page of yesterday's New York Times, focused on the United States Department of Agriculture's schizophrenic mission of encouraging consumption of US agricultural products while also being in charge of nutrition guidelines.

 In his article, Moss explains how the USDA created an organization called Dairy Management, which is a marketing entity charged with increasing the consumption of dairy products in the United States. Dairy Management has achieved its goals magnificently - it is the group responsible for the brilliant marketing campaigns that have boosted Domino's pizza sales, convinced Americans that drinking milk is part of a good weight-loss strategy, and  ingrained "Got Milk?" into our national consciousness. All while one of the main contributors to obesity is saturated fat - yes, the fat found in dairy products.

Therein lies the conflict. You can't encourage Americans to eat more fat and address the obesity epidemic at the same time.

The story is not new. The USDA has long been conflicted about its role in business versus health. Remember the four basic food groups that the USDA touted until 1992? Meat, dairy, grains, fruits and vegetables - the foods most grown by American farmers (disclosure: I grew up on an American grain farm).  The food pyramid came next. This fascinating article, written by a nutritionist who worked on the original food pyramid, shows just how overt the USDA has been in promoting certain foods regardless of their effect on health.

It's unfortunate that we can't look to our government to provide unbiased nutrition information. That's why others, such as the good docs at Harvard's School of Public Health, have created their own food pyramid. Harvard's pyramid and the USDA's pyramid are similar in that both have their foundations in science. But Harvard stops there, without adding the heaping helping of influence from special interest groups that can sour even the best intentions.


Saturday, November 6, 2010

Don't eat the oil

Sorting through my kids' candy bounty after the recent national holiday of Halloween got me to thinking about how slowly change comes to the food industry. It's been fairly well accepted for years now that some food dyes cause adverse reactions, especially in children. After all, children may weigh a fraction of what an adult weighs, but still consume the same level of artificial chemicals in a bag of Skittles. Way before  the EU mandated that foodstuffs carry warning labels if they contain certain artificial colors, the Feingold Association has been publicizing the sensitivities some kids have to artificial colors, flavorings, and preservatives - sensitivities that have been misdiagnosed as conditions as severe as ADHD, bipolar disorder, and obsessive-compulsive disorder. More recently, the Center for Science in the Public Interest has adopted artificial colors as a project, and is lobbying the US Congress to remove some of them from our food supply.

But still, here I sit at my kitchen table, sifting through the Nerds, Skittles, and Starbust Chews for some good old chocolate that hasn't been too adulterated with artificial flavorings (synthetic vanillin is cheaper than vanilla) or colorings. The rub is that having travelled overseas many times in the past few years, I've eaten Starbusts and M&Ms made with natural colors so I know that we don't have to settle for foods that are colored with dyes made from petroleum products.

It bewilders me why the United Kingdom is way ahead of us on this issue. Mars, the company that makes M&Ms, was so sensitive to the public's concerns over red dye #2's possible link to cancer that it removed red M&Ms in 1976, despite the fact that its candies did not contain that specific dye.  However, the company seems resolute in in its use of red #40, the synthetic chemical that has colored its red candies since the late 1980s, even though red #40, is not recommended for consumption by children in Europe and is outright banned in Denmark, Belgium, France, Germany, Switzerland, Sweden, Austria, and Norway.

And it's not just candies that are affected by the regulations in Europe. The syrup in a strawberry sundae from McDonald's in London is colored with real strawberries, whereas a strawberry sundae in Atlanta carries a hefty dose of red #40. Nutri-Grain bars, a snack food many parents consider healthy, are vastly different here and abroad, as the illustration below shows.

Kellogg's Nutri-Grain Cereal Bars ingredients. From Britian compared to the US.

                                                    Illustration: Center for Science in the Public Interest                                                       

The issue isn't just one for little kids. Research is showing that you don't outgrow these sensitivities. Teens may act aggressively. Adults may get headaches. The list goes on and on. One of the most compelling real-life examples of the link between poor food and negative behaviors comes from Appleton, Wisconsin. By replacing typical cafeteria fare, sodas, and processed foods in its high school lunchroom and vending machines, this school - which serves troubled youths - has experienced drops in truancy and aggression, as well as increases in attention and learning. Foodie Alice Waters wrote about this school in The Nation, and it has received coverage on Good Morning America as well as numerous other places.

There really is a lot of research out there showing that some people are sensitive to artificial flavorings, colors, and preservatives, and that those sensitivities can be so extreme that they interfere with normal functioning. That's why it is upsetting that the pace of change in this industry is so glacial.   My point is that we don't have to accept impurities in our foods - our European counterparts don't. I encourage everyone to read the labels on their foods and evaluate what is in them. The Center for Science in the Public Interest maintains an excellent food coloring database that lists the synthetic colorings found in common foods. Bagels, cake mixes, cereals, you name it. Most foods that are prepackaged have been tarted up with a rainbow of colors intended to fool us into thinking the foods are purer, freshers, and healthier than they are. Then let your Congressional representatives know that you would rather have the more natural alternative that our friends across the pond enjoy.

Friday, October 22, 2010

And So It Begins

CDC, Public Health Image Library
I am fortunate to have the Dengue Vaccine Initiative as a client. Through this group, I have traveled the world, meeting with doctors and scientists, working to lay the groundwork for a coming vaccine against dengue fever. As our work has progressed from discussing issues with surveillance and diagnostics, we have moved into communication issues - the need to raise awareness among politicians, healthcare professionals, and consumers of a coming vaccine, and the lifesaving (and cost saving) benefits such a vaccine will confer on countries in which dengue sickens hundreds of thousands of people annually.

One of the issues that confronts us is anti-vaccine activism. This is a worldwide phenomenon. Activists' concerns range from what we see in the United States - concerns about autism - but also include cultural-specific worries. For example, in Argentina, a branch of the Catholic church warns that vaccines will cause women to abort their fetuses. In parts of Asia with large Muslim populations, there are concerns that some vaccines are made with cells from dogs or from pork gelatin. It is stiff opposition that can usually be satisfied with factual answers.

But overall, countries outside of the United States are hungry for vaccines. When PATH and The Gates Foundation worked with India to quickly distribute a vaccine against Japanese Encephalitis - a mosquito-borne disease common in rural areas that causes paralysis and death in high numbers - they were able to vaccinate 32 million children in a year and a half because people were desperate for protection. From the safety of the United States, it may be difficult to understand that polio still cripples hundreds of children in India each year or that measles killed over 160,000 people worldwide in 2008. We have become used to a childhood without those terrible diseases.

This is likely a generational issue. My mother remembers having to stay indoors during the hot summer months, away from other people, when polio epidemics were raging throughout the countryside. Isolating her family was the only way my grandmother could protect her children.  As a kid, probably around 3 years old, I stood in line in a school gymnasium - a very long line snaking around the gym and outside the door - to receive a dose of the Sabin polio vaccine on a sugar cube. I have a fuzzy memory of the darkness of the gym but really what I remember is the solemnity of the occasion. Granted, it was a long time ago, but I like to think I was feeling the resolve of all those moms who brought their kids in to protect them against the seasonal fear of fever, paralysis, iron lungs. And I, too, am part of the generational divide: I have a round and dimpled scar on my upper left arm from a smallpox vaccination, a badge that signifies me as a woman of a certain age, to be sure, because today's kids don't get vaccinated against smallpox because it is no longer a threat.

Unlike smallpox, most vaccine-preventable diseases are not eradicated, just kept under control. That control, however, is tenuous because we rely on herd immunity - keeping a high proportion of our population vaccinated in order to prevent diseases - to protect our society. In other words, all those families who don't vaccinate their kids can be reasonably assured that their kids won't get childhood diseases because so many other families do vaccinate their kids. However, there is always a tipping point, where diseases can race through unvaccinated kids and infect those with partial immunity, such as the elderly who have lost their immunity, children who have not received boosters, or infants who have not received vaccinations.   Recent news carried a report of a death from whooping cough, not in Nigeria, not in Bangladesh, not in Cambodia. But here, in the great state of California. And it's the 10th one in California this year. This infant's death is attributed to families not vaccinating their children against pertussis, thus allowing this potentially deadly disease to spike again.

Recent estimates show that over 7.0% of children entering kindergarten in Marin county, a wealthy suburb of San Francisco, have waivers exempting them from childhood vaccinations based on their parents' beliefs. A private school in San Diego reports that 51% of its kindergartners had such exemptions. These are shockingly high numbers because once these percentages reach the tipping point, we will lose our herd immunity. And evidence is growing that we are approaching that that point: For each one percent increase in exemptions at a school, the risk of having a pertussis outbreak went up by 12%, a 2000 study in the Journal of the American Medical Association found. The study, which was conducted in Colorado, also found that at least 11% of the vaccinated children in measles outbreaks were infected through contact with somebody who was exempt.

Epidemics start with a whisper. A case of pertussis here, a few cases of measles there. But make no doubt about it: we are on the cusp of an epidemic of many diseases that we thought we left behind. What is it about human nature that makes us reinvent the wheel again and again? If you don't want to vaccinate your kids, I recommend you travel to poor countries around the world. Tell a mother who fears seasonal outbreaks of diseases that you turned down the opportunity to vaccinate your kids against those diseases. Of course, many who don't vaccinate their kids point out that we don't live in developing countries, and that many vaccine-preventable diseases are rare in the United States. That is true. These diseases are rare because people vaccinate their kids. And they won't stay rare if we don't.


Thursday, October 21, 2010

Hurts So Good

Welcome to the month of pink. For those who have been living in a cave for the past decade, October is National Breast Cancer Awareness Month.  It's the one month out of the year in which the word "breast" is spoken freely and clearly and without any tinge of sexuality and pink is everywhere: on hats, billboards, and the shirts of the evening news anchors.

I know the ad I chose to illustrate this post isn't pink (except for the tasteful pink ribbon in the word "breast"). But it is funny! And it played off of my second point about how breasts are icons of sex. The fact that the ad is from India also points out how ingrained this month is in the world's consciousness. Way to go, India!


In honor of this great month, I got my annual mammogram.

Mammograms have to be in the top 10 of weird diagnostic tools. Most medical procedures find you sitting, or reclining, with only the part in question exposed to light. But for a mammogram, you have to stand up while your breasts, one at a time, are clamped in a vice. The rest of your body is free to move (as if!), but you are literally held in place by a machine that is gripping your boob. So there you stand, in your regular shoes (which in my case happened to be high heels) while your top half is draped in a hospital gown, in a cold room (the machines have to stay cool). In summary: you're half naked, in heels, with your nipples announcing the temperature. Maybe breast cancer awareness month is about sex after all?.


But that's all foreshadowing of what's to come. Because once the real procedure begins, the train of mild discomfort and indignity moves on into the station of painful because mammograms hurt. Like holy heck. But, not to sound all twisted about it, it's a good hurt. Because a mammogram that captures the bits off to the sides - the chest wall, the underarm area - requires a lot of pulling and squeezing and manipulating of the breast tissue. And squeezing. And more squeezing. But all those machinations are important because you really want those parts shown on your mammogram. So I don't mind.

Fourteen years ago, when I was pregnant with my first child, I felt a lump in my breast. As my pregnancy progressed, the lump grew. Daily. I brought it to my doctors' attention, we decided that an excisional biopsy - one that would remove the entire lump - was the way to go. I remember being on the operating table under local anesthesia thinking how strange it was to be carrying new life while being worried about my own. I remember the smells - the sharp, medicinal smell of the sterilizing fluid followed by the warm, metallic smell of blood as the surgeon first sterilized, then sliced into my breast. I turned my head away from the surgeon, while he engaged me in chatter. Fortunately, the lump was not cancerous. But it was a very scary time.

So that's why I don't mind that mammograms hurt. Because I want every inch of my mammary tissue exposed so the radiologists can look for cancer.

Over the years, as I've aged, mammograms have become a fact of life for me. Every other year at first, and now, every year, with a scary year during which I had one breast checked three times because of irregularities on the mammograms. So far so good.

Why don't all women get mammograms? The reasons are as varied as the women themselves. Some women don't have time (or don't think they have time). Some women don't have insurance and don't realize there are places to get free, or reduced price, mammograms. Some women are afraid: of the procedure, or of the possible bad news it can bring. All completely understandable reasons, but not very valid. Because catching cancers early gives you the best options for treatment.

So, happy October, friends. Take care of yourselves, and get your mammogram. Even though it hurts, it really could save your life. And that's good.

Thursday, October 7, 2010

The Drumbeat Grows Louder

More on overuse of antibiotics in livestock production.

Typical push/pull of health vs economics. At some point, we're all going to have to take the long view and realize that health = economics. We're going to have to pay for all those sick people somehow, so we might as well avert problems when we can. Right?

Saturday, September 18, 2010

I Like Bacon

Disclaimer: I like bacon. And steak and chicken.

But I don't like antibiotic-resistant bacteria.

It's no secret that the reason US livestock producers can raise thousands of animals in close confinement is because they use antibiotics not to treat, but to prevent infections in animals. This means every animal receives antibiotics at certain ages as a matter of course. It also means that when bacteria ultimately learn how to survive in those conditions - and they always do - that they are resistant to the antibiotics that include many that humans use. And that spells trouble not only for the herds of animals but for humans who come in contact with the resistant microbes in their meat.

From a recent NYT article that outlines the issue and talks about possible enhanced regulations on livestock antibiotic use: 
"In a letter to Congress in July, Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention, cited “compelling evidence” of a “clear link between antibiotic use in animals and antibiotic resistance in humans.”"

I understand the food economics argument, that the use of antibiotics keeps the price per animal down, which translates into cheap food to feed our citizens. But I also understand that Americans eat too much fatty food - and that includes bacon and hamburger. Maybe a small increase in price would encourage smaller portions, or meals without meat as a centerpiece, or more consumption of plant-based foods.

And I understand the commodity argument, that livestock growers make a slim profit per animal and that profit would be reduced if they could not use antibiotics in the current way. But it sounds as if Denmark farmers - who produce most of Europe's pork - have found ways to keep their animals healthy without antibiotics. Here is testimony given by a representative of the Danish Veterinary and Food Administration explaining their success.

I think limiting or eliminating the use of prophylactic antibiotics in animals is a step in the right direction. We have a decent model provided by our Danish friends, let's follow it.


Thursday, September 16, 2010

Mean People Suck

When my oldest son was beginning to take swim lessons, around age 4, we took the advice of many preschool moms and enrolled him with Miss B, a tough older woman with a large pool outside of her magnificent house on the banks of the Chattahoochee River here in Atlanta. We had heard about her tough-love approach to teaching swim lessons, so I was somewhat prepared for a no-nonsense, let's-do-this attitude. That's fine. I'm from the Midwest where no-nonsense is practically a middle name. But instead of the  familiarity of "my people," we found ourselves unexpectedly thrust into a foreign land of ridicule, abuse, and actually some danger. That's because Miss B's approach to teaching a shy, cautious child to swim boiled down pulling him into the deep end of the pool and then letting him go to find his own way to the side. She sidestroked alongside him, far enough away that he couldn't reach out to her, but close enough to barrage him with negative comments along the lines of "don't be a baby," and "big boys learn to swim."

When my son reached the side, crawled out of the pool, and then collapsed into a puddle of shrieking goo on the pool deck, she clasped her hands together, looked toward the sky, and said, "Please God, give me patience to deal with this child."

It happened so quickly that I was in shock. One minute, a sunny day, a swim lesson, a grandmotherly person. In my memory I can hear birds. See clouds. Admire the green of the trees lining the river. The next minute, my heart is pounding and I'm running to the side of the pool (she requested that parents stay away from the pool during lessons - warning!), this old lady is sarcastically praying, and my son is a mess. Ten years later, my feelings can still race from from serene to murderous just thinking about that day.

Needless to say, one "lesson" was all we took from her. But over the years I've been raising kids, I've seen more than one Miss B - nurses who are impatient, doctors who want preschoolers to "man up" and not be scared of shots, teachers who think the best way to learn is to sit down, shut up, and finish that work sheet. I've always wondered why these people wanted to work with children in the first place.

They seem especially crazy (and mean) when you run into professionals who really "get" working with kids.  Since the Miss B episode, our family has been fortunate to experience many gifted professionals who put the kids first. One first grade teacher I especially loved would simply open the door to her classroom, which was next to the playground, and shoo the kids outside when the wiggles got to be too much. A quick 10-minute expenditure of energy and the kids could resume the day's schedule with appropriate focus. Imagine that. Letting kids play. I also fondly remember an upper-GI specialist singing "drink chugalug, chugalug, chugalug" in order to help my son down the nasty drink that would provide contrast to the x-ray he was having of his throat and esophagus. There are good eggs out there.

So we've experienced bad, and we've experience good. But my kids are neurotypical and can bounce back from the bad (as long as it is an isolated incident) without losing a lot of traction. We still talk about how crazy Miss B was, but the following summer, my son willingly took swim lessons and ended up being a wonderful swimmer.

Parents of kids with autism can't be guaranteed of such a benign outcome. A bad run-in with a doctor may mean it is almost impossible to get the kid in the door the next time - a dire situation when a broken bone, cut hand or other medical emergency requires quick action. An impatient dentist could mean saying bye-bye to dental care for years. It takes a PhD in empathy on top of whatever other professional degree the person has to provide care or instruction to kids who live on the edge of fight or flight.

An Atlanta mom, who has a son with an autism diagnosis, has experienced her fair share of knuckleheaded doctors. Fortunately, she found an angel of a dentist, whose approach to working with  children with special needs should be taught in medical, dental, nursing, education, any school that is turning out professionals who will work with people. Here is her blog posting explaining what makes a good health professional for kids with special needs. She also has an example of a bad doctor visit a few entries earlier. Compare and contrast, if you will.

So for the Miss Bs, the bad doctors, the grumpy teachers, I say, find something else to do. You're doing more harm than good. But for those good ones, well, I hope you know how special you are.


Sunday, September 12, 2010

Tell me it ain't so

Please tell me that it is not novel for doctors to send unusual cases that stump them around to their colleagues, and their colleagues' colleagues, via online networks.

From the Diagnosis column in today's NYT Magazine: "If he was the second opinion, then the patient clearly needed a third. Suddenly Schumann had an idea. What if they opened the mystery of his symptoms to other doctors? What if they put his case on the Internet — on a blog read mostly by doctors — and let some new eyes and brains work on this problem? The patient was excited by the idea."

Hello, medical profession? There's this new thing called the Internet. We think you'll like it.

Friday, September 10, 2010

More Research is Needed

Yesterday, the details of the US government's settlement with a family whose daughter has an autism diagnosis became public. Hannah Poling had been developing normally, but began regressing after receiving multiple childhood vaccines during her 18-month-old check up. The Vaccine Injury Compensation Program found Hannah's case credible in 2008 and yesterday released the details of the monetary settlement.

The emergence of these details has many saying vaccines cause autism. It's doubtful that is true. What is true, however, is that kids are not genetically identical to each other and often have underlying sensitivities that are exacerbated by vaccines or other environmental factors, such as pollution or food dyes or gluten. 

By admitting that vaccines may have triggered Hannah Poling's autism because of her mitochondrial disorder, the US government raised a larger issue: If autism can result from vaccines + mitochondrial disorders, why aren't kids tested for such mitochondrial problems before vaccines are given? If such knowledge was available, parents and pediatricians could assess whether the risk of significant childhood disease outweighs the risk of vaccinating against it.

Admittedly, mitochondrial disorders are rare. Some estimates note that approximately only 4,000 infants are born each year with them (out of over 4 million babies born each year in the US). But those are the most severe cases, where the physical manifestations of mitochondrial disorders, e.g., eye or respiratory problems, delayed development, etc., are present. What about mild cases that may go unnoticed until later in life, when diseases such as Parkinson's disease, Alzheimer's disease, or cancer develop?

Mitochondrial issues are not something that are routinely tested for. But can they be? Anything that might address the epidemic of autism should be explored. Never forget that the United States government exists to work for us. Let your Congressional representatives know that you encourage research into mitochondrial diseases so that s/he can influence the National Institutes of Health's research agenda.

Don't know who your Congressional reps are? Go here to find out.

The Foundation for Mitochondrial Medicine  supports research and therapies for mitochondrial disorders.

Here is the CBS News Report on the Poling family.

The Poling family opened the door for the rest of the country. Let's build on what they started.