Kidney Health

March is National Kidney Month.

Kidneys filter blood, remove waste to make urine, control blood pressure, and regulate hormones. Damaged kidneys limit the body’s ability to filter blood and causes waste to build up in the body. More than 26 million U.S. adults have been diagnosed with kidney disease. The risk factors for kidney disease are: diabetes, high blood pressure, cardiovascular disease, and a family history of kidney failure. If kidney disease is detected early, treatment might be available to delay or prevent kidney failure.

End stage renal disease (ESRD) is the last stage in the  progression of kidney disease and usually requires dialysis or a kidney transplant. Dialysis generally require three treatments a week, each lasting 3-4 hours. In the United States in 2010, 580,741 people were living with ESRD. Since Chronic Kidney Disease and ESRD generally impact Americans who are older and on Medicare, the economic cost for the public is high. Kidney disease costs Medicare about $41 billion a year in treatment.  

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Kidney Health Disparities

Chronic Kidney Disease and End Stage Renal Disease disproportionately affect minority communities. African Americans are 3.6 times more likely to have kidney failure compared to the general population. While African Americans are about 13 percent of the U.S. population, 32 percent of the people with kidney failure are African American. Hispanic Americans and Native Americans are also at increased risk compared to the general public. Since 2000, the number of Hispanics with kidney failure has increased by more than 70 percent.

Kidney disease is also linked to higher levels of poverty, especially in African Americans. Study results show that African Americans who had incomes less than $20,000 were three times more at risk for kidney disease that African Americans earning more than $75,000.  

Not only are racial minorities more likely to have kidney disease, they are more likely to die from it. Nearly 70,000 patients are on the waiting list for kidney transplants, with African Americans comprising 35% of these patients. In addition, minorities that do get kidney transplants are more likely to spend more time on the waiting list than whites.

Why the huge disparities?

Like many other diseases, the reason for the kidney health disparities is largely environmental. Diabetes is a leading cause of kidney disease, and minorities and those living in poverty are more likely to be diagnosed with diabetes than the general American population. In 2009, diabetes caused 38.4 percent of all kidney failure. The reason for the higher rates of diabetes among minorities may be attributed to lack of health services within minority communities, limited supply of nutritious foods, lack of safe places for exercise, and chronic sources of stress such as community violence and financial instability.

Another reason for the disparities in kidney disease is that historically, in the United States, there has been a racial disparity in who received organ transplants. Matches across race are more difficult and a higher proportion of organ donors are white while a higher proportion of those needing kidneys are black. Therefore more racial minorities die waiting for a kidney transplant.

Decreasing the burden of kidney disease

The Affordable Care Act will provide more Americans with access to preventative health services. For many people, diabetes, a leading cause of kidney disease, can be prevented through adequate diet and exercise. Access to insurance can also provide those with beginning stages of kidney disease treatments to delay the progression of the disease to kidney failure. Early diagnosis is the key and for a diagnoses, individuals must have a health care provider who is easily accessible and trusted. General awareness about kidney disease is also important, especially within minority communities. Many people who already have diabetes or high blood pressure are not aware of their increased risk of kidney disease. Even more alarming, a study in Mississippi found only one in six African-Americans found to have Chronic Kidney Disease was aware of having the condition. In honor of National Kidney Month, consider becoming an organ donor.

Should You Vaccinate Your Children? YES

In the last few years, there has been a surge in the number of people who believe that vaccinations cause autism.  Thanks to a few celebrities, this belief continues to spread.  The celebrity most associated with this belief is Jenny McCarthy, but the most recent to espouse it is Kristin Cavallari.  So, are they right?  No, let’s look at the arguments and address them one by one.

1.) Studies show that vaccines cause autism - FALSE

The article that started this myth, “Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children” by Andrew Wakefield, was originally published in The Lancet in 1998.  Not only has no-one been able to reproduce the results of that study (which by the way only had 12 participants), but investigations into Wakefield found that “he had been paid by a law firm that intended to sue vaccine manufacturers” - a serious conflict of interest.  Over the years, not only has the Lancet retracted the article (which you can see by clicking the link), but Wakefield has been found guilty of unethical behavior by the General Medical Board in Great Britain and has since been barred from practicing medicine in the UK.

You can even check out a small list of some of the studies that have shown no relationship between vaccines and autism here or here.  Finally, there have been studies on the cause of autism that point toward environmental pollution, not vaccinations.  Multiple studies have shown a strong association between children exposed to high levels of air pollution in the wob and autism.  

2.) As the number of vaccines has increased, the incidence of autism has increased - TRUE-ISH

    Yes, the number of vaccinations that we give our children has increased over time, especially in the last 70 years.  It is also true that the number of children diagnosed with autism has increased over the years; however, the CDC has only tracked autism diagnoses since 2000 which leaves more than 50 years of increased vaccinations without data to connect to.

Moreover, “Mark Roithmayr, president of the advocacy group Autism Speaks, says more children are being diagnosed with autism because of better diagnosis, broader diagnosis, better awareness, and roughly 50% of 'We don't know’.”  Even experts understand that at least some of the increase in diagnosed cases is not from an increases in cases but in better recognition of cases.

    It is also important to note that just because there is a correlation between two events - increased number of vaccinations and increased incidence of autism - does not mean that there is a causal link between the two.  As cases of autism have increased, sales of organic foods have increased, but no one is arguing that organic food causes autism.

3.) But the Homefirst pediatric group and the Amish don’t vaccinate and have no cases of Autism. UNPROVEN and UNTRUE

    Kristin Cavallari mentioned the Homefirst pediatric group in Illinois who treat children whose parents refuse to vaccinate them (because many doctors refuse to for the safety of their other patients).  They claim to treat some 35,000 children and to have had no cases of autism in their unvaccinated patients; however, they have never published a study or proven that through data.  Moreover, Homefirst has a troubling history when it comes to financial conflicts of interest, medical malpractice and doctors lying/changing their story under oath.

    The idea that Amish children aren’t vaccinated and don’t have autism is patently untrue.  Amish parents do vaccinate their children, though potentially not on the recommended schedule.  You may be thinking “aha! that proves it!”, but no, it doesn’t.  The Amish live very different lives from the rest of us which means we can not ascribe causation to just one of the differences.  They are not exposed to the same chemicals, preservatives, and pollutants that we are and they are a fairly isolated genetic pool (not many people born outside of the Amish community decide to become Amish) which means that if a genetic abnormality causes autism, it may not be present in the Amish gene pool.

4.) The risk of the vaccine is worse than the disease - FALSE

    All medical interventions come with risks and that includes vaccinations.  The vaccine that most anti-vacciners target is the MMR, which can lead to mild forms of the diseases vaccinated against (symptoms include fever, rash, loss of appetite, swelling of glands, and painful joints); rare side effects can include bruise like spots, seizures, and allergic reactions.  

When thinking about if a medical intervention’s risks are worth it, you should look at the risks to contracting the disease.  Measles causes fever, a runny nose, a full body rash and a cough. “About one out of 10 children with measles also gets an ear infection, and up to one out of 20 gets pneumonia. About one out of 1,000 gets encephalitis, and one or two out of 1,000 die.”  Measles is highly contagious - 90% of people exposed who are not vaccinated will contract the disease.  The good news is that vaccines are generally 85-95% effective which means that if 100 people who were vaccinated were exposed to measles between 5 and 15 would become infected; whereas if 100 people who were not vaccinated were exposed about 90 would become infected.  

5.) “It’s our personal choice, you know, and if you’re really concerned about your kid, then get them vaccinated and it shouldn’t be a problem.” ~ Kristin Cavallari - FALSE

    Many parents who chose not to vaccinate their children say things just like this and it is completely untrue.  Diseases that had been completely or almost eliminated in the US have been making a comeback lately because of the increase in unvaccinated.  In 2010 there was an outbreak of whooping cough in California that was proven to be the spread by unvaccinated children.  9,120 people caught the disease and 10 died.  In Texas, 21 members of a church that advocated against vaccinations came down with Measles after a member brought the disease back from a mission trip.  New York City has had a recent out-break of measles as well - there have also been cases in California, Connecticut, Illinois, Massachusetts, Hawaii, Pennsylvania, Texas, Washington, Oregon, Florida, New Jersey, Virginia, Colorado, North Carolina, and Michigan since the beginning of 2013.

   

Keep in mind the vaccination schedule for children as well.  Children aren’t vaccinated against Measles (MMR) until they are a year old, which means if they are exposed to the disease before then, they could contract it when they are most vulnerable and when their parents could do nothing to protect them.  People with cancer who are currently receiving chemo, or those who are otherwise immunosuppressed are also at risk.  And, as I mentioned before, vaccinations are generally 85-95% effective, so some people who have been vaccinated can also contract the disease in an outbreak.  Of course, outbreaks are much more rare when everyone is vaccinated.

Conclusions

    Please do not take medical advice from celebrities or people who stand to make more money if you follow their advice.  It is fine to question the safety of medical interventions, and it is understandable that parents want to do anything they can to prevent their child from getting autism or any other disease/delay/health issue.  However, vaccines do not cause autism, have relatively few risks and protect not only your child but other people’s children from things far worse than those risks.

Community Health Workers

Who are Community Health Workers?

According to the U.S. Health Resources and Services Administration (HRSA), Community Health Workers (CHW) are “lay members of communities who work either for pay or as volunteers in association with the local health care system…and usually share ethnicity, language, socioeconomic status, and life experiences with the community they serve” (HRSA CHW tool kit).

While the concept of CHW is not new, the Affordable Care Act brought a new buzz to the topic. The Affordable Care Act (Section 5313) gives the Centers for Disease Control and Prevention (the CDC) the responsibility to award grants to public or nonprofit private entities to promote health behaviors in underserved communities through the use of CHWs.

CHWs go by several names including community health advisor, outreach worker, community health representative, promotora, promotores de salud, patient navigator, navigator promotores, peer counselor, and lay health worker. In 2012, there were 38,020 CHWs employed in the United States.

What do Community Health Workers do?

The Labor Bureau of Labor Statistics has an occupation code for CHWs that defines a CHW as someone who:

• Assists individuals and communities to adopt health behaviors through education
• Conducts outreach for medical personnel or health organizations to implement programs
• Links the community to available resources
• Provides social support, informal counseling and basic health screening
• Advocates on behalf of the community’s health needs

Benefits of Community Health Workers

There are several benefits to using CHWs, including:

1. Elimination of language barriers. One of the main criteria to be a CHW is that he/she must speak the same language as the community in which he/she serves. This is especially beneficial for newly immigrated populations.  An example is  increased screening rates for hepatitis B virus within the Hmong population.
2. Trust. There is a strong distrust of medical and government officials within some communities in the United States. For example, individuals that are undocumented immigrants or have undocumented immigrants in their family may be nervous to seek traditional medical care. CHWs usually have similar experiences and can relate to the people they serve. 
3. Cultural relevance. Many cultures have unique ways to improve health. For example, addressing obesity is highly cultural. It would not be helpful to completely ignore the cultural part of diet or the cultural barriers to exercise.
4. Traveling to the community. CHWs can go to the people, instead of relying on people to seek services. This is especially needed in isolated (either physically or culturally) communities. For example, Kentucky Homeplace employs community health workers to deliver services in rural counties and improve health outcomes in those communities.
5. Quick training. Unlike public health educators, an individual can be trained quickly. For non-profits with quick grant cycle turn around, this is helpful because a CHW can get out into the community delivery services with only a couple weeks of training.
6. Cost-effective. Much of CHW’s work is preventative - for example prevention of ER visits, prevention of low-birth weight, or prevention of obesity. The Christus Spohn Health System links CHW activities to reductions inappropriate emergency department usage translating into a substantial cost saving as well as better health for the patient. Prevention, in general, is hard to do cost-benefit analysis for because of the challenging calculation of the amount saved by preventing a disease. However, in the simplest of terms, we know that chronic conditions, like obesity, are expensive for families and society and with fewer obese people, dollars would be saved. Unfortunately, there is little published research on the effectiveness of outcomes of CHW interventions.

Challenges of Community Health Workers.

While there are many benefits and success stories, there are also many challenges:

1. Recruitment. Finding the right person in the community can be difficult. Ideally, the CHW should already have personal connections with neighbors and a history of casual relationships. For tight-knit communities with high distrust of others, it could be challenging to find a person for a CHW role. Not only is it challenging to find the right person to be a CHW, it is difficult to find the right person to supervise CHWs.
2. Training. There isn’t one definitive CHW training. Training, evaluation, and outcome deliverables vary widely, so it is hard to compare programs and develop best practices.
3. Low education levels. What is a benefit of CHW programs (no need for advanced degrees) is also a challenge. Unlike public health educators, CHWs do not have the educational background that might be necessary in all situations. It is a challenge to make sure CHWs know what they need to be effective with the community.
4. Accountability. Since there is a wide variation in CHW’s tasks, it is hard to track their impact. Traditional models of employee accountability (also used for grant reporting) focus on measures such as number of people talked to. This might not always be a good measure since this is an individual approach and sometimes some families need more than others. CHWs are also out in the field and working alone, which makes it difficult to audit the authenticity of service delivery.

The future for CHWs

CHWs can be effective to improve health within the community, especially within communities that face barriers to health. The opportunities to improve health using CHWs outweigh the challenges. Some people will scoff at promoting CHWs without extensive research on cost-effectiveness or randomized control trials. The research, in someway, does need to be done but in the meantime innovate programs have improved health and that alone is exciting.

Raising the Minimum Wage

President Obama announced in his State of the Union address that he would increase the minimum wage for federal government contract workers to $10.10 and hour.  He has also proposed that congress should raise the federal minimum wage for all workers to the same level by 2015 and then index it to inflation (meaning the minimum wage would increase each year with inflation).  There has been a lot of talk from both Democrats and Republicans about whether this is a good thing, so let’s break down the numbers:

1.) The current federal minimum wage is $7.25 an hour and has not changed since 2009.  That is just over $15,000 a year before taxes assuming a 40 hour work week.  To see if you could live on your states minimum wage (some are higher than the federal currently), check out this calculator.

2.) A single person is at 133% of the federal poverty line at $15,521.  A family of two is at 100% of the FPL at $15,730.

3.) If the minimum wage were $10.10 a worker would make just over $21,000 a year pre-tax if they worked 40 hours a week which would keep a family of up to 3 people above the poverty line.  It would also keep a family of up to 2 people above 130% of the FPL.

4.) To receive SNAP benefits (food stamps) a family must be at or below 130% of the poverty line.  

5.) In 2012, 15% of Americans (46.5 million) lived in poverty.  As of January of this year, the unemployment rate was 6.6% (10.2 million Americans).

6.) Income inequality has been increasing since 1979.  From 1979 to 2011 the income of the top 1% rose 128.9% while the income of the bottom 99% increased 2.5%.  Between 2009 and 2011 alone, the income of the top 1% increased by 11.5% while the income of the bottom 99% decreased by 0.7%.

What do the Experts Say Will Happen?

The CBO recently released a report that estimated that the $10.10 minimum wage would reduce employment by 0.3% or 500,000 workers though they say the range could be between a very slight decrease to 1 million workers.  However, they also estimate that 900,000 people would be lifted out of poverty and 16.5 million low wage workers would see income increases.  Finally, it would mean $5 billion more a year for families in poverty and $12 billion more a year for families between 100 and 300% of the poverty line.

Though many economists and conservative lawmakers still stick to the idea that increasing the minimum wage will increase unemployment, the research does not support this.  Check out Business for A Fair Minimum Wage’s summary of the research done on this topic.  Lawrence Katz of Harvard University even said that if the CBO had focused on higher quality studies, it would have estimated a smaller job loss.  Many argue that, even with some job losses, increasing the minimum wage would provide net benefits for the economy by increasing personal spending which would in turn potentially increase employment.

A recent study out of the The Equal Opportunity Project has shown that income mobility in the United States has not improved in the last century.  Moreover, it found that “areas with greater mobility tend to have five characteristics: less segregation, less income inequality, better schools, greater social capital, and more stable families.”  So by increasing the minimum wage and thus raising some families out of poverty now, we may decrease the chances that those children will live in poverty throughout their lives.  For more check out this great summary The “Ripple Effect” of a Minimum Wage Increase on American Workers.

How Would Raising the Minimum Wage Affect Health

Economic research has started to reveal that raising the minimum wage can improve public health to the extent that it might reduce the costs of medical care in this country.  Some research shows that low wages predict higher rates of obesity, hypertension (high blood pressure), diabetes, heart disease, arthritis and premature mortality - all of which adversely affect the lives of individuals and cost society money.

In Conclusion

Although raising the minimum wage may lead to a slight decrease in jobs (though that is not for sure), even if the worst case scenario for job losses occurs, I believe that the benefits far outweigh the costs.  I especially support the idea that the minimum wage should be indexed to inflation.  Otherwise, minimum wage workers earn less real dollars each year.