We are Thankful for Health Policies - Day 3

Day three of our Thanksgiving countdown is here.  We know many of you are already starting to cook in preparation for tomorrow’s big feast, but take a minute and check out some awesome health policies to be thankful for.

Emily is Thankful for...

Paid Sick Time Policies.

The United States lacks a national standard for sick time. Not only do millions lack paid sick days, million of people also lack a guarantee that they can’t be fired for being sick. One state, Connecticut (Public Act 11-52), has legislation requiring paid sick time. Seattle, Portland, San Francisco, Milwaukee, and Washington D.C. have passed city laws regarding paid sick time. Many more states and cities are actively working on paid sick day campaigns. To find out the details in legislature in states and cities, check this report.

According to the Economic Policy Institute, roughly 40% of private sector Americans do not have paid sick days or even policies that allow them to call in sick without fear of termination. Women, minorities, and low-income people are all less likely to have paid sick days.

Here are some benefits to paid sick time:

• Sick people do not prepare your food. Eighty-two percent of  workers who make less than $8.25 an hour do not have sick time. Yup, those are people that work at restaurants.
• People stay home when sick. People without sick time are 1.5 times more likely to go to work with a contagious infection. The American Public Health Association found that giving all employees paid sick days, the spread of the flu is reduced by 6%.
• The national economy is better. If employees were offered seven sick days a year, the national economy would save $160 billion a year from reduced turnover and increased productivity.
• Kids can stay home sick. Just like going to work sick, sending kids to school sick spread viruses. When a child can see a doctor in a timely fashion and rest, ER visits and chances of recurring illness goes down.
• Decreased healthcare costs. A study found that if all workers had paid sick days, 1.3 million ER visits could be prevented. ER visits are a huge cost and costs taxpayers billions. People without sick time either wait too long to go to the doctor (the illness becomes an emergency) or they are unable to go to the doctor during the clinic’s hours.

Paid sick days, including time off for ill family members, is essential. No one should be fired for a cold or because they had to bring a sick child to the doctor. Since low-income people, women and minority workers are less likely to have paid sick time, lack of policy around this issue  increases the health disparities already apparent in these groups.

Heather Is Thankful For…

The HIV Organ Policy Equity (HOPE) Act.  

The HOPE Act was introduced in February of this year as a bipartisan bill.  Both the House and Senate passed it unanimously and President Obama signed it into law this month.  The act allows the Department of Health and Human Services to research whether HIV positive to positive organ donation is feasible.  If the research shows that positive to positive donation is possible, the Act could save hundreds of lives.  It would help the hundreds of HIV positive patients waiting for organs get them faster, and it would shorten the list for non-HIV positive patients.  As a bonus, this Act also shows that there is still such a thing as bipartisanship in congress.  We haven’t seen both parties work together to pass a law in a while now, so this gives me hope.

We are Thankful for Health Policies - Day 2

In the spirit of Thanksgiving, we are continuing our list of health policies we are thankful for.  Today’s theme seems to be centered around being able to breathe.  Feel free to tell us about the health policies you are thankful for in the comments.

Emily is Thankful For...

Smoke free laws. A smoke free policy prohibits smoking in a specific space. States, local governments, counties, and workplaces can pass smoke free policies. Thirty-six states have smoke-free laws that prohibit smoking in restaurants, bars and/or workplaces - impacting 81.5 of the U.S. population.

According to the U.S. Surgeon General, secondhand smoke causes lung cancer and heart disease in non-smoking adults. In children, secondhand smoke increases the risk of infant death syndrome, low birth weight, respiratory and ear infections, and asthma attacks. There is no safe level of exposure to secondhand smoke and in the U.S. secondhand smoke kills about 50,000 people each year. Besides all the dangers of secondhand smoke, I am thankful that in the states I frequent (Illinois and Minnesota) I no longer need a special ‘bar’ coat and that I won’t come home from eating out smelling of smoke.

Heather is Thankful For…

The Clean Air Act.  This act went into effect on December 17th, 1963 and was amended significantly in 1970, 1977 and 1990 to add more regulatory controls.  The Act is a federal law that aims to control air pollution that is widely recognized as being harmful for public health.  When congress last amended the Act, they added a requirement that the costs and benefits of the act be studied.  The result is that we now know that not only has the act been successful in reducing some of the most common air pollutants (particulate, ozone, lead, carbon monoxide, nitrogen dioxide, and sulfur dioxide, as well as other pollutants), but it has also done so without harming the economy.  In fact, it may have helped it.  The EPA estimates that the Clean Air Act cost $0.5 trillion which is a lot of money; however, the benefits of the Act were estimated to be between $5.6 trillion on the low end and $49.4 trillion on the high end.  Even if the more conservative estimate is the right one, that is a $5.1 trillion net benefit.  

Even more importantly, by 2020, the 1990 amendment of the Act alone will have saved 4.2 million lives, 43.8 million asthma exacerbation events, 3.3 million heart attacks, 2.1 million hospital admissions, 2.2 million ER visits and 3.3 million lost work days.  There is also research to suggest that the Act has reduced chronic and acute bronchitis and has increased life expectancy at the time of birth by 7 months.

Policies We Are Thankful For - Day 1

Health policies improve lives every single day. These policies are varied and wide reaching - from national policies that set standards so that you have safe drinking water to school district policies that require that children receive health education.  In the spirit of the holiday, we have decided to countdown to Thanksgiving by sharing two of the health policies that we are most thankful for each day.

Emily is Thankful for...

Section 4207 of the Affordable Care Act which amended the Fair Labor Standards Act. This amendment requires that breast feeding mothers get break time and a private place to breast feed during the day. All employers in the United States must follow this law. Breastfeeding has many benefits for babies.  It lowers the risk of ear infections, stomach viruses, respiratory infections, asthma, obesity, and diabetes. For the mother, breastfeeding lowers the risk of diabetes, some cancers, and depression. For many women who are low income and struggling financially, breastfeeding is a free way to provide nourishment for their babies. 

Heather is Thankful for...

States that Legalized Same-Sex Marriage.  Currently, fourteen states (CA, CT, DE, IA, ME, MD, MA, MN, NH, NJ, NY, RI, VT and WA), the district of Columbia, eight counties in New Mexico,and eight Native American tribal jurisdictions have legalized gay marriage covering 38% of the US population.  Hawaii and Illinois also recently passed gay marriage which will officially begin on December 2, 2013 and June 1, 2014 respectively.  Although a greater number of states have banned same-sex marriage, I am also thankful for the fact that, according to a recent Gallup poll, more than 52% of the population supports gay marriage.  More importantly, more than 60% of the 18 to 34 group supports it which mean it is only a matter of time before the rest of the country legalizes it.

I am thankful for these state laws not only because I support equality in general, but also because some of the people I love the most are part of the LGBTQ community.  Even if you don’t share that with me, here’s why you should be thankful too.

     1.) States that allow gay marriage have lower divorce rates than states that don’t.  In fact, their divorce rates are a whopping 20% lower.  My home state of Massachusetts, the first state to legalize gay marriage has the lowest divorce rate.

     2.) Gay Marriage could boost the economy.  The Williams Institute estimates that Washington State will get a $88 million economic boost from wedding spending in the first three years after it legalized gay marriage.  There is also the economic benefit of allowing same-sex couples to get spousal health insurance benefits - same sex couples are much less likely to have health insurance than different sex couples. (The Economic Benefits of Same Sex Marriage)

   3.) Bans on Gay Marriage may increase STD’s by increasing homophobia and risky homosexual behaviors.  Feeling like you are a social outcast can take its toll on a person, so it isn’t surprising that same sex marriage bans increase the rate of syphilis (which is more common in men who have sex with men) and HIV.

E-Cigarettes: A Call for Policy Interventions

What are e-cigarettes?

E-cigarettes are battery powered devices that deliver nicotine in the form of a vapor. In appearance, e-cigarettes look like cigarettes. Below is a general depiction of an e-cigarette. 

In the United States, e-cigarettes can be legally sold to anyone and the FDA has not yet regulated e-cigarettes. However, some states and local governments do regulate e-cigarettes.  Since 2009, 25 states and the District of Columbia have passed measures to regulate the sale of e-cigarettes, including banning minors from purchasing them. In recent years, e-cigarettes have increased in popularity, both with users of traditional cigarettes and non-smokers. One reason for this may be that celebrities have been photoed smoking e-cigarettes. The below picture is from e-cigarette company Blue Smoke

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Wall Street predicts sales of e-cigarettes could reach $1 billion in 2013, doubling since 2012. According to the CDC, about one in five U.S. adult smokers and about 6 percent of the total adult population have tried an e-cigarette. So, are e-cigarettes a healthy way to quit smoking traditional cigarettes or are e-cigarettes just dangerous?

Are e-cigarettes less damaging than regular cigarettes?

Very little is known about the long term health effects of e-cigarettes. When e-cigarettes are used as a tool to quit smoking, there may be health benefits. The FDA, however, does not endorse the switch to e-cigarettes as a way to quit smoking. Many researchers believe that it is not nicotine that causes lung cancer, but the other chemicals in traditional cigarettes. The e-cigarette still provides the highly-addictive nicotine, but without the chemicals which seems like a good thing for those who currently smoke traditional cigarettes.  

The economic costs of smoking cigarettes are huge. Between 2000-2004, the CDC estimated that cigarette smoking was responsible for about $96 billion in medical expenses and $97 billion in loss of productivity. Cigarette smoking also is responsible for a lost of 5.1 million of potential years of life lost annually. The switch to e-cigarettes could therefore have economic benefits.

Without the toxic fumes of regular cigarettes, e-cigarettes do not create second-hand smoke to the degree regular cigarettes do. Secondhand smoke causes lung cancer and heart disease in nonsmoking individuals and can contribute to sudden infant death syndrome, respiratory infections, and asthma attacks.  Not harming innocent bystanders is a good thing.

Although all of that sounds promising,  it is important to note that in general, research does not indicate that e-cigarettes are more helpful than other, FDA-endorsed methods to quit smoking. According to the CDC, “There is currently no conclusive scientific evidence that e-cigarettes promote long-term cessation.”

Are e-cigarettes safe, even for non-smokers?

E-cigarettes still provide the body with a dose of nicotine, which is an addictive drug. Children can (and do) legally purchase e-cigarettes. Little is known about the health effects of nicotine on children, especially in the long term. Teens and children are trying e-cigarettes.  In 2012, the percent of high school students that reported ever using e-cigarettes increased to 10 percent, a 4.7 percent increase from 2011.  In total, 1.78 million U.S. middle and high school students had tried e-cigarettes in 2012. In the same study, 1 out of 5 middle schoolers that said they used e-cigarettes, said they do not use traditional cigarettes. Since e-cigarettes do contain nicotine, they are introducing a highly addictive drug to the child.

Conclusion

E-cigarettes can be helpful or e-cigarettes can be harmful, depending on the situation. What is clear is that policy is needed to regulate the purchase and consumption of e-cigarettes.

E-cigarettes - Policy solutions

1. Restrict sales of e-cigarettes from minors. In order to enforce the sale ban of e-cigarettes to minors, e-cigarettes would be kept behind the counter at retail stores and ID would be required for purchase. Similarly, there would have to be a fine for sale of e-cigarettes to a minor.  Several states have already passed laws restricting sales of e-cigarettes to those over 18. Since we don’t know the long-term effects of e-cigarettes, especially on developing lungs, a mandatory age to purchase e-cigarettes is necessary.

2. Ban e-cigarettes in certain areas. Many jurisdictions are ‘smoke free’ meaning they do not allow traditional smoking within a certain geographic area. An option would be to include e-cigarettes in that ban. The concern is that e-cigarettes look similar enough to regular cigarettes that people would become confused and think that smoking is allowed. A ban in certain areas would still allow those to use e-cigarettes as an alternative to regular cigarettes, just not in many public spaces.

Source

3. Taxation of e-cigarettes. Traditional cigarettes are highly taxed. The point of taxation is that it will deter people from purchasing. Some states have redefined their tax codes so that e-cigarettes are taxed like regular tobacco products. At this time, the FDA has not determined that e-cigarettes are a way to quit smoking and therefore not considered a therapy. However, it might not be wise to tax something that is used as a less deadly alternative to normal cigarettes.

4. Regulate advertising. E-cigarettes are not under the same FDA regulations as normal cigarettes. Therefore e-cigarettes are able to use the tactics they know boosts sales - celebrity sponsorship, adding flavors, and advertising to kids. Since e-cigarettes look the same as normal cigarettes, especially to children, it can be extremely damaging.

Here is the mascot of eJuiceMonkeys. It appears to be a cartoon monkey smoking a cigarette.

The future of e-cigarettes

A spokesperson for the FDA said that there is a proposed rule for e-cigarette regulation that was sent to the Office of Management and Budget and the Office of Information and Regulatory Affairs for review. The proposed rule is not yet open for public review. It seems appropriate to only allow those over age 18 to purchase e-cigarettes. There also has to be a serious effort to decrease any attempts to market to children. While waiting for the FDA, school districts need to address e-cigarettes both within school walls and the education curriculum. Most importantly, research needs to continue to uncover the health effects of e-cigarettes in the short-term and long-term.

Veteran's Health

In 1919, after the end of the first world war, President Wilson proclaimed November 11th as Armistice Day to commemorate the end of fighting in Europe.  The day was originally meant to honor veterans of WWI alone, but in 1954, congress changed the name to Veteran’s day to honor those who served during WWII and those who would serve in later wars.  This post on Veteran’s health is in honor of all veterans but especially those in my family - My grandfather Edwin (WWII), My grandfather John (Korean War), My Uncle Tommy (Panama and Operation Iraqi Freedom), My Uncle Marty (Operation Iraqi Freedom), My Sister Lindsay (Operation Iraqi Freedom) and my Brother-in-law Juan (Operation Iraqi Freedom) - and in Emily’s - her Grandpa Koebnick (WWII) and her Grandpa Huso (WWII).  Thank you all for your service.

The Current Health of Veterans

The VA recently stopped releasing the number of soldiers injured in Iraq and Afghanistan, but we know that as of last December more than 900,000 soldiers had been injured in Operations Iraqi Freedom and Enduring Freedom.  Earlier reports put the monthly influx of injured at around 10,000 which means it is likely that about 1 million soldiers have come home injured so far. (VA Stops Releasing Data On Injured Vets As Total Reaches Grim Milestone)  

Although all war injuries are potentially life changing, I will focus on two that are especially pervasive and devastating to recent veterans - Traumatic Brain Injuries (TBI) and Post Traumatic Stress Disorder (PTSD).  

Traumatic Brain Injury

It is difficult to know exactly how many soldiers return with TBI. Penetrating brain injuries are easily diagnosed, but closed brain injuries like concussions are more common and harder to recognize.  However, in 2006, a study out of the walter Reed Medical Center suggested that there were more TBIs in current wars because of advancements in body armor technology that has saved the lives of soldiers who otherwise would have died, but who now live with injuries to their heads and extremities.  It also pointed out the increased use of explosives as a contributing factor.  By the time of the report, 28% of all soldiers who were medically evacuated from a war zone had TBI, with 56% of them having moderate to severe TBI. (Military TBI During the Iraq and Afghanistan Wars)

If you think that TBI sounds familiar, it is probably because you have been hearing about professional football players suffering from, and in some cases eventually dying from, TBI.  “TBI can cause changes in a person’s ability to think, control emotions, walk, or speak, and can also affect sense of sight or hearing” (What are the effects of a traumatic brain injury?).  Mild TBI generally causes temporary changes while moderate to severe have more long term effects.  The physical symptoms of TBI can often cause depressions, insomnia and anxiety.  These injuries likely contribute to the disproportionate rate of suicide that veterans face - a recent VA report states that 22 veterans take their own lives every day (VA Issues New Report on Suicide Data).  What is even more horrifying is that most agree that the number is actually higher because of limitations in how we report deaths and veteran status in this country.

Post Traumatic Stress Disorder

    Since 9/11, almost 30% of all soldiers from Operation Iraqi Freedom and Operation Enduring Freedom who have been treated by the VA have been diagnosed with PTSD.  Those who are deployed more than once are more than three times as likely to suffer from PTSD than those who only deploy once.  There is some argument about the percent of all veterans (not just those who are treated by the VA) who have PTSD, but the VA currently estimates it at 20%.  (Report on VA Facility Specific Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans Coded with Potential PTSD - Revised)

    PTSD is when your fight or flight response is “damaged” by a traumatic event.  Fight or flight is a natural and healthy response to a dangerous situation, but those who suffer from PTSD continue to experience the response after the danger is gone.  Symptoms include reexperiencing the event through nightmares and flashbacks, feeling emotionally numb, depression, and hyperarousal (being easily startled, difficulty sleeping, angry outbursts, etc). (What is Post Traumatic Stress Disorder?)  There is also often a connection between PTSD and homelessness.  Sadly, veterans are 50% more likely to be homeless than non-veterans and they are often homeless for longer periods of time.  PTSD often hinders a person’s ability to maintain relationships and employment which can cause homelessness which then exacerbates the PTSD. (PTSD and Homelessness Form a Vicious Cycle That Plagues Many Young Veterans From Iraq and Afghanistan)

How Can You Help?

    We often talk about supporting our troops, but it isn’t always easy to know how best to do that.  This Veteran’s Day, consider honoring those who have served in the armed forces by donating time or money to an organization that helps soldiers suffering from physical or psychological injuries or one that helps house veterans.  You can find reviews of non-profit veteran organizations here and here but two suggestions are:

The Bob Woodruff Foundation - started by Bob and Lee Woodruff after Bob (a journalist) suffered a severe traumatic brain injury from a roadside bomb in Iraq

Homes for Our Troops - an organization that builds homes for Iraq and Afghanistan Veterans with serious injuries

If you know of a great organization that helps Veteran’s, feel free to share in the comments below!

Neighborhood - A Risk Factor for Diabetes

November is Diabetes Awareness Month

According to the CDC, in 2011 18.8 million people were living with diagnosed diabetes while an additional 7 million people had diabetes that went undiagnosed. Roughly 1 of every 3 Americans are at high risk of developing type 2 diabetes. The risk factors for type 2 diabetes include:

·       Being 45 or older

·       Having a family history of diabetes

·       Being overweight

·       Not exercising regularly

·       Having high blood pressure

·       Having low HDL, also known as "good" cholesterol and/or high levels of triglycerides

·       Certain racial and ethnic groups (e.g., Non-Hispanic Blacks, Hispanic/Latino Americans, Asian Americans and Pacific Islanders, and American Indians and Alaska Native.)

One large factor that isn’t explicitly mentioned is neighborhood - poor neighborhoods tend to have high diabetes prevalence among residents compared to higher income neighborhoods. In New York City, the diabetes-related mortality rate was 2.7 times higher among individuals in high-poverty neighborhoods than in low-poverty neighborhoods. One in seven residents in South Los Angeles has diabetes, compared to one in 12 in West Los Angeles. Forty-two percent of South L.A. residents live below the federal poverty level, compared to twelve percent in West Los Angeles.

There is a clear gradient between diabetes diagnosis and income. The graph below is from the CDC and shows that as income level increases, the percent of people diagnosed with diabetes decreases.

Before we address why diabetes is more common in poor neighborhoods, we need to differentiate between the two types of diabetes. Below is a simplified overview.

Type 1 diabetes

• Roughly 5% of diagnosed diabetes
• Usually first diagnosed as children
• Risk factors are largely genetic or autoimmune and not preventable

Type 2 diabetes

• Roughly 95% of diagnosed diabetes
• Mainly associated with lifestyle and preventable

While type 1 diabetes is a serious condition, note that most of what I am writing about pertains to type 2 diabetes.

There are several reasons why diabetes prevalence is higher in poor neighborhoods and among lower income families. I will focus on two of the most important reasons.

1. Association between food deserts and diabetes. According to the CDC, food deserts are “Areas that lack access to affordable fruits, vegetables, whole grains, low-fat milk, and other foods that make up a full and healthy diet.” Food deserts exist in areas that lack large grocery stores but have small convenience stores and fast food options. Many low-income, minority, and rural neighborhoods are considered food deserts. Food deserts are environmental constructs and a result of centuries of social and business politics. There are many reasons why people live in food deserts - racial housing practices, the high cost of housing in other areas of a city, family history, transportation, etc.  It is not surprising that high-food desert counties had rates of adult diabetes that are five times higher than counties with enough grocery stores. Above is a food pyramid emphasizing the importance of fruits, grains, and vegetables in the diet. For people who live in neighborhoods that lack access to healthy foods, diet is not a personal choice, as they must rely on heavily processed foods that are available. 
2. Association between neighborhood walkability and diabetes. Researchers in Toronto found that people who live in less walkable neighborhoods are significantly more likely to develop diabetes.  This makes sense since one of the risk factors for diabetes is limited physical activity. Walkable communities ‘trick’ people into physical activity since they can walk rather than drive to the bus stop, to school, and to stores. Although many poorer neighborhoods might be considered walkable based on density and mixed use developments, poor neighborhoods have fewer street trees, clean streets, and sidewalk cafes, and higher rates of felony complaints, narcotics arrests, and vehicular crashes. Basically, if residents do not feel safe, they will not walk. Walking is a great form of physical activity. It is cheap and doesn’t take equipment but it isn’t so easy for someone in many low-income neighborhoods to go for a walk.

So, would moving people into higher income neighborhoods decrease their likelihood of diabetes? Maybe! Researchers looked at a group of mothers who were moved from high to low poverty areas. A decade later, they report that rates of diabetes and severe obesity are about one-fifth lower in the women who moved than in those who did not.

Type 2 diabetes is a highly preventable and controllable disease. However, for millions of Americans living in poor neighborhoods, type 2 diabetes is not preventable. To decrease rates of diabetes, the first step is to recognize the link between income and diabetes. The next step is to stop universally considering type 2 diabetes a preventable disease. Stop blaming the person or family and start looking at the environment. In many cases, the solution is not simply to tell someone to walk more and modify his diet. The solution is much more challenging. The solution is to create policies that improve poor neighborhoods that have been ignored for so long with access to fresh foods and safe streets.