Healthiest children … in wealthy zip-codes

It’s a little provocative sounding, but the research from Adam Drewnowski at the University of Washington shows most of the obesity and overweight epidemic is closely tied to poverty.

I’ve been blogging about obesity issues all week (see “recent posts” or the tag “obesity”).  Today, I talked to Drewnowski.  I’ll share more about his ideas later. But, this one merits re-stating.  In work that was published in 2008, he took the basic federal data on obesity trends, and overlaid that onto a map of King County.  The wealthier the zip code, as measured by property values, the lower the obesity rates, and vice versa.

He told me the data might have been even more dramatic, because it turns out that the wealthiest areas (such as Medina) are not even represented.  As he put it, Rich people don’t answer surveys.

For the past two years, he’s been digging into some of the reasons why poor people are less healthy.  His baseline theory is the most obvious: eating well and taking care of yourself can be expensive, in time and money.

In work to be presented soon, he’ll argue against the idea that poor people need more grocery stores and fresh produce sold in their neighborhoods.  It turns out, most people will go several miles to get their groceries (except for the very poorest 1%).  Some people drive to the cheapest store, others drive to what they see as the better quality store. So, having more grocery stores wouldn’t make a difference.

You might get different results in Los Angeles, or Detroit — two cities where a lot of the research was conducted re.  lack of access to grocery stores.  He says that work doesn’t hold for Seattle/King County.

He does see a role for better food education (such as, cooking classes).  I’ll have that report Friday morning on KPLU.

Swine flu and school closures – how much longer?

Wondering if you child’s school will be next?

The top public health officials in King County — Dr David Fleming, Director, and Dr. Jeff Duchin, Chief Epidemiologist — have been hinting that school closures may not be a tactic for much longer.

As my KPLU colleague Liam Moriarty reported this morning (Friday),  “So far, none of the folks in King County with the H-1-N-1 (swine) virus have gotten any sicker than they might from any of the old familiar flu viruses. Dr. Fleming says if that trend holds in the coming days – and this bug proves to not be particularly nasty – some of the precautions such as closing schools could be relaxed ….”

On the other hand, three students at Lakes High School, south of Tacoma, were taken to Madigan Army Hospital with severe flu-like symptoms, and as of Friday morning, two of them were in intensive care units, in serious condition.  That led to closing the school, as a precaution.

Seems sensible and prudent.   If tests show that they indeed are suffering from the swine flu H1N1, then we might see school closures  as a good tactic that should continue.

I have to say, the top officials in public health agencies and school districts have seemed remarkably indifferent to the hardship the closures cause.  In particular, for single parents and parents working jobs that offer little or no sick/vacation leave, this is a whole separate crisis.

When will a leader (the Governor? a Health Director?) stand up and say to employers, “We are in an emergency situation, and I’m asking all employers in the state to give extra sick days to anyone whose child’s school has been closed for a week?”

[UPDATE, Friday afternoon: Seattle Mayor Greg Nickels deserves a prize for being the first to address the work issue.  He told a news conference today that the city is offering extra flexibility to its employees … and he called on other employers to do the same. ]

In case you missed it, in King County, four schools have been closed (as of noon Friday)(five schools as of Friday 4 pm)  because they each have a student who probably has swine flu.  (The reason for closures is to slow down the spread of the virus — to prevent a situation where lots of people are getting sick at once.  But, once the virus is confirmed to be widespread in the community, then there’s not much benefit from closing individual schools.)

If you’re like me, keep crossing your fingers that your child’s school doesn’t have a “probable” case during the next week, and maybe after that we’ll be beyond school closures.

Vaccines and autism on trial

For anyone who still thinks vaccines are causing an epidemic of autism, please take a deep breath and open up to the possibility that such a theory might be completely wrong.

The latest verdict comes from a special tribunal.   A 3-judge panel has ruled against plaintiffs who were seeking damages, claiming their children had developed autism because of preservatives in the measles-mumps-rubella (MMR) vaccine.  We have a brief version of the story on our website.

This isn’t quite as dramatic as the Darwin trial in Dover, PA.  There was no jury, no courtroom theatrics.  Instead, it’s a court that exists only to hear complaints under the National Vaccine Injury Compensation Program.  But, the judges, who are not part of the public health infrastructure, reviewed thousands of pages of studies and other documents.  It sounds like they ruled pretty conclusively.  No link between autism and the vaccine.

This is not a surprise.  Every time an independent group has taken a look at this issue, they’ve come to the same conclusion.  And earlier this week, one of the British authors of a study that has fueled the anti-vaccine movement was revealed to have  faked some of his data (thanks to dogged reporting by The Times of London).

Opponents of vaccines have evolved their theory over the years.  Many now say, it isn’t just one vaccine, it’s the fact that so many are given at such a young age.  (Moving target?)   Still, I haven’t seen any credible evidence to suspect the vaccines.

Vaccine subsidies may end

My story on KPLU about a proposal to end state subsidies of childhood vaccines only brushed over the impact on pediatricians and family doctors.  It was a short story, written for a newscast.  This is not the most important budget cut pending in Olympia, or the one that will impact the most people.  But, it’s an example of a good program that probably is in trouble in this economy.

I traded messages with the president of the Washington chapter of the American Academy of Pediatricians.  Dr. Neil Kaneshiro wrote an eloquent explanation of what it might mean:

The burden on the pediatrician depends on how they respond to the change. As you have found out, it is a dramatic shift in policy. In the “old days” before Universal Purchase, pediatricians used to see kids for their checkups and then send them to the health dept for their vaccines. Not a very good system as some of those parents didn’t bother or weren’t able to take the kids in to a separate facility on a different day possibly missing work again just to get their vaccines. Now the vast majority of immunizations for kids are delivered in the pediatrician/family practitioner office because the immunization program makes it a seamless process. The benefits for kids were easy to see. No hassles and no barriers to immunizations. Immunization rates improved. (Many will say that Universal Purchase does not correlate with high immunization rates. That is true, but it definitely helps the rate by removing all financial barriers to immunizations so that any parent who wants one for their child can get it. The problem with immunization rates in Washington State is primarily with the strong anti-immunization sentiment fueled by celebrities like Jenny McCarthy. We have the highest proportion of families who opt out of school mandated vaccines in the nation.)

There are significant costs associated with provision of immunization services. Ordering, inventory, refrigeration/freezer capacity, needles, syringes, nurse/medical assistant time, physician counseling of patients.
Those are the costs with the current Universal Purchase program. When that is taken away, several other things come into play.
1. Acquisition cost. I estimate we have $150,000-200,000 worth of vaccine in our refrigerator and go through that monthly.
2. We would need vigilant monitoring of insurance reimbursement because doctors in other parts of the country have lost significant amounts of money because insurers were not reimbursing less than the actual cost of vaccine.
3. We would need to set up an entirely separate ordering and inventory system and institute failsafe measures to prevent vaccine from moving from VFC stock to Commercial stock and vice versa. Lots of potential fraud issues arise if VFC vaccine is used for someone with Blue Cross insurance. And potential bankruptcy issues arise if purchased vaccine is given to Medicaid kids.

Medicaid reimburses essentially nothing for the above services. Commercial insurance reimburses for the administration, but sometimes not the ordering, inventory refrigeration, insurance/overhead costs. The unspoken deal with the state was that physicians would move immunization services for Medicaid into the medical home since they were providing vaccines for everyone. In turn the state would be able to reduce the immunization infrastructure in the public health system as the primary care providers were taking care of it.

Depending on individual pediatricians vaccine purchasing power and negotiating position with insurers, buying and selling vaccine could be either profitable or not. Pediatricians are unfortunately not known for their business savvy and this will cause some practices to go under or stop doing immunizations.

I think that since pediatricians lose money every time they give a vaccine to a Medicaid child, it is possible that the financial strain will force some to revert back to the old system of referring kids to the health department for immunization services. Unfortunately much of that public health infrastructure has been dismantled and is unlikely to be rebuilt under the current budget situation.

The bottom line is that this will introduce barriers to immunization for kids that are not there now and our immunization rates will fall.

Mr. Gates, Rotarians, and polio

The Gates Foundation (do we still have to refer to it by its full, formal name?) is giving a whopping $255 million to help eradicate polio from Earth.  Bill made the announcement to a Rotary International conference today (1/21/09), because the Rotarians have been leading the push for polio eradication (raising money, volunteering, and using their local branches in places like India and Nigeria to push for political support).

Polio remains present in just four countries — India, Nigeria, Afghanistan, and Pakistan.   You can imagine the political/warfare challenges to delivering vaccine to remote villages in the “-stans.”  In India, the pockets of disease are also in remote areas (mostly in Uttar Pradesh).  And Nigeria has had a host of troubles, including a rumor five years ago that the vaccines were a plot against Muslim girls.  That caused a huge setback and a resurgence of the disease.

Some additional challenges today have to do with how polio behaves in the presence of other endemic diseases.  In those cases, it’s harder for the vaccine to provoke immunity, and more doses are required (sometimes 10 doses!).

There’s been a lot of debate over whether it’s worth the huge cost (billions of dollars) to wipe out the last few cases of one disease, when so many other diseases are causing more harm.  There are now fewer than 2,000 cases of polio a year.  But global health leaders say the resurgence we saw in Africa after the Nigerian troubles shows that you can’t permanently contain this highly contagious disease.  (It’s spread by a virus, either in contaminated water or by people who are carriers.)

Gates gave quite an inspirational speech to the Rotarians in San Diego.  I didn’t get a chance to hear it, but I was sent a transcript.  It turns out his wife Melinda has an aunt who was afflicted with polio, and has been in braces most of her life.

If the campaign succeeds, polio would be the second disease eradicated, after smallpox (officially gone as of 1980, according to the World Health Organization).

Malaria and the Holy Grail

Ah, the dilemma of Hope vs. Hype. I reported earlier this week that medical researchers and global health activists (including many at PATH in Seattle) are feeling a bit of success in the latest test of a malaria vaccine. It appears, so far, to be the best hope for protecting people living in malaria-infested areas. Malaria kills about a million people every year, mostly children in sub-Saharan Africa.

What I only mentioned, but didn’t have time in my radio report to explore, was the fact that the vaccine is still barely more than 50% effective. There’s no telling whether it will be better or worse than 50% once it gets into a less controlled context, in a final field trial that starts next year.  It likely will leave roughly half the population unprotected.

There are other potential malaria vaccines in the pipeline.  If any of them proves practical and at least partially effective, then you might combine two vaccines, and maybe make a big difference.  This would be like creating the “cocktail” of drugs that are helping AIDS patients survive.

Other researchers say we need a vaccine that’s at least 90% effective, ore else we’re going to allow malaria to remain the scourge of Africa.  But, there are vast challenges (scientific, technical) in creating a vaccine that good.  One candidate comes from Stefan Kappe’s lab at Seattle Biomedical Research Institute.  You can listen to my profile of him from last year, or read a recent profile by Luke Timmerman at Xconomy.com.

And, there are entire websites devoted to debunking all this as hype.

I think it’s great for science and possibly for human welfare that the Gates Foundation and others are funding this research into malaria.  But, for the next decade at least, it looks like old-fashioned remedies will have to do.

Medical clinics where you shop

Last week, I wrote a story about the mini-clinics inside grocery and drug stores. It included this paragraph:

“Most treatments are priced at 59 dollars. You’d be billed twice or three times as much at a traditional urgent-care clinic. MultiCare accepts insurance and Medicaid, so most people end up with just a co-payment either way. To break even, the mini-clinic needs to see at least 25 patients a day. That covers rent and the salary for the Nurse Practitioner who staffs it. The one-person staff keeps costs down – along with treating only minor ailments. Is this the next big trend? Not yet, despite hype from some chains. It’s been moderately successful in other parts of the country – but not a revolution.”

For Tacoma’s MultiCare health system, the key is integrating the retail clinic with their larger system. Many of the patients (including the two that I interviewed in the drugstore) were referred from MultiCare’s traditional urgent-care clinic, which was overcrowded.

The question I did not address, but hinted at, in the story is this: Are these retail clinics a good indicator of how much you pay for inefficient overhead during your basic medical appointment? We’ve been hearing for years how wasteful the medical system is, and how paperwork eats up a big share of every dollar. But this seems to be a graphic illustration, at least for all those visits that didn’t need fancy MRI machines and surgical suites nearby.