Addressing Vaccine Fears Proactively

Washington State, is in the midst of a measles epidemic because of a high rate of unvaccinated children in Vancouver, Washington, a city just across the mighty Columbia River from Portland, Oregon. There have been multiple cases of measles in eleven other states this year. This article suggests ways to bridge the gap between the vaccinated and the unvaccinated populations.

Facts About Measles

• Measles is highly contagious-Entering a room within two hours after an infected person has left can transmit the disease
•  Measles can cause permanent hearing loss and brain damage
•  People die from Measles and it remains the leading cause of vaccine preventable death in the world; approximately 1 to 2% of those exposed to Measles die and 110,000 people died from exposure to the disease in 2017 alone
•  People with impaired immune systems are more likely to have complications from Measles

Why the Hysteria About Vaccines?

Parents have two main fears regarding vaccines, one is the mercury in the vaccine from thimerosal, a preservative and the other is a belief that exposure to vaccines will trigger autoimmune responses leading to other health conditions. Let’s look at the scientific studies on the mercury in vaccines to determine if there is any harm from this stabilizing component. The American Academy of Pediatricians published this document which is a meta-analysis of available high-quality studies on vaccine safety to address parental concerns about vaccines. After analysis of credible studies on vaccine safety this august body of physicians made the following conclusions:

1.   Increased exposure to antibody stimulating proteins is not associated with autism (DeStefano F, 2013)
2. On-time first year vaccines did not harm neurological development (C, 2010)
3. A 14-year study found no link to autism or inflammatory bowel disease and vaccinations (Peltola H, 1998)

 Here is a link to scientific studies which showed no harm in the organic compound thimerosal in vaccines. https://www.fda.gov/biologicsbloodvaccines/safetyavailability/vaccinesafety/ucm096228#bib

Addressing Vaccine Fear

Mercury Exposure

Parents are concerned about injecting thimerosal, which contains mercury and is used as a vaccine preservative into their children.

Solution-Give your child a vaccine without the thimerosal component

Too Much Too Soon

Solution-Provide parents information on these multi-national studies which involved thousands of children over an extended period of time and demonstrated no link to neurological conditions. Vaccines are not profitable for drug companies to manufacture so there are no customize-able versions for parents who want to break up the Measles, Mumps, and Rubella vaccine. Individual doses of Measles, Mumps, and Rubella vaccines were discontinued in 2009. (Control, 2009) Presently in the United States the combined MMR vaccine is the only option.

Seizure Risk

Solution-Explain to concerned parents that the risk of a child getting a seizure from a vaccine is extremely rare, approximately 30 children out of 100,000 who received the MMR vaccine may have a febrile seizure, which is related to the fever. The involuntary shaking should last no more than two minutes and usually does not cause any long-term damage. These seizures can occur at any time throughout childhood as a result of any fever. However, if the fever and risk of seizure is a concern, parents may wish to avoid the combined Measles, Mumps, Rubella, and Varicella vaccine as it has been shown to have an increased risk for seizure versus the MMR. Choose the lower risk MMR vaccine. (Control C. f., 2019)

Safety of the Vaccine Manufacturing Process

There have been cases were faulty vaccines were sold and these are usually in India and China, but this is extremely rare in the U.S. The Centers for Disease  monitors vaccine safety and publishes alerts if a recall is necessary. Your clinician would receive notice of the recall and alert patients.

However, it is in our best interest to increase the efficacy of vaccines, not to curb them. A biologist friend of mine recently suggested a solution to increase vaccine safety through testing. Essentially, we would require the vaccine's supplier to perform a random and routine assay test for antibodies in the vaccines. This would be a simple and cost-effective method to assure that the vaccines were real.

Population or Herd Immunity

Preventing the spread of preventable diseases is a public health obligation and the best way to do that is through vaccines. A community needs a vaccination rate of 90% to assure adequate immunity from the disease for a population, which means not your house, but your county, your region. Clark County had a 78% vaccination rate for MMR, which is below the threshold to prevent an outbreak.

Vaccine Exemptions

Washington State is one of 17 states which allow philosophical exemptions for vaccines. In February, Washington passed a House bill to ban philosophical exceptions for vaccines and there have been demonstrations in the state capitol since. Vaccines are proven to prevent disease and the actions of a few individuals should not be allowed to endanger everyone else. This is why we have drivers license testing, speed limits, and background checks for the purchase of weapons. Public safety trumps the individual needs. If parents willfully choose not to vaccinate their children they should not be allowed to enroll in public school. However, the community health risk for everyone else is only partially mitigated by limiting school exposure, because participation in any public activity, such as swimming in the local pool, using the play fields, or public transportation could expose you to preventable disease. Wearing those surgical masks, the Chinese sport everywhere doesn’t seem so odd now.

And this is the healthpolicymaven signing off encouraging you to read good science, make informed decisions, and prudently get your vaccinations. A healthy diet is not going to prevent Measles, Mumps, or Rubella.

This article was written by Roberta E. Winter, author of Unraveling U.S. Healthcare-A Personal Guide, which ranked vaccination rates by state as evidence of public health, and was published by Rowman and Littlefield in 2013. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References

C, S. M. (2010). On-time Vaccination Receipt In The First Year Does Not Adversely Affect Neuropyschological Outcomes. American Journal of Pediatrics, 125(6), 1134-41. Retrieved March 6, 2019, from http://pediatrics.aappublications.org/cgi/content/abstract/125/6/1134

Control, C. f. (2009, October 21). Monovalent M-M-R Vaccines. Retrieved March 6, 2019, from Centers for Disease Control: https://www.cdc.gov/vaccines/hcp/clinical-resources/mmr-faq-12-17-08.html

Control, C. f. (2019, March 6). Vaccine Options Fact Sheet. Retrieved from Centers for Disease Control.gov/Vaccines: https://www.cdc.gov/vaccines/vpd/mmr/hcp/vacopt-factsheet-hcp.html

DeStefano F, P. C. (2013). Case Control Study on Frequency of Vaccines and Risk for Autism. Journal of Pediatrics. Retrieved March 6, 2019

Peltola H, e. a. (1998). No Evidence for Measles, Mumps, and Rubella Vaccine Associated with Autism or Inflammatory Bowel Disease. Lancet, 351, 1327-28.

Medicare For All-An Idea Whose Time May Have Come

With the 2020 Presidential election looming on the horizon and tortuous months of political speeches one thing that clearly sets the Democrats apart from the Republicans, currently in control of the national purse strings, is their vocal promotion of healthcare access and protections for all. Republicans raced into Congress on the anti-Affordable Care Act platform only to learn that voters like their government sponsored healthcare, resulting in their rout in the midterm elections last November. This article reviews the motive, financial implications, and method to assess a national Medicare Plan.

Motive

The United States spends 40% to 60% more for healthcare than any other industrialized country and this does not produce improved health or better outcomes than nations spending considerably less per capita. In 2017 the U.S. spent $10,224 per person for healthcare, as tracked by the Petersen-Kaiser Health System Index Tracker. (Cox, 2019) This total is 28% higher than when my book, Unraveling U.S. Healthcare-A Personal Guide was published in 2013. (Winter, 2013) The next closest country in medical spending was Switzerland which still spent 28% less than the U.S. France, whose health system provides family clinics, coverage for all, and high tech services spent $4,902, less than half of the U.S. And Australia spent only $4,543 per capita for their national healthcare system. Canada spent $4,826 per person for their national healthcare program. Everyone of these industrialized nations are capitalistic in terms of business, but they offer healthcare to all of their citizens.

The cost of healthcare in the U.S. is impeding resources that could be used to improve education, rebuild critical infrastructure such as bridges, and improve the quality of life for most families. By refusing to enact and enforce national healthcare policy the nation continues to be overcharged by profiteers who gouge the American public. The government has the domain to negotiate better policies for drugs, medical devices, and reimbursements at the clinic/hospital level. However, only Bernie Sanders from Vermont, had the political will to actively run on a platform for nationalizing healthcare. This phenomenon all changed with the mid-terms and public polls show a size-able majority of the American people want government run healthcare. Families are tired of being forced to spend more on their health insurance than for housing.  Diabetics are forced to skip their doses, because of the high cost of insulin, which has resulted in deaths. Even seniors, who have benefited greatly from Medicare, the Bush Medicare Modernization Act which provided drug coverage, and the Affordable Care Act which closed the doughnut-hole exclusion for drugs are still gouged for the cost of care. A public case could be made that Medicare enrollees are better off in terms of healthcare access and coverage than working class families in the United States. This situation is untenable financially and politically. The 2020 election will give us a chance to see how far the American people are willing to go to reform their expensive and exclusionary health system.

Means

In 2003, I was part of a team of graduate students at the University of Washington School of Public Health and Community Medicine who analyzed a single payer health system. In fact, I published an article on it in this column in 2009.[1] My role, as an MHA student, was to come up with a financing model that was plausible. For a 3% increase in the payroll tax, born equally by employees and employers, which currently funds Medicare and Social Security, we could implement a national healthcare program.

 A second way to fund healthcare is through an income tax increase, which is how most other nations do it. Crucial information which would inform any financing of a citizen’s initiative would include the 2020 census findings. However, Trump and his administration aren’t anxious to conduct this census and are still seeking to restrict access and questions based on citizenship and other factors.

Social programs are consuming a larger portion of the national budget, which is normal for an aging population. Republicans like to brag about defense budget increases yet rail at any increase in spending for entitlements for our residents. Higher taxes are necessary to even meet the current Social Security and Medicare projects, which must be addressed.

U.S. Proposed Federal Budget-2018	Defense, includes security for national nuclear supply, Veterans Affairs, Homeland Security, State Department, Afghanistan, Iraq, Syrian wars; Does NOT include discretionary private contracting which consumes another 10-20%	Social Security- paid through trust fund until 2032@1.046 trillion Medicare-partially funded by payroll tax Medicaid-100% paid from general fund@1.037 trillion
Proportion of Federal Budget	20%	24%+24%= 47%
$4,407,000,000,000	$892,700,000,000	$2,083,000,000,000

The federal budget item that is growing the fastest is the national deficit, which the Trump Administration exploded with it’s corporate and wealth tax cuts in 2018. Currently the deficit is 985 billion dollars or 22% of the federal budget. (Amadeo, 2019)

Method

Any healthcare program in the U.S. will include private insurance at some level, as Medicare, the healthcare expansion model currently does. The idea that the behemoth private medical insurance industry will go away is wrong. However, private insurance has a much higher administration cost than Medicare/Medicaid, which uses 6% of cash inflows for overhead as opposed to 15-20% for the private sector. And you can expect that the insurance industry/medical/pharma lobby, which is the largest and most well-funded of the shark infested Washington DC lobbying cabal will be drafting the details, just like they did for the Affordable Care Act. They succeeded in eliminating the Medicare-for-all idea during the Obama Administration, but that was just buying time. The longer the nation waits to draft a sane health policy the costlier it will be for the tax payers.

Many employers would thankfully get out of the medical insurance business. Also, a national health policy which has the same costs everywhere, would create an even playing field for business competition and innovation. It will also greatly reduce regulatory costs, which are the bane of clinical staff everywhere. Efficiency could go up in clinics because the doctors and nurses would have more time to actually see patients instead of processing insurance paperwork.

Finally, with national healthcare policy, we could also fund the scary shortage of primary care providers, by providing free medical education (and maybe forgiveness of school loans) to those who go into primary care, such as pediatrics, family practice, and obstetrics.

End to the Madness

Obviously, we will have to enact some type of policy which will mute the overcharging, take back control of generic drug prices, create true price transparency for services, and quit gouging American families. We can hardly expect the Millennials, whom will have to clean up our mess, to pay higher and higher payroll taxes and not get anything in return. We can start by offering affordable healthcare for all, which won’t happen under the current, reimbursement-based-on-the-prevailing-inflated-cost method of pricing.

And this is the health policy maven signing off encouraging you to learn as much as you can about healthcare systems outside the U.S. so that we can build a better one for our people.

Works Cited
Amadeo, K. (2019, January 21). US Federal Budget Breakdown-The Components and Impact on the US Economy. Retrieved from The Balance.com: https://www.thebalance.com/u-s-federal-budget-breakdown-3305789

Cox, B. S. (2019, February 10). How does health spending in the U.S. compare to other countries. Retrieved from Petersen-Kaiser Health System Tracker.org: https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-start

Winter, R. E. (2013). Unraveling U.S. Healthcare-A Personal Guide. In R. E. Winter, Unraveling U.S. Healthcare-A Personal Guide (pp. 31-35). Rowman & Littlefield. 

This article was written by Roberta Winter, a freelance journalist and health policy analyst in the Seattle area.

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[1] https://healthpolicymaven.blogspot.com/2009/08/overhauling-healthcare-czarina-style.html

We Must Stop Torturing Elderly Patients with Unnecessary Medical Procedures

Until this afternoon I was going to post a more policy-oriented article, but I received a call indicating my father-in-law, who is 95 years old, is now in a rehabilitation facility after a fall which did not result in any broken bones. This event resulted in a cardiac surgeon installing a cardiac device in his heart to keep it pumping rhythmically regardless of the patient’s wishes. Mel was not in distress and at age 95 merely had a low heart rate, because he is approaching the end of his life. At this point he is forgetful and in the early stages of dementia. This invasive medical intervention was not solicited by the family and was encouraged only by the medical providers.

Pacemakers are forced on elderly patients all of the time in the United States. It often provides no improvement in quality of life and in fact, contributes to the patient living longer to suffer through dementia, incapacity to perform activities of daily living, and to lose other aspects of a good life. I am anguished that my father-in-law has been subjected to this treatment because it will only prolong his suffering and not improve his life. His mother, Rosemary, died at age 93, active up until the end, so why deny Mel this graceful exit.

 Further, there isn’t a single clinician who would submit to this procedure at that age, so why are they imposing it on their elderly patients?

To further understand how aberrations in the U.S. healthcare system encourage overuse, sales of extremely expensive medical devices, and dehumanization of healthcare, I encourage you to read Katy Butler’s Knocking on Heaven’s Door, The Path Way to a Better Way of Death, which was published in 2013. It is her personal story of how the cardiac pacemaker kept her 93-year-old father alive through dementia and other misery. Here is a link to my review of her book in the New York Journal of Books:

https://www.nyjournalofbooks.com/book-review/knocking-heaven%E2%80%99s-door

Cardiac surgeons are the top earners for physicians and there are tremendous financial incentives to install pacemakers and other cardiac devices on increasing numbers of patients, regardless of viability and efficacy. Mel, with his private insurance can afford to pay whatever the procedures will cost and this is like the “whale” in the healthcare system, the patient whom is so lucrative he will provide financing for a whole host of things in the healthcare system. Doctors in the U.S. don’t make any money for telling a patient to go home and enjoy the last days of their life. They are paid to provide intervention regardless of systemic costs and not to think holistically.

In 2013, my guidebook to the U.S. healthcare system devoted a chapter to creating a good death and I encourage you to read that, so that you may have more control over the last days of your life than Mel has. Here is a link to that book, which is still selling in eBook and hardcover versions:

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

As for me, I hope my son will send me out on raft and set my bones on fire in a true Viking style in spiritual reverence for the veracity with which I have lived my life.

And this is the healthpolicymaven signing off encouraging you to draft medical powers of attorney and don’t leave it up to your children to make these care decisions, appoint a professional clinical advocate.  A sound living will requires more than designating treatments which you will eschew, you need to have a medical advocate who understands the U.S. healthcare system.  And please don’t sign blanket releases when you enter medical facilities, be clear on that for which you consent and that for which you do not.

Happy Holidays

Roberta E. Winter an independent health policy analyst and writer has continuously published this column since 2007. All opinions expressed here are her own and not subject to any corporate or institutional constraints.

Changes Undermining the Affordable Care Act Under the Trump Administration

Since the Republicans took control of the federal legislative agenda in 2016, they have been hell bent on getting rid of the Patient Protection and Affordable Care Act (ACA), known as Obamacare. This 2010 landmark legislation, still covers nearly 12 million enrollees and their families through private insurance plans and was REVENUE NEUTRAL through 2016. Annual open enrollment for Obamacare runs until December 15^th and is accessible through government run insurance exchanges.

Briefly here are the changes the Trump Administration has made to the Affordable Care Act:

1. Removed the individual penalty for lack of medical insurance, which only applied to people who didn’t qualify for any of the existing exemptions, such as; religious objection, insurance falls outside the range of affordability, hardship provision, etc.[1] The Congressional Budget Office has estimated this will cut 338 billion from funding for the Affordable Care Act by 2019.[2]
2. Removed the 2.3% tax from the lucrative medical device industry, which provided funding for the Affordable Care Act; cutting about 3 billion a year from the government subsidized insurance program
3. Cut the open enrollment period in half from twelve weeks to six, which is the period when individuals can elect or change insurance plans without a change in family status
4. Reducing advertising and even web site information on the Affordable Care Act, which has made it more difficult for people to obtain information and enroll. 

Affordable Care Act Affects Most Insurance Plans
The Affordable Care Act impacts nearly all medical insurance plans in the United States through a variety of provisions about nondiscrimination based on health, linking healthcare quality to reimbursements, and standardization of coverage. This table shows where people obtain their insurance in the United States.

Source	Employer Plans	Medicaid	Medicare	Insurance Exchanges	Military	Uninsured
Population Covered	46%	19%	15%	3%	5%	10%

  

Slightly more than half of all U.S. businesses offer medical insurance to their workers (56%).[3] But the rate of employees who obtain medical insurance through work was less than 50% of the population in 2016 (49%). The rate of employer coverage also depends on where you live.  Private employers receive 250 million in tax subsidies for offering medical insurance to their workforce.[4]

This map from the Kaiser Family Foundation State Health Facts site shows the percentage of employers which provide medical insurance for their employees across the United States.

  

Though the Trump Administration has cut funding for the promotion and support of the ACA in 2018 there were nearly as many participants as in previous years. People like the access to an array of insurance plans which are subsidized by government tax credits and enrollment has remained steady over the years. Further, many of those covered under the ACA lacked access to healthcare before 2010, because they work for employers who do not provide health insurance, are self-employed, disabled, or have a pre-existing condition.

Next Up on the Trump ACA Attack

The Affordable Care Act mandates that insurance companies may not discriminate or deny coverage to persons with pre-existing conditions. The Trump Administration wants to reduce this protection by allowing insurance companies to circumvent the ACA requirement by offering contracts not subject to the ACA protections. These types of contracts already exist and take the form of travel insurance policies or special risk contracts. Student insurance is another example, but since the ACA allows youth to remain on their parents medical plan until age 26, those have declined in popularity. Also, many students are enrolled on Medicaid plans while they complete their education. Foreign students must obtain private medical insurance, which is offered through their universities. Make no mistake about it, offering more restrictive but cheaper insurance contracts hearkens back to the old insurance offerings including; life time limits on benefits, exclusions for certain conditions, conditional insurability, and other fine print.

The Trump Administration also sought to eliminate the risk sharing funding that insurance companies received, as a part of the ACA, to offset higher costs from accepting all people, regardless of health, and not being able to charge more for risk in the insurance exchanges. However, for the moment this effort has been defeated due to lack of Congressional support, which will erode further when the Democrats take back the House of Representatives in January. 

And this is the healthpolicymaven wishing you a content Thanksgiving and encouraging you not to sign blanket release forms for medical procedures, do stipulate that for which you consent and that for which you decline. Also, be careful about the information you share with insurance companies, which will be used to figure out what to charge and how to market to consumers, not necessarily to improve your health.

 Roberta Winter is a freelance writer and health policy analyst and all opinions expressed here are her own, not subject to corporate funding or dictates. She is the author of a guidebook to the U.S. healthcare system, https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

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[1] http://healthpolicymaven.blogspot.com/2015/12/understanding-your-accountability-under.html

[2] https://www.cbo.gov/publication/53300

[4] https://www.commonwealthfund.org/blog/2017/decline-employer-sponsored-health-insurance

Trump Administration Shoots Foot While In Mouth

How the Trump Administration Shot Itself In the Foot

According to national demographics, white voters vote at a higher rate than other groups, but the proportion of white votes is diminishing based on the age of dinosaurs like evangelical minister, Pat Roberts. I am still shaking my head in disbelief that this nonagenarian preacher was trotted out as some foreign policy expert on Fox News to make excuses for the Saudi murder of journalist and House of Saud critic, Jamal Khashoggi. Evangelical Christians, who are apparently behind the Kavanaugh appointment and many other Trump era efforts, make up only 25.4% of the nation or about half of all protestants and yet are dictating futures to us all. The second largest demographic group for religion are those who are unaffiliated, agnostic, or atheist representing 29.9% of the nation. Those reporting Catholic as their religion accounted for 23%. The fastest growing religion in the US is Islam.

A quick analysis reveals that the diminishing white Christian majority will not be the majority for much longer. Experts predict that by 2045 the US Caucasian or white population will be the minority, and it could happen before then. I for one, expect to be alive at that point, and welcome the diversity. The religious right-wing minority dictates to the Trump Administration and represent a last gasp to reverse this inevitability. Unfortunately, rising temperatures and sea levels are also edging toward the 2 degrees mark in global warming. I can just hear the eschatologically inclined orgasmicly describing their day of revelation. Unfortunately for the more sentient, this is no comfort for the rest of the nation or the planet for that matter.

Short of putting a finger in the proverbial dike, what can the rest of us do to stop the march to the end of environmental live-ability? It comes down to the math, the Republicans cannot afford to lose the white suburban female vote and hold on to their majority. More than twice as many voters with university degrees voted for Clinton than Trump, both male and female representing 30% of the electorate. Among whites with less than a four-year-degree, 64% voted for Trump, representing 44% of all voters. However, the proportion of those women who voted for Trump was a lot smaller than male voters, with 54% voting for Clinton, based on Pew Research.  

 Thanks to Orin Hatch, Lindsey Graham, and President Trump’s performance before and after the Kavanaugh/Dr. Ford hearing, they may have already lost those votes. Women, no matter how conservative, do not consider sexual assault a laughing matter, taunting the victim of a sexual assault is considered an offense of the highest order, and calling women dogs and other animal euphemisms doesn’t play well either. I think its clear this charmless Republican bunch has already shot itself in one of their club feet. Expecting the rest of us to just “lay back and enjoy it” is asking a bit much. We’ll see how it blows up on November 6^th.

Curing Type 1 Diabetes

Type 1 Diabetes is an autoimmune disease where the pancreas cease producing insulin, which is essential for the body to process hormones for regulating bodily fuel or sugar. Without insulin Type 1 Diabetics will die. At present there is no cure for diabetes, but the administration of insulin allows most diabetics to function normally. However, the disease is fraught with all kinds of comorbidities or side affects such as failing vision, circulatory problems, nerve damage, and increased risk of infections frequently leading to amputations. Diabetics often end up on kidney dialysis, which reduces life expectancy and increases the risk of infections even more. According to the Centers for Disease Control and Prevention (CDC) 50% of patients with chronic kidney disease are diabetic.

Approaches to Curing Diabetes

Scientific studies for potential cures for Type 1-Diabetes include:

1.  Cellular manipulation by removing the attacking mutation to restore normal pancreatic function
2. Possible vaccines to prevent diabetes
3. Increased public health surveillance to screen for those at risk of diabetes before they lose their pancreatic function

 All approaches are focused on preventing damage and intervening before diabetes has ravaged the pancreas. Once a person ceases to create insulin the only way to change that is through a transplant, which must come from a deceased donor, as a pancreas is an essential organ.

Current Research to Detect Those at Higher Risk for Diabetes
The T-1 study through Benaroya Research Institute examines tissue samples from people with increased risk of diabetes, which is based on a screen for the presence of islet autoantiboides and the genetic risk for diabetes. Through the application of scientific methods Dr. Marika Bogdani, MD, PhD and her research team at BRI have identified cellular behaviors indicating which individual human samples likely represent early and advanced stages of damage in insulin making tissue inside the pancreas. Her team is researching this cellular behavior with the goal of blocking the agent which damages the pancreas in high-risk individuals. Dr. Bogdani's research shows that people with Type 1 Diabetes have a modified islet cell which produces more Hvaluronan (HA). Her research recently showed these cells are modified earlier before the onset of diabetes in individuals whom have these hostile islet autoantibodies. The very presence of these antibodies is an indication of cellar damage for insulin producing cells. In scientific terms, possessing two or more of these antibodies and the presence of the observed genotype is an indication of increased risk for developing Type 1 Diabetes. There are stages of diabetes before someone requires insulin and the first stage of the disease is the presence of these antibodies. The second stage is called dysglycemia and the third stage is insulin dependency.

Next Steps in Research and Clinical Application

Dr. Bogdani's group is now studying how the timing of this cellular modification impacts insulin cell function and survival, which will illuminate how to effectively minimize pancreatic damage. Current study of islet cells will also reveal which cells, such as endocrine or mesenchymal, are creating the HA growth and what causes the cells to make HA. This will lead to further refinements in potential clinical interventions.  

https://diabetesresearchconnection.org/cause/offensive-blocking-to-defeat-t1d-before-it-strikes/

Current Clinical Applications at the Patient Level

Scientifically there is enough information to be able assess individual risk for diabetes through blood samples. The increased presence of HA in the islet cells is an indication of Type 1 Diabetes at a very early stage and the Trialnet study screens for these antibodies. For more information on participating in the Trialnet study go to Benaroya Research Institute’s site:

https://www.benaroyaresearch.org/our-research/diabetes-clinical-research/find-study/trialnet-pathway

https://www.benaroyaresearch.org/blog/post/fighting-type-1-diabetes-one-blood-draw-time

Next Steps in A Public Health Intervention

 Primary healthcare should include diabetic screening tests, not just for adults, but for children as well, as Type 1-Diabetes primarily strikes children and young adults. Screenings could be done by individual clinicians during the annual wellness exams.

 A more comprehensive approach would be to screen all school-age children. Since many diabetics do not realize they have the disease until quite late in its gestation, this would provide greater population surveillance of this costly disease. The earlier a person is screened for diabetes the less damage the antibodies can cause to pancreatic function. It is possible to intervene while an individual still has pancreatic function. Earlier diagnosis in disease progression is best.

The author rode from Washington State to Napa, California in eight days, to raise awareness about the plight of diabetics, and raised $5,000 for the Benaroya Research Institute, to fund medical research to cure Type 1 Diabetes. She is the author of a guidebook to the U.S. healthcare system, which was published by Rowman and Littlefield in 2013.
 https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972. 

This column has been continuously published since November 2007, the year her brother, Russell died from complications of Type 1 Diabetes.
This is the healthpolicymaven signing off, encouraging you not to sign blanket releases, but do specify that for which you consent and that for which you do not before you undergo a medical procedure.

Your Health and the Environment Trampled by Trump

Scientists knew about the dangers of global warming in 1957,[1] the year I was born, and in 1970 the Environmental Protection Agency was created under the Nixon Administration.[2] After 40 years of protections and environmental cleanup of super fund pollution sites, the Trump Administration wants to roll the clock back to the pre-Nixon era of toxic dumping, energy inefficiencies, and blatant disregard for public health.

Taking Responsibility

The Paris Climate Accord is a voluntary agreement by the major industrial nations and 174 total countries to recognize the catastrophic effects of global warming and attempt to do something about it. The 2016 climate accord’s goal is to limit global warming to no more than 2 degrees.  The odds of meeting this target are slim (1 in 20) and require drastic changes in human behavior, which include; reducing carbon dioxide levels generated by; coal burning, fossil fuel powered vehicles, and industrial pollution from CFC’s and other poisons. Scientists have been studying global warming for sixty years, through core ice samples, air quality tests on top of mountains, and space surveillance of the ozone layer. There is plenty of scientific evidence to validate the unprecedented global warming the world is now experiencing and the link to human causes. Under the Trump Administration the United States dropped out of the Paris Accord, leaving China to absorb a leadership role in compliance. The U.S. is the single largest contributor to global warming on a per capita basis, which means the proportion of carbon generated from each US resident is far greater than the rest of the world. The top three countries for global warming carbon emissions are; China, United States, and India.[3]

What happens if we exceed 2 degrees warming

To put the challenge of an uncontrolled warming of the earth into perspective, here is what is currently happening to harm our world and the delicate mixture of oxygen and carbon on which we all rely.

Dying Oceans Which Support Biodiversity and Serve as the World’s Air Conditioner

Massive decline in coral and seagrass resources, which support sea life and provide food for fish and humans has already occurred. This precipitous decline could contribute to a dead ocean at some point, unable to support much of the biodiversity we now have. Besides food, we also rely on the oceans for medicine and even cosmetic products, so a real decline in Gross National Product will occur with loss of ocean habitat. Island nations which are hyper dependent on the seas, like Japan, the Philippines, and all South Pacific Islanders will experience the greatest losses.

Permanent Rise in Sea levels

Antarctic ice is melting and the Ross Ice Shelf alone will raise sea levels by several meters. A sea level raise of three meters is nearly ten feet and that means that millions of people throughout the world will have to evacuate their current homes. All coastal cities would be affected.  I live in a coastal city off of Puget Sound (recently renamed the Salish Sea) and at present I am about 39 feet above sea level. By 2050 it is expected this will be reduced by 10%. At that rate, here is a map showing how the rise of sea levels will impact the United States. At least 270 households live at sea level on low or no bank property, which would be susceptible to a sea level rise of 4 feet in my city. In Seattle 800 households are living on land susceptible to a sea level rise of 4 feet, which is expected to occur, by 2050, at least during storms. You can use the risk finder map to see how your community would be impacted by a four-foot sea rise.

https://riskfinder.climatecentral.org/place/bremerton.wa.us?comparisonType=place&forecastType=NOAA2017_int_p50&level=4&unit=ft

You will recall that New York City’s subways were flooded during the last hurricane. Boston, is already at sea level and much of the city would be flooded. Ditto for Washington, D.C., all of Florida, Houston, New Orleans, the entire Gulf Coast region, and much of the west coast. Here is a map showing how many households would be affected throughout the U.S. with a sea level rise of 4 feet.  

http://www.climatecentral.org/news/us-with-10-feet-of-sea-level-rise-17428

https://www.nytimes.com/interactive/2018/04/20/sunday-review/climate-flood-quiz.html

Water Shortages

Global warming means there will be less snowpack and that means less water in the rivers and aquifers. This means Washington and Oregon will have less water to sell to California, where half of the state is a desert. Colorado will also have less water to offer California, New Mexico, Texas, and Arizona as the mighty Colorado will not be refilled with as much water from the less snowy Rocky Mountains. Much of the produce in the United States comes from Southern California and water rights will dominate the politics there.

In addition to flooding and loss of useable land, salt water incursion will occur in water reservoirs, which are underground aquifers. This means drinkable water will be greatly reduced in coastal areas and of course, island communities. Lopez Island and others may become unable to sustain populations due to lack of drinking water. Salt water desalination is already being used by those who can afford it on Whidbey Island. Goodbye ten-minute showers, hello compost toilets, and forget about washing your car.

Global warming also means higher and higher temperatures and environmental stress on current power systems and water supplies. Farming in the deserts of Arizona, California, Texas, and Mexico will no longer be sustainable. This phenomenon is already happening in Arizona, where family wells have run dry because of industrial farming demands.[4] It is highly likely a new dust bowl era will occur in the Midwest, including Oklahoma, Arkansas, Nebraska, destroying the livelihoods of millions.

Massive hurricanes and other wind storms will occur with greater ferocity. Yet the Trump Administration did not require that FEMA funded rebuilding after the 2017 hurricanes meet storm surge standards which were developed under the Obama Administration. This is an expensive folly which will be paid for by taxpayers. All of these scenarios are happening now and will only worsen in the next twenty-years.

Trump Administration Actions Which Increase Global Warming

This table shows Trump Administration actions which seek to roll back environmental protections to the Reagan era, by minimizing enforcement and standards for the Environmental Protection Agency.

Environmental Factor	Current Law	Trump Actions
Clean Air Act established by Congress in 1963, but amendments were added in 1970 and 1990; restricts emissions of harmful pollutants which cause asthma, COPD, and other health problems	Standards are set based on scientific evidence, which are meant to reduce adverse health impacts and environmental harms; these data are drawn from long term studies, which are observational and include solid data measurement criteria and statistical analysis	Trump has cut the NASA climate monitoring program; his administration doesn’t want to measure emissions standards, wants to change scientific standards for administering the Clean Air Act; 1,000 scientists have signed a petition protesting Trump’s rewriting of science rules which may be applied to the EPA; also cutting funding for voluntary emissions reducing programs[5]
Clean Water Act was enacted in 1948 and expanded in 1972; prior to this act industrial pollutants were contaminating ground water unimpeded, feel free to Google the Love Canal for more information	Obama Administration rule would limit fertilizer run off into streams, which produce harmful algae blooms, harm fisheries, and impact drinking and recreational water quality; the rules were meant to protect large ecosystems like Chesapeake Bay and Puget Sound from stream and river runoff impacts	January 2018, Trump’s EPA suspended the enforcement of these rules; Essentially this administration says that people in urban areas must comply with environmental protections but those in rural areas are exempt; For example, much of the City of Bremerton (40,000 people) has secondary treatment for storm runoff through the sewer system
Auto Emissions Standards are codified to include measurement of greenhouse gas emissions; for example, auto exhaust measurement in order to renew license tabs, as a compliance mechanism for the California emissions standards, which were effective in 2001[6]	California has its own stricter emissions standards to reduce greenhouse gas emissions and this represents 1/3 of all vehicles in the US, 13 other states, including Washington use this standard; federal standards were stipulated in a 1965 amendment to the Clean Air Act	August 2018, Trump revokes a legal waiver for California under the 1970 Clean Air Act allowing them to mandate stricter air quality standards for emissions and fuel efficiency; federal standards will be rolled back to pre-1970 pollution standards and mute the sale of clean fuel vehicles
Fuel Efficiency Requirements for cars, light trucks, and SUV’s, reduce fossil fuel pollution without impeding transportation efficiency; electric and alternative fuel vehicles have been mass produced for 20 years; one third of all electric cars in the US are in California	American autos average 26 miles per gallon fuel efficiency now, Obama raised the standard to 54 MPG by 2025; fuel efficiency in Europe is 56.8 MPG and 56.6 in South Korea; the rest of the world is way ahead of the US in fuel efficiency in transportation	Trump rolled back fuel efficiency standards to 37 MPG, also revokes California’s stricter fuel efficiency requirements; 19 states are currently suing the federal government over this executive order[7]
Obama protocols curbed Power Plant Pollution, cutting methane gases and greenhouse gases called hydrofluorocarbons; targeted coal power plants	The Obama Administration created a clean power plan to reduce emissions by 32% by 2030[8]	Trump EPA scrapped the clean power plant mandate to reduce emissions from coal power plants, which kill forests and have harmful health impacts
Building Code updating due to climate change impacts, especially in coastal areas; 128 military installations are at high risk for flooding[9]	Both the Bush and Obama Administrations included climate change for emergency planning; Obama criteria included changing building codes for flood prone areas to mandate construction of key roads and bridges above flood levels	Trump won’t allow FEMA to consider climate change in federal emergency planning nor will it require upgrading building codes for flood prone areas, even for public infrastructure

[10]

Action Required-What You Can Do

Here is a list of things I have done to reduce my impact on the environment over the past forty years: 

1. Ride a bicycle-you save money, stay fit and it provides zero pollution
2. Use public transportation instead of a single occupancy vehicle (where possible) 
3. Share a ride through one of the ride sharing options 
4. Produce less waste-don’t buy plastic, use recyclable bags, eschew straws, buy in bulk
5. Cook and grow some of your own food
6. Recycle what you can and give things away rather than toss them into a landfill 
7. Be mindful about purchasing things, repair things rather than throwing them away
8.  Buy less but do more-do more hiking, biking, and swimming but make fewer trips to the mall
9. Join recreational clubs where you can share access to boats and recreational equipment
10. Buy recycled products when possible
11. Use natural cleaning products you can make yourself from vinegar and oranges at home
12. Design gardens which do not require poisons to maintain  
13. Collect rain water, through rain gardens or other catchment systems
14.  Increase the energy efficiency of your home by installing insulated window coverings and other energy saving features
15. Avoid Styrofoam containers and packing, but recycle it if you receive a package containing it
16. Do not buy any products which have CFC’s in them, which greatly increase global warming because they stay in the atmosphere including: aerosol sprays, solvents, foam blowing agents-like insulation, and refrigerants. Nasal inhalers for asthmatics are now available in the US which are CFC free. Refrigerants manufactured after 2010 are less harmful than before, so newer appliances help. Refrigerants must be handled by EPA certified contractors and that includes decommissioning.
17.  Do not buy vehicles with poor fuel efficiency, refuse to buy cars or trucks which do not meet the EPA emissions standards of California, which have been adopted by 15 other states (Arizona's governor repealed theirs in 2012). Here is a list of states which have adopted the California Emissions Standards-California, Connecticut, District of Columbia, Maine, Maryland, Massachusetts, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, and Washington[11]
18. Do not book or attend conferences or conventions in states which refuse to support healthy environmental practices and are stripping the power of the EPA.    
19. Work with the National Resources Defense Council and other advocacy groups to contact your legislators and prevent the wholesale gutting of the clean air and clean water provisions of the Environmental Protection Acts. We cannot afford to go backwards, as our lives are at stake, this is about much more than profits.   
20. Follow federal and state legislation that will adversely impact your health. Here are some links:

https://www.neha.org/about-neha/advocacy
https://www.congress.gov/state-legislature-websites

And finally, get involved politically, most importantly vote, in local elections, in state elections, and at the national level. Save the planet before we all burn up or drown-get Trump out of office!

And this is the healthpolicymaven signing off, encouraging you not to sign blanket waivers when consenting to medical procedures or hospital admissions. Do specify that for which you consent and that for which you decline, otherwise your health is subject to medical policies based on someone else’s religion, values, or business plan. If you need help with this, bring a patient advocate to your pre-op session.

Roberta Winter is a freelance writer and healthpolicy analyst who has continuously published Straight Talk on Healthcare since 2007. Her writing has been published by Rowman and Littlefield, the New York Times, the New York Journal of Books, and she has served as a peer reviewer and technical editor for healthcare  publications. She has continuously published under the healthpolicymaven trademark since 2007. All opinions expressed here are hers and are not subject to any corporate or institutional approval.

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[1] https://www.nytimes.com/interactive/2018/08/01/magazine/climate-change-losing-earth.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=photo-spot-region&region=top-news&WT.nav=top-news

[2] https://www.epa.gov/history

[3] https://www.ucsusa.org/global-warming/science-and-impacts/science/each-countrys-share-of-co2.html#.W2RvB9JKjIU

[4] https://www.nytimes.com/2018/07/19/magazine/the-water-wars-of-arizona.html

[5] https://news.nationalgeographic.com/2017/03/how-trump-is-changing-science-environment/

[6] https://www.dieselnet.com/standards/us/ld_ca.php

[7] http://www.latimes.com/politics/la-pol-ca-vehicle-emissions-lawsuit-20180501-story.html

[8] https://news.nationalgeographic.com/2017/03/how-trump-is-changing-science-environment/

[9] https://www.npr.org/sections/thetwo-way/2017/08/16/543712263/trump-rolls-back-obama-era-flood-standards-for-infrastructure-projects

[10] https://www.nytimes.com/2018/08/02/climate/trump-auto-emissions-california.html

[11] https://www.greencarreports.com/news/1109217_which-states-follow-californias-emission-and-zero-emission-vehicle-rules