Monday, December 5, 2011

Happy and Healthy Birthday

Today is a very important day in history. You may wonder why. Is it because it’s the day Prohibition was repealed in 1933? No, although I’ll happily toast Prohibition’s prohibition, that’s not what makes December 5th special. Nor is it because on December 5th, 1927, the first worldwide roller canary singing championship was held in Manitoba (although that is fascinatingly esoteric.) Actually the 5th of December is of vital importance because it is the day on which my wife Angela was born. And I would put myself at great risk if I were to forget this. As Robert Frost once wrote, “A diplomat is a man who always remembers a woman's birthday but never remembers her age.” So, to keep healthy, I follow Frost’s advice as well as that of my brother, who often reminds me, “happy wife, happy life.”
Sadly, for many adults (my wife excluded) birthdays aren’t associated with happiness or wellness. Sure, “making” it to the next birthday can be a big event, especially if it is year 100, but too often birthdays herald unhealthy thoughts and behavior. In these cases, people agree with John Glenn that there is “still no cure for the common birthday.” In fact, studies show that the reality and awareness of one’s own mortality, (scientists call this “mortality salience”) may not only lead to the “birthday blues,” but also increase mortality risk. For example, a study of former major league baseball players, now dead, found they were more likely to die on their birthday than on any other day. Similarly, an investigation published in Neurology in 2006 reported that strokes and heart attacks are more common on birthdays. The researchers speculated that associated stress was to blame. Yet another study looked at suicides committed on one’s own date of birth – finding a slightly increased risk – especially among those over the age of 35.
Could the birthday blues be a self-fulfilling prophecy? One fulfilled like so: 1) someone is convinced something bad will happen on his birthday (for example, one might feel superstitious upon reaching the age at which one’s mother or father died); 2) a physiological stress response ensues; 3) blood pressure rises and arteries constrict, resulting in; 4) a vascular event (such as a heart attack); and 5) the birthday celebrant now actually is more likely to die. Or, in the worst-case scenario, someone might actuate the birthday stress in the extreme by taking her own life. Pretty depressing. Depressing enough to convince me that the American Adult Birthday needs an extreme health makeover.
Recognizing that birthdays will never again be like they were when we were kids – events giddily anticipated for months in advance – I think there is a way to make them less deadly for adults. So, in honor of my wife’s birthday (funny, I don’t seem to recall how old she’ll be this year), I’d like to propose that the birthday take a turn for the happy and healthy. Yes, you can still have the cake and an extra drink or two, but how about also making several birthday declarations? Let’s call these “candlelight promises.” Try stick to just a handful of them (save the rest for New Years) and your birthday can become a healthy turning point. Looking for ideas?
*Plan and execute one big trip or event each year – something that you have always wanted to do but haven’t gotten around to. The planning itself will keep you focused and give you something great to look forward to. As Lincoln wrote, “And in the end, it's not the years in your life that count. It's the life in your years.” By choosing the life that excites us, we may actually stick around longer. 
*Pick up one new sport or hobby and give it a whirl. Doesn’t have to be anything extreme – taking up technical mountain climbing to celebrate your 90th may not be too wise – but what about painting, sculpture, or Yahtzee?
*Commit to one new healthy habit. You may like Lucille Ball’s suggestions; “The secret to staying young is to live honestly, eat slowly, and lie about your age.” Or you may prefer mine, which is to floss twice daily.
So there you go; hopefully this gives you something new for a day that may have lost its luster. And to my wife, I wish you a happy and healthy birthday.

Monday, November 28, 2011

Bicycle Helmets are for Everyone (Marin IJ)

Some time ago, I received a call from a friend of mine named Ecke. A retired Ross Valley Fire Captain, Ecke was wondering if he’d seen me biking down Butterfield Road earlier that day. Why yes, I said, that was me. “I couldn’t help but notice,” he rejoined, “that you weren’t wearing a bicycle helmet.” He was absolutely right, I hadn’t been. “Here you are,” Ecke continued, “talking big in the paper about safety and stuff and really you’re just a phoney-baloney.”

Thankfully, Ecke is just about the most good-natured guy I know, and he was just poking fun at me. But nonetheless, I felt a wee bit ashamed. Because I do know better; head injuries are by far the leading cause of death and disability among cyclists and helmets have repeatedly been proven a powerful preventive device. For example, a 1991 study from the U.C. Berkeley Institute of Transportation Studies found that out of 1,430 bicycle-related head injuries, 1,216 (85 percent) could have been prevented or mitigated by helmet use, with a potential savings (in hospital charges alone) of $16.7 million. Because of evidence like this, the state of California mandated helmet use for children under the age of 18 back in 1993. Similarly convinced of helmets’ worth, the city of Berkeley recently gave away nearly 1,500 of them.

The helmet give-away (which ended last month) was paired with instruction on safe biking practice and was part of a year-long injury prevention program sponsored by the City of Berkeley and the California Office of Traffic Safety. Kate Clayton, MPH, Chief of the Health Promotion Section for Berkeley Public Health, explains; “Recognizing that helmets are an important strategy for reducing morbidity and mortality when collisions do occur,” she said, the program “focused on youth and their families in low-income neighborhoods with relatively poorer health outcomes compared to the rest of the city.”

This seems like a noble endeavor, but can giveaway programs really make much of a difference in helmet compliance? Two decades ago, a seminal study in Seattle demonstrated that the barriers to bike helmet use go beyond cost and include knowledge and perception. In the Seattle area (and elsewhere as well, I’m sure), a significant factor behind children’s failure to don helmets was their concern that “wearing a helmet would result in their being viewed as ‘nerds.’” Thus, if helmet use is to be encouraged (without the strong arm of the law) a multi-pronged approach – one that includes education and culture change – offers the best chance at lasting success. This observation was borne out by a meta-analysis (a study reviewing multiple prior studies) published in Injury Prevention in 2006. The authors re-analyzed data from multiple publications on the topic of encouraging bike helmet use without legal interventions, and reported that the most effective tactics were community-based efforts to give away free (rather than subsidized) helmets.

Promising, but what about also giving helmets an image makeover – re-inventing them to exude style and fashion? Impossible? Probably. But there are brands that are bravely trying to market the hipster helmet. Yakkay, ( for example, uses the tagline “brainwear for smart people” and makes helmets that look like hats with chin strap accessories.  And while they don’t carry a 49ers lid, and their style is not quite Supra-esque, the checkered Cambridge design does make a certain statement.

Fortunately, even though most helmets remain style-deficient, here in Marin a large percentage of our cyclist population is cool with wearing them. In fact, on weekends, the streets of Fairfax (where I live) are practically teeming with helmeted cyclists. Yet, there is still room for improvement. Some people who reflexively click their seatbelts every time they get in the car somehow have a blind spot for head protection. For example, I routinely see parents biking down busy streets to school with their kids, and the child is wearing a helmet, while mom and/or dad is not. I’ve obviously been guilty of something like this too. Sometimes we forget (that’s my excuse!), sometimes items are misplaced, and sometimes we just don’t think there is much of a risk. But, parents need to remember three things: 1) children model their behavior, 2) biking without a helmet is indeed taking a significant risk, and 3) a traumatic brain injury is an awful thing to have.

My friend Ecke has a favorite saying: “Yesterday’s history, tomorrow’s a mystery, today’s a gift. That’s why they call it the present.” If you think it’s no big deal to forego your helmet when biking, remember today IS a gift, protect it. Use a helmet to safeguard your head and your reputation.

Thursday, October 27, 2011

Healthy Eats

You are what you eat. I’m guessing you’ve heard this cliche before. But have you thought about what it means and whether it’s true? Surely, “You are what you eat,” doesn’t mean that later today I’ll morph into a frosted doughnut with Halloween sprinkles. What it does mean is that my body is built, mostly, on nutrients I consume. There are, of course, exceptions – women are born with all of the (non-surrogate) eggs they will have for their lives and medical devices do not use diet to sustain themselves. Tooth enamel and cerebral cortex neurons stay constant but, other than that, our bodies undergo constant turnover. And, as we all know, the substrate for that turnover is what we eat (so, if you had a turnover for breakfast, that turnover is used for turnover). And even those things in our bodies that are not directly the result of diet are affected by it. Your teeth, for example, are highly sensitive to the food you eat and its sugar content. So, food matters – and food quality affects health. But, eating well is expensive, right?

Consider a recently published University of Washington study that examined the cost of eating a diet compliant with the federal Dietary Guidelines for Americans, 2010 – which recommends increased dietary quantities of vitamin D, calcium, dietary fiber and potassium and less sugar and saturated fat. Using a survey to assess eating habits and then tallying retail prices at Seattle-area food suppliers, the study team tabulated the estimated dollars needed to get enough of some key nutrients, such as potassium. Based in part on the fact that such nutrients are plentiful in fresh produce and hard to find elsewhere, the researchers reported that meeting the guidelines would add to food costs. In fact, for one nutrient (potassium), an additional $380 was needed per person per year to meet recommended guidelines. On the other hand, for every 1% increase in dietary calories obtained from sugar and saturated fat, study subjects saved approximately $26 (sugar) to $102 (saturated fat) per person per year. Based on these findings, the authors concluded that, “Improving the American diet will require additional guidance for consumers, especially those with little budget flexibility, and new policies to increase the availability and reduce the cost of healthful foods.”

This study certainly has limitations in terms of its scope and methods (including the fact that the calories and costs were estimated rather than directly observed), but it nonetheless supports the conventional wisdom that you have to be rich to eat a healthy diet. I argue, however, (and I’m not alone in this) that conventional wisdom is simply not true on this point. It is, of course, a lot easier to be a healthy eater if you have a fat wallet, but it’s certainly possible without one. And while I agree with the basic tenet of AB 581(declaring access to healthy food items a basic human right), I don’t think this issue should be left to legislation alone. For example, here is a quick recipe of tips for economic and nutritious eating.

Recipe for Eating Well on a Tight Budget.

·      Mix the following into your routine
o   Two parts buying local, fresh and in-season when possible.
o   Three cups planning nutritious meals that can be re-served another night.
o   One part frequent thick and hearty soups (these will cut back the urge to splurge).
o   Three carts of buying generic and in bulk and freezing perishables.
o   Six tablespoons of reading food labels. You’ll be shocked at all the added sodium.
·      Cook this mixture slowly in a reduction sauce dedicated to cutting back on unrefined sugar, saturated fat and expensive and unnecessary vitamin supplements.
·      Finish with three thimbles of nutrition education.

It is in the finishing that the most enduring benefit will be found – for you and your family. In particular, we could be doing a much better job of teaching our children about food and nutrients and creating a life-long appreciation for their importance. As a father who delivers sprinkled doughnuts home on a bi-weekly basis, I am likely more delinquent on this point than many in Marin. So, for parents like me a great place to start the schooling sauté is at the North Bay Discovery Day. On November 5th, in an event sponsored by The Buck Institute, over 50 exhibitors will gather at Infineon Raceway, all tasked with helping to make science fun and accessible for kids.

Among the exhibitors is accomplished chef Ted Smith, founder of Kids Cooking for Life (KCL) which is a community program that focuses on educating children on food, cooking and (big bonus!) table manners.

The KCL exhibit (in partnership with Kaiser Permanente) on Discovery Day is called a “Whole Grain Adventure” and will feature fun and games (including a Fiber Race) and deliver the message “that whole grains (and the fiber they contain) are an essential ingredient of a healthful diet.”

Ted Smith writes, “I strongly believe that you don't have to be wealthy to eat healthy. What I’ve learned as an owner-operator of restaurants in Chicago for over 23 years (and having served over 18 million customers) is this: fruits and vegetables are a lot cheaper than meat, seafood and poultry! And fruit and vegetables is where you find healthy eating.”

And don’t worry, a diet rich in produce will not turn you into a turnip.

For more info about Discover Day check out

Monday, October 3, 2011

The Good, The Bad, The Ugly (Marin IJ)

You may have noticed that vaccines are back in the news. In fact, the last few weeks have brought several related stories, which as a vaccine advocate, I would categorize as the Good, the Bad and the Ugly (yes, vaccines and Clint Eastwood movies do have something in common!) These developments can be summarized as 1) Good; rotavirus vaccine benefits children and public health, 2) Bad; pertussis (whooping cough) vaccine wears off sooner than previously thought (after about three years) and 3) Ugly; the Human papillomavirus (HPV) vaccine was blindsided by hearsay from a U.S. presidential candidate. More plot details below…
Good: Rotavirus vaccine decreases health costs
Have you heard of rotavirus? As a medical student studying for the boards, I had trouble remembering what type of infection this bug caused until I learned the mnemonic R-O-T-A, which stands for “right out the a@*&#.” That pretty much sums it up. Rotavirus is a leading cause of diarrhea, especially in children under the age of five. Tens of thousands of kids visit emergency departments each year because of rotavirus (which can cause life-threatening dehydration), and thousands more will require hospitalization for re-hydration. According to the CDC, just five years ago, rotavirus was responsible (annually) for approximately 55,000 to 70,000 hospitalizations and 20 to 60 deaths among young children. Even in mild cases, rotavirus is a bummer for everyone involved, except, that is, for the diaper industry.
The good news is that there are now two licensed vaccines against rotavirus (RotaTeq and Rotarix) and recent evidence suggests that they are working well. In the September 22nd issue of the New England Journal of Medicine (NEJM), researchers from the CDC reported the results of a 2001-2009 study comparing pre- and post-vaccination outcomes. Their results suggest that the vaccine (first widely available in 2007) resulted in an approximately one-half reduction in diarrhea-related ED visits and hospitalizations. Furthermore, the researchers calculated that the vaccine had likely prevented over 20,000 hospitalizations a year since 2007, resulting in a health care cost savings of over $90 million a year. I think you’ll agree; that’s a public health benefit we shouldn’t be flushing away.
Bad (well, not totally bad): Pertussis vaccine wears off earlier than thought
Hopefully by now everyone knows that we are in the midst of a pertussis (whooping cough) epidemic – one in which (quite regrettably) Marin County has led the way. This epidemic is multi-factorial – it is due in part to natural disease fluctuation, but also related to significant rates of personal belief exemptions (PBEs) for vaccines and waning immunity in older kids and adults. We have suspected for some time that the typical schedule of acellular pertussis vaccination (in older kids and adults) does not provide adequate protection and very recent (and still unpublished) evidence from the 2010 pertussis outbreak seems to confirm this. Dr. David Witt (infectious disease) and Dr. Paul Katz (pediatrics) from San Rafael Kaiser Permanente recently studied over 15,000 kids under the age of 18 in Marin County and identified 132 confirmed cases of pertussis. Their preliminary results, presented two weeks ago at the American Society for Microbiology in Chicago, suggest several important trends; 1) vaccinated children (age 2-18) are less likely to get whooping cough than unvaccinated ones, 2) younger children (age 2-7) who are vaccinated are well protected against disease and 3) older kids (with a peak around age 12), even if vaccinated, are very susceptible. In fact, the risk for 12-year olds is approximately ten times higher than for 2-7 year olds. This, then, seems to be good justification for the idea of a pertussis booster shot (as now required by state law AB 354) for 7th-12th graders. Fortunately, and this is where the bad news is not really so bad, Marin County seems to be doing very well with these boosters. According to public health officer, Dr. Jason Eberhart-Phillips, “We are nearly there to full compliance in Marin at this time. Local education officials understand and value the health and well-being of their students! “

Ugly: The HPV vaccine flap
Genital warts are not a pleasant topic. Especially when you consider that the causative virus (HPV) is a major risk factor for cervical cancer. Cervical cancer is nasty, even for cancer, and it kills young women. If you have any doubt about how horrible this cancer can be, consider this description of metastatic disease from The Immortal life of Henrietta Lacks by Rebecca Skloot… “Henrietta’s body was almost entirely taken over by tumors. They’d grown on her diaphragm, her bladder and her lungs. They’d blocked her intestines and made her belly swell like it was six months pregnant.” Fortunately, HPV immunization offers significant protection (70% or so) against cervical cancer in addition to genital warts. But despite its well-documented safety (over 35 million doses given worldwide), the context of the topic (teenagers having sex) has fueled some political pushback.

On September 13, the day after a GOP presidential candidates debate, Michelle Bachmann claimed on several media outlets that the HPV vaccine was hazardous and could cause “mental retardation.” Later, Bachman told Matt Lauer on the “Today” show that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk." As it turns out, these statements were based, not on fact, but on a single anecdotal account from a woman who had talked to Bachmann at a campaign event. This sort of   “a person I knew had a…” approach to public health is not healthy. In fact, this tact by a public figure was so egregious that Dr. Arthur Caplan of the University of Pennsylvania Center for Bioethics, challenged Bachmann – offering her $10,000 of his own money (to be given to a charity of her choice) if she could, in Caplan’s words, “produce a person within a week who had been made ‘retarded’ by the HPV vaccine, and if that claim could be verified by three doctors.” It’s been several weeks now and Caplan’s challenge remains unanswered. I asked Dr. Caplan to summarize his opinion of the situation:

He says, “Bachmann decided to base her campaign on an anti-vaccination platform. To do so she had to claim that vaccines like the HPV vaccine to prevent cervical cancer are dangerous.  Her willingness to throw away women's lives for political gain is not only unworthy of a Presidential candidate it is morally despicable.”
“As a recent study in NEJM on vaccines against rotavirus demonstrated,” Caplan continues, “vaccines remain our best response to lethal and disabling diseases in children and adults. By continuing to allow politicians, celebrities and crackpots to spew utter nonsense about vaccine dangers the medical, scientific and media communities are complicit in compromising the health of the public both in the U.S. and worldwide.  Vaccines do have risks as do every other health intervention from alternative medicine, to aspirin, to anesthesia.  But, vaccines are among the safest and most effective tools we have to fight dread diseases.  The public should know that and hopefully my challenge to Bachmann will help make that happen.”
Ugly situation indeed, but if it results in a better understanding of vaccines, including their minimal risk in the face of major benefits, it will lead to a prettier picture of public health.

Wednesday, September 21, 2011

Michelle Bachmann's Assault on Public Health (Art Caplan)

Michele, My Warning Bell about Vaccine Fear-Mongering
Public Health
Arthur Caplan, 09/20/2011

Read more:

Greg Kaebnick, the editor of the Hastings Center Report (and, full disclosure, a former student of mine!) kindly invited me to offer some comments on my decision to publicly challenge Congresswoman and presidential candidate Michele Bachmann’s comments on the safety of the HPV vaccine. I am happy to do so. It lets me tell a story that might be of interest to the bioethics community and to offer a few comments about my own thinking about the public work in which some bioethicists engage.
Yesterday, Bachmann abandoned her claim that the vaccine was dangerous, saying she was only repeating a story she had been told. Of course, rumor-mongering is hardly a defense. Moreover, she has apparently decided to make an antivaccination stance a key part of her campaign to dislodge Texas Governor Rick Perry from his position as the GOP’s leading presidential candidate.
In running against vaccines, Bachmann is willing to dissemble and lie about vaccine safety to try and score political points. She is also apparently willing to sacrifice the lives of young women in the U.S. and around the world to cancer, as well as others who may die of whooping cough or flu to her political ambition by impugning the safety and efficacy of vaccines and vaccine mandates. This stance should not only disqualify her from selection as the GOP candidate for any national office, but it should also lead her Minnesota constituents to think about whether she belongs in Congress at all.

The HPV flap to date

 On Tuesday, September 13, the day after the GOP presidential candidates debate, Bachmann claimed on various media outlets that the HPV vaccine was dangerous and could cause “mental retardation”. Bachman told Matt Lauer on the “Today” show that she had met a woman who said her daughter had “suffered mental retardation from the vaccine.” She went on to say that the HPV vaccine has "very dangerous consequences" and that it puts "little children's lives at risk."
The whole off-the-wall discussion during the debate about Perry’s push to promote the HPV vaccine through an executive order had me angry. Bachmann’s fear-mongering about vaccine safety to gain an edge on Perry pushed me over the edge. Within hours, I wrote an impassioned column trying to get the facts straight. I posted it on my Facebook page and tweeted it as well. The column got some attention, and I got a number of requests for radio and print interviews about it on Tuesday.
On Wednesday I happened to see a Facebook post by my friend and former colleague at the University of Minnesota, Steve Miles. He, too, was angry about Bachmann’s lies about vaccine safety and had posted this item: “I am offering $1,000 for the name and medical records release of the person who Michele Bachmann says became mentally retarded as a consequence of the HPV. Please share this message.”
The American Academy of Pediatrics also issued a strong statement, and a few commentators and fact-checking items in the newspapers noted that her remarks were not true. Still, I worried that the stench of fear was going to linger around vaccines yet again, and I decided I should take on Bachmann’s untruths, too. I did not want Bachmann to give more fuel to anti-vaccinators or to risk the lives of children whose parents might not get them vaccinated because of fears she was continuing to stoke.
Although I thought Steve’s $1,000 wager would get some attention, I thought we needed to up the ante. We needed a gimmick to debunk the Bachmann blarney. So I tweeted and e-mailed my own challenge: If Bachmann could produce a person within a week who had been made “retarded” by the HPV vaccine, and if that claim could be verified by three doctors that she and I agreed upon, then I would give $10,000 of my own money to a charity of her choice. If not, she would give $10,000 dollars to a charity of my choosing.
I repeated the challenge on the radio interviews I had that Thursday morning and said the clock had started ticking. Pretty soon, my phone was ringing and e-mails were coming in from journalists. Steve let me know he did not agree with the terms of my challenge but that he was on board with me and would add his $1,000 dollars to it. So there was an $11,000 throwdown.
During interviews that Thursday, I pointed out again and again that there was no evidence at all that the HPV vaccine caused “retardation,” that the CDC/VAERS Web site had never received any such report, that there had been no report I knew of in any other country in the world of any such side-effect despite more than 35 million doses administered, and that it was reprehensible that the same sort of fear-mongering that was causing infants to die of pertussis, flu, rotavirus, measles, and polio around the world was being offered up about HPV vaccine by a serious contender for the presidency of the United States.
I then received a request for an interview on “Anderson Cooper 360” on CNN about my challenge. The power of TV in American culture is still impressive. After the Anderson Cooper interview, the issue of Bachmann’s vaccine fear-mongering became national news, splashed all over the print, radio, and Internet. Bachmann was being held accountable, and lying about vaccine safety was costing her. By Saturday she had dropped in the polls.
Her campaign has not responded to Steve or me. An NPR reporter told me that her press person said she would not respond because she had not received “a letter” from me challenging her views about the HPV vaccine. That response is absurd on its face.

On taking a public stand

Part of the reason I was angry about Bachmann’s comments is that I have been working on vaccine ethics long enough to be acutely aware of the harm caused by vaccine misinformation. In 2004, I had been asked by a Pennsylvania official for help in determining how best to allocate the then-scarce supply of flu vaccine. I told him I did not know anything about vaccines, but that I was sure some bioethicists were working in this area. It turned out that I could not find any to recommend.
I began wondering why that was, since vaccines are the single most effective medical intervention ever mounted against disease, with at least one major scourge of humanity, smallpox, eliminated due to vaccines and another, polio (which I had as a child), close to eradication. Long story short, I ended up launching a project at Penn on vaccine ethics and a related project, which I run with the able help of Jason Schwartz.  I signed up for a course on how to make vaccines; sat in on lectures on vaccine issues; and met Paul Offit, of our Children’s Hospital and department of pediatrics, who had been waging a one-man war against anti-vaccination propaganda for years. I got deeply involved in the subject and wound up publishing quite a bit on vaccines in general and on HPV vaccine in particular.
Having been involved in a highly visible way in other situations where politicians, zealots, or advocates have tried to advance misinformation in the name of a political or medical goal – including the Terri Schiavo case, the battle over federal funding of embryonic stem cell research, the claim that a Belgian man had “woken up from a 23-year coma” to use facilitated communication to reveal the horror of his experience, and crackpot offers of cures with untested adult stem cell therapies, among others – I knew a few things about the importance of speaking up, the need to have scholarship in place to back up one’s comments, and the price that often has to be paid for doing so.
The need to speak from an ethical perspective in public forums and outlets about inaccurate, misleading, or outright false claims about bioethical issues should be self-evident. While it is important to publish one’s views in the peer-reviewed literature and to share them in the seminar room, it is equally important for those who have the skills and the facility to communicate with broader audiences to do so. Like economics, political science, climate science, agriculture, and engineering, bioethics is not a purely theoretical field. To do what nearly all of those in the field claim it seeks to do – advance patient interests, enhance the prospect for justice for the least well-off, correct abuses of patient and subject rights – some in the field must engage in policy and public dialogue. At the same time, of course, if one is going to speak up, then it is important either to have published on the matter or to have mastered the relevant subject area at least to the point where one is comfortable teaching and lecturing about it.
The danger in advancing civic debate and public understanding is that your own peers will not know your scholarly work on a topic and will see any highly visible public activity as self-promotional pandering – or at best as popularizing, although that is little better on the academic scale of value. The duty to get involved surely overwhelms the price.
It is also true that entering the public arena means interaction with the media. Time and again, I have seen my comments distorted, misstated, or simply misused, even by highly respected journalists. It has already happened in the HPV vaccine story. The Internet only makes matters worse, given its immense power of repetition.
I think my decision to call out Michelle Bachmann on her comments about vaccine safety and vaccine mandates with my $10,000 challenge was the right one. I believe it is having the effect I intended. The lack of evidence behind nearly all of the claims of vaccine dangers and risks remains in the news. There may even be a better understanding of what is involved in creating different types of vaccine mandates. And women and men in America may be more willing to get their children vaccinated against a disease that kills and maims thousands and to support efforts to get the HPV vaccine to poor women worldwide to prevent many of the hundreds of thousands of deaths that occur every year from cervical cancer.
If vaccination is going to be a key part of the winnowing process of those who want to be president, then the framing of that debate has been reset in a much more positive mode.
Arthur Caplan is the Emanuel & Robert Hart Director of the Center for Bioethics and Sidney D. Caplan Professor of Medical Ethics at the University of Pennsylvania, and a Hastings Center Fellow. Follow him on Twitter @ArthurCaplan.
Caplan’s references and writings on vaccines:
Boom and bust-have we learned what we need to from the flu vaccine shortage?” Johns Hopkins Advanced Studies in Medicine, 2005: 522-3.
“Off the grid: Vaccinations among home-schooled children,” The Journal of Law, Medicine & Ethics, 35, 3, 2007: 471-77. (with D Khalili).
“Lessons from the failure of human papillomavirus vaccine state requirements”, Clinical Pharmacology and Therapeutics, 82, December, 2007: 760-3, (with JL Schwartz, RR Faden and J Sugarman).
“Leveraging Genetic Resources or Moral Blackmail? – Indonesia and Avian Flu Virus Sample Sharing,” American Journal of Bioethics, 7, 11, 2007: 1-2 (with DR Curry).
“Ethics” in: S. Plotkin, W. Orenstein and P. Offit, eds., Vaccines, 5th ed., 2008: 1677-1684 (with JL Schwartz).
“Genital warts: mountains or molehills?” The Lancet Infectious Diseases, 8, 5, 2008; 277-8 (with SC Hull).
“A proposed ethical framework for vaccine mandates: Competing values and the case of HPV”, Kennedy Institute of Ethics Journal, 18,2, 2008: 111-124. (with RI Field).
“Is Disease eradication unethical?” The Lancet, 373, 2009: 2192-3.
“Disease eradication –  a response,” The Lancet, 374, 2009: 1144 (letter).
“The case for vaccinating boys against HPV,” Public Health Genomics, 12, 2009:362-7 (with S Hull).
“Unlicensed Pandemic a (H1N1) Vaccines: Explicit ethical rules of the road are needed in public health emergencies,” The Lancet, 2009: 375, 2010 444-45.
“Physician attitudes toward influenza immunization and vaccine mandates,” Vaccine, 28, 2010: 2517-22 (with J Desante and A Behrman, F Shofer).
“Influenza vaccination of healthcare personnel,” Infection Control and Hospital Epidemiology, 31, 2010: 987-995 (with TR Talbot, H. Babcock, D Cotton, LL Maragakis, GA Poland, DJ Weber).
“Clinical trials of drugs and vaccines in poor nations -- ethical challenges and ethical solutions,” Clinical Pharmacology and Therapeutics, 88, 5, 2010: 583-4.
“Health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital” Vaccine, 29, 9, 2011: 1762-9 (with K Feemster, S Coffin, P Offit, C Feudtner and M. Smith).
“Vaccination: facts alone do not policy make,” Health Affairs, 30, June 2011: 1205-8.
“Ethics of vaccination programs,” Current Opinion in Virology, 1, 2011: 1-5. (with Jason Schwartz).
“Time to mandate influenza vaccination in healthcare workers,” The Lancet, 378, 2011: 310-311.
“Vaccination refusal: ethics, individual rights and the common good,” Primary Care Clinics Office Practice, 2011, in press. (with Jason L Schwartz)
Posted by Susan Gilbert at 09/20/2011 11:36:03 AM |

Monday, September 19, 2011

Too Many Tasks (Marin IJ)

I’m sitting down to write on an important topic. I should check my email. Right, where was I? An important topic for students, parents, professionals, and, well, just about everyone. Who’s texting me? Oh shoot; I need to finish that Amazon order. I forgot to call the plumber. And the dog needs to go out. Did I feed my daughter’s Brazilian water frog? I should check my email. Wait, focus. Important topic. Interesting topic. And it’s critical that everyone understand the limitations and risks associated with it. I really should check my email. Multi...must check email! …Tasking.
Like many people in our digitalized and sensory-loaded world, I’m a fervent multi-tasker. Email, bills, scheduling, patient-care, child-care, pet-care, Twitter-care, fantasy sports; I can do it all. And I can do it all at the same time! At least so I thought. Just checked my email for the fourth time this paragraph. My wife wants to know if we can go to a school fundraiser tonight. My boss is trying to schedule a tennis match. I wonder which QBs are available on the cbsportsline waiver wire? Expedia has a new fare alert for me. $299 bucks to fly to Omaha! Sweet. Contrary to the ethos I’ve prided myself on, in a world of information overload, constant data processing can actually “smog,” “asphyxiate,” and starve away productive time. In fact, multi-tasking may threaten efficiency more than aid it. 
Skeptical? Well, stay with me here (your stock portfolio and Facebook newsfeed can wait), and consider evidence from cognitive testing. Researchers looking at individuals performing two or more tasks at once have found that, quite consistently, people complete tasks faster if they do them serially (one, then the other) rather than in parallel (start one, start the other, back to the first, and so on). In fact, loss of efficiency has been estimated to be around half-a-second per task switch and up to twice the sum of the time needed to complete two tasks in order. So, for example, if it takes me two minutes to check and respond to my email and three minutes to order a new mattress online, it would take me up to ten minutes to do the two tasks “at the same time” (switching back and forth between tasks with a delay with each switch). But if I did the tasks serially (i.e. focusing on one task and completing it before moving on to the next), the two tasks should take me only five minutes.
Now, as we all know, multi-tasking is more or less a fact of life. Most of us are forced to multi-task some or all of the time, both at work and at home. A busy shift in the Emergency Department (ED) is an excellent example of this, and one that I’m quite familiar with. I spend my days talking with patients, performing physical exams, entering orders, documenting, calling consultants, communicating with nursing and other personnel, performing procedures, making referrals, all while trying not to neglect an important task like prescribing the correct medication. Studies of ED physicians demonstrate that their tasks will be interrupted four to fourteen times per hour, or every four minutes or so. An observational study of nurses reported that ED nurses (at work) multitask 34% of the time. Each and every single one of the interruptions that ED providers experience could have disastrous consequences. (This is why we have developed safety mechanisms like timeouts and checklists.)
But of course, some multi-tasking is unavoidable. Our patients surely appreciate that we break away from a routine task, like charting, to tackle another more critical task, such as providing acute resuscitation. And, keep in mind that some “multitasking” is not harmful. For some people, listening to music while driving or studying is not really multi-tasking at all but rather a multi-sensory approach to a task. This habit may or may not affect efficiency and performance. People are (according to cognitive studies) able to train themselves to block out distractions when performing an assignment. Note that I say “distractions” and not tasks. Tasks, especially ones that require working memory - very short term memory designed to aid in completion of short term tasks - will be more efficiently completed in order and cannot be blocked out as part of a multisensory approach. Working memory is ephemeral and highly sensitive to interruptions. We all experience this as those “I lost my train of thought” moments.
Can you minimize brain stalls and achieve a healthy level of multi-tasking? Maybe, but first you have to set aside dedicated time to think, focus, and plan. Creativity benefits from focus and people who have planned or rehearsed tasks beforehand are less likely to suffer delays. Here’s another tip: try to resist over-dosing on jolts of satisfaction (“dopamine squirts”) associated with compulsive behavior – like checking email every 2.4 minutes. And when possible, finish what you started  - NOW – rather than deferring it to the “later” bucket. Working memory is temporary and what may seem unforgettable right now is actually quite forgettable in 15 minutes. Finally, experiment with focus adjuncts – meditation or paying attention to your breathing may help, as might noise-erasing headphones (which, my wife lovingly has dubbed “wife- and kid-erasers”). Of course, a lot of the modern world cannot be easily “noise-erased,” but if you make an effort to slow down, especially with important endeavors, your reward, ultimately, will be higher efficiency and fewer mistakes.
Well, phew, I’ve made it through this task. Hope you did too. How many unread emails do I have? That frog must be absolutely starving. Now, if you’ll excuse me, I’ve got a few other things to do…

Work Does Not Have to Hurt (Marin IJ)

This Labor Day, as we honor workers, let us also celebrate workplace safety. Well, perhaps workplace safety is not so much something we celebrate, as it is something we should expect. And if you consider where we’ve come from, remarkable progress has truly been made. Over one hundred years ago, Upton Sinclair’s novel The Jungle depicted the truly awful working conditions of the early 20th century Chicago meatpacking industry. For example, consider the job of “beef-boner”…”Your hands are slippery, and your knife is slippery, and you are toiling like mad, when somebody happens to speak to you, or you strike a bone. Then your hand slips up on the blade, and there is a fearful gash. And that would not be so bad, only for the deadly contagion. The cut may heal, but you never can tell.” Grimy and grim. And workplace danger was not restricted to beef boners – in year 1913 alone, the Bureau of Labor Statistics (BLS) documented 23,000 industrial deaths among a workforce of 38 million, equivalent to a rate of 61 deaths per 100,000 workers. And there were likely thousands more that went un-documented. Even thirty years ago, in the 1980s, after vast improvements in working conditions and safety, over 7000 people a year died on the job.

Last week, the BLS released the data for 2010, reporting 4,547 fatal work injuries, a rate nearly twenty fold improved from 1913. Of the year 2010 deaths, 1,766 were transportation related, 808 from assaults (including self-inflicted), 732 from being struck by an object, 635 from falls, 409 from toxic exposures and 187 from fires and explosions. Occupation-wise, the greatest magnitude of deaths was seen in transportation/material moving (1,115) and construction/mining industries (760). A somewhat surprising third were management occupations (533) – including 29 (no longer) top executives.

So nowadays, as you can see, workplace deaths are rare enough that they are fastidiously tracked – in fact you can find a description of specific events on the OSHA website (this, by the way, is only recommended for Faces of Death aficionados). Cleary, further improvements in work safety are possible but nonetheless, non-fatal injuries on the job are a problem of much greater frequency. According to 2009 BLS data, there were over 3.2 million workplace injuries or illness reported in the private sector alone. These include 195,150 back injuries and 212,760 falls. Ouch. In all, days-away-from-work approached one million in 2009 (this was actually an 11% decrease from 2008). As one might expect, high risk professions include those with significant lifting/physicality requirements – such as patrol officers, nursing aides, orderlies and attendants, delivery truck drivers, construction laborers, and janitors and cleaners.

No profession, however, is immune from on the job injuries. Even pillow softness testers must suffer some risk– although it is not immediately evident to me what this might be. Hazards exist in the offices and hallways around us. To help keep you safe in these environments, I canvassed the web ( and Dr. Scott Levy, Chief of Occupational Medicine at San Rafael Kaiser, for some safety tips.

1) Boot the boxes…
And other clutter out of the hallway and walkways. Tripping over your own box of files would not only be embarrassing, it could also be quite painful.

2) Don’t carry anything higher than your eye level or read while walking.
Can’t see where you are going? Carrying a heavy load? Not noticing Wobbly Wanda and her cup of very hot tea. Ruh-oh.

3) Don’t run unless someone’s life is at stake.
Stieg Larsson, author of The Girl with the Dragon Tattoo, died prematurely because the elevator was broken and he ran seven flights of steps to make a meeting on time. His heart couldn’t take the stress of always being in a rush. Can yours?

4) Look before you sit.
Seems simple, but a chair is not always that clear of a target to hit – especially if you’re distracted. A bruised bum or a bum back could be your penance for poor sitting technique.

5) Think Ergonomically
A properly designed (ergonomic) workstation can help minimize work place injuries. This fact becomes quite obvious when people with very different proportions attempt to use the same workspace.

6) Something’s in the air around here
Besides hazards that lead to musculoskeletal injuries, consider other sources of injury. Strong scented colognes and perfumes can easily aggravate allergies and trigger asthma attacks.

7) Wellness is not for Wussies.
Consider starting or joining a workplace wellness program.  There's a lot of evidence that having a healthier workforce will lead to fewer injuries.

8) Light Matters
Don't overlook the importance and relevance of your office lighting. Traditional fluorescent light bulbs flicker very rapidly and can lead to increased fatigue – not to mention irritability.

9) Control the Urge to Multi-Task
This is a tough one – and I’m as guilty as the next over-stimulated employee. More on this another time, but just know that serious multi-tasking does not help you to be more effective, in fact it can be quite detrimental. You are much more likely to forget something important (such as driving on the right side of the road) if your mind is flipping back and forth between two activities.

In sum, advises Dr. Levy…“Although office injuries will never drop to zero despite our best efforts, there are ways to minimize the numbers.  Developing an ongoing program where office hazards are continually monitored will lead to improved staff morale in addition to the obvious benefit of an overall safer workplace.”

Indeed, work does not have to hurt.

Wednesday, August 24, 2011

A Back to School Basic

The phrase “Back to school,” can elicit a wide range of thoughts. Emotional responses include excitement, nerves, and in the case of my wife a profound “Thank Goodness!” My daughter, about to enter first grade, has a somewhat different opinion. “Can my American Girl go instead?”. No matter what, this is the time of year of making back to school plans and lists. Pencils, erasers, coloring books and computer accessories. Notebooks, crayons, backpacks and brown bag lunches. Scissors, sanitizer and glue sticks. Gym clothes, clean underwear and shoes that fit. Feel like something important is missing? Well if you are a 7th-12th grader without an up to date pertussis (whooping cought) booster, than yes, something important is missing. In fact, this something is critically important – as you may not be allowed to attend school without it.
Last year, the state legislature passed AB354, which mandates an up to date pertussis booster (as part of the Tdap immunization) for all 7th-12th students. Based on this new law and immunization records, an estimated 5,000 students in Marin will need to move the Tdap shot to the top of their back to school list, or else there may just not be a school to go back to. Now, if you or your children are in this group, this requirement likely seems like a hassle, and it is. But, there is a good reason. I’ll take a moment to explain...

Vaccination efforts during the past century have made certain childhood diseases so rare that they seem like remnants of an uncivilized past. Few of us have actually seen a new case of polio or measles, so it’s easy to be lulled into thinking that these ailments are so antiquated they couldn’t possibly cause trouble again. Unfortunately, this is just not true. The diseases that we vaccinate against are not extinct; they are lurking, waiting for enough people to drop their guard. If you think that I am an alarmist, consider these recent outbreaks: polio in Nigeria, measles across the U.S. and whooping cough in Marin County.

We are currently in the midst largest pertussis outbreak in 40 years – with ten deaths in California alone. Nationwide, measles is back – with a confirmed 156 cases in the first half of this year – the most since 1996. These outbreaks should remind us that we aren’t as safe from vaccine preventable diseases as we may think. Pertussis, for instance, is a highly contagious lung infection that can affect both children and adults and classically causes a “whoop” after coughing. In the days before DTP (diptheria-tetanus-pertussis) immunization, pertussis killed thousands of infants every year – often because the cough was so severe that it caused them to start bleeding in the brain. Thankfully, with the advent of widespread vaccination, the number of infections declined 99% between the 1930s and the 1980s and the death rate plummeted to single digits by the 1990s. In the last ten years, however, we’ve seen a resurgence of this infant-killer. Nationwide in 2005, there were over 25,000 cases of pertussis reported to the CDC; 21 of these were in Marin County. There are several explanations for pertussis’ comeback, but mostly it can be blamed on under-immunization. The protection afforded by the pertussis vaccine tends to wear off three to five years after vaccination, thus even children who have received the recommended DTaP series (five shots between the ages of 2 months and 6 years) are at risk for contracting the disease later.  Because of herd immunity (immunity that occurs when the vaccination of part of the community – or herd – provides protection to unvaccinated individuals) many parents think that their children are protected against pertussis (and other diseases) even if they are not fully vaccinated. Unfortunately, the more parents who believe this and exercise the (personal belief) exemption to mandatory vaccination, the more likely it is that herd immunity will fail. This is why a group of pediatricians in Philadelphia have published a manifesto to those who “absolutely” refuse to immunize: “by not vaccinating your child you are taking selfish advantage of thousands of others who do vaccinate their children ... We feel such an attitude to be self-centered and unacceptable.” These pediatricians would be appalled with vaccination rates in Marin – according to the California Department of Public Health, the Marin County kindergarten immunization rate is 84.7%, significantly below the state rate of 92.1%. And while we have long suspected that un-immunized children are at greater risk of disease, we now have solid evidence of this. Two papers published in 2009 by a team of researchers from Colorado document significantly increased risk of pertussis (twenty-three fold risk) and varicella (nine-fold) in children whose parents refuse these immunizations.

So, what can we do to ward off a further surge in preventable infectious disease? Well, a great place to start is at the top of that back to school list. Fortunately, efforts are in play to make this as hassle free as possible. The Marin County Department of Health and Human Services is partnering with the Marin County Office of Education, San Rafael Kaiser Permanente, the Marin County School Nurses’ Association and the Marin Medical Reserve Corps to offer five vaccine clinics in school sites around the county just before the start of classes. At these clinics the vaccine will be offered at no cost to Kaiser members and the many students who qualify for free vaccine under federal rules and at a maximum will cost $32. Dates are August 15th, 16th, 17th, 19th and 22nd. For more information and details visit