Category Archives: Public Health

Academia, Health Care, Public Health, Society

Leadership & Character

Juxtaposing Two Renowned Leaders of Health

When considering leadership in health care, I think first of how that leadership has affected health care in particular. Being a leader in health care does not guarantee great impact; however, an effective leader can have great impact over a large scope. This is how I framed my search to find two leaders in health care to highlight in this paper.

The first leader of health care that I will discuss is Clara Barton. According to Chambers (2002), Barton, independent to a fault, has been described as having a persuasive power about her. A fairly timid girl, Barton had self-image problems growing up that were at times debilitating; however, it seemed that as long as her interest was in helping others Barton performed selflessly, with heroism and bravado usually reserved for men during the time. Barton, a school teacher, found herself in the middle of the Civil War caring and tending to the soldiers on the battlefield. Dubbed the angel of the battlefield, Barton would not cease in caring for the soldiers even under enemy fire.

Barton, according to Chambers (2002) was not a very effective manager, but she could convince anyone to do anything that she needed to get done, it was said. Barton presents with a leadership style that is transformational (Robbins & Judge, 2010). She sees a need and immediately works to fill the void, inspiring others to do the same. Barton was ultimately responsible for founding the American Red Cross, a neutral organization that today responds to over 67, 000 disasters per year providing medical supplies, food, and housing in order to promote health equity even during wartime. Barton was a socialized charismatic leader, and her accomplishments are truly inspirational (Robbins & Judge, 2010).

The second leader of health care, more so in death than in life, that I chose to discuss is Johns Hopkins. Most people are familiar with Johns Hopkins Hospital and Johns Hopkins University, but it might be surprising to know that these namesakes were only made possible by the posthumous gift of $7-million from Hopkins’s estate (Herringshaw, 1901; “Johns Hopkins,” 1891). Hopkins started life from an affluent family, but a choice to free the family’s slaves forced Hopkins out of his formal education to help on the family tobacco farm. Since leaving the family farm, it seemed, by all accounts, that Hopkins had an innate ability for business (“Johns Hopkins,” 1891). Hopkins became very successful in business early in his lifetime, and he always tried to return his good fortune to the community. This innate ability for business, along with his unwavering business ethics, would seem to make Hopkins a likable and well-respected leader, possibly invoking a sense that he was born with these traits (Borgatta, Bales, & Couch, 1954; Cawthon, 1996; Robbins & Judge, 2010). It was in the spirit of community leader that Hopkins fulfilled his final philanthropy by funding an orphanage, a university, colleges, and a hospital that to this day is world-renowned. Johns Hopkins was an authentic leader (Robbins & Judge, 2010).

Whether a leader is naturally born with certain traits or learns behaviors from their environment, what matters most is that they be prepared to lead when the time comes. Without the onus of personal responsibility, no true leaders can exist.

References

Borgatta, E. F., Bales, R. F., & Couch, A. S. (1954). Some findings relevent to the great man theory of leadership. American Sociological Review, 19(6), 755-759. doi:10.2307/2087923

Cawthon, D. L. (1996). Leadership: the great man theory revisited. Business Horizons, 39(3), 1-4. doi:10.1016/S0007-6813(96)90001-4

Chambers, L. (2002). Fearless under fire. Biography, 6(4), 64-67, 96-97.

Herringshaw, T. W. (Ed.). (1901). Johns Hopkins. Herringshaw’s encyclopedia of American biography of the nineteenth century. Retrieved from http://books.google.com/

Johns Hopkins. (1891). The national cyclopaedia of American biography (Vol. 5). Retrieved from http://books.google.com/

Robbins, S. P. & Judge, T. A. (2010). Leadership. Essentials of Organizational Behavior (pp. 159-180). Upper Saddle River, NJ: Pearson Prentice Hall.

Academia, Health Care, Public Health, Society

Determinants of Health – Mental Illness

When attempting to solve many of the issues relevant to public health, it is essential to understand the factors that contribute to disparities across various ethnic, racial, cultural and socioeconomic boundaries (Satcher & Higginbotham, 2008). In northeastern Connecticut, however, health disparities are primarily related to the socioeconomic strata, as much of the population is Caucasian and there are identifiable health disparities within this group (U.S. Census Bureau, 2002, 2008; U.S. Department of Health and Human Services, 2009). The disparity that I will focus on in this paper is mental illness.

According to Adler and Rehkopf (2008), unjust social disparity leads to greater health disparity, but what is unjust about social disparity? Adler and Rehkopf continue to describe efforts of researchers to evaluate how socioeconomic status, both, in conjunction with and independent of race or ethnicity, contribute to health disparities. There exists a significant difference in the manner in which different cultures approach mental health needs (Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008). Whites, who are more prone to suffering mental health issues, according to McGuire and Miranda (2008), preferring to seek professional care while Blacks are more likely to opt for self-directed care. Though Wang, Burglund, and Kessler (2001) tell of mental health treatment disparities between Whites and Blacks, in their study, 14 times more Whites responded than Blacks which may suggest that Whites are more apt to discuss mental health issues and Blacks might not unless they are motivated by extrinsic factors, such as poor care or the impression thereof. As long as Blacks are not prevented or discouraged from seeking care, there is no injustice in choosing self-care; however, it may not be the most effective option. Cultural awareness on the part of health care providers who may have an opportunity to provide health education to Blacks may alone increase the utilization of mental health services among the Black demographic.

More importantly, mental illness often exists in the presence of poverty and the lack of education. Much of the literature, such as Schwartz and Meyer (2010), seems to make the implication that low socioeconomic status is a causative risk-factor for mental illness, yet the literature also makes the distinction that one of the lowest groups on the socioeconomic ladder, Blacks, have a lower incidence, overall, of mental illness. This may be true in some instances; however, it is more likely that mental illness may be the proximal cause for an afflicted person’s socioeconomic status, especially if the illness manifested early enough to interfere with the person’s education.

More research needs to be undertaken to identify effective programs that aim to mitigate bias of mental health conditions within the community. As mental health disorders lose their stigma, more people who suffer from mental health issues will be able to seek care comfortably and unafraid, leading to increased treatment rates and increased synthesis within the community. This synthesis alone would alleviate much of the socioeconomic burden. Additionally, we need to shift our focus and strive to fix health issues locally, not nationally or globally. The world is comprised of a network of communities of individuals. Impacting the individual is the first step to affecting positive social change. Focusing on individual health will ultimately impact community, national, and global health.

The U.S. Health care system is overtaxed in caring for people with mental illness. According to Insel (2008), we need to refocus our efforts on providing care for mental illness to reduce the enormous indirect costs estimated at $193.2-billion per year. A viable solution in addressing mental illness as a health disparity, I feel, lies in understanding the manner that mental illness causes lower socioeconomic status which, in turn, causes risk of disparate care. Programs designed to aim for situational mitigation instead of mental health recovery will be less costly, more effective and, overall, more ideal. There will still be an obvious and great need for treatment and recovery programs, but with mitigation, I posit that they will be more effective, also.

References

Adler, N. E. & Rehkopf, D. H. (2008). U.S. disparities in health: descriptions, causes, and mechanisms. Annual Review of Public Health, 29(1), 235-252. doi:10.1146/annurev.publhealth.29.020907.090852

Hatzenbuehler, M. L., Keyes, K. M., Narrow, W. E., Grant, B. F., & Hasin, D. S. (2008). Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population. Journal of Clinical Psychology, 69(7), 1112-1121. doi:10.4088/JCP.v69n0711

Insel, T. R. (2008). Assessing the economic costs of serious mental illness. American Journal of Psychiatry, 165, 663-665. doi:10.1176/appi.ajp.2008.08030366

McGuire, T. G. & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Affairs, 27(2), 393-403. doi:10.1377/hlthaff.27.2.393

Newport, F. & Mendes, E. (2009, July 22). About one in six U.S. adults are without health insurance: Highest uninsured rates among Hispanics, the young, and those with low incomes. Gallup-Heathways Well-Being Index. Retrieved from http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx

Satcher, D. & Higginbotham, E. J. (2008). The public health approach to eliminating health disparities. American Journal of Public Health, 98(3), 400–403. doi:10.2105/AJPH.2007.123919

Schwartz, S. & Meyer, I. H. (2010). Mental health disparities research: The impact of within and between group analyses on tests of social stress hypotheses. Social Science and Medicine, 70, 1111-1118. doi:10.1016/j.socscimed.2009.11.032

U.S. Census Bureau. (2002). Census 2000. Retrieved from http://www.ct.gov/ecd/cwp/view.asp?a=1106&q=250616

U.S. Census Bureau. (2008). Population estimates: Annual estimates of the resident population by age, sex, race, and Hispanic origin for counties in Connecticut: April 1, 2000 to July 1, 2008 [Data]. Retrieved from http://www.census.gov/popest/counties/asrh/files/cc-est2008-alldata-09.csv

U.S. Department of Health and Human Services. (2009). Community health status indicators report. Retrieved from http://communityhealth.hhs.gov/

Academia, Health Care, Public Health, Society

Community Health: How Healthy is My Community?

I currently reside in Windham County, Connecticut. Windham County is primarily rural with one community, Willimantic, comprising most of the urban demographic. Windham County is functionally divided in half (north to south) in regards to health and hospital services. Primarily, Windham Community Memorial Hospital serves the west and Day Kimball Hospital serves the east. Accordingly, the eastern and western portions of the county may not be representative of each other, yet both are represented as a singular group when considering county-based statistics. This is a shortcoming of county-based statistics. In this instance, Willimantic, in the western portion of Windham County, may negatively affect the statistics of towns like Killingly, Pomfret, and Putnam, in the eastern portion of the county, due primarily to an increase in impoverished populations residing in Willimantic (U.S. Census Bureau, 2002). Additionally, data is lacking for a number of measures, according to the Community Health Status Indicators Project Working Group (2009), but continuing efforts will be made to increase reporting over time.

According to the U.S. Census Bureau (2008) and the U.S. Department of Health and Human Services (2009), the population of Windham County is 117,345 and is predominantly white (94.3%) with the remaining (5.7%) divided among, in order of predominance, Hispanics, Blacks, Asians and Pacific Islanders, and American Indians. The particularly vulnerable populations identified are adults age 25 and older who do not hold a high school diploma, are unemployed, are severely disabled and unable to work, suffer major depression, or have recently used illicit drugs. The uninsured rate in Windham County is well below the 16% national average at 9.5% (Newport & Mendes, 2009; U.S. Department of Health and Human Services, 2009).

Windham County fares equal or better in most measures, at least within the margin of error; therefore, I feel that Windham County, though not exceptionally healthy, is better than most and striving to meet the national standards (U.S. Department of Health and Human Services, 2009). For example, though the incidence of cancer and subsequent death resulting remains higher than peer counties, Windham County falls well within the expected range of death measures and exceeds peer counties in homicide, stroke, suicide, and unintentional injuries. Windham County also falls below the national standardized target for both stroke and coronary heart disease deaths. Infant mortality and birth measures seem representative of peer counties. Windham County also meets or exceeds environmental standards in all cases except for two reports of E. coli infections. There were also reports of five cases of Haemophilus influenzae B, two cases of Hepatitis A, and three cases of Hepatitis B — the only unexpected cases of infectious diseases reported. Pertussis incidence was limited to 25% of expected cases.

Windham County is not exceptional, but living here gives me the sense that the focus is on preventative care rather than acute care, which might explain how the health goals are being achieved overall. The report from the U.S. Department of Health and Human Services (2009) is in agreement.

References

Community Health Status Indicators Project Working Group. (2009). Data sources, definitions, and notes for CHSI2009. Retrieved from http://communityhealth.hhs.gov/

Newport, F. & Mendes, E. (2009, July 22). About one in six U.S. adults are without health insurance: Highest uninsured rates among Hispanics, the young, and those with low incomes. Gallup-Heathways Well-Being Index. Retrieved from http://www.gallup.com/poll/121820/one-six-adults-without-health-insurance.aspx

U.S. Census Bureau. (2002). Census 2000. Retrieved from http://www.ct.gov/ecd/cwp/view.asp?a=1106&q=250616

U.S. Census Bureau. (2008). Population estimates: Annual estimates of the resident population by age, sex, race, and Hispanic origin for counties in Connecticut: April 1, 2000 to July 1, 2008 [Data]. Retrieved from http://www.census.gov/popest/counties/asrh/files/cc-est2008-alldata-09.csv

U.S. Department of Health and Human Services. (2009). Community health status indicators report. Retrieved from http://communityhealth.hhs.gov/

Emergency Medical Services, Health Care, Public Health

Long-term care versus acute care

This discussion, again, allows me to ponder some musings of my colleagues and consider them in scholarly reflection. As a paramedic, I frequently respond to skilled nursing facilities (SNFs) to care for patients with minimal medical complaints or exacerbations of chronic conditions. The comments are always the same: What is the point of having nurses here if they cannot care for their patients? As I have never had an acceptable answer to this quandary, I will use this opportunity to explore the usefulness of SNFs based on measured outcomes. I will also compare the abilities of acute care facilities (ACFs) with those of SNFs to weigh the appropriateness of relying on ACFs to care for SNF patients.

The leading number of long-term care facilities are elderly SNFs, and as such, the elderly are the major demographic cared for in SNFs, yet there is a shortage, even within SNFs, of health care providers skilled in geriatric care (Cohen, 2002; Gaugler, Duval, Anderson, & Kane, 2007; Shi & Singh, 2011b). As Gaugler, Duval, Anderson, and Kane (2007) describe, the mere admission of an elderly patient into an SNF is associated with poor outcomes, “questionable quality of care, early mortality for many residents, and psychological or emotional upheaval for caregiving families” (p. 14). As long-term care also includes varying degrees of home care, family care, and limited residential care (e.g. assisted living centers), an international effort has been underway to help determine ways of identifying and limiting SNF admissions in order to limit potential negative outcomes and maintain patients’ self-efficacy and quality of life (Kennedy et al., 2007).

SNFs and ACFs are similar in that they both house patients, have nursing staff, are demographed by the number of beds housed, and, typically, have some sort of medical team responsible for the patients’ overall care. ACFs are numerous in type and offering. General hospitals, specialty hospitals, free-standing emergency clinics, and tertiary care centers are just some of the ACFs available to treat illness and injury (Shi & Singh, 2011a). ACFs tend to focus treatment on acute manifestations of illness and injury, while SNFs (and other long-term care facilities) focus on continuing care for chronic maladies (Shi & Singh, 2011a, 2011b; Singh, 2011). While ACFs rely on outcome measures to improve the care that is offered, such as that in stroke, it appears that SNFs and other long-term care facilities operate on a more traditional sense without regard to their effect on patient outcomes (Ahmed & Ekundayo, 2009; Díez-Tejedor & Fuentes, 2001; Kennedy et al., 2007; Martin & Ancoli-Isreal, 2008).

As I contemplate my original question in light of the available literature, I find that the elderly should only be institutionalized as a last resort (e.g. lay-led self-care, home health care, independant or assited living), training in geriatric care needs to be improved within SNFs, and outcome measures need to be further developed and assessed to fully understand the impact of long-term care on the elderly population (Ahmed & Ekundayo, 2009; Cohen, 2002, Gaugler et al., 2007; Kennedy et al., 2007, Martin & Ancoli-Israel, 2008). Until these three issues are rectified, SNFs will need to rely on ACFs to safely, effectively, and efficiently care for their patients.

References

Ahmed, A. & Ekundayo, O. J. (2009). Cardiovascular disease care in the nursing home: The need for better evidence for outcomes of care and better quality for processes of care. Journal of the American Medical Director’s Association, 10(1), 1-3. doi:10.1016/j.jamda.2008.08.019

Cohen, J. J., Gabriel, B. A., & Terrell, C. (2002). The case for diversity in the health care workforce. Health Affairs, 21(5), 90-102. doi:10.1377/hlthaff.21.5.90

Díez-Tejedor, E. & Fuentes, B. (2001). Acute care in stroke: Do stroke units make the difference? Cerebrovascular Diseases, 11(Suppl. 1), 31-39. doi:10.1159/000049123

Gaugler, J. E., Duval, S., Anderson, K. A., & Kane, R. L. (2007). Predicting nursing home admission in the U.S: a meta-analysis. BMC Geriatrics, 7(1), 13-26. doi:10.1186/1471-2318-7-13

Kennedy, A., Reeves, D., Bower, P., Lee, V., Middleton, E., Richardson, G., … Rogers, A. (2007). The effectiveness and cost effectiveness of a national lay‐led self care support programme for patients with long‐term conditions: a pragmatic randomised controlled trial. Journal of Epidemiology and Community Health, 61(3), 254–261. doi:10.1136/jech.2006.053538.

Martin, J. L. & Ancoli-Israel, S. (2008). Sleep disturbances in long-term care. Clinical Geriatric Medicine, 24(1), 39–vi. doi:10.1016/j.cger.2007.08.001.

Shi, L. & Singh, D. A. (2011a). Inpatient facilities and services. Current issues in healthcare policy and practice (pp. 1-44). Sudbury, MA: Jones & Bartlett.

Shi, L. & Singh, D. A. (2011b). The future of health services delivery. Current issues in healthcare policy and practice (pp. 123-156). Sudbury, MA: Jones & Bartlett.

Singh, D. A. (2011). Overview of long-term care. Current issues in healthcare policy and practice (pp. 123-156). Sudbury, MA: Jones & Bartlett.

Academia, Clinical, Emergency Medical Services, Health Care, Public Health, Technology

Scrutinizing the Literature of EMR

 As I scrutinize Dimitropoulos and Rizk (2009) for possible inclusion in a literature review for my research, I find it both promising and troubling. The article appears to be pertinent to my research question of how various laws and practices might adversely affect shared access of electronic health records; however, it is important to understand if this article is a documentation of primary research or a review of existing research, and as I describe below, this is unclear. This lack of clarity obscures other facets of the article that important to a researcher. These are also described below.

Initially, the work of Dimitropoulos and Rizk appears to be pertinent to my research based on the title and the publication in which it appears. Health Affairs is a respected journal within the realm of public health research, practice, and instruction, and it is ranked seventh of all health policy and service journals by Journal Ranking (http://www.journal-ranking.com). Publication within Health Affairs does not degrade the reputation of the authors and serves only to promote their work to their peers. As my research is within the realm of public health, Health Affairs is an obvious avenue to pursue for relevant work, and as this article by Dimitropoulos and Rizk appears to reflect a specific focus on the relationship between privacy laws and the ability, or lack thereof, to share health information, it appears to have relevance.

According to the abstract, Dimitropoulos and Rizk (2009) examine how variations is state (and, territorial) privacy laws might inhibit sharing health information via an central exchange, or repository. Though it would seem plausible for Dimitropoulos and Rizk to conduct their own research, the abstract seems to imply that they are merely reporting on the findings of a committee charged with examining such irregularities in privacy laws amongst the states and territories, presumably, of Canada. After reading the report, though, I find a disconnect between the abstract and the article. In the abstract, it appears more as if the authors are detached reporters, but within the body of the article, it seems as though they appear to take ownership of the primary research. This is confusing as it was plainly stated that the research was conducted by a large consortium of state officials: “the project initially engaged organizations in thirty-four … and later … forty-two jurisdictions. This collaborative work is commonly referred to as the Health Information Security and Privacy Collaboration (HISPC)” (p. 429).

This report is confusing to read as the perspective shifts frequently between first- and third-person. Additionally, the authors describe opinions formed and emotions felt during the primary research (opinions and emotions that only the primary researchers could know), yet it is unclear if these were transmitted through other writing or if the authors formed and felt these themselves. It is unclear whether the authors, Dimitropoulos and Rizk (2009), were participating researchers or merely reporters.

Both authors are noted to work for RTI International’s Survey Research Division, yet this corporation is not credited with any of the original research (Dimitropoulos & Rizk, 2009). I would have to conduct further research into the authors, their employer, and the project, itself, in order to make a final determination of the credibility of this article. This research would, hopefully, give the authors’ words better context, also. Complicating this is the absence of clearly delineated references, although a few appear within the Notes section that appear to be worth investigating.

Dimitropoulos and Rizk (2009) describe an effort to create a cohesive environment that will enhance the ability to share health information throughout a number of jurisdictions. As such, there is no scientific inquiry and it follows that adherence to the scientific method would be inappropriate. Again, however, it is unclear if this research is original or not.

In closing, it appears that Dimitropoulos and Rizk (2009) are credible in their writing; however, as each article must be able to stand on its own, and the article is lacking in form and perspective, I question the origination, application, and utility of this article, at least as it pertains to my original research question. Privacy in computing has been a major concern in the past two decades (Johnson, 2004). I feel that I could find more pertinent literature by expanding my search beyond this article.

References

Dimitropoulos, L. & Rizk, S. (2009).A state-based approach to privacy and security for interoperable health information exchange.Health Affairs, 28(2), 428-434. doi:10.1377/hlthaff.28.2.428

Johnson, D. G. (2004). Computer ethics. In L. Floridi (Ed.), The Blackwell guide to the philosophy of computing and information (pp. 65-75). Malden, MA: Blackwell.

Academia, Clinical, Culture, Emergency Medical Services, Health Care, Politics, Public Health, Society

Physician-assisted Suicide

I have always maintained that the best thing that I have ever done for a patient was to hold their hand as they died; however, there are few scenarios that I can posit where I would ever cause the death of another, and I would never do it in my capacity as a medical professional. In the State of Connecticut, assisting a patient in their suicide is illegal (Kasprak, 2003; Saunders & Smith, 2010). Saunders and Smith (2010) describe the use of “semantic ploys” (para. 3) in arguing for physician-assisted suicide and how the court deemed the “issue rests with the legislature, not with the court” (para 4).

Two states have laws permitting physician-assisted suicide, Oregon and Washington (Death with Dignity Act, 1997; Death with Dignity Act, 2008). The other 48 states either have laws forbidding assisted suicide, such as Connecticut, rely on common law, or have no laws permitting or forbidding the practice (Kasprak, 2003). Personally, my thoughts on the matter are clearly reflected in my opening statement. More compelling, however, is a recent discussion on the discontinuation of implanted cardiac devices in patients with a desire to “refuse continued life-sustaining therapy” (Kapa, Mueller, Hayes, & Asirvatham, 2010, p. 989). Many of the respondants to this study viewed the discontinuation of pacemakers akin to physician-assisted suicide, whereas less felt the termination of cardioverter-defibrillator therapy was an ethical issue. Oddly, lawyers indicated less problems discontinuing therapy than did physicians.

There are conditions that are so intractably painful and wrought with suffering that I would not even consider thinking less of a person suffering such a malady who took their own life. Death, for many people, is a fear beyond fear, and for a person (of considerable sound mind) to choose death as a viable alternative to such suffering, I commend their bravery and choose not to judge them negatively. No physician or other health care provider should cause the death of a person directly, but acknowledging the patient’s will to die is another matter. In lieu of providing a chemical means of ending life, a physician could, in my mind, counsel a patient on the means and methods that might be viewed as more effective and humane than other means which might result in unwanted suffering. I do believe that a person has the right to choose an alternative to a surely painful and agonizing death, regardless of the presence of depression. If a person is suffering from depression because of a terminal illness that is causing physical suffering, it is hard to imagine this person will resolve the depression before succumbing to the causal disease process. In these cases, the person has the right to choose a more dignified death. For those cases where the person is incapacitated and cannot make health care decisions, I feel that any friend or family member, or a consensus of available friends and family members, should be able to make the decision to continue or discontinue life-sustaining measures. Even if the decision is wrong for the patient, most of the time the decision is for the benefit of the family and friends and lacks medical relevance aside from resource management, though there are spiritual, emotional, and moral considerations that the next of kin may face which are no less relevant.

Personally, I grant any person permission to end my life if they see me engulfed in flame or if taken on the battlefield by an enemy known for public torture. Beyond these two circumstances, I will always choose to live so long as I have my thoughts. I have heard some people intimate that they would wish to die if they were conscious but perpetually paralyzed (i.e. locked-in syndrome); however, I am not so sure that I would want to die just for lacking the ability to communicate with others. I would want to view the world, though, perhaps by television or radio. I am too curious as to what comes next for the world. As we interfere with the dying process, it does make sense that we address the morality in which we do this. It does not seem right to have brain dead patients connected to ventilators and feeding tubes forever. It’s Orwellian.

References

Death with Dignity Act of 1997, O.R.S. 127.800 et seq. (1997).

Death with Dignity Act of 2009, R.C.W. 70.245 (2008).

Kapa, S., Mueller, P. S., Hayes, D. L., & Asirvatham, S. J. (2010). Perspectives on withdrawing pacemaker and implantable cardioverter-defibrillator therapies at end of life: Results of a survey of medical and legal professionals and patients. Mayo Clinic Proceedings, 85(11), 981-990. doi:10.4065/mcp.2010.0431

Kasprak, J. (2003, July 9). Assisted suicide (OLR Research Report No. 2003-R-0515). Retrieved from http://www.cga.ct.gov/2003/olrdata/ph/rpt/2003-R-0515.htm

Saunders, W. L. & Smith, M. R. (2010, June 21). Assisted-suicide advocates fail in Connecticut. National Review Online. Retrieved from http://www.nationalreview.com

Emergency Medical Services, Public Health

A Tertiary Care Transfer

On December 18, 2009, “Simon Jones” called 9-1-1 and summoned emergency medical services (EMS) to his residence after developing a significant difficulty in breathing over the last few days. Mr. Jones is an elderly male who lives alone after his wife passed away three years ago. His two adult children live out of state. As EMS arrived, they found Mr. Jones to be in moderate distress with difficulty breathing, a low-grade fever, pale and cool skin, and general complaints of weakness. Mr. Jones stated a significant past medical history, including coronary artery disease, diabetes, hypertension, angina pectoris, myocardial infarction, congestive heart failure, and chronic obstructive pulmonary disease. Mr. Jones was treated by EMS with intravenous fluids, provided a breathing treatment, and transported to the local community hospital’s emergency department (ED).

Upon arrival at the local hospital, Mr. Jones was registered as a patient during turn-over from EMS to the nurse and attending physician who initially prescribed antibiotics and continual oxygen by nasal cannula. Within an hour, Mr. Jones spiked a high fever, became severely short of breath, and his blood pressure dropped precipitously indicating systemic inflammatory response syndrome (SIRS), or sepsis. The attending physician quickly ordered IV fluids run wide open with vasoactive medications added to support the patient’s blood pressure. Mr. Jones was unable to breathe effectively, however, and required intubation and was subsequently placed on a ventilator. The attending physician consulted with the University Hospital “One Call” physician who recommended transferring Mr. Jones to the intensive care unit (ICU) at University Hospital. A critical care transport (CCT) unit, staffed by two critical care paramedics and an emergency medical technician driver, was called for the transfer.

Mr. Jones was transferred to University Hospital without issue. Upon arrival, the intensivist accepted patient care from the CCT crew and began formulating a team to care for Mr. Jones, specifically mindful of his complicating medical history. Mr. Jones still had a low blood pressure and required ventilatory support, but his core temperature began dropping below normal. After a few days of using medication to attempt to correct the infection and hemodynamics (blood pressure, et al.), the patient developed acute renal failure (ARF). Mr. Jones, however, did not develop acute respiratory distress syndrome (ARDS), which was a concern from being on the ventilator with SIRS. Mr. Jones received continuous bedside hemodialysis for added kidney support.

After eight more days in the ICU, Mr. Jones’s hemodynamics began to self-regulate, and he seemed to be improving quite well. After three more days, Mr. Jones’ kidney function began to improve and hemodialysis was discontinued. Four days later, Mr. Jones was extubated, removed from the ventilator, and transferred to a medical/surgical bed. After a short stay, Mr. Jones was discharged to a skilled nursing rehabilitation center for improvement of his activities of daily living (ADLs). Mr. Jones soon returned home with no lasting effects from the medical confinement. He continues to follow up with his primary care physician.

Academia, Health Care, Politics, Public Health, Society

Addressing Health Disparities

It is troubling to many people to see any person suffering in our society. It is even more troubling to see inequality extend to whole ethnic and racial groups within our society. We certainly do not want to be an unjust society, and we certainly want every member of our society to benefit from the technological gains made in the last century.

One of the more troublesome areas that many view as unjust is health and health care. It is unfortunate that some members of our society suffer from disparities in health. For instance, immunizations and vaccines for most of the common deadly pathogens are readily available, yet many people fail to immunize themselves or their family.

Immunization and vaccination programs have eradicated smallpox and polio and have all but eliminated the threat of measles in the United States (U. S. Department of Health and Human Services [DHHS], 2000). With influenza and pneumonia causing 30,000 to 41,000 deaths in the U. S., annually, the importance of vaccinating against these diseases is quite evident. Obviously, lacking immunity to a deadly pathogen is a disparate condition of health status, and Hispanic and African American populations are vaccinated with less frequency than Whites. How are these issues being addressed?

On the international level, the United Nations (2009) is addressing health disparities by attempting to eradicate poverty on a global scale. Unfortunately, many of these global initiatives have created an environment rife with economic turmoil that we are just now starting to see and understand. Though the premise of helping people out of poverty is very noble, the reality seems to be that we can only offer means for people to help themselves. Otherwise, we risk thrusting whole populations into a world they know nothing about, setting them up for failure. Poverty is based on local economy, and I believe that these interrelated problems are best addressed on the local levels with assistance from states, nations, and global endeavors. The people must direct their own path for a successful transition. They must take responsibility for their own successes and failures.

The United States addresses these concerns on a federal level, offering guidance to states and municipalities in ways to address them. One of these methods is a report from the U. S. Department of Health and Human Services. Healthy People 2010 (DHHS, 2000) has two stated major goals: 1) to increase quality and years of healthy life, and 2) to eliminate major health disparities. There are also 467 objectives in 28 focus areas designed to further these two major goals. Immunization is one of these focus areas.

According to the CDC’s National Center for Disease Statistics (2010), the goal of achieving a 90% immunization rate for children 19-35 months of age is close to being reached. The combination diphtheria, tetanus, and pertussis (DTP) vaccine (85%) and pneumococcal conjugate vaccine (75%) are the only two recommended childhood vaccines that are not being administered at least 90% of the time. According to DHHS (2000), the goal for DTP vaccination was 80% in 2000. It appears that this goal has been reached and exceeded.

Conversely, older adults, age 65 and greater, are at an increased risk of contracting illnesses that could be prevented by vaccination. “In 1999 approximately 90 percent of all influenza and pneumonia-related deaths occurred in individuals aged 65 and older” (Centers for Disease Control and Prevention, Office of Minority Health and Health Disparities, 2007, para. 2). DHHS (2000) does not state a quantitative goal for vaccinating noninstitutionalized older adults, though it does mention a need to “increase the proportion of noninstitutionalized adults who are vaccinated annually against influenza and ever vaccinated against pneumococcal disease” (p. 42). In 2000, 46% of the population in the U. S. were vaccinated against pneumococcal disease, and 64% were vaccinated against influenza (DHHS, 2000). In 2009, pneumococcal disease vaccinations increased by 15%, whereas influenza vaccinations increased by only 3% (Centers for Disease Control and Prevention, National Center for Health Statistics, 2010).

Striving to eliminating health disparities is a noble endeavor; however, the mere fact of attaining this goal contributes to the increase of health care disparity. By increasing the health care delivery model for one at-risk population, we must accept negative gains in the delivery of health care for all other populations. This is an example of the law of conservation describing the divisional nature of finite resources: when an isolated system undergoes change, its change in entropy will be zero or greater than zero (Negi & Anand, 1985). This concept is better stated as it applies to the zero-sum game of our economics today. Kathleen Madigan (2010), in a Wall Street Journal blog post, stated, “More spending in one area has to be financed by less purchases elsewhere” (para. 5).

Two conclusions can be drawn from observing this phenomena in health care. First, if people are spending their health care dollars on other staples, such as food, clothing, and shelter, then we should see a decline in the health of individuals that are making these choices. Second, within health care, in order to increase a focus on one population, an equal negative effect will be seen in all other population groups.

In all aspects of health care delivery, care should be taken to ensure just and equitable delivery of care regardless of socioeconomic factors, race, gender, religion, or creed. All people should have access to the minimum required care in order to maintain a healthy and productive life. We can counsel and educate our patients and clients to best health practices, but we cannot, however, force people to choose health over other facets of their lives.

References

Centers for Disease Control and Prevention, National Center for Health Statistics. (2010). Immunization. FastStats. Retrieved from http://www.cdc.gov/nchs/fastats/immunize.htm

Centers for Disease Control and Prevention, Office of Minority Health and Health Disparities. (2007). Eliminate disparities in adult & child immunization rates. Retrieved from http://www.cdc.gov/omhd/AMH/factsheets/immunization.htm

Madigan, K. (2010, August 3). With wallets thin, consumers face zero-sum game. Real time economics: Economic insight and analysis from the Wall Street Journal. Retrieved from http://blogs.wsj.com/economics/2010/08/03/with-wallets-thin-consumers-face-zero-sum-game/

Negi, A. S. & Anand, S. C. (1985). The second law of thermodynamics. A textbook of physical chemistry (pp. 241-289). Retrieved from http://books.google.com/

United Nations. (2009). The millenium development goals report: 2009. Retrieved from http://www.un.org/millenniumgoals/pdf/MDG_Report_2009_ENG.pdf

U.S. Department of Health and Human Services. (2000, November). Healthy People 2010: Understanding and improving health (2nd ed.). Washington, DC: U. S. Government Printing Office.

Academia, Health Care, Public Health, Society

Cultural Influences on Health Disparities

Disparities in the availability, access, and delivery of health care are a great and growing concern. Some of the factors leading to disparite health include race, socioeconomic status, and gender (Chen, Martin, & Mattews, 2006). Chen et al. describes how race and socioeconomic status are major factors in the United States, based on the Healthy People 2010 data (U.S. Department of Health and Human Services, 2000). According to the results of this study, our public health efforts seem to be misguided. As the researchers of this study indicate, “race and SES effects on child health are best understood in concert, rather than separately” (p. 705). The differences in race and socioeconomic status are a factor only to White and Black children when looking at prevalence rates for activity limitations and circulatory conditions, as illustrated by Chen et al. in Figures 1 and 2. These figures show that higher education actually has a small but negative effect on the health status of Asians and Hispanics while having a dramatically positive effect on Blacks. Additionally, in Figure 3, Chen et al. show a significant negative effect of education on incidence rates for acute respiratory conditions. There is no significant relationship for the same with regards to Whites or Blacks.

This study shows that there are certainly correlations between race, economic status, and differences in the health status of children in America, but these factors might only be relative. We need to understand if other factors can be identified as causative. In order to explain how Whites and Blacks share correlations while Asians and Hispanics share correlations, we might consider the length of time each population has been exposed to American culture. Whites and Blacks have been in America for over 300 years while Asians and Hispanics have migrated more recently. In addition, there is also evidence of attitude and preference differences for minorities towards health care, though the Institute of Medicine (2002) marginalizes this phenomena in their study.

As a health care provider and regardless of the causes of disparities in health status, it is advisable that I understand these causes so that I may better direct a patient’s care with a holistic understanding of the patient.

References

Chen, E., Martin, A. D., & Matthews, K. A. (2006). Understanding health disparities: The role of race and socioeconomic status in children’s health. American Journal of Public Health, 96, 702-708. doi:10.2105/AJPH.2004.048124

Institute of Medicine. (2002). Unequal treatment: What healthcare providers need to know about racial and ethnic disparities in health. Retrieved from http://www.nap.edu/html/unequal_treatment/reportbrief.pdf

U.S. Department of Health and Human Services. (2000). Healthy people 2010: Understanding and improving health. Washington, DC: Author.

Academia, Emergency Management, Health Care, Public Health, Society

Immunization and Infectious Disease Mitigation

Cultural Models of Immunization and Infectious Disease Mitigation

The members of some communities, such as Puerto Rico, do not understand the scope and severity of some infectious diseases until they become infected (Pérez-Guerra, Zielinski-Gutierrez, Vargas-Torres, & Clark, 2009). The lack of a basic understanding of illness and infection poses a roadblock to mitigating disease transmission within the community. For Pérez-Guerra et al., the perception of severity and mitigation is important as they investigate the difference in attitudes towards dengue infections because dengue cannot be controlled by vaccine and must be mitigated by community participation in mosquito abatement activities. Other infectious diseases, however, can be controlled by vaccine, but efforts to limit infection are met with ignorance or misconceptions (Lau, Griffiths, Choi, & Tsui, 2010; Leask, Sheikh-Mohammed, MacIntyre, Leask, & Wood, 2006).

Public health officials, in concert with community leaders, should seek to educate affected communities about the infectious diseases they face along with effective mitigation strategies and the importance of vaccination, if available. Coreil (2010) describes the importance of cultural models in “[gaining] a deeper understanding of the cultural context of behavior” (p. 83). If behaviors are not understood, then it will be difficult to redirect them. Reaching out to community leaders has the added effect of allowing the leaders to alter the message just enough so that it might be effectively communicated to the community.

Providing a cultural health model allows for a larger scope of audience while effectively tailoring the message so that most of the target audience will appreciate the nature of the message. Approaching health behaviors from a cultural stand-point also offers the advantage of allowing peer support to propagate messages through out the community. This might be especially true when dealing with a multitude of subcultures where the message might better be disseminated via interpersonal means. Eventually, the message will be received by many individuals who will begin to have discussions with others in the community. For communities where individuals are not likely to speak to each other regarding personal health-related matters, the cultural health model allows a general message to reach each individual.

References

Coreil, J. (Ed.). (2010). Social and behavioral foundations of public health (2nd ed.). Thousand Oaks, CA: Sage.

Lau, J. T. F., Griffiths, S., Choi, K. C., & Tsui, H. Y. (2010). Avoidance behaviors and negative psychological responses in the general population in the initial stage of the H1N1 pandemic in Hong Kong. BMC Infectious Diseases, 10(139), 1-13. doi:10.1186/1471-2334-10-139

Leask, J., Sheikh-Mohammed, M., MacIntyre, C. R., Leask, A., & Wood, N. J. (2006). Community perceptions about infectious disease risk posed by new arrivals: A qualitative study. The Medical Journal of Australia, 185(11/12), 591-593. Retrieved from http://www.mja.com.au/public/issues/185_11_041206/lea10999_fm.pdf

Pérez-Guerra, C. L., Zielinski-Gutierrez, E., Vargas-Torres, D., & Clark, G. G. (2009). Community beliefs and practices about dengue in Puerto Rico. Pan American Journal of Public Health, 25(3), 218-226. doi:10.1590/S1020-49892009000300005