Erin N. Marcus, M.D.2013-05-24T11:45:02-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/author/index.php?author=erin-n-marcus-mdCopyright 2008, HuffingtonPost.com, Inc.HuffingtonPost Blogger Feed for Erin N. Marcus, M.D.Good old fashioned elbow grease.Dr. Sonjia: A Multicultural Dr. Ruth for the 21st Centurytag:www.huffingtonpost.com,2013:/theblog//3.28072732013-03-05T16:41:20-05:002013-05-05T05:12:01-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/Dr. Sonjia Kenya considers herself a multicultural Dr. Ruth for the 21st Century. She grew up in San Francisco, the daughter of a mother of English descent from Plymouth, Mass. and an African-American father from Shreveport, Louisiana. Dr. Kenya (or Dr. Sonjia, as she prefers to be called) earned a doctorate in health education from Columbia University before beginning a career as a researcher in HIV and diabetes. She is a certified sexologist and serves as sex columnist for the South Florida Sun Post. She recently authored the book Sex In South Beach.
Dr. Sonjia (courtesy, Sonjia Kenya)
Why did you decide it was important to write this book?
SK: A lot of people have sex problems, and most of these problems result from a lack of education about them. A lot of sex education is inaccessible, or is delivered in a way that targets specific populations. No one just talks to people and tells them the real deal. And people have been very, very receptive. The more I talk about sex, the more they want to talk about it.
Do you see this as a public health issue?
SK: It's definitely a public health issue. I've never had an HIV positive patient tell me, "I was in a great relationship, I was having great sex, and I contracted HIV." It's just never happened. I was trying to figure out a way to study this. I asked infectious disease clinicians, "have any of your patients contracted HIV from 'wow' sexual relationships?" They all agreed that their patients were not having great sexual relationships when they contracted HIV. So that's really how it started.
My mother founded Divorce With Dignity (a national alliance of divorce professionals) after my parents' divorce. If you see people who are getting divorced, there's no intimacy, no intimate connection, there seems to be no love, even though many will have to raise these kids together and figure these things out. It was easy to observe that that their physical relationship and satisfaction with their intimate relationship diminished long before the divorce began. Once the intimate connection is gone, it's difficult to find the motivation to work things out, which often leads to problems and eventually divorce.
I saw similarities in HIV positive people -- they were having these intimate relationships but they weren't communicating about what is and isn't ok, about fidelity issues, about negotiating condom use, and even about experiencing sexual pleasure. They weren't having these talks and I thought maybe we could start preventing divorces, HIV transmission, other things if we could really teach people how to have more pleasurable intimate interactions.
After completing postdoctoral research in New York, you moved to the Cayman Islands and then to Miami. How did that move shape your work?
SK: I taught at the medical school in the Cayman Islands. You know, people go on vacation and one of the primary motivations is to have sex when they're on vacation. I started writing a sex column for the newspaper, and all the pastors took out ads against me. I talked about masturbation, "the real deal," and it caused a public uproar. I said, it's the safest sex you can have, and it also prepares you to have better sexual relationships because you're more informed about what you like or don't like. I don't want some man teaching a young girl "this is what you like" or "this is what you don't like." If you don't have sex education and no one's talking about it, how is anyone supposed to learn it? When I moved to Miami, I just transferred the column to here.
In a recent documentary, Tom Wolfe said," New York is all about money, Washington is all about power, and Miami is all about sex." Miami also has the highest incidence rate of HIV in the U.S. What particular issues does this area face in terms of sexual problems?
SK: People take a lot of risks here. It's vacation land. The weather is conducive to free flowing behaviors. You can be anything here -- you can be gay, you can be bisexual, you can be a transvestite, you can be a lot of different things and feel accepted and find your people so to speak. Also, because of the warm weather, people are motivated to wear less clothing. Everything is so tempting -- but I know people who have gotten themselves into sexual situations and they may not have known that the person was HIV positive, and then they're like, "Oh my God, I've got to get tested."
Because of the huge immigration issues, a lot of women are trying to get a husband for legal reasons and men as well. I find that a lot of women put themselves in a vulnerable position because they think they're gaining something by giving someone sex. We have a really high immigrant population that wants legal status.
What issues do you often need to address in your practice?
SK: Almost everything that I work on with couples is making them understand how the other person works in terms of that person's brain. Most people lack understanding of what motivates the other person.
This is a generalization, but often women crave intimacy and that intimate connection while men crave sex. There's a real disconnect. With women our testosterone levels only peak a couple of days a month; if you want to get a woman excited you have to do things. As my mentor says, you can't start a car in fifth gear. With women it's Time, Talk, Touch, Trust, then she's ready. If men could learn how to do those things, then they could have a lot more sex -- if that's what they're looking for.
You have done a lot of work with the transgender community. What misconceptions does the general public have about transgendered people?
SK: That it's a choice and that they're weird, not normal. Also, sexuality and sexual orientation are quite different than gender. Just because you change your gender doesn't mean you're gay.
It's not a choice. You would never choose something that would put you through additional hardships. I've heard it described as a cognitive dissonance between who you are on the inside and who you are on the outside. Even getting dressed can take hours of crying -- people just don't want to put on these "man clothes" or these "woman clothes." It can just lead to such reduced self esteem. But most transgenders I've met would fit into all of our "normal" quote unquote categories, these are normal people. So it's really important for me to help the world understand that it's not a choice.
You have recently branched out into television and other media. What are you hoping to accomplish?
I want people to have easy, fun and informed conversations that lead to more fulfilling sexual relationships. People don't get divorced, people don't contract HIV, people don't experience sex problems when the communication is clear. When people are honest, you have nothing to lose. It's the dishonesty that hurts.]]>One Size Does Not Fit All: Do Current Prostate Cancer Screening Guidelines Neglect Race?tag:www.huffingtonpost.com,2012:/theblog//3.19751982012-10-18T16:58:51-04:002012-12-18T05:12:02-05:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
Henderson's views aren't unusual. For years, doctors have routinely ordered the PSA on men older than 50, along with tests for cholesterol and blood sugar. Just as the goal of screening mammograms is to prevent deaths from breast cancer, the goal of routine PSA testing is to catch prostate cancer early, when it's easier to treat and more likely to be cured. Prostate cancer is the second leading cause of cancer death among men in the United States, and routine PSA tests have led to the diagnosis of early prostate cancer in millions of men with no symptoms of the disease. Overall, 16 out of 100 men will be diagnosed with prostate cancer during their lifetime, and 3 out of 100 will die of the disease.
Prostate cancer hits black men especially hard. One out of every 5 black men will be diagnosed with prostate cancer during his lifetime, and 5 out of 100 will die of the disease. Black men are more likely to be diagnosed with prostate cancer that is more aggressive and more advanced than are men of other ethnicities. They are also more likely to develop the disease at a younger age than other men.
Unfortunately, the PSA isn't a great test. It's often abnormal in men who don't have cancer (and sometimes, it's normal in men who do have cancer). Widespread testing has led to millions of men without prostate cancer undergoing biopsies, in which a needle is used to take a small piece of the prostate to examine under the microscope. Also, prostate cancer is extremely common, and most early cases don't spread to other organs. Those that do spread often take many years to progress to the point where they are fatal. Most men with prostate cancer die of other diseases. Because of early detection, many men undergo aggressive treatment for a cancer that, left alone, would not kill them.
Because of these drawbacks, the United States Preventive Services Task Force (USPSTF), a prominent panel of doctors and health experts, recommended earlier this year that men not undergo routine screening. After reviewing several large studies of PSA testing, the panel concluded that the risks of testing -- specifically, complications of biopsies and of treatment, such as infections, bleeding, urinary and sexual problems -- outweigh the benefit of lives saved as a result of the test.
The USPSTF reported that routine PSA testing saves one man out of 1,000 -- at most -- from dying of prostate cancer. Meanwhile, out of 1,000 men who are screened, 30 to 40 will develop erectile dysfunction or problems controlling their urination, two will have a heart attack or stroke, and one will develop a potentially life-threatening blood clot as a result of treatment for prostate cancer. In all, the USPSTF reported, 1 out of 3,000 men screened for prostate cancer will die due to complications from surgical treatment.
The studies the USPSTF reviewed didn't include many black men, and most were done in Europe. Nonetheless, the panel didn't make a separate recommendation for blacks. Instead, it stated that because so few black men were in the studies, "no firm conclusions can be made about the balance of benefits and harms of PSA-based screening in this population" and described PSA screening based on race as "problematic ... in the absence of data." The panel's report also cited a recent large U.S. study that did include a large number of black men with early prostate cancer and found no difference in survival at 12 years between those who underwent aggressive prostate surgery, versus those who were closely monitored but didn't receive prostate cancer treatment.
The leading black physicians' organization, the National Medical Association (NMA), vehemently disagreed with the USPSTF's recommendation.
"It just doesn't make sense," said Dr. Cedric Bright, a general internist who is an associate professor of medicine at the University of North Carolina at Chapel Hill and a former NMA president. "I've seen enough prostate cancer that started early and was more aggressive." He added that the panel's conclusions "may be more generalizable to those who are of European background. There are very few African-Americans in the studies."
In a statement issued in response to the USPSTF recommendation, the NMA describes PSA screening as "the best method to detect early stage, curable prostate cancers." The NMA supports the American Urologic Association's screening guidelines, which include beginning PSA screening at age 40, including a doctor's office rectal exam as part of the screening, assessing a man's risk based on his age, ethnicity, family history, and aspects of his PSA result, such as how much it has increased over the past year and whether it is high compared to the size of his prostate. It also encourages men to engage in a discussion of risks and benefits with their physicians, and advocates educating people in the community about prostate cancer and making health care easier to obtain.
The NMA statement cites a 2010 autopsy study of more than 1,000 black and white men in Detroit suggesting that prostate cancer grows more rapidly in black men and/or changes from an indolent to an aggressive form sooner in blacks.
Bright believes there's a need for more research to study PSA screening's effectiveness among black men. In the meantime, however, he is worried that insurance companies will respond to the USPSTF's recommendations by deciding not to cover PSA screening. He says he has already begun to see a "backlash" of men deciding not to be screened.
And while Marc Henderson is aware of the USPSTF's recommendation, he says it doesn't affect his decision to get the PSA. "Yes, statistics may be good for the population, but everything in life is individual," he said. "African-American males need to be cognizant of their health."
A similar version of this article originally appeared on the web site of New America Media.
For more healthy living health news, click here.]]>Watch Your Step: There Might Be a Needle on the Sidewalktag:www.huffingtonpost.com,2012:/theblog//3.17055992012-07-27T14:05:00-04:002012-09-26T05:12:33-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
Tookes, age 30, is an expert at identifying the detritus of injection drug use. As a public health student on hiatus from medical school, he led a group of researchers who walked the streets of Miami for four months, methodically counting discarded syringes in neighborhoods with high rates of drug arrests. As they crisscrossed more than 800 city blocks, the team spotted 328 used syringes, in parks, lots and along sidewalks.
"We found syringes every day we went out, in every neighborhood we went to," he said. "We're all at risk from accidental needle sticks."
Miami is home to an estimated 10,500 people who inject illegal drugs, approximately one in five of whom is infected with HIV. Tookes and other public health researchers believe the high number of syringes on the city's streets is largely due to Florida's drug paraphernalia laws. For many years, these laws have made it illegal to give a syringe to anyone who is likely to use it to inject illegal drugs, thus preventing the establishment of large-scale programs to provide drug users with clean needles. Florida law bans carrying syringes for the purpose of illegal drug use, and police regularly arrest users for carrying syringes. Some users say this rule makes them more likely to throw away their paraphernalia anywhere that's convenient. "The nervous types are going to throw it wherever they can without regard for who might come across it," said Andrea E. Labbee, 52, an injection drug user who lives in South Florida. "They're more worried about getting it out of their possession than they are about the consequences of where it ends up."
Elsewhere, needle exchange programs have been embraced by public health officials as a means of reducing the spread of HIV and Hepatitis B and C. According to Evan Anderson, a senior legal fellow at the Robert Wood Johnson Foundation Center for Public Health Law Research at Temple University, 14 states have enacted laws explicitly allowing the existence of syringe exchange programs, and five states lack laws restricting the free distribution of syringes, thus allowing syringe exchange. In three other states, local governments have allowed syringe exchange programs to operate based on their interpretation of state law. The U.S. Department of Health and Human Services lifted rules preventing the use of federal funds for needle exchange programs in 2009, but, under political pressure, reinstated the ban in December of last year.
Most large-scale needle exchange programs do more than simply give out syringes. They usually hand out "sharps" containers for needle disposal, require that users return used needles in order to receive new ones, and offer condoms and information about drug treatment programs and local health clinics. "We don't get too much controversy anymore," said Katie Bouche, the manager of syringe access programs for the San Francisco AIDS Foundation, which runs the city's largest needle-exchange program. "We're really lucky here in that the Department of Public Health backs us."
To study the effect of needle exchange programs on the number of unsafely discarded syringes, Tookes and his colleagues collaborated with researchers in San Francisco, where large-scale programs have operated openly for two decades, and where pharmacies are allowed to sell clean needles and syringes without a prescription. The San Francisco researchers walked along 1000 randomly selected blocks in neighborhoods with the city's highest rates of drug arrests and hospital admissions for drug treatment. They counted only 11 syringes - a number Tookes' team multiplied by 4, to account for their having stayed on one side of each block in San Francisco, as opposed to walking along each side of every block in Miami. In all, the researchers estimated that on average there were 44 syringes in every 1000 blocks in San Francisco, versus 371 syringes in every 1000 blocks in Miami.
The study, which was published late last year in the journal Drug and Alcohol Dependence, is the first to compare the number of publicly discarded needles in a city with needle exchange programs and a city without such programs. The authors admit that other factors might influence the number of syringes they found. But even though San Francisco and Miami differ significantly in geography, ethnic makeup, and politics, neither has an organized syringe clean-up plan, and their litter removal and street cleaning policies are similar. San Francisco also has more than twice as many injection drug users than Miami.
Tookes' team supplemented their findings with a survey of more than 1000 active injection drug users in both cities. Of the 448 people interviewed in Miami, more than 2 out of 3 - 69 percent -- said they had gotten rid of their used needles in public places, such as parks, alleyways, or bushes, over the preceding month. Of the 602 people interviewed in San Francisco, only 11 percent said they had discarded their needles in such a way. After adjusting for homelessness, sex, HIV status, and age, the researchers calculated that users in Miami were 34 times more likely to dispose of their syringes in a public place than were those in San Francisco.
Still, needle exchange opponents contend that the programs condone drug use and may lead to more drug activity and discarded needles in surrounding neighborhoods. "We've seen a lot of hope, but not a lot of results," said W. Shepherd Smith, a former board member of the Children's AIDS Fund, a non-profit HIV support and advocacy group. Smith acknowledged that South Florida has a needle disposal problem, but said the study's results may have been affected by a culture of needle sharing that is more common on the East Coast of the U.S. "It would have been more helpful to compare two East Coast cities," he said.
"Having a lot of used needles is really a hazard," said Natalie Cramer, Director of Prevention for the National Alliance of State and Territorial AIDS Directors, a nonprofit scientific, policy and advocacy group. "Exchange programs have been a real help in preventing accidental needle sticks."
There are no reliable estimates on how many children or passersby are inadvertently stuck by discarded syringes each year. For garbage collectors, street cleaners and recycling plant workers, however, needle sticks are a serious risk, according to Jenny Schumann of the Coalition for Safe Community Needle Disposal in Houston. The coalition estimates that 7.8 billion needles are discarded each year in household waste in the United States. Of these, an estimated 1.2 to 1.5 million were used to inject illegal drugs and the remainder for medications such as insulin. Even though some health departments (including Miami's) accept used biomedical "sharps," including needles, in secure containers for disposal, this program is aimed at people with chronic medical conditions and is virtually never used by the city's illicit drug users, Tookes said.
But given the state's current political climate, it's unlikely Florida will change its drug paraphernalia laws any time soon -- meaning the residents of inner city Miami will need to continue to watch their step. "They clog the court system up with things like a little petty syringe," said Eugene Anthony Jones, 61, a native Miamian and longtime injection drug user. "There probably would be less of them thrown on the ground if it was legal. But this is the Deep South."
A similar version of this article originally appeared on the website of New America Media.]]>Home Blood Pressure Monitoring: Easy And Valuabletag:www.huffingtonpost.com,2011:/theblog//3.9081952011-08-02T08:23:22-04:002011-10-02T05:12:02-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
Take the humble blood pressure machine, for example. It's been around for years, and it's cheap, compared with a lot of other medical devices. It's simple to use, and it doesn't require a medical or a nursing degree to operate. But the numbers it reports are valuable in helping predict a person's risk of a host of medical problems, including heart failure, stroke and kidney failure, and can help doctors determine whether a person really needs to take medicine to control his or her high blood pressure.
Because they're taken in a familiar environment, home blood pressure readings tend to be lower than the measurements taken in a doctor's office or clinic, and better reflect a person's true blood pressure. They give doctors and nurses a better sense of how well a person's treatment is working, compared with sporadic readings taken in the office, and may enable some people to avoid medication entirely. In a few cases, they also help detect the opposite -- blood pressure that's in an abnormally high range at home, even though it seems normal during visits to the office. Home blood pressure monitoring can also help people save money and avoid missing work time, by reducing the number of visits they have to make to the doctor's office or clinic.
"There's emerging evidence that home blood pressure readings are good predictors of cardiovascular outcomes for most people," said Dr. Mahboob Rahman, an associate professor and hypertension researcher at Case Western Reserve University and University Hospitals Case Medical Center in Cleveland. "Patients are probably further along (in the habit of checking home blood pressure) than physicians, but we need to provide them with guidance."
Below are some suggestions from Dr. Rahman, as well as from the AHA/ASH/PCNA "Call to Action" statement, regarding the best way to check your blood pressure accurately:
1. Pick a blood pressure machine that gives automatic readings and that's been "validated," meaning it's been tested for accuracy according to a widely accepted set of standards. Dr. Rahman recommends a nonprofit website, Dableducational.org , which lists monitors that have been tested according to the standards of the European Society of Hypertension. It's also helpful to get a machine that will keep a log of your readings so that you'll have something to show your doctor or nurse practitioner.
2. Arm monitors -- meaning, machines with a "cuff," or sleeve that fits on the upper arm -- tend to be more accurate than wrist monitors, according to the "call to action" statement, and finger monitors should generally be avoided. Wrist monitor readings can change with the position of the wrist. The wrist needs to be held at the level of the heart to get the most accurate reading.
3. Make sure the cuff -- the sleeve of the machine that fits around your arm -- is the correct size for your arm. The inflatable part of the sleeve should fit around 80 percent of your upper arm. If your arms are large, you may need to buy a large cuff separately.
Before using the machine, bring it to your clinic or doctor's office so that the staff can check its accuracy and make sure you know how to operate it correctly. The American Academy of Family Physicians and British Hypertension Society also post online instructions that can help orient you when you begin using your machine.
4. Basic rules for checking blood pressure (in the clinic as well as at home) include sitting in a chair that supports the back, with both feet in a comfortable position on the ground, for five minutes before taking the measurement. Smoking, exercising and drinking coffee should be avoided for half an hour prior to the reading, since these can make blood pressure levels rise transiently. If you need to use the toilet, do so before you check your blood pressure -- don't take a reading when your bladder is full. Try to relax.
5. Check your blood pressure two to three times a week, at times when you are relatively calm. The "call to action" statement recommends that doctors review at least 12 recordings prior to making any decisions about beginning, stopping, or adjusting medication. The statement also says that a home value of 135/85 or above is high, as opposed to the 140/90 level that's usually considered elevated. For people with diabetes and other conditions that increase their risk of heart disease, the goal blood pressure is 130/80 or lower.
6. Remember, the goal of checking your blood pressure at home is to keep an overall record that will help your doctor or nurse decide on what treatment to recommend. Home monitoring is not meant to figure out why you might feel ill at any one particular moment. "Some people get in the habit of 'I'm not feeling well, so I'll check to see if my blood pressure is high or low," Dr. Rahman said. "That's not the best use of the blood pressure machine." If you're not feeling well, call your doctor or nurse so that they can diagnose the reason why.
7. Don't panic if the levels fluctuate. In most people, blood pressure tends to be a bit higher in the morning and at work, and it's normal for them to ebb and flow. "The variability of readings is high," the joint statement explains. "Individual high or low readings have little, if any, significance."
8. Bring your machine back to your doctor's office every year, so that the staff can make sure it's still working accurately.
9. Don't rely on the free blood pressure monitors available at the grocery store or pharmacy, as they aren't always accurate. If you can't afford to buy your own machine, check with your local fire department to see if they offer "drop-in" times when you can get your blood pressure checked.
Don Wiggins, a 60 year old radio host and sales manager, uses a $50, battery-powered machine to check his blood pressure, and says it's an important part of his daily routine. He began recording his blood pressure 3 years ago, after he underwent emergency heart bypass surgery. A home nurse showed him how to use his blood pressure monitor. "At that point, I was ready to listen to anybody," he recalled recently. "But the machines are so easy. There's really no excuse for anyone not to check his or her blood pressure."
"High blood pressure is very prevalent, especially among African-American men," he added. "It's a silent killer, and it's important to keep it under check."
A similar version of this article originally appeared on the website of New America Media.
]]>Three Weeks After Japan's Disaster, What Are the Real Risks in the U.S.?tag:www.huffingtonpost.com,2011:/theblog//3.8421282011-03-30T08:26:06-04:002011-05-30T05:12:01-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
The Union of Concerned Scientists (UCS), an independent scientific research-based environmental advocacy group, has been monitoring the crisis closely. Below is a condensed version of some of the information the UCS has placed on its website regarding the health consequences of the Fukushima disaster, as well as information shared at news briefings by David Lochbaum and Edwin Lyman, nuclear safety experts with the UCS:
What are radioactive isotopes, and which ones are of most concern in a nuclear power accident?
UCS: Radioactive materials decay, releasing particles that can damage living tissue and lead to cancer. Some elements have different forms, called isotopes, that differ in the number of neutrons in the nucleus.
The radioactive isotopes of greatest concern in a nuclear power accident are iodine-131 and cesium-137. Iodine-131 has a half-life of 8 days, meaning half of it will have decayed after 8 days, and half of that in another 8 days, etc. Therefore, it is of greatest concern in the days and weeks following an accident. It is also volatile so it will spread easily.
In the human body, iodine is taken up by the thyroid, and becomes concentrated there, where it can lead to thyroid cancer later in life. Children who are exposed to iodine-131 are more likely than adults to get cancer later in life.
To guard against the absorption of iodione-131, people can proactively take potassium iodine pills so the thyroid becomes saturated with non-radioactive iodine and is not able to absorb any iodine-131.
Cesium-137 has a half-life of about 30 years, so will take more than a century to decay by a significant amount. Living organisms treat cesium-137 as if it were potassium, and it becomes part of the fluid electrolytes and is eventually excreted. It can cause many different types of cancer.
Is there a threat to Americans in Hawaii, Alaska, or the U.S. West Coast? Should residents of these areas take potassium iodide pills to protect against thyroid cancer?
UCS: No. While wind patterns will likely carry the radioactive plume eastward, since Japan is thousands of miles from the United States, radioactive material in the air will be so diffuse by the time it reaches Hawaii, Alaska, or the mainland United States that it is highly unlikely to create significant health concerns.
As a result, people in those locations will not have to worry about direct inhalation of a radiation plume, which is the kind of exposure potassium iodide (KI) pills are most effective against.
Americans could also be exposed to radioactive iodine if agricultural products were contaminated. Radioactive iodine could be ingested by dairy cows, for example, and then would be concentrated in milk. Potassium iodide, however, would not be effective in that situation. Moreover, federal and state health authorities would test for such contamination and could take products off the market if necessary.
The people of Japan should be given priority access to KI pills. Indeed, if there is a run on medication in the United States, or elsewhere, there might not be enough left for Japanese residents who truly need it.
Radioactive Iodine has been found in water supplies as far away as the East Coast of the United States. Should U.S. residents be concerned about the safety of their drinking water supply?
Dr. Lyman: In my judgment, at this point, no. We have to use a disclaimer that no level of radiation is safe, because the scientific consensus is that there's no threshold to the carcinogenic effect of radiation, but the risk is proportional to dose, and the dilution that's experienced as a plume travels many thousands of miles is highly significant.
Also, the quantity of iodine that's available for release is decreasing rapidly in time because of the short half-life of iodine 131. So, provided the reactors don't go critical again, which they take measures to prevent, the total amount of iodine will decrease steadily.
Can you be exposed to dangerous levels of radiation if you fly in a plane across the United States due to the radiation released in Japan?
UCS: No. As noted in the previous question, since Japan is thousands of miles from the United States, radioactive material carried by the wind to Hawaii, Alaska, or the mainland United States will be so diffuse that it is highly unlikely to create significant health concerns. This is true whether you are on the ground or in an airplane.
Can plants in the United States withstand disasters such as the earthquake and tsunami that crippled nuclear reactors in Japan?
UCS: Some U.S. reactors are sister plants to the Fukushima Unit 1 reactor, which is a boiling water reactor (BWR) of General Electric design, and they are operating under similar regulations. If confronted with a similar challenge, it's folly to assume the outcome would not also be similar.
U.S. plants have the same key vulnerability that led to the crisis in Japan. The basic problem is that the Japanese reactors lost both their normal and back-up power supplies, which are used to cool fuel rods and the reactor core. The reactors had batteries that could supply power for eight hours until the back-up system or normal power supply was restored. But officials were unable to fully restore either.
Most U.S. reactors are designed to cope with station power outages (where both primary and back-up power supplies are out) lasting only four hours. Measures that increase the chance of restoring power within the four-hour time period, and provide better cooling options if that time runs out, would make U.S. reactors less vulnerable.
In addition, we know that earthquakes can cause fires at nuclear reactors, and U.S. reactor safety studies conclude that fire can be a dominant risk for reactor core damage by disabling primary and backup emergency systems. Yet dozens of nuclear reactors in the United States have operated for years in violation of federal fire protection regulations, with no plans to address these safety risks any time soon.
Finally, reactor emergency plans in the U.S. assume that a reactor accident would be the only demand on emergency response resources. The accident in Japan is another reminder of the need to revisit emergency plans to ensure that emergency responders are able to respond to both the problem at the power plant and the nearby community's needs.
Since 9/11, the U.S. nuclear industry has implemented additional power plant safeguards. Are we better equipped than the Japanese to cope with such a situation?
Mr. Lochbaum: Well, I think with the situation they have, they have to grasp at straws to try to explain why what happened there can't happen here. They're basically similar reactor designs operating under similar regulations, so if our reactors were faced with a similar challenge, the outcome would be similar.
There are certain things that were done since 9/11 that help, but I don't think that's a panacea that makes any of our reactors invulnerable to the type of problem that Japan faced.
Dr. Lyman: First of all, the plans are secret. So, no member of the public actually knows what those plans involve. Second, what we do know is that because those were addressing what (the Nuclear Regulatory Commission) considers to be a beyond design basis event, mainly an aircraft attack on a currently operating plant, we do know that the equipment, any equipment that would be staged or designated for that post-accident management would not meet the highest nuclear safety standards that are required for protecting its design basis events.
So, for instance, (the) Nuclear Energy Institute (an industry group) already admitted that that equipment is not safety-related and would not be seismically qualified. So, if you have an event other than an aircraft crash, let's say a large earthquake, it's not clear that those plans and that equipment would actually survive to be available, and putting U.S. reactors in the same spot that they were in Japan.
Will washing Japanese produce make it safe? Can Japanese produce be decontaminated?
Dr. Lyman: With regard to iodine, that is a limited problem, and will be cleared in a few months. To the extent there's contamination with cesium, and other longer lived isotopes, frankly, I don't think there are any good answers about how affected produce can be decontaminated. There are both national limits in Japan, international limits for destruction of contaminated produce, and I think those will have to be followed.
The problem is going to be when the contamination is within limits that the authorities say is safe. I think people need to understand more. I think I've said before, understand the potential doses associated with those levels and make their own decisions whether they should consume the produce or not.
But I would think whether or not it can be washed off, because I've been watching NHK and seeing what people are saying, I would be very wary of any unverified information about how to make produce safe at this point.
There have been concerns about radioactive water from the plant entering the ocean. Is seafood safe to eat?
Dr. Lyman: There is the potential, when you're talking about certain types of seafood, that you can have reconcentration. So, even dilute levels of contamination can be enhanced in certain marine life, just like mercury concentrates in large fish, like tuna. Also, plants like seaweed are known to concentrate certain isotopes, and so are certain types of shell fish.
But I would think certainly in the fishing industry in the region, they're most likely going to have to take measures to inspect their catches, and I guess the primary responsibility for that will have to be with the Japanese to inspect and interdict any contaminated seafood. So, it certainly could be an issue.
I would think (dangerous levels of radiation are) unlikely for seafood that is not caught relatively close to the Japanese shore, but, you know, we haven't done any analysis on this, so we can't really speculate.
The FDA has banned the import of milk and fresh produce from the Fukushima region. Should the U.S. ban all Japanese food products?
Dr. Lyman: Obviously it's not just the real risk, but it's also public perception and it's the same, whether it's Mad Cow Disease or melamine or lead. Unfortunately, one of the economic outcomes of this type of event ... is the perception of contamination which can be as damaging as the actual, or more damaging than the actual health risk, and that will have an economic impact whether or not there's actually a significant health risk.
So, unfortunately, it's going to take a long time for Japan to restore confidence in the safety of its exports.
A similar version of this article originally appeared on the website of New America Media.]]>Health Effects From the Gulf Oil Spill One Year Latertag:www.huffingtonpost.com,2011:/theblog//3.8397022011-03-23T14:56:30-04:002011-05-25T18:40:24-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/Dr. Gina Solomon, an Associate Clinical Professor of Medicine at the University of California, San Francisco, and Senior Scientist at the Natural Resources Defense Council. Dr. Solomon was on the Louisiana coast during the oil spill, studying its environmental effects.
Dr. Gina Solomon, monitoring air pollution levels on the Gulf of Mexico (courtesy: NRDC)
What health effects have been seen so far? What kinds of symptoms are residents experiencing?
A wide array of health concerns have been reported. The predominant complaint is dermal (skin rashes) such as eczema. Many (symptoms) are nonspecific -- headache, confusion, memory problems, upper and lower respiratory symptoms, asthma, persistent cough, bronchitis, complaints of GI symptoms, episodic diarrhea. There have been a couple of well-publicized cases of people who have become very sick with health issues that have not been sorted out. These individual stories are flying and there's public concern, but it's hard to make clear links. We're struggling to determine how much is related to the oil and how much is coincidence.
The other set of issues is that people are under immense psychological strain due to economic insecurity and the effect of the spill on the gulf seafood industry. People are hurting. This was already an area of the country with poor health coverage and poor access to health care. It's greatly increased the level of worry about health problems. The psychosocial issues are huge -- anxiety, depression, symptoms of post traumatic stress disorder.
What health effects do you anticipate will occur?
My biggest concern is for the workers who were offshore doing cleanup. Studies of past oil spills have shown chronic respiratory problems after the Exxon Valdez, and markers of DNA damage after a spill off the coast of Spain. It will be important to look for signs of chronic bronchitis and markers of DNA damage that could precipitate cancer or birth defects.
There are very well-documented psychological effects from oil spills both in clean up workers and residents. This was documented after the Exxon Valdez. The psychological effects run the gamut from depression to anxiety disorder to Post Traumatic Stress Disorder (PTSD) to higher rates of substance abuse and suicide and intimate partner violence. There already was an uptick in mental health issues after Katrina and this was a second hit. It's not the same as the PTSD you see in war veterans with flashbacks -- instead, (people suffer) sleep disorders and hyper-vigilance and inability to get the oil spill off their minds.
Should Gulf Coast residents be concerned about the health effects of the dispersants used to break up the oil?
The good news about the dispersants is that they are not persistent in the environment. The dispersants are highly irritating to the skin and respiratory tract, but there are not likely to be long-term health consequences.
There are widespread rumors that the dispersants are still being sprayed. There's no evidence of that, but this is an indication of the level of anxiety.
Are there illnesses that aren't being reported or aren't getting attention?
The mental health issues need to be taken more seriously. Also, because of the fact that some chemicals can damage DNA, there's real concern for women who were pregnant during the spill and reproductive outcomes. There's a need to identify the women who were pregnant during the oil spill and find out about their pregnancy outcomes and how those kids are doing.
From a health perspective, who has been most affected by the spill?
Definitely the clean-up workers and the fishermen who were out on the water on the edges of the spill. There's a large population of Vietnamese subsistence fishing communities along the Gulf Coast in Louisiana and Mississippi. Some of these people were doing clean up work, and many eat an extremely large amount of seafood. Because of limited language skills, many were not getting health advisories. Some translation was done by local Catholic churches, but it was really a grass-roots effort and was not systematic.
Are there adequate health care resources to address the illnesses that gulf-region workers and residents may be facing as a consequence of the spill?
Oh my Lord, no. This is really an illustration of some of the major deficiencies in our health care system. There are problems with access to care, which the Gulf Coast has to a greater degree than the rest of the country. There are geographic issues. The area in the Bayou is so isolated, and it's not that easy to get to New Orleans to see a doctor. Most of the locals just don't get care.
It's also hard to find folks who can see them. There are very few specialists. I have not been able to locate a board-certified occupational/environmental specialist in the area. There's nobody who's an expert in exposure to oil.
Has BP or the government set up clinics to provide care in the aftermath of the spill?
There were temporary clinics set up to screen the clean-up workers during the immediate spill over the summer, but there hasn't been a concerted effort to set up the kind of clinic structure that's needed. The oil vapors are no longer floating in the air, and the spotlight has turned to other things, but the medical concerns continue.
How can gulf-region workers and residents protect themselves from the spill's health effects?
At this point the acute health risks are over and there aren't any special steps people need to take. If people are having health problems, they should do what it takes to find a health professional who will listen to them and take the time to figure out what's going on.
How can consumers determine whether seafood from the region is safe?
The good news is that fin fish, free swimming fish (for example, Mahi Mahi) are effective at excreting oil contamination. The kinds of fish people should avoid are those that should be avoided anyway because of mercury, such as swordfish, king mackerel, grouper, and blue fin tuna.
The big controversy has been about shellfish. Shellfish can accumulate oil because they don't have the enzyme system to detoxify and excrete contaminants such as oil. Most of the testing so far has not shown high levels. I probably wouldn't eat oysters or shrimp every day, but eating them once or twice a week would not raise significant concerns.
What are the long-term implications of what you're seeing, in terms of health effects & health costs?
Based on previous spills we can confidently predict that the mental health issues will last for years. In terms of other issues, it's hard to say what the long-term implications will be. We still don't have a complete handle on this spill, and it will take several years of study. There needs to be more done to gather information on the health effects and to provide access to good health care for people on the Gulf Coast.
Dr. Gina Solomon at work on the Gulf of Mexico (courtesy NRDC)
This interview originally appeared on the website of New America Media]]>Haiti: A Deportation Death Sentence?tag:www.huffingtonpost.com,2011:/theblog//3.8257852011-02-22T08:22:15-05:002011-05-25T18:35:25-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/Florida Immigrant Advocacy Center in Miami.
Q: Why did the U.S. government resume deportations to Haiti?
They tell us is it's all about public safety, keeping the American public safe.
What they told us at the time (that they announced the new policy) was they were going to be deporting the worst of the worst criminal offenders -- axe murderers, rapists, that kind of thing. We subsequently learned that anybody who is labeled a criminal -- and in Florida, for example, if you're driving with an expired drivers license for four months, you've committed a crime -- that even individuals like that could be subject to removal under this new policy. So obviously, we were very concerned.
Q: So far, one planeload of 27 Haitians has been sent back to Haiti. Who was on that plane?
According to the U.S. government, they were folks who had been found guilty of a crime. They had all finished serving their sentences. It may be that some of these Haitians had serious criminal histories, but we also believe that a number of them do not. In the vast majority of cases, they had already been released by immigration and customs officials and were abiding by all the requirements of their release. They didn't get into trouble again. They were doing everything that our government was expecting them to do, and then the next thing they knew, this new policy went into effect and they were rounded up, sent to different jails across the country, and the first planeload of Haitians left Louisiana and arrived in Haiti on January 20th.
Many Haitians and other detainees have told us they pled guilty because they were advised to do so by their attorneys, they were told the sentence would be light and they'd get out of jail sooner. They didn't understand the serious repercussions of a guilty plea with respect to their immigration status.
We know that first flight that went back included folks like Roland Joseph, whose entire sentence was six months. Nonviolent offense. Regardless of the criminal history, if someone has served their time, served their sentence, they shouldn't be sent back to a country where they could well be facing a death sentence.
Q: What happened to the people who were returned?
The Haitians who were returned on January 20th were placed in four different jails outside of Port-Au-Prince. Our government has repeatedly told us that they've been working on a viable re-integration policy so that when Haitians are sent back they're properly cared for. I can tell you, the re-integration policy is practically non-existent. They've reached out to a group, Alternative Chance, a non-profit operating on a shoestring budget, and they can't begin to provide these detainees with the help they need.
Q: What have you heard about conditions in the jails?
We know that conditions are horrific, and one of those 27 Haitians who were sent back unfortunately died. Imagine the worst case scenario and that's it. Recently there was a cholera outbreak in the jails. Not surprising, given the crowded and unsanitary conditions.
If you don't have family or friends to bring you clean water and food, you don't eat, and you don't drink clean water. You don't get anything unless you have family there to care for you. In the best case scenarios, these (deportees) have distant family members or family members in Haiti whom they haven't seen in long time.
Q: What do you know about Wildrick Guerrier, the deportee who died?
It's our understanding that he was sent back at the last minute. Shortly after he arrived in Haiti and was jailed, his condition quickly deteriorated and he wasn't getting proper treatment. He [had been a lawful U.S. resident since 1993, when he arrived as a teenager, and ] had no family in Haiti, so an aunt who lives here in South Florida flew to Haiti, realized he was deathly ill, and insisted they release him. They released him on Jan. 27th and he died shortly thereafter. We know he had cholera-like symptoms -- uncontrollable diarrhea and vomiting -- but we don't know whether he died of cholera.
Guerrier had served less than two years in a U.S. jail for being a felon in possession of a firearm while he was working as an security guard. Earlier, he was accused of committing battery on a police officer during a traffic stop, but he only got probation. There was a probation violation and that's when he got one year, six months, suspended. When we interviewed him over the phone, he said his lawyer told him to plead guilty (and) he wanted to clear up his immigration record.
(The remaining deportees were released from jail in Haiti on January 31).
Q: What do you know about the logistics of how these Haitians were detained by immigration officials?
In many cases, immigration officials went to their homes in the early morning hours and at gun point arrested them, detained them. 100 of these Haitians were at the Krome Detention Center (in southern Miami-Dade County) early on and we had a number of attorneys wanting to meet with them, but rather than permitting us to do that, the Haitians were transferred to three jails in Louisiana, where it's virtually impossible for them to get legal assistance.
We have asked the government to bring the Haitians back to Miami or other places where there are viable pro-bono programs so they can get proper representation. We believe some of these Haitians are eligible for relief from removal, but it's extremely difficult for us to help them given that they're in Louisiana and we're not.
Q: Deportations have been suspended in the cases of immigrants from other countries after natural disasters and political upheavals. Do you think Haitians have been singled out for particularly harsh treatment?
Here at the Florida Immigrant Advocacy Center, we represent folks from all over the world. I know of no other group that's been discriminated against to the extent that the Haitians have. They just want to be treated like human beings. Federal courts in the past have said that Haitians have been singled out for discriminatory treatment. Many Cubans with criminal histories are not being deported at this time.
Q: How has the Haitian government's responded to the resumption of deportations?
It's my understanding that the Haitian government is not issuing travel documents in these cases. They're very concerned that our government is deporting Haitians back to their country at a time, frankly, when their country is in many ways worse off than it was right after the earthquake, because we've got the cholera outbreak now, we've got the fiasco following the elections, we've got Baby Doc Duvalier there. The United States government on January 20th had originally wanted to deport 59 Haitians. The Haitian government only agreed to take 28, and it's my understanding that only 27 went back.
Q: What could be done to change the U.S. deportation policy?
Right now this administration can say, well, we're not going to deport these Haitians at this time because it's the wrong thing to do and there's nothing right about this. That can be done in a heartbeat. It's just unconscionable that our government is sending anybody back to Haiti at this time. We have repeatedly said this could amount to a death sentence, and sadly we were right.
Q: What is the status of other Haitian immigrants?
A number of Haitians arrived post-earthquake because their homes had been destroyed, their kids were living in tents in the street, and we are asking this administration to re-designate Temporary Protected Status and to permit those Haitians to apply, so that if Haitians arrived here in the aftermath of the earthquake in order to survive they have an opportunity to remain here temporarily. A lot of these Haitians had jobs in Haiti, their kids were in school, that's the country they love and the country they want to return to. But they need a temporary reprieve. We have applied for deferred action for a number of these Haitian families and in most cases we've gotten no decision, so we fear that those cases are going to be denied.
We're also very concerned about the 55,000 Haitians in Haiti whose relatives in the U.S. are lawful permanent residents and U.S. citizens. These relatives had applied to get visas for them to come here legally. Those visa petitions have been approved, but the Haitian beneficiaries aren't being allowed to come here because there's a quota system and there are backlogs and so they could wait five or 10 years. Our government recently renewed a program that grants Cubans in the same situation parole so that they can be reunited with their U.S. family until the visa becomes available.
I talk to Haitians here and they say the visa's been approved, but my loved one is living in a tent. Why can't I bring them here? Haitians here who have family members in that situation are traumatized because they feel helpless.
A similar version of this interview originally ran on the website of New America Media.]]>National Cancer Institute's Helpline: A Valuable, Underused Resourcetag:www.huffingtonpost.com,2011:/theblog//3.8162752011-02-01T08:10:12-05:002011-05-25T18:30:24-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
Searching on the Internet for more information about the disease, Bryant found the telephone number of the National Cancer Institute's Cancer Information Service (1 800-4-CANCER, or 1-800-422-6237). The woman who answered told her about local support groups and medical specialists in her area and shared her own story of having breast cancer. "The person on the other line was really comforting," Bryant says. "It made me feel like I might have some hope."
Despite its 35-year history, the NCI's free service remains under the radar to many. The helpline handles about 78,000 calls a year, in English as well as in Spanish, from patients, family members, and others who have questions about different types of cancer. By contrast, in 2007, some 11.7 million Americans were living with the disease.
The service is especially underused in ethnic minority communities, according to Dr. Nancy Burke, a researcher at the University of California, San Francisco. "There's an issue of awareness, and there's also the comfort issue of seeking information over the phone," she says. "But once we introduce people to it, they love it. Cancer patients are often overwhelmed by information, and the line can help them sort through it."
The cancer line fields a wide variety of queries, including what to expect after different diagnoses; what to ask doctors; where to get help with financial, legal and transportation problems that might interfere with treatment; the benefits and side effects of different treatment options; and what clinical trials are available for different diagnoses.
Callers are encouraged to share as many details as possible about the exact type and stage of their cancer, so that the staff can tailor the information they provide. "But if they don't know this, we can help them formulate questions they can take to their doctor," says Mary Anne Bright, a former oncology nurse who directs the program. "We will spend as much time with somebody as they need."
Unlike many other toll-free helplines, "we're not a pharmaceutical company, and we're not collecting donations," Bright adds. "We're all about reporting the most accurate and up-to-date information about cancer and the results of research in a way that people can understand."
The phone line is open Monday through Friday, from eight a.m. to eight p.m. Eastern time. Callers aren't asked for their name, unless they want to receive printed material in the mail, and only their area codes are collected. They are asked some basic demographic questions at the end of the call, but can choose not to answer, and "it won't have an impact on how we deliver our service," Bright says.
The Cancer Information Service also handles questions by email and by instant messaging. Recently, the line has been answering more questions about where to get financial help, how to pay for treatment, and where to get free or low-cost screening tests, such as mammograms.
Burke says one unexpected benefit of the call line is the confidence it instills in patients navigating the medical system. "Many people don't feel entitled to getting good service," she says. "It was empowering for people to feel they were going into their appointment with questions to ask and information to discuss with their doctor."
Brenda Bryant called the line a second time, a month after her initial breast cancer diagnosis. Even though she had insurance, she was worried that she wouldn't be able to afford her treatment, and she also wanted information about a clinical trial that her cancer specialist was pushing. She ended up deciding to go with the standard treatment for her type of cancer, and she reports that she is now doing well.
"They just gave me a lot of information on different services, and they didn't promote any treatment or trial," she says. "I just felt that it was a good resource."
A similar version of this article originally appeared on the website of New America Media.]]>Cholera in Haiti: A Look From the Trenchestag:www.huffingtonpost.com,2011:/theblog//3.8065522011-01-12T08:33:19-05:002011-05-25T18:25:24-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
Dr. Vulcain divides his time between Haiti and Miami and has advised the Haitian Ministry of Health's HIV care program. He was in Haiti during the earthquake, and provided immediate care in the aftermath of the disaster.
Dr. Andre Vulcain
Q. You recently returned from a three-week trip to Haiti, where you were treating cholera patients. What was the situation you faced during this most recent trip?
When they announced there was a formal epidemic, we started putting together an embryonic cholera treatment center in Cap Haitien even before (the epidemic) got there. We expected 25 to 50 patients a day, but there was a quick escalation of the epidemic. It was a very difficult situation. The center was designed for 200 to 250 patients and they were taking care of 600 patients.
The big problem was there was not enough trained human resources and not enough accommodations in terms of beds. I was in charge of a room with 80 patients with three to four nurses. Most of the patients we had were severely dehydrated, and 100 percent needed IV hydration. One week earlier, there was political agitation in the city, and for five or six days people were staying home or people died in the streets. It was a very difficult situation, but I think our results were good because the mortality rate was maintained below one percent in the whole center.
Q. You were in Haiti during the earthquake, and treated thousands of patients in the immediate aftermath of the disaster. Do you see things worsening from a public health perspective?
Before the earthquake, the public health system was falling apart. Since the earthquake, things are more challenging. We had to divert energy to the earthquake effort itself. The fact that we have to concentrate on the cholera epidemic displaces attention from other health care programs, which are already weak. Now, on top of that, you have this election that went bad.
During the past 25 years, Haiti has made progress only in one major indicator of health care status -- the infant mortality rate, which has been reduced by 50 percent for the past 20 to 25 years.
All the other indicators (such as) maternal mortality, malnutrition of children, are steadily going up. The maternal mortality now has reached an astronomical level. It's over 600 maternal deaths for 100,000 live births -- (and this was) prior to the earthquake.
Q. What were your primary objectives in treating cholera patients?
When you are dealing with cholera, you have to work with a two-pronged strategy. The two main things are first, that the patient needs to be treated to prevent fatality -- that's the medical care. (It) is not rocket science -- IV hydration for the patient who is severely dehydrated, or oral hydration salt for the patients who are moderately or lightly dehydrated.
The second aspect, which is very important, is to try to block the transmission of the cholera in the community, so you need to work on the education of the community and also, more challenging, see what you can do in the short term to mitigate the sanitation problem. Access to clean water is important.
We had mass communication education, and a lot of people were aware of what's going on, but you also need the kind of education that comes with a demonstration of what needs to be done. So what we did and what a lot of organizations are doing was to send community health workers who can teach people to make sure they understand how to apply preventive measures.
Q. What were some of the barriers you faced in caring for cholera patients?
The sheer number of patients was difficult to manage, even though the basic logistics were there. We definitely needed more human resources. But everybody was doing his best. (More generally), there is a lack of knowledge (about cholera) and skills among the health care workforce.
This is the first time that we have had cholera in Haiti. We have started a medical education program that will train most of the providers. We think that cholera is here to stay in Haiti for a long time, given the conditions, so it's important for the whole workforce to be familiar with the cholera epidemic.
Q. What are some of the misconceptions people in the U.S. may have about the cholera epidemic? Would you say things are better or worse than they are being depicted in the media?
From what I saw before I traveled to Haiti, the coverage was reasonably fair. I didn't see anything that was grossly distorted or any kind of misinformation. I have noticed since I came back that the election in Haiti has replaced cholera as news, so they don't talk a lot about the cholera epidemic. But it's still a serious situation and we will have to go two to three more months before seeing it subside totally. Eventually we will have to face the endemicity of this epidemic.
Q. What are some of the misconceptions people in Haiti have about cholera?
Some people thought you could contract cholera through the air, and on the street some people were wearing medical masks. But I think the education that's being done has minimized that.
Some people thought that it could have been something intentional related to some political situation, or something else. The communities that are affected don't spend a lot of time speculating about those things -- they are more interested in how to protect themselves.
Cholera is, in large part, caused by inadequate infrastructure and unclean water.
Q. Do you see the epidemic abating anytime soon? Will it be possible for the government to end this epidemic soon, given the need for significant improvements in infrastructure?
Political instability has always had a negative effect on public health programs in Haiti. The ability of the state to provide for the needs of the people has been weakened. You need time to build a sanitation infrastructure. It's not going to happen tomorrow, it's more a long term thing.
Q. Did you have any concerns about your personal health as you cared for cholera patients?
I had some concerns. Even in the center, the sanitation wasn't optimal. The patients were on plastic sheets on the floor and I had to kneel to start IV's and to examine patients. Basically, I abided by some specific rules. I tried to never touch my face or mouth with my hands. Every hour or so I went outside of the tent, where you can wash your hands with chlorine solution.
Every day before leaving the center I decontaminated the soles of my sneakers. When I arrived home, I had a bucket with chlorine water into which I dropped my scrubs overnight for disinfection. I took good showers with a lot of soap. I think that those measures are very effective. The key is your hands, because that's what brings something to eat into your mouth, so I made sure my hands were constantly being washed and I never touched my face.
Q. What changes have you seen in Haitian society since the disaster?
I think people's fatalistic attitude has increased. The other thing that is worrisome is that you have so many people living in a tent city culture. Even in the slums, there was some organization, there was some sense of community, you knew the people close to you.
Under a tent, it's a new environment, new people, way less privacy, you are constantly exposed. It's very concerning in terms of how it's going to affect the values of this society, how people relate with other people, how people express their solidarity, how people are going to value self-reliance, because in those tents, people are totally assisted with food, water, medical care.
A child who spends five years under the tent -- what kind of mentality does he have, what does he think of life, what is his vision of normalcy when he grows up, what kind of contribution will he be able to make when his reference frame has been to live under a tent for so many years? It's a big human issue.
A similar version of this article originally appeared on the New America Media website.]]>The Lesser-Known Complications of HIV/AIDStag:www.huffingtonpost.com,2010:/theblog//3.7880272010-11-29T07:51:55-05:002011-05-25T18:15:22-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
Then he slipped one day while on vacation and broke his wrist. He underwent an operation to insert pins in his bones and needed to wear a cast for a month, keep his arm elevated, and then do physical therapy for two months to get to the point where he could lift a five pound weight. "It was one of the most difficult things I've ever been through in my life," he said. "I ran, biked, lifted weights and now all of a sudden I couldn't turn the page of a newspaper. It just really got to me."
After a few simple tests, the reason for Levin's fracture became clear: His bones were weak from osteoporosis, a disease that's most commonly seen in older women, but that's also associated with HIV.
"The giddiness of the age of HAART is over," said Levin, referring to highly active antiretroviral therapy, the life-saving drug regimen prescribed to people with HIV. "We should have an aging clinic in every hospital that's serving HIV patients."
Osteoporosis is one of many conditions associated with old age that is now being seen with increasing frequency in people with HIV. Research suggests that long-term exposure to the virus, and to the inflammation it triggers, make people vulnerable to premature aging and to a host of conditions seen with aging, heart and kidney disease, dementia, and osteoporosis.
Additionally, the overall population of people with HIV is getting older, thanks to improved medical therapy. At present, 1 in 4 people with HIV is age 50 or older. The U.S. Senate Special Committee on Aging has predicted that half of all adults with HIV will be older than 50 by the year 2015. Over the past few years, the National Institute of Health has increased its funding for research on HIV and aging, and the White House hosted a conference on October 27 on HIV and aging.
"The evidence is pretty clear," said Levin, who directs The National AIDS Treatment Advocacy Project (NATAP), a New York-based HIV education and advocacy group. "We're going to see early frailty, early senescence and people are going to start dying at earlier ages."
Compared to other conditions associated with HIV and aging, osteoporosis is relatively straightforward to forestall and treat. To maintain bone strength, it's important for all people with HIV to make sure they are consuming an adequate amount of calcium and Vitamin D. A recent article in the journal Clinical Infectious Diseasesrecommends 1,000 to 1,500 mg of calcium and 800 to 1,000 IUs of Vitamin D daily, as well as at least 30 minutes of weight-bearing exercise, such as jogging or walking, at least three days a week. Calcium is plentiful in dairy products and sardines, and is available in supplements such as calcium carbonate and calcium citrate. The National Institutes of Health has an online information sheet listing ways to get calcium. It's also important to avoid smoking and heavy alcohol use, since these can cause osteoporosis.
HIV is thought to be associated with osteoporosis for a variety of reasons. The infection, itself, causes inflammation, which in turn impacts the cells that maintain bones. Many conditions common in people with HIV, such as Vitamin D deficiency, being underweight and low testosterone, are associated with osteoporosis. Antiretroviral therapy and other medications frequently prescribed to people with HIV, such as Prednisone, also cause bone loss.
Even though many antiretrovirals can cause bone loss, osteoporosis is not a reason to stop taking them. "Antiretroviral therapy is life-saving, and we know that stopping antiretroviral therapy is not a good strategy for preventing complications," said Dr. Todd Brown, an endocrinology specialist at Johns Hopkins University who co-wrote the article in Clinical Infectious Diseases.
Brown and his coauthors recommend that all HIV-positive men older than age 50 and women who are past menopause undergo testing for osteoporosis, since it's a condition that usually doesn't cause symptoms until the person breaks a bone. His own research has found that osteoporosis is "alarmingly" prevalent among African Americans in inner city Baltimore. "Because of the perception that osteoporosis is a white disease, people of color get short shrift for screening," he said. "This concept that African Americans are protected shouldn't be a reason to neglect them."
Once someone is diagnosed with osteoporosis, it's important to take action to prevent falling, such as removing clutter and slippery rugs from the floor. Physical therapy can help improve strength and balance, which also reduce the risk of a fall. The person also should get his or her vision checked and review his or her medication list with a doctor to try to minimize any drug side effects or interactions that might cause drowsiness or unsteadiness.
A class of medicines called bisphosphonates can improve bone strength, but do have some rare risks. "While they do decrease the risk of fracture, they're not totally benign drugs," Brown said. "On the flip side, you shouldn't not use them in the patient who is at high risk of a fracture."
Levin urges all people with HIV to be assertive about discussing osteoporosis and other age-related conditions with their doctor. "My guess is that 90 percent of patients know nothing about any of this and a lot of clinicians and case managers don't know about it either," he said. "Every patient should ask their clinician, 'are you aware, are you monitoring me for heart disease, diabetes, bone disease, cognitive impairment, kidney disease?' This is an important issue for everybody."
A similar version of this article originally appeared on the website of New America Media.
]]>10 Tips for Kicking the Smoking Habittag:www.huffingtonpost.com,2010:/theblog//3.7726812010-10-25T10:04:16-04:002011-05-25T18:05:23-04:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
Before you embark on your attempt, keep in mind that tobacco dependence is a physical and psychological addiction, not a personal failing. To succeed at quitting smoking, it's crucial to make a commitment, map out a strategy and get support. The National Cancer Institute has a helpful web page on tobacco cessation, as do the U.S. Centers for Disease Control and the American Lung Association.
1. To succeed at quitting, you first have to decide that this is something you really want to do. Medicine and classes won't work unless you have made a commitment. In L.J.'s case, a graphic video that his counselor played at his first stop smoking class made him resolve to quit. It showed pictures of smokers that he could not forget: a man missing an eye and part of his nose from mouth cancer. People breathing through tracheostomies, holes that doctors surgically cut in their throats when cancer prevented them from breathing. "You have to be willing to give it your all," L.J. told me. "But the pros outweigh the cons."
2. If you can, join a stop smoking group. This can be difficult to do, as these groups sometimes meet during working hours. But if you can find one at a time convenient for you, these groups can be very helpful in providing support and strategies and keeping you focused on your goal. L.J. attended seven classes in total, each of which took an hour, and describes them as crucial to his success. To find out about classes near you, call your local county health department or hospital and ask if they offer or know of a local smoking cessation program. The American Lung Association can direct you to smoking cessation classes in your region: 1-800-lung USA.
3. Set a quit date and prepare in advance for what you will do once you quit. This includes changing your environment by removing ashtrays and other smoking-related items from your home. It also includes telling your friends and loved ones about your plan and asking for their support. The first few weeks are the toughest, and the time when you will probably be most tense and irritable. Plan in advance about what you can do to alleviate the stress you will feel during that time, be it through exercise, meditation, using a stress ball or sharing your feelings with a friend (see #5).
4. If you plan to use medication, fill the prescription in advance of your quit date. Research indicates that the odds of succeeding are higher with medication. There are three different medications: varenicline, or "chantix," which helps treat nicotine withdrawal as well as smokers' cravings for tobacco after they quit; bupropion, or "zyban," which reduces cravings; and nicotine replacement, which is sold in the form of patches, inhalers and gum. Varenicline can be used alone, while bupropion and nicotine replacement are often used together. You will need a prescription for varenicline or bupropion, and they can have side effects. If you're paying for them on your own, none are cheap: at my local pharmacy, bupropion costs $62 a month, nicotine replacement patches run about $90 monthly and varenicline costs $156 a month. In considering cost, remember how much you will save by not buying cigarettes, which on average run from $4 to $8 a pack. Some state Medicaid programs and insurance plans cover these medications. For more information, check the American Lung Association's State Tobacco Cessation Coverage page. Occasionally, free or discounted medication may be available through some state telephone quit lines: call 1-800-QUIT NOW for more information.
What about those ubiquitous "e-cigarettes" that you may see at kiosks in your local shopping mall? Testing by the U.S. Food and Drug Administration has found that some contain cancer-causing chemicals and toxic compounds such as diethylene glycol, a component of anti-freeze. Suffice it to say, they aren't FDA-approved for smoking cessation.
If you are dead-set against pharmaceuticals, some people have succeeded with a tapering program that involves divvying up their cigarettes into sandwich bags and allowing themselves one bag per day, until they are down to zero. (This approach involves cutting the quantity by half every week or so). I haven't seen any research evaluating the effectiveness of this approach, however.
5. If you can, find a sponsor or a friend, who will be there for you when you are trying to quit. For some smokers, this is someone who listens when they feel frustrated; for others, it's someone who can be empathetic as they mourn the ending of a lifelong habit, which can feel like losing an old friend. In L.J.'s case, his sponsor was a non-smoking friend who rationed his cigarettes when he was tapering down and listened to him when he was withdrawing. "He was a good sponsor -- he didn't cut any corners or do me any favors," L.J. said. "In the beginning I would get aggressive, and he was somebody who was willing to be yelled at and ignored."
6. Know your smoking triggers, and take steps to avoid them. For L.J., being alone and isolated triggered him to smoke, so when he felt isolated, he would talk to his sponsor. He also has been in touch with friends and family, and has avoided places that he fears would make him go back to his old habits, such as his old apartment building.
7. Be aware that most people make many attempts to quit before succeeding. If you have tried before and failed, you aren't alone, and that doesn't mean you should give up. It takes five to seven attempts, on average, before succeeding. Some smokers succeed with far fewer attempts; others require many more. Mark Twain said it best: "Quitting smoking is easy. I've done it a thousand times."
8. Remember the Five D's. Dr. Mary Mites-Campbell recommends these in her smoking cessation class. They are: Drink water -- up to eight glasses daily, to cleanse your body of nicotine; Deep breathe, to help you relax; Do something else, to get your mind off smoking; Discuss, or talk about what you're experiencing (see #5); and Delay -- when you get the urge, count to 250. When L.J. got the urge to buy a pack of cigarettes, he would stash the money in a jar and after several weeks he had saved enough to buy an $80 pair of shoes.
9. Put something in your mouth other than food. Many people who are trying to quit miss the sensation of having something in their mouth. L.J. uses gum when he gets a craving (go sugar-free if you are going to do that); some people find the plastic twizzler sticks used to stir coffee to be helpful.
10. Quit lines may help.These are toll-free telephone lines, organized by the National Cancer Institute, that provide telephone counseling free of charge. L.J. found the lines very helpful when, in his words, he was "searching for ways to not focus on picking up a cigarette." The numbers are: 1-877-44U-QUIT and 1-800-QUIT NOW.
A similar version of this column originally appeared on the website of New America Media. ]]>Low-Income Health Care: Exploring Medical-Legal Partnershipstag:www.huffingtonpost.com,2010:/theblog//3.7516092010-10-11T12:02:00-04:002011-11-17T09:02:45-05:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/National Center for Medical Legal Partnership (NCMLP) brings together lawyers, doctors, nurses and social workers to help patients with problems that may have a legal remedy, such as qualifying for food stamps, getting insurance benefits or avoiding eviction.
Medical-legal partnerships (MLP's) are usually based in clinics, hospitals and other medical settings that serve low-income people. The NCMLP is affiliated with more than 81 sites in 37 states, and helped more than 13,000 individuals and families in 2009. Congress has taken notice, and the bipartisan Medical-Legal Partnership for Health Act was introduced in both the U.S. House of Representatives and the U.S. Senate on July 29, 2010. The Act calls for $10 million to be set aside each year for five years to fund medical-legal partnership demonstration projects around the country, and to study whether they improve health and reduce health care costs for hospitals and clinics.
I recently spoke with Drs. Barry Zuckerman and Megan Sandel about the NCMLP. Dr. Zuckerman founded the Medical-Legal Partnership for Children, which evolved into the NCMLP, in 1993. He is The Joel and Barbara Alpert Professor of Pediatrics at Boston University School of Medicine, Professor of Public Health at Boston University School of Public Health, and Chief of Pediatrics at Boston Medical Center. Dr. Sandel is an assistant professor of Pediatrics at the Boston University School of Medicine, the medical director of the NCMLP, and the former director of Pediatric Healthcare for the Homeless at Boston Medical Center.
EM:Why did you establish this organization?
BZ: As a pediatrician taking care of children in inner city Boston, it was upsetting for me to see children become sick and hospitalized for conditions that my children or children living in my neighborhood wouldn't suffer from. These included conditions related to inadequate food, to poor housing conditions, to utilities being shut off, to violence in the community, and other problems related to their social environment. I realized there are a lot of protections and benefits that our public officials have put into policy and I thought the best way to address these problems was to hire a lawyer to see that patients got help, and to reduce unnecessary preventable illnesses.
MS: We all know that medicine alone can't solve all health problems when there are underlying material hardships, and many adverse social conditions have legal remedies. MLP is really about integrating legal services into health care in order to address those underlying legal needs. It's not about getting people new services, it's about getting them services they were entitled to in the first place.
EM:What are the major problems MLP's address?
MS: One of the biggest is income support -- things like food stamps or welfare benefits or, if you're disabled, getting disability. Also, insurance benefits. Housing is a big area, both in terms of affordable housing but also in terms of housing conditions and keeping the utilities on. Education for kids and employment for adults -- helping people get either employment training or not be discriminated against in their jobs. Legal issues can be difficult, both immigration issues, or if someone has a criminal background that is impairing their ability to get a job. Lastly, there are personal or family issues that can really interfere with care, whether it be guardianship issues for kids or advance directives for people at the end of life. We really try to remove those legal needs from being barriers to effective care, to help patients get and stay healthy.
EM: With the downturn in the economy, have you seen an increase recently in people needing your services?
MS: When we talk to our local sites in the network, they are seeing a huge increase in not only the simple basic needs such as food stamps and people needing to get the proper amount of food stamps that they're eligible for, but also severe housing stress, families falling behind on their rent, potentially having their utilities shut off, maybe even becoming homeless and suffering from foreclosures.
The thirst for this among health care institutions that are serving low income populations is huge and unlimited. In 2005, we had 20 sites. In 2010, there are 80 programs across the country, serving over 200 hospitals and health centers. Our goal over the next five years is to get to 500 health care sites, and even then we'd only be at 15 percent of the health care institutions that serve vulnerable populations.
EM: How well do you think doctors and other health workers identify health-related legal issues?
BZ: In medical school we were all taught about psychosocial problems, and words like housing and food were always important. But nobody taught us how to ask about it, and even if they did it wasn't clear we wanted to because we wouldn't know to do about it. Now, having legal interventions available puts more of an obligation on us to identify legal problems.
It's analogous to doctors identifying domestic violence. Twenty years ago, physicians didn't identify domestic violence; they didn't know what to do. There are a lot of interventions available now, and it's unthinkable that they wouldn't do it; it's become standard of practice. I feel this will rise to the same level.
MS: Doctors can make the connection that social conditions affect health, but they have a very hard time envisioning this as part of their job. The MLP can train them on how to screen for these issues, particularly early before they reach a crisis proportion. Because the lawyers are integrated into the health care team, doctors now have an intervention that can be part of their treatment plan.
EM:Your website states that MLP's foster prevention. How?
BZ: We're hopefully preventing health exacerbations or health problems by addressing the sources of it instead of treating the consequences, whether it's housing conditions or inadequate food or all those things. Our job is to identify the legal problem before it becomes a catastrophe, which will then become a medical health problem.
MS: If you can detect the legal problem early, the intervention actually takes fewer hours than waiting until it's a catastrophe. Eviction is a classic example. You know you're falling behind on your rent, you know your utilities have been shut off. If we can identify those underlying warning signs early, we can intervene with a few hours of time, sometimes not even with a lawyer. That can be an efficient use of limited resources in the community.
EM:What is the financial effect of an MLP on a hospital or clinic?
BZ: Depending on the hospital, the MLP can help with what's called health care recovery dollars, when hospitals don't get paid by insurers. The lawyers can also intervene to make sure people get signed up for insurance.
MS: It just takes a couple of really expensive cases to pay for everyone else to get the legal service. Patients who have cancer, for instance, sometimes need to stay in the hospital for longer periods of time or may not have their insurance up to date because they've lost their job. MLP's sometimes can help the patients get discharged earlier, or can help the hospital get compensated for care that they gave. We had an MLP based out of a cancer center, and over the course of three years, they had a three-to-one return on investment based on just a handful of cases -- really, just 10 or 20 percent of the cases that then paid for the rest of the entire program.
EM: Your website has a map showing your network. But what if you need help and live in an area that lacks an MLP?
MS: Every area has a legal services agency. The legal services corporation federally funds such services across the country, and locally there can be bar associations or pro bono networks. In our experience, most patients don't realize that their adverse condition has a legal remedy, and it's only in crisis like an eviction notice or a certain complaint that they seek legal assistance. Part of why MLP's are so innovative is that by bringing legal services into the medical home, you can detect problems earlier.
MS: It calls for a federal demonstration project for the U.S. Department of Health and Human Services to implement over the next five years, to try to prove that the model has health benefits and to do a cost analysis and evaluate the model for future investment. It's a similar approach to other demonstration projects . One model that we were looking to is the hospice model. Twenty years ago hospice was an informal service that sometimes was in church basements and other places, and now it's a 3-4 billion dollar industry.
EM:People don't usually think of doctors and lawyers as allies. Has it been tough to create such alliances?
BZ: It's a very simple idea, and yet its complex to implement. We've medicalized the whole thing, and our lawyers are like any specialists available for advice or to see patients when the health care team gets stuck. But there are issues about confidentiality and just styles of practice. I tell the lawyers that this is like a cross-cultural experience for them.
MS: A lot of the technical assistance that our national center provides is helping the lawyers understand how to talk to physicians, how to talk to nurses, how to talk to social workers, how to understand the hierarchy of the medical sites, because it can be a real mythic experience for them.
EM: What adjustments do doctors need to make when working with legal services?
MS: The expectation for feedback is important. They're not going to hear every nuance of the legal case.
Just like a doctor would use a specialist like a cardiologist, they have to get very comfortable being able to ask a couple of questions to decide on the treatment plan. We want (doctors and nurses) to get comfortable thinking, "OK, I've screened (these patients) for food insecurity, do I need to send them to a pantry, do I need to send them for food stamps, or have they been wrongfully denied and is there a legal issue?" They need to be able to think about the question in a decision tree format, and this requires a familiarity with the law.
BZ: As physicians, we witness how policies play out, both in their effectiveness and ineffectiveness. By having lawyers in a health care setting, we have the capacity to change health institutions and help them evolve, just like when social work came through and changes were made. MLP's can change how health institutions see themselves and can change systems and policies for the greater good.
A similar version of this interview originally appeared on the website of New America Media.]]>Skin Cancer Doesn't Discriminatetag:www.huffingtonpost.com,2010:/theblog//3.7201902010-09-23T07:00:00-04:002011-11-17T09:02:45-05:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/
Ivis Febus-Sampayo (center) with members of her immediate family (Courtesy, Ivis Febus-Sampayo)
The mole on Ivis Febus-Sampayo's face looked odd. But it wasn't until her son needed treatment for acne that she went to a dermatologist.
"As mothers, we're working, we're busy," she said. "I forgot about me and called the dermatologist to make sure my son was getting taken care of."
The doctor removed a sliver of the mole, and reassured Ivis that it was probably nothing to worry about. Two weeks later, she received a diagnosis she never imagined possible: melanoma.
"I'm of olive complexion, I'm not a sun worshiper, I never baked in the sun, and I don't like the beach," said Ivis, a Latina who was born in Spanish Harlem and grew up in Philadelphia and New York. "At no time did I ever think I could have skin cancer."
But anyone can get skin cancer, and over the past few decades, melanoma -- the most aggressive form of the disease -- has become far more common. Its incidence has increased faster than that of any other cancer, and it's now the fifth most common cancer diagnosis in men and the seventh most common cancer diagnosis in women. Even though African Americans and Hispanic Americans are less likely to develop melanoma, they are more likely than white non-Hispanics to be diagnosed after the disease has spread, when it's at a stage that's tougher to treat.
"There's a misconception that if you have darker skin, you will not get melanoma," said Dr. Claudio Dansky Ullmann, a researcher at the National Cancer Institute. "It may be that you are less sensitive or less likely to develop it, but that doesn't mean you aren't going to develop it."
Exposure to ultraviolet radiation from the sun is the biggest risk factor for melanoma and skin cancers generally, and the one that people can do the most to avoid. (Genetics and some skin and immune conditions can increase risk, and some studies suggest that workers exposed to polychlorinated biphenyls (PCB's) may be at increased risk, too). Cancer specialists stress that it's important for everyone to protect their skin, regardless of their pigmentation. The American Cancer Society (ACS) promotes a "Slip, Slop, Slap, Wrap" approach -- meaning slip on protective clothing (the tighter weave, the better), slop on sunscreen (and re-slather every two hours), slap on a hat (with a two to three inch brim all around), and use wrap-around sunglasses that block ultraviolet light (melanoma can start inside the eye, too). The ACS and other groups also recommend minimizing outdoor activities between 10 a.m. and 4 p.m., when the sun's rays are strongest.
There's been some controversy about the safety of sunscreens, and the Food and Drug Administration plans to issue new guidelines on sunscreens this year. Dermatologists have traditionally recommended using sunscreen with an SPF ("sun protection factor") of 30 or greater. My colleague Dr. Robert Kirsner, a professor of dermatology at the University of Miami Miller School of Medicine, says it's more important to make sure the sunscreen protects against UVA (ultraviolet A) as well as UVB (ultraviolet B) rays. The Environmental Working Group, a research and advocacy organization, has raised questions about the safety of many sunscreens, and characterizes the SPF label as misleading. It posts its own rating system for sunscreens.
Of course, the best protection is to limit time spent in the sun, and avoid tanning salons. If your job requires you to be outdoors, try to cover up with a hat, long sleeves and pants, and try to work under an awning or in the shade.
Another key part of preventing deaths from skin cancer is early detection, since the prognosis is better when the disease is caught early, before it penetrates the layers of skin and spreads to other organs. The American Academy of Dermatology (AAD) urges everyone get regular skin exams by a medical professional, and the ACS also recommends everyone examine their own skin monthly. (Of note, the United States Preventive Services Task Force gives routine physician skin screening exams an "insufficient" rating -- because there isn't enough research to recommend them one way or the other). If you don't have health insurance, the AAD organizes free skin screenings , as does the Skin Cancer Foundation.
Many dermatologists recommend using an "ABCDEF" approach to look at your skin, and seeking attention if you notice anything that has one or more of the following characteristics:
Assymetrical
Irregular Borders
More than one Color Diameter more than 5 millimeters (i.e., about the width of a typical pencil eraser) Evolving, meaning it's changing Funny looking (also known as the "ugly duckling" sign, meaning a growth on the skin that looks different from its neighbors)
It's also important to inspect your finger and toe nails, the soles of the foot, and covered areas, such as the groin. Some studies indicate that African Americans in particular often develop melanomas on the bottom of the feet.
There are many new techniques for diagnosing melanoma, but only one in four primary care doctors get any training in this area during their residencies. If you feel your primary care physician isn't taking your concerns about a skin lesion seriously, push to see a dermatologist. Published research suggests that the specialists are generally better at telling apart a benign skin lesion from a cancer. (And as a primary care physician myself, this isn't a recommendation I make lightly).
In Ivis' case, the melanoma was caught at an early stage. A few days after her cancer surgery, she returned to her job as the director of Latina Share , a New York-based support and advocacy group for women with breast and ovarian cancer. She now wears a hat and applies sun screen every day. "I think it's really important that people understand you don't have to be fair skinned, with blue eyes and blonde hair to get skin cancer," she said. "We need to become advocates for our own health, especially in the Latino community, where it's always family first. I always tell women, you need to take care of yourself -- if you're not here, you can't take care of them."
A similar version of this column originally appeared on the website of New America Media.]]>Interview: While the NGO's Thrive, Haiti's Doctors Need Helptag:www.huffingtonpost.com,2010:/theblog//3.6982642010-09-01T14:17:39-04:002011-11-17T09:02:45-05:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/Six months after the earthquake in Haiti, I spoke with Dr. Herold Merisier, president of the South Florida chapter of the Association de Médecins Haïtiens a l'Étranger (Association of Haitian Physicians Abroad). Dr. Merisier earned his medical degree at the State University of Haiti and then trained in Port-au-Prince, Paris, France, and Miami. He is a board-certified family medicine physician in Plantation, Florida.
Dr. Herold Merisier
You last visited Haiti in late June. What happened during that trip?
I went as a private citizen and visited with Haitian physician friends and my colleagues from school, many of whom had lost family members. I visited them at the General Hospital and private offices. In most cases, their offices were empty and patients weren't coming, because they could go to the (foreign) NGO clinics for free. Therefore the Haitian physicians couldn't compete.
What are the biggest health problems in the country at this time?
The two biggest issues are access to care and affordability. Even prior to the earthquake, there weren't enough Haitian physicians to cover the entire territory. After the earthquake, the problem was exacerbated. Patients aren't able to get to a physician, and when they get there they aren't able to pay for the care.
A couple of additional challenges are the rehabilitation of amputees, and the mental health challenges. A lot of people were traumatized and have post traumatic stress disorder. There are also people with underlying mental health conditions such as depression that have been exacerbated. We don't have enough mental health professionals in Haiti to address these issues.
Are there any health problems that the public health community did not anticipate?
I think they were anticipating major epidemics that didn't occur, such as cholera and emerging infections. Fortunately, we were able to avoid them, but since I'm not practicing in Haiti, I can't say I have all the information on that.
What are health services in Haiti like today? Where are people going to get their medical care?
Obviously, there's less access to care than existed prior to the earthquake. A lot of the hospitals crumbled, a lot of providers' offices were damaged, a lot of providers died. There are fewer providers providing care. Right now many people are going to their previous providers and dispensaries, but these have been supplemented by the makeshift hospitals that the NGO's set up after the earthquake. Some areas, particularly the rural areas, still lack health care, and people still need to travel long distances in the back of a car, on the back of a donkey, or on a cart to access health care.
What are the challenges that Haitian health professionals are facing at this time?
From the standpoint of the Haitian doctors, they have a dilemma. Although they understand that there aren't enough Haitian health care providers, they feel there is unfair competition from the health care providers from abroad who provide care for free. They can't compete with them, and the government can't compete with them. Yes, they understand that people need care and the NGO's are providing a service that's needed, but they would prefer that there be some grant support to the Haitian health care workers, who can provide culturally sensitive care at a much lower cost, and reach more people. It would also help reinvigorate the economy in Haiti. There are a lot of Haitian doctors who are unemployed or underemployed, and have no source of income.
What are the specific needs of Haitian health professionals at this time?
They need to rebuild whatever situation they had before the earthquake, and they would appreciate it if the international community provide some financial support, at least on a short term basis, to help them rebuild the health system. The local physicians could do ten times more work with the money provided to support a physician from the outside. There's also no doubt that it's much more difficult for physicians from the outside to communicate with Haitian patients, and they don't have the cultural background to do so. The foreign physicians aren't going to stay in Haiti for the long term. There is a need for support for the healthcare institutions in Haiti to allow them to provide care in their local communities, and for help rebuilding the local healthcare infrastructure.
How did your organization react immediately after the earthquake?
Our first priority was to find ways for our members to travel to Haiti in order to assist with the emergency medical response. Since we did not have the resources to organize flights to Haiti, we relied on the logistical support of other major organizations. We had a list of medical volunteers ready to travel to Haiti at a moment's notice, but it was difficult to find flights.
It was very frustrating. We had a lot of people who were eager to go, but Haitian physicians weren't on the priority list.
How has your organization's mission changed since the earthquake?
Before the earthquake, we focused on providing assistance to the general hospital in Haiti and academic support, such as lectures and exchange programs to do training in the States. These are on hold, since the medical schools have been destroyed. Our new strategy is to identify local Haitian health care institutions that have specific programs serving Haitian people and provide funds, whether it be for physician salaries or supplies. Our other focus is to help to rebuild the academic health care institutions in Haiti.
What did you think of the media coverage after the earthquake? Has it been balanced?
We are grateful to the media in general for providing extended coverage of the earthquake aftermath and for keeping the focus on Haiti for a long time. Concerning the emergency medical response, the media put the spotlight almost exclusively on American and other foreign medical teams, largely ignoring the contribution of local Haitian physicians, or physicians of Haitian descent who traveled to Haiti from the US or Canada. They treated lots of patients and contributed significantly to the relief effort, and it wasn't reported.
A similar version of this interview originally appeared on the website of New America Media.
]]>Colorectal Cancer Screening: Know Your Optionstag:www.huffingtonpost.com,2010:/theblog//3.6857502010-08-21T08:00:00-04:002011-11-17T09:02:45-05:00Erin N. Marcus, M.D.http://www.huffingtonpost.com/erin-n-marcus-md/ Stanley Thornton, Colorectal Cancer Screening Advocate
(Courtesy, Stanley Thornton)
It's exceedingly uncommon for a healthy middle-aged man to walk into his doctor's office and demand a colonoscopy. But even though he lacked a family history, Stanley Thornton, an African-American engineer who was then in his mid-40's, wouldn't take no for an answer.
"I was concerned that African-Americans do get colorectal cancer earlier, and I said, 'hey, let me lead by example,'" he said recently. "We argued about it for a month or two. He felt I should wait until I was 50."
Eventually, Mr. Thornton got the test, and was found to be clear of cancer. He describes the "prep" -- the liquid he had to drink to clean out his intestines the night before the procedure -- as "not the nicest thing in the world," and said he was apprehensive as his wife drove him to his appointment since he didn't know what to expect. But he said the only uncomfortable part of the test, in which a doctor put a thin tube up his rectum in order to inspect his large intestine, was when the nurse inserted an IV needle to give him a sedative. "All I remember is talking and then being wheeled back to the room."
Colorectal cancer is the second leading cause of cancer death in the U.S., after lung cancer. It's one of the easiest cancers to pick up early, since it usually begins as a growth called a polyp and grows silently for many years before spreading into the body. Screening people between the ages of 50 and 75 for colorectal cancer is so effective at preventing deaths that the United States Preventive Services Task Force (USPSTF) gives it an "A" rating , higher than its ratings for breast or prostate cancer screening.
People who have a strong family history or medical condition that increases their risk of colorectal cancer usually need to start getting colonoscopies before age 50. One doctors' group, the American College of Gastroenterology , recommends African Americans start getting colonoscopies at 45, because they're at higher risk of being diagnosed with colorectal cancer after it's already spread (and is thus more difficult to treat), and dying of the disease.
A colonoscopy is considered the "gold standard" screening test for colorectal cancer, since it's the only test that allows the doctor to inspect the entire large bowel and also the only test that allows immediate removal of the polyp. But it can be expensive (running from $500 to $3000 if you're paying out of pocket) and has some small risks, such as perforating the colon (which occurs in fewer than 1 out of 1000 people) and bleeding, which is more of a risk if you're on a medicine that interferes with clotting. And even though it's good at picking up pre-cancerous changes, it's not perfect.
For most people, the most bothersome thing about a colonoscopy is the "prep," or powerful laxative they must use to clean out their colon in advance of the test. (For a good laugh, read Dave Barry's account of his bowel prep experience). Colonoscopies need to be done in a monitored environment, since they require that the person receive a sedative. If the first screening colonoscopy doesn't show anything abnormal, most "average risk" people can wait 10 years before repeating the test.
Many insurance plans cover screening colonoscopy in people 50 and older. But what if you lack insurance, have a plan that doesn't cover it, are at high risk for a complication, or simply can't stand the thought of the test? The USPSTF says it's also OK to screen "average risk" people with high sensitivity fecal immunochemical tests (or "FIT"), which look for globin, a component of blood cells that's concealed in the stool. This test is a lot less expensive (usually under $30 if you're paying out of pocket; many insurance plans will cover it), but it must be repeated every year to be most effective. To do the test correctly, you have to take home two small brushes and cards on which you'll smear your stool after two different bowel movements.
Many doctors give their patients an older type of home test called the guaiac test, which involves three cards; the USPSTF says this isn't as effective as the FIT method, and no longer recommends it. You should also be aware that simply having your stool smeared on a single card (which doctors sometimes do as part of an office rectal exam) is not an adequate way to screen for cancer.
The USPSTF also says it's acceptable to do a flexible sigmoidoscopy every five years, in combination with high sensitivity fecal occult blood testing every three years, as a screening test. The flexible sigmoidoscopy is similar to a colonoscopy, except that the tube the doctor uses is shorter, so that he or she can only see the lower part of the large intestine, and might miss a cancer that's higher up. It doesn't require sedation, involves an easier bowel prep, and is less expensive, usually less than $300 if you're paying the full cost. According to a recent editorial in the Journal of the American Medical Association, research suggests screening with colonoscopy isn't necessarily more effective at preventing colorectal cancer deaths than screening with flexible sigmoidoscopy.
Keep in mind that if your fecal occult blood test or flexible sigmoidoscopy show anything concerning for cancer, you'll need to undergo a full colonoscopy, so that the doctor can look more thoroughly and remove any suspicious tissue for more tests. Also, even if you've had a "clean" colonoscopy within the past 10 years, you may need to repeat the test if you notice blood or other changes in your stool -- so don't ignore such symptoms.
What about screening for colorectal cancer using the fecal DNA test, or virtual colonoscopy? The USPSTF says there isn't adequate proof yet that the benefits of such strategies outweigh the harms, and gives them an "incomplete" rating. (The American Cancer Society and Multi-Society Task Force on Colorectal Cancer say they're acceptable). Both are expensive. Virtual colonoscopy requires a bowel prep, and exposes patients to radiation.
In recent years, many doctors have been offering patients a slightly easier colonoscopy prep, involving either a smaller amount of liquid laxative than in the past, or laxative pills instead. Taking the prep correctly is important, since even a tiny bit of stool could hide an abnormality. It's important to drink plenty of water and/or clear fluids on the day before the test, to keep hydrated. (Avoid anything red or pink, though). Some people suggest putting yellow Crystal Light lemonade powder in the prep and refrigerating it to make it more tolerable. If you have kidney or heart problems, tell your doctor, since there are certain types of preps you may need to avoid.
Stanley Thornton, now in his 50's, underwent a second screening colonoscopy recently, and said the prep was "much cleaner and nicer."
Stanley Thornton urges everyone 50 and older with access to a colonoscopy to get the test. "The 'big C' is something we don't like to talk about in the black community, but we need to take charge of our health and get it done," he said. "Anything short of that, we're shortchanging ourselves."
A similar version of this article originally appeared on the website of New America Media.]]>
