Public

SECTION I

Cases and Discussion Questions

© Elena Elisseeva/ShutterStock, Inc.

HIV/AIDS DETERMINANTS AND CONTROL OF THE EPIDEMIC

A report appeared in the CDC’s “Morbidity and Mortality Weekly Report” (MMWR) on June 5, 1981, describing a previously unknown deadly disease in five young homosexual males, all in Los Angeles. The disease was characterized by dramatically reduced immunity, allowing otherwise innocuous organisms to become “opportunistic infections,” rapidly producing fatal infections or cancer. Thus, acquired immune deficiency syndrome (AIDS) first became known to the public health and medical communities. It was soon traced to rectal intercourse, blood transfusions, and reuse of injection needles as methods of transmission. Reuse of needles was a common practice in poor nations. It was also widespread among intravenous drug abusers. Within several years, the disease was traced to a previously unknown retrovirus, which came to be called the human immunodeficiency virus (HIV).

A test was developed to detect the disease and was first used in testing blood for transfusion. Within a short period of time, the blood supply was protected by testing all donated blood, and transmission of HIV by blood transfusion became a rare event. Diagnostic tests for HIV/AIDS soon became available for testing individuals. For many years, these were used by clinicians only for high-risk individuals. In recent years, HIV testing has become more widely used, as the testing no longer requires blood drawing and the results are rapidly available. The CDC has put increasing emphasis on testing as part of routine health care.

In subsequent years, much has been learned about HIV/AIDS. Today, it is primarily a heterosexually transmitted disease with greater risk of transmission from male to females than females to males. In the United States, African Americans are at the greatest risk. Condoms have been demonstrated to reduce the risk of transmission. Abstinence and monogamous sexual relationships likewise eliminate or greatly reduce the risk. Even serial monogamy reduces the risk compared to multiple simultaneous partners. Male circumcision has been shown to reduce the potential to acquire HIV infection by approximately 50%.

In major U.S. cities, the frequency of HIV is often greater than 1% of the population, fulfilling the CDC definition of “high risk.” In these geographic areas, the risk of unprotected intercourse is substantially greater than in most suburban or rural areas. Nearly everyone is susceptible to HIV infection, despite the fact that a small number of people have well documented protection on a genetic basis.

Maternal-to-child transmission is quite frequent and has been shown to be largely preventable by treatments during pregnancy and at the time of delivery. CDC recommendations for universal testing of pregnant women and intervention for all HIV-positive patients have been widely implemented by clinicians and hospitals and have resulted in greatly reduced frequency of maternal-to-child transmissions in the developed countries and in developing countries in recent years.

Medication is now available that greatly reduces the load of HIV present in the blood. These medications delay the progression of HIV and also reduce the ease of spread of the disease. These treatments were rapidly applied to HIV/AIDS patients in developed countries, but it required about a decade before they were widely used in most developing countries. Inadequate funding from developed countries and controversies over patent protection for HIV/AIDS drugs delayed widespread use of these treatments in developing countries.

New and emerging approaches to HIV prevention include use of antiviral medications during breastfeeding, postcoital treatments, and rapid diagnosis and follow-up to detect and treat those recently exposed.

Discussion Questions

1. Use the BIG GEMS framework to examine the factors in addition to infection that have affected the spread of HIV and the control or failure to control the HIV/AIDS epidemic.

2. What roles has health care played in controlling or failing to control the HIV/AIDS epidemic?

3. What roles has traditional public health played in controlling or failing to control the HIV/AIDS epidemic?

4. What roles have social factors (beyond the sphere of health care or public health) played in controlling or failing to control the HIV/AIDS epidemic?

SMOKING AND ADOLESCENTS—THE CONTINUING PROBLEM

The rate of smoking in the United States has been reduced by approximately one-half since the 1960s. However, the rate of smoking among teenagers increased in the 1980s and 1990s, especially among teenage females. This raised concerns that young women would continue smoking during pregnancy. In addition, it was found that nearly 90% of those who smoked started before the age of 18, and in many cases at a considerably younger age.

In the 1980s and most of the 1990s, cigarette smoking was advertised to teenagers and even preteens, or “tweens,” through campaigns by companies such as Joe Camel. In recent years, a series of interventions directed at teenagers and tweens was put into effect. These included elimination of cigarette vending machines, penalties for those who sell cigarettes to those under 18, and elimination of most cigarette advertising aimed at those under 18. In addition, the Truth® campaign aimed to convince adolescents, who often see smoking as a sign of independence from their parents, that not smoking is actually a sign of independence from the tobacco companies who seek to control their behavior. Evaluation studies concluded that these interventions have worked to reduce adolescent smoking by about one-third.

Despite the successes of the early years of the 2000s in lowering the rates of cigarette smoking among adolescents, the rates have now stabilized at over 20%. Evidence indicates that adolescents who smoke generally do not participate in athletics, more often live in rural areas, and are more often white and less often African American. Males and females smoke about the same amount overall, but white females smoke more and Asian females smoke less than their male counterparts.

New drugs have recently been shown to increase the rates of success in smoking cessation among adults with few side effects. Evidence that the benefits are greater than the harms in adolescents is insufficient to recommend them for widespread use because of increased potential for adverse effects, including suicide. A series of interventions has been suggested for addressing the continuing problem of adolescent smoking. These include:

•   Expulsion from school for cigarette smoking

•   Focus on adolescents in tobacco warning labels

•   Selective use of prescriptions for cigarette cessation drugs

•   No smoking rules for sporting events, music concerts, and other adolescent-oriented events

•   Fines for adolescents who falsify their age and purchase cigarettes

•   Higher taxes on tobacco products

•   Rewards to students in schools with the lowest smoking rates in a geographic area

•   Higher auto insurance premiums for adolescents who smoke

•   Application of technology to reduce the quantity of nicotine allowed in tobacco products to reduce the potential for addiction

•   Testing of athletes for nicotine and exclusion from competition if they test positive

•   Encouragement of the use of e-cigarettes, which utilize smokable nicotine but not cancer-causing components of cigarettes

•   Provision of tobacco counseling as part of medical care covered through insurance

Discussion Questions

1. How does this case illustrate the P.E.R.I.E. process?

2. Which of these interventions do you think would be most successful? Explain.

3. How would you classify each of these potential interventions as education (information), motivation (incentives), obligation (required), or innovation (technological change)?

4. What other interventions can you suggest to reduce adolescent smoking?

REYE’S SYNDROME: A PUBLIC HEALTH SUCCESS STORY

Reye’s Syndrome is a potentially fatal disease of childhood that typically occurs in the winter months at the end of an episode of influenza, chicken pox, or other acute viral infection. It is characterized by progressive stages of nausea and vomiting, liver dysfunction, and mental impairment that progress over hours to days and result in a range of symptoms, from irritability to confusion to deepening stages of loss of consciousness. Reye’s Syndrome is diagnosed by putting together a pattern of signs and symptoms. There is no definitive diagnostic test for the disease.

Reye’s Syndrome was first defined as a distinct condition in the early 1960s. By the 1980s, over 500 cases per year were being diagnosed in the United States. When Reye’s Syndrome was first diagnosed, there was over a 30% case-fatality rate. Early diagnosis and aggressive efforts to prevent brain damage were shown to reduce the deaths and limit the mental complications, but there is no cure for Reye’s Syndrome.

In the late 1970s and early 1980s, a series of case-control studies compared Reye’s Syndrome children with similar children who also had an acute viral infection, but did not develop the syndrome. These studies suggested that use of aspirin, then called “baby aspirin,” was strongly associated with Reye’s Syndrome, with over 90% of those children afflicted with the syndrome having recently used aspirin.

Cohort studies were not practical because they would require observing very large numbers of children who might be given or not given aspirin by their caretakers. Randomized controlled trials were neither feasible nor ethical. Fortunately, it was considered safe and acceptable to reduce or eliminate aspirin use in children because there was a widely used alternative—acetaminophen (often used as the brand name Tylenol)—that was not implicated in the studies of Reye’s Syndrome.

As early as 1980, the CDC cautioned physicians and parents about the potential dangers of aspirin. In 1982, the U.S. surgeon general issued an advisory on the danger of aspirin for use in children. By 1986, the U.S. Food and Drug Administration required a Reye’s Syndrome warning be placed on all aspirin-containing medications. These efforts were coupled with public service announcements, informational brochures, and patient education by pediatricians and other health professionals who cared for children. The use of the term “baby aspirin” was strongly discouraged.

In the early 1980s, there were over 500 cases of Reye’s Syndrome per year in the United States. In recent years, there have often been fewer than 5 per year. The success of the efforts to reduce or eliminate the use of “baby aspirin” and the subsequent dramatic reduction in the frequency of Reye’s Syndrome provided convincing evidence that aspirin was a contributory cause of the condition and its removal from use was an effective intervention.

Discussion Questions

1. How does the Reye’s Syndrome history illustrate the use of each of the steps in the P.E.R.I.E. process?

2. What unique aspects of Reye’s Syndrome made it necessary and feasible to rely on case-control studies to provide the evidence to help reduce the frequency of the syndrome?

3. What types of methods for implementation were utilized as part of the implementation process? Can you classify them in terms of when, who, and how?

4. How does the Reye’s Syndrome history illustrate the use of evaluation to demonstrate whether the implementation process was successful?

SUDDEN INFANT DEATH SYNDROME (SIDS)

Sudden infant death syndrome, or SIDS, was first recognized as a distinct public health problem in the late 1960s when over 7,000 infants each year were found to die suddenly and unexpectedly. “Crib deaths” have been recognized for centuries, but until they were formally recorded and investigated, little was known about their cause, leading some to conclude that intentional or unintentional suffocation by parents or caregivers played an important role.

Data from the investigations of SIDS indicated that the syndrome was very rare before babies’ first month of life, increased during the second month, and peaked during the third month, before rapidly declining in frequency to again become rare after the fourth month of life. The timing of SIDS suggested that the condition occurs after infants begin to sleep for extended periods but prior to the time in which children can raise themselves up and roll over on their own. Additional evidence suggested a seasonal trend, with more cases of SIDS occurring during cold weather months than during warm weather months.

In the 1980s, several case-control studies of SIDS cases and similar infants without SIDS established that infants who slept on their stomachs were at substantially increased risk of dying from SIDS. The studies indicated that the chances increased four to seven times, suggesting that if a cause-and-effect relationship exists, a clear majority of SIDS cases could be prevented if infants slept on their back. Many parents and clinicians remained skeptical because the traditional teaching emphasized sleeping prone, or on the stomach, to reduce the possibility of choking on regurgitation and vomit. Despite the lack of evidence for this hazard, generations had been raised on this practice and belief.

Additional evidence of the effectiveness of a “back-to-sleep” intervention was provided by the experience of New Zealand, which was the first country to begin a program to encourage caretakers to put infants to sleep on their backs. The rates of SIDS in New Zealand declined rapidly in parallel with the increased rate at which infants were put to sleep on their back. Similar declines in SIDS did not occur in other countries that had not yet instituted similar back-to-sleep programs.

In 1992, the American Academy of Pediatrics made a recommendation that infants be placed on their back to sleep. The initial recommendations also endorsed side sleeping. In 1994, with the support of the American Academy of Pediatrics, the National Institutes of Health (NIH), and the U.S. Public Health Service, the Back-to-Sleep campaign was launched. The educational campaign included public service announcements, brochures and other publications, including information accompanying new cribs, plus efforts for pediatricians and others who care for infants to educate parents and caretakers about the importance of having infants sleep on their backs.

The frequency of infants sleeping prone in the United States was found by survey data to be reduced from approximately 70% to less than 15% during the years immediately following the initiation of the Back-to-Sleep campaign. During these years, the rates of SIDS fell by approximately 50%, an impressive change but less than expected by the initial data. The rate of prone sleeping among African Americans was found to be over twice as high as the rate among whites, and African American infants continued to have higher rates of SIDS than whites.

Continuing studies suggested that the side position was being commonly used. It was found that many infants moved from the side to the prone position, and movement from the side to the prone position carried a high risk of SIDS. Additional case-control studies suggested that soft objects and loose bedding as well as overheating were associated with SIDS. These relationships are consistent with the initial finding of an increase of SIDS in colder weather months.

Studies of the infants who slept on their back indicated an increasing in flattening of the head, or plagiocephaly. These changes were shown to be reduced by increasing the amount of “tummy time,” or play periods in which infants are placed prone under supervision. Guidelines for tummy time are now part of the evidence-based recommendations.

SIDS continues to be an important cause of infant mortality, and new contributory causes continue to be investigated. SIDS reflects the use of evidence-based public health and the importance of continuing to study and develop new approaches to public health problems.

Discussion Questions

1. Discuss how the problem description component of the evidence-based public health approach suggested hypotheses for the etiology of SIDS.

2. Discuss the types of evidence used to support the relationship between sleeping prone and SIDS as well as the limitations of the evidence.

3. Discuss how the evidence-based recommendations incorporated potential benefits and harms.

4. Discuss how implementation and evaluation worked to establish sleeping on the back as a standard intervention to prevent SIDS.

5. Discuss how the continuing presence of the problem of SIDS has produced a new round of use of the evidence-based public health approach.

OXYGEN USE IN PREMATURE INFANTS AND BLINDNESS

Oxygen seemed like just what premature infants needed to address the underdevelopment of their lungs, which often led to pneumonia and death. Thus in the 1940s, after effective means were developed to administer oxygen to pilots in World War II, physicians began to routinely administer high-dose oxygen to nearly all premature infants. The unexpected association between high-dose oxygen and blindness only became established after over 10,000 premature infants, including its most famous victim, Stevie Wonder, developed blindness.

The first hint of a problem came in 1942, when a report of five cases of blindness of premature infants in which no other cause could be determined appeared in the research literature. Once the condition became known, many more cases were identified that met this definition. The process that produced blindness could be seen upon examining the back of the eye during a clinical examination. Proliferation of blood vessels followed by scarring or fibrosis called retrolental fibrosis (RLF), with subsequent detachment of the retina, could be seen in severe cases that had produced blindness.

Using case-control studies, researchers quickly recognized an association between state-of-the-art medical care provided at the most up-to-date medical centers and blindness due to severe RLF. They examined a range of factors associated with state-of-the-art medical care. Reports of constriction of the retinal arteries in fighter pilots given high-dose oxygen led researchers to look for and find similar findings in infants. They found that longer durations of oxygen administration were associated with longer term and more severe retinal artery constriction.

Reinforcing the accumulating clinical evidence were studies of high-dose oxygen use in a variety of animal species. High-dose oxygen used in premature kittens produced retinal damage similar to RLF. The pattern of constriction of the retinal arteries of kittens while on high-dose oxygen was followed by proliferation of new blood vessels similar to that seen leading to scarring or fibrosis in human infants with RLF.

A cohort study was soon conducted in three hospitals in Melbourne, Australia. One had incubators that could give premature infants air with 2 or 3 times the 20% concentration of oxygen in atmospheric air. The second used a less efficient way of delivering oxygen. The third required patients to pay for supplementary oxygen, so oxygen was rarely used. The medical records for 1948 through 1950 revealed that at the hospitals where oxygen was given most intensively, 19% of premature babies developed evidence of RLF. At the other two, where it was used less aggressively, the rate was only 7%.

A large randomized controlled trial was needed to convince clinicians to restrict the use of oxygen for premature infants, especially because clinicians were concerned that restrictions in oxygen use would result in brain damage and a higher mortality rate. A large randomized controlled trial sponsored by NIH was soon conducted at 18 institutions by randomizing infants at 2 days of age to routine supplemental oxygen or to a curtailed-oxygen group that received lower concentration oxygen only as needed.

The study showed that RLF severe enough to produce blindness, if continued, occurred in 17% of the babies receiving routine high oxygen, but in only 5% of the curtailed-oxygen group. The death rate in the two groups was similar. The investigation was continued with all infants assigned to curtailed oxygen. The follow-up study found that the duration of oxygen use was key to the risk of developing RLF and that supplemental oxygen at even low levels increased the risk of developing RLF.

Recommendations of the American Academy of Pediatrics and other authorities, published soon after the release of the study, were key to changing the attitudes and practices of clinicians. By the mid-1950s, follow-up studies showed that the use of routine oxygen for premature infants was on the decline, and so was the rate of RLF. By the late 1950s, RLF had declined to rates seen only before the widespread use of high-dose oxygen.

The evaluation of the impact of oxygen use for premature infants was not over. Soon after the rapid reduction in oxygen use began, the death rates among premature infants began to increase. Investigators in the United States and Britain found an increased mortality rate and rate of brain damage and paralysis among premature infants with underdeveloped lung function. Investigators noted that the randomized controlled trial included only infants who had survived for 2 days, the period of the highest number of deaths from respiratory related causes. Thus, by the early 1960s, it was clear that a trade-off existed between the use of oxygen to reduce early mortality and morbidity and limiting oxygen use to reduce the incidence of RLF.

Evidence-based recommendations encouraged the use of oxygen to limit the impact of too little oxygen while minimizing the level and duration of oxygen. When oxygen was used, clinicians were expected to conduct frequent examinations of the retina to identify early evidence of RLF.

In recent years, there has been an increase in RLF even as clinicians have limited and monitored the use of supplemental oxygen. The increase has been largely attributed to the increased number of premature infants and the ability to keep very premature infants alive. The greater the degree of prematurity, the greater the risk of RLF. In fact, this process may occur in premature infants even without the use of oxygen. Therefore, in recent years, the name of the condition has been changed to retinopathy of prematurity, or ROP.

Clinicians now monitor the retina of premature infants, looking for early signs of ROP. Interventions to treat early ROP, including laser treatments and surgical interventions, are now part of the effort to detect and treat ROP at an early stage to prevent blindness. Evidence-based recommendations of the American Academy of Pediatrics outline this approach and provide specific recommendations for its implementation.

Prevention, detection, and treatment of ROP is now seen as part of an overall approach to the care of premature infants. The success of the current approach requires ongoing evaluation and continued efforts to look for ways to improve the care of newborns.

Discussion Questions

1. What roles did the distribution of disease and biological plausibility play in suggesting the hypothesis that supplemental oxygen causes infant blindness?

2. Discuss the roles played by case-control and cohort studies as well as randomized controlled trials in establishing oxygen supplementation as a contributory cause of blindness in premature infants.

3. Discuss how the evidence-based recommendations sought to balance the benefits and the harms of oxygen use.

4. Discuss how this case illustrates the need for ongoing evaluation and efforts to modify evidence-based recommendations based on new evidence.

SECTION II

Cases and Discussion Questions

© Orhan Cam/ShutterStock, Inc.

DON’S DIABETES

Don had been a diabetic for over a decade and took his insulin pretty much as the doctor ordered. Every morning, after checking his blood sugar levels, he would adjust his insulin dose according to the written instructions. From the beginning, Don’s doctor worried about the effect of the diabetes—he ordered tests, adjusted dosages and prescriptions, and sent his patient to the ophthalmologist for assessment and laser treatment to prevent blindness.

It was the amputation of his right foot that really got Don’s attention. Don was not exactly athletic, but he did play a round of golf once in a while. He first noticed a little scratch on his foot after a day on the golf course. It was not until a week later that he noticed the swelling and the redness in his foot and an ulceration that was forming. He was surprised that his foot did not hurt, but the doctor informed him that diabetic foot ulcers often do not cause pain. That is part of the problem with diabetes—you lose your sensation in your feet.

After six months of receiving treatment on a weekly basis, a decision had to be made. “There is not any choice,” his doctor said. “The foot infection is spreading, and if we do not amputate the foot, we may have to amputate to the knee or even higher.” So after describing the potential benefits and harms of the surgery and asking whether there were any questions, the doctor asked Don to sign a form. The next morning, Don’s leg was amputated above the ankle, leaving him with a stump in place of a foot.

The surgeon came to Don’s room the day after surgery to take a look at his amputation. “Beautiful work,” he said with a big smile on his face. Maybe it is a beautiful stump, Don thought to himself, but it does not work like my old foot. At first, he felt sorry for himself, thinking of what lay ahead to literally get back on his feet.

The physical therapist who visited Don in the hospital told him, “You got off lucky—now, are you going to take control or let diabetes control you?” But diabetes is already controlling me, Don thought to himself—daily insulin; blood sugar testing; weekly trips to the doctor; and now, despite it all, an amputated foot.

“Diabetes is a bad disease,” his doctor told him. “We are doing everything we can do, and you are still experiencing complications.”

Maybe the doctors were doing everything they could, but Don wondered what else was possible. He enrolled in a self-help group for diabetics. They shared stories of medical care, new advances in diabetes management, and their own frustrations with the disease and with their medical care. Don realized he had received good medical care, but he also acknowledged that good care by good doctors is not enough. There needs to be a system that makes the pieces work together, but there also needs to be a patient who takes charge of his care.

So take charge, he did. He worked closely with the practice’s physician assistant and nurse practitioner, who were experts in diabetic management. He learned how to interpret his blood tests and how they were useful for day-to-day monitoring of his disease. He also learned about hemoglobin A1c blood tests, which measure how well diabetes is doing over periods of months. After several months, his clinicians taught him how to adjust his dose of insulin to accommodate for changes in his routine or during minor illnesses. They always let him know that care was available and that he did not need to make decisions all by himself. Don also learned to examine his feet and how to prevent minor injuries from turning into major problems. His sporadic eye doctor appointments turned into regular question-and-answer sessions to compare the most recent photographs of his retina to those from the past.

Don found himself keeping his own records to be sure that he had them all in one place, fearing that one doctor would not talk to another and that the records in one office or one hospital would never make their way to the next. Don’s fears were well founded: when his kidney function began to deteriorate and his primary care doctor sent him to a kidney specialist, who sent him to a transplant surgeon, and then to a vascular surgeon to prepare him for dialysis, sure enough, the only records the dialysis doctors could rely upon were the ones that Don had kept on his own.

Soon the dialysis doctor told Don that he had a tough decision to make. Did he want to come into the dialysis center for half a day twice a week, where they take care of everything, or did he want to learn home dialysis and take care of this treatment on his own? Don had lots of questions. He needed to understand what each dialysis scenario entailed and the advantages and disadvantages of both options, including the costs and discomforts. He also wanted to know about any other potential treatments. Don asked questions of his doctors, learned as much as he could about dialysis on the Internet, and outlined the pros and cons of home dialysis. After that, it was an easy decision for Don. “Sure, I will learn how to do it myself. I want to be in charge of my own care. I want to stand on my own two feet,” he told the doctor without a moment’s hesitation.

Discussion Questions

1. What type of decision-making process was going on during the early stages of Don’s diabetes? Explain.

2. What type of decision-making process was used to reach the decision to have an amputation? Explain.

3. What type of decision-making process occurred in the decision about dialysis? Explain.

4. In Don’s case, what are the advantages and disadvantages of each of these approaches to decision making from both the patient’s and the clinician’s perspectives? Explain.

A NEW DISEASE CALLED SADS—A DECISION ANALYSIS

Imagine that a new disease called sudden adult disability syndrome (SADS) has become the most common cause of death among previously healthy 18- to 24-year-olds. The etiology of SADS is unknown, but it is thought to be infectious. SADS is a disease of sudden onset that without treatment produces progressive weakness, slow mental deterioration, and death within a year 50% of the time. The other 50% of individuals who develop SADS make a rapid, spontaneous full recovery without any treatment.

There are three known treatments for SADS:

•   Ordinary Knowledge (O.K.)—the conventional treatment (in other words, standard treatment)

•   Live-Better

•   Live-Longer

The probabilities of cure and side effects have been extensively investigated:

•   Ordinary Knowledge (O.K.) results in an 80% probability of cure without side effects. The remaining 20% die of SADS.

•   Live-Better results in an 85% probability of cure. There are no known side effects. The remaining 15% die from SADS.

•   Live-Longer results in an 80% probability of cure. However, 10% of those who take the treatment become totally and permanently blind in both eyes. The remaining 10% die of SADS.

Discussion Questions

1. Prior to conducting a decision analysis, which intervention would you recommend?

2. Draw a decision tree indicating the potential outcomes for each of the three treatments (O.K. therapy, Live-Better, and Live-Longer) and indicate the probability of occurrence of each of the potential outcomes.

3. Assume cure brings your utility to full health, in other words, 1.0, and death’s utility is 0. Use a utility of 0.5 for blindness. Can any of the possible interventions be eliminated based on the expected utilities? Explain.

4. Now use a utility of 0.8 for blindness and recalculate the expected utilities. Which intervention is now recommended by the decision analysis?

5. Now use a utility of 0.2 for blindness and recalculate the expected utilities. Which intervention is now recommended by the decision analysis? What can you conclude about the importance of the utility that is placed on blindness?

6. Now use the utility for blindness that indicates the utility that you personally place on blindness. Again recalculate the expected utilities. What intervention is recommended by this decision analysis? How does this recommendation compare to the recommendation you made prior to conducting the decision analysis? If it is different, what other factors did you take into account in reaching your own recommendation?

JOSÉ AND JORGE—IDENTICAL TWINS WITHOUT IDENTICAL LIVES

José and Jorge were identical twins separated at birth. José grew up in a large family in an impoverished slum in the middle of a crime-ridden and polluted district of a major city. Jorge grew up in an upper-middle-class professional family with one other brother in a suburban community in the same city. Despite the fact the José and Jorge were identical twins, their lives and health could not have been more different.

José had few opportunities for medical care or public health services as a child. His nutrition was always marginal and he developed several severe cases of diarrhea before he was 1 year of age. He received a polio vaccine as part of a community vaccination program, but never received vaccinations for measles, mumps, rubella, or other childhood illnesses. At age 4, he developed measles and was so sick, his mother was sure he would not make it.

As a child, José also developed asthma, which seemed to worsen when he played outdoors on hot smoggy days. Dropping out of school at age 14, José went to work in a factory, but quit when he found himself panting for breath at the end of the day.

As a teenager, José was repeatedly exposed to crime and drugs. Once, he was caught in the cross fire of gangs fighting for control of drugs in his community. Experimenting with drugs with his teenage friends, José contracted HIV from use of contaminated needles. José did not know he had HIV until he was nearly 30 years old and developed tuberculosis (TB). He did receive treatment for the TB free of charge from the health department, but once he felt better, he did not follow up with treatment.

By the time the TB returned, José had lost 30 pounds and could barely make it into the emergency room of the public hospital because of his shortness of breath. He was hospitalized for the last two months of his life, mostly to prevent others from being exposed to what was now drug-resistant tuberculosis. No one ever knew how many people José exposed to HIV or TB.

Jorge’s life as a child was far less eventful. He received “well child” care from an early age. His family hardly noticed that he rarely developed diarrhea and had few sick days from diseases of childhood. He did well in school, but like José, he developed asthma. With good treatment, Jorge was able to play on sports teams, at least until he began to smoke cigarettes at age 14.

Jorge soon began to gain weight, and by the time he graduated from college, he was rapidly becoming obese. In his 20s, he developed high blood pressure, and in his 30s he had early signs of diabetes. Jorge had a heart attack in his mid-40s and underwent bypass surgery a few years later. The treatments for diabetes, hypertension, and high cholesterol worked well and Jorge was able to lead a productive professional life into his 40s.

By the time that Jorge turned 50, his diabetes began to worsen and he developed progressive kidney disease. Jorge soon needed twice-a-week dialysis, which kept him alive as he awaited a kidney transplant.

Discussion Questions

1. How do social determinants of health contribute to the different disease patterns of José and Jorge?

2. How do factors in the physical environment explain differences in the health of José and Jorge?

3. What role does medical care play in the differences between the health outcomes of José and Jorge?

4. What roles do public health services play in the health outcomes of José and Jorge?

THE OBESITY EPIDEMIC IN THE UNITED STATES—THE TIP OF AN ICEBERG

Before the last half of the 1900s, obesity was often seen as a sign of prosperity. Look at the great art of 18th and 19th century Europe and you will find portraits of the prosperous and portly prominently displayed. In the last half of the 1900s and the early years of the 2000s, obesity has become the province of the poor and the middle class.

Obesity is defined as a BMI over 30. Overweight is defined as a BMI from 25 to 30. The BMI is calculated as the weight in kilograms/height in meters squared. A BMI of 30 for a 5 foot, 8.5 inch male or female is approximately 200 pounds. To determine whether a child aged 2 to 19 years is considered obese, a BMI for age is calculated, but further assessment is needed to determine fat distribution, such as measurement of skinfold thickness. The prevalence of obesity has been steadily rising in the United States over the last 50 years, increasing over 250%. Today, approximately 20% of children aged 2 to 19 are obese, along with approximately 35% of adults.

U.S. data confirm a strong association of obesity with lower socioeconomic levels overall and in most but not all racial and ethnic groups. Overall, children and adolescents 2 to 19 years in families with an income under 130% of the poverty level (about $30,000 for a family of 4) have almost twice the prevalence of obesity as children and adolescents in families with income over 350% of the poverty level. However, these patterns do not apply to non-Hispanic black girls or to Mexican American boys or girls, in whom high levels of obesity occur at all income and educational levels.

A number of factors play important roles in giving the portrait of obesity in the United States a far less prosperous persona. The availability of cheap, high-calorie foods has played an important role in allowing access to abundant quantities of food by lower socioeconomic individuals. Newer technologies using concentrated sugars, such as high fructose corn syrup, and trans fats have reinforced this tendency. Once obesity is established, exercise may be more difficult, setting in motion a vicious circle of sedentary lifestyle and increased weight. Similarly, once obesity is established, the large quantities of food required daily often necessitate the purchase of cheap high-calorie food.

Obesity is strongly associated with a constellation of other health conditions in what has been called a syndemic, or the occurrence together of two or more health conditions. Obesity is the strongest risk factor associated with type 2 diabetes. Abdominal obesity, defined as a waistline of approximately 37 inches for males and 31.5 inches for females, is central to what is called the metabolic syndrome. The metabolic syndrome requires the presence of abdominal obesity and also includes diabetes, high blood pressure, and cholesterol and triglyceride abnormalities, including low good cholesterol. Each of these conditions can and should be treated, but treatment is far more successful and carries fewer side effects if weight can be reduced. Often a 5 or 10% reduction in body weight has a major impact on these conditions. Cigarette smoking, another strong risk factor for heart and vascular disease as well as cancer, actually has a small impact on reducing weight.

A number of approaches have been suggested to address the epidemic of obesity in the United States. An increasing number of drugs are being developed and approved to treat obesity. A surgical approach called gastric bypass surgery or more generally bariatric or weight loss surgery have been demonstrated to have efficacy using randomized controlled trials, including long-term weight loss and reduction in complications especially among those with a BMI greater than 40.

Newer dietary approaches, such as low-carbohydrate diets, have been shown in a randomized controlled trial to increase weight loss over the short run, but like other diets, the low-carb diet has less impressive results over longer periods of time. A variety of sugar substitutes have been investigated and introduced in recent years. It is controversial whether these sugar substitutes have had a substantial impact on obesity or have merely led to increased consumption of other high-calorie foods.

Other approaches attempt to get at the cultural influences on obesity, including the fact that the average portion size in restaurants has increased over the last few decades. Efforts to limit the size of high-calorie soft drinks are one example of this approach. Focusing on children and adolescents by restricting the availability of food with high sugar and carbohydrates in school lunches and offering healthier alternatives is also being tried. Taxing high-calorie, low-nutrition food is another option being debated. Increasing requirements for physical activity in schools is yet another policy change being advocated.

The answers to the weighty question of obesity in the United States remain a great challenge. What do you think we should do about it?

Discussion Questions

1. Identify the contributions of social determinants of health, including cultural factors, to the increased rate of obesity in the United States. Explain.

2. Discuss the relationship between obesity and other health conditions that lead to cardiovascular disease, including the interactions that occur.

3. Which of the interventions discussed in this case would you endorse? Explain why, including considering the positive and negative aspects of each intervention.

4. How would you combine the interventions that you selected in question number 3 to effectively address the national epidemic of obesity?

CHANGING BEHAVIOR—CIGARETTE SMOKING

It was not going to be easy for Steve to stop smoking. He had been at it for 30 years—ever since he took it up on a dare at age 16 and found that it was a good way to socialize. In his 20s, it seemed to make dealing with the work pressure easier, and in those days, you could smoke in your office and did not even need to shut the door—much less deal with those dirty looks he was getting now.

Steve was always confident that he could take cigarettes or leave them. He would quit when he was good and ready, and a few cigarettes could not hurt. But then he talked to some friends who had quit a decade or more ago and said they would go back in a minute if they thought cigarettes were safe. Maybe for some people, those cravings just never go away, he worried to himself. However, there was that bout of walking pneumonia, and then the cough that just did not seem to go away. The cough was so bad that he had trouble smoking more than a few cigarettes a day. The physician assistant let him know that these symptoms were early warning signs of things to come; however, Steve just was not ready to stop. So the physician assistant gave him a fact sheet and let Steve know there was help available when he was ready.

It might have been his fears about his 10-year-old son that finally tipped the scales. “Daddy, those cigarettes are bad for you,” he said. Or maybe it was when he found cigarette butts in the backyard after his 16-year-old daughter’s birthday party. Steve knew enough to believe that a father who smokes has a child who smokes. So this time, he would do it right.

Steve’s physician assistant recognized that Steve was finally ready to quit. He let him know in no uncertain terms that it was important to quit totally, completely, and forever. He also informed Steve that he could rely on help—that he was not alone. With the encouragement of his physician assistant, Steve joined a support group, set a quit date, and announced the date to his friends and family. The new medication he was prescribed seemed to relieve the worst cravings and the feeling he called “crawling the walls.”

His wife, Dorothy, was supportive. She cleared the cigarette butts and ashtrays out of the house and dealt with the smell by having all the drapes cleaned. She also helped by getting him up after dinner and taking a walk, which kept him from his old habit of having a cigarette with dessert and coffee. It also helped keep him from gaining too much weight, which she confided was her greatest fear. Dorothy’s quiet encouragement and subtle reinforcement without nagging worked wonders.

Saving a couple of dollars a day did not hurt. Steve collected those dollars and put them in a special hiding place. On his first year anniversary of quitting, he wrapped up the dollar bills in a box and gave them to Dorothy as a present. The note inside said: “A trip for us for as long as the money lasts.” Dorothy was delighted, but feared the worst when Steve began to open up his present to himself. As he unwrapped a box of cigars, he smiled a big smile and said, “I am congratulating myself on quitting smoking.”

Discussion Questions

1. How are each of the phases in the stages of change model illustrated in Steve’s case?

2. What other theories or models can be applied to the public health issue described in this case? Explain.

3. Which effective public health (or population) approaches does this case illustrate?

4. What is the impact of combining individual clinical approaches with public health (or population) approaches?

THE ELDERLY DRIVER

It was late in the afternoon on a sunny April day. Maybe it was the sun in her eyes, but 82-year-old Janet found herself in her car in a ditch at the side of the road, unsure of how she got there. Once at the hospital, her son and daughter joined her and heard the good news that Janet had escaped with just a broken arm. The police report strongly suggested that she had swerved off the road, but it was not clear why.

This was not Janet’s first driving “episode”; in fact, her driving had been a constant worry to her daughter for over two years. Her daughter often offered to take her Mom shopping and insisted that she do the driving when they were together. “Do you not trust me?” was the only thanks the daughter received. When alone, Janet continued to drive herself, staying off the freeway and increasingly driving only during the day. She knew it was not as easy as it used to be, but it was her lifeline to independence.

Then, a few months after the April incident, the form for Janet’s license renewal arrived. A vision test and a physical exam were required, along with a doctor’s certification that Janet was in good health and capable of driving; however, no road test was required. So Janet made a doctor’s appointment, and at the end of it, she left the forms with a note for the doctor saying, “To the best doctor I have ever had. Thanks for filling this out. You know how much driving means to me.”

On Janet’s way home from the doctor’s office, it happened. She was driving down the road when suddenly she was crossing that yellow line and heading toward an oncoming car. The teenage driver might have been going a little fast, but Janet was in the wrong lane and the head-on collision killed the 16-year-old passenger in the front seat who was not wearing a seat belt. The 18-year-old driver walked away from the collision unharmed, thanks to an inflated airbag.

Janet was never the same emotionally. And despite escaping the collision with just a few bruises, the loss of her driver’s license symbolized the end for her. Those lost weekly shopping trips and the strangers in the assisted living center were not the same as living in her own home. The young man in the collision screaming for help woke her up almost every night. It was only a year after the collision when Janet died, and it was just like she had said: “Take my license away and it will kill me.”

Discussion Questions

1. How does this case reflect the important issue of balancing the legal rights of the individual and the rights of society as a whole?

2. What role do you believe healthcare providers should play in implementing driving laws and regulations?

3. Identify any changes you would make to prevent the types of outcomes that occurred in this case study.

4. How would you communicate the lessons learned in this case to new and inexperienced drivers?

SECTION III

Cases and Discussion Questions

© justasc/ShutterStock, Inc.

HIGH BLOOD PRESSURE: A PUBLIC HEALTH AND HEALTHCARE SUCCESS

Elevated levels of blood pressure, or hypertension, have been observed since the development of blood pressure measurements in the 1800s. It was soon recognized that populations with a high frequency of elevated blood pressure were also populations with a high frequency of strokes, yet the dangers of high blood pressure often went unappreciated until recent years.

High blood pressure is a condition that historically has affected both the privileged and the underprivileged in our society. Presidents Woodrow Wilson and Franklin Delano Roosevelt both had high blood pressure and suffered strokes and heart disease. Today, the condition is disproportionately present among African Americans—15 to 20% have some degree of elevated blood pressure.

For many years, high blood pressure was considered a consequence of disease rather than its cause. Clinicians seeing a patient with a stroke, for instance, often attributed their elevation in blood pressure to the stroke rather than the other way around. Long-term studies, such as the Framingham Heart Study, which followed a large number of individuals for many years, established that the high blood pressure actually preceded strokes and not the other way around. High blood pressure as a contributory cause of strokes, as well as heart and kidney disease, was fully confirmed only after randomized controlled trials in the late 1960s and early 1970s established that lower blood pressure leads to reduced frequency of these diseases. Screening for high blood pressure became widespread in the same period in large part as a result of these investigations.

Elevated levels were initially defined as 140/100 or greater, based upon a range of normal obtained by measuring the blood pressure on large numbers of adult Americans. What were once considered acceptable levels of blood pressure have been redefined as elevated levels in recent years. Today, the desirable level is considered 120/80 or lower. These changing levels are justified by follow-up data from a large number of individuals that demonstrates that even levels of blood pressure only slightly above 120/80 are associated with increased risk of stroke and heart disease.

The fluctuating levels of blood pressure often make it difficult to establish an individual’s average level. Electronic monitoring of blood pressure over a 24-hour period has become a feasible and acceptable gold standard for establishing an individual’s average level. Early detection and successful treatments have been shown to effectively reduce the consequences of high blood pressure. Weight loss and salt restriction are often prescribed initially, with subsequent introduction of one or more drugs. Most, if not all, individuals with elevated blood pressure respond to drug treatment with tolerable or no side effects, but need to continue treatment for many years—usually for the rest of their lives.

A national public health campaign began in the 1970s to encourage individuals to know their blood pressure and to urge clinicians to treat detected elevated levels. In recent decades, national surveys have indicated that a gradually increasing percentage of patients with elevated blood pressures are being successfully treated and that there has been a substantial reduction in strokes and deaths from strokes. Recent evidence showing that reducing the high salt levels in the U.S. diet can reduce the average level of blood pressure has prompted renewed public health efforts to change eating habits and the contents of commercial foods.

Today, treatment of high blood pressure is recognized as one of the most cost-effective interventions. Its cost per quality adjusted life-year (QALY) saved is only a few thousand dollars a year for the average person. For high-risk groups, such as those with diabetes, it actually saves money to monitor and treat high blood pressure rather than allow it to cause or exacerbate other health problems requiring more expensive treatments.

Discussion Questions

1. How does this history of high blood pressure demonstrate the problem description and etiology components of the P.E.R.I.E. process? What different types of studies were used to establish etiology or contributory cause?

2. How does this history of high blood pressure illustrate the evidence-based recommendations and implementation and evaluation components of the P.E.R.I.E. process?

3. Explain the justification for updating the definition of what is considered a “healthy” blood pressure level.

4. How does this history of high blood pressure demonstrate the application of the four criteria for a successful screening program? Explain.

5. Using the four quadrants of cost and effectiveness, how would you classify treatment of hypertension for the average person? For those with diabetes? Explain.

TESTING AND SCREENING

Ken had just turned 40, and with a little encouragement from his wife, he decided that it was time to have a physical—it would be his first real visit to a doctor since he broke his arm as a kid. Seeing a doctor had not made sense to him before. He was in great shape, felt fine, and did not smoke. Maybe it was his 65-year-old father’s sudden death from a heart attack just a few weeks after his retirement that finally convinced Ken to find himself a doctor. He knew that his father had had high cholesterol, but he was told his own cholesterol level and electrocardiogram results were okay when he entered the military at age 18. Besides, Ken was not big on desserts and only ate a Big Mac when he took the kids out after their soccer games.

The examination was quite uneventful and Ken was reassured when the doctor could not find anything of concern. A few recommendations on nutrition and better ways to exercise were about all that came out of the visit. Then he got the call from the doctor’s office—could he make a follow-up appointment to discuss his cholesterol?

His low-density lipoprotein (LDL, or “bad” cholesterol) was 165 and his high-density lipoprotein (HDL, or “good” cholesterol) was 40.

“We used to think these levels were okay because they are so common,” his doctor began. “However, now we consider your LDL cholesterol too high because it increases your chances of developing heart and other blood vessel diseases. There is no evidence of heart disease at this point, but your cholesterol needs attention.”

“What do you mean by ‘attention’?” Ken replied. “I exercise, do not smoke, and generally keep my fats down.”

Ken soon learned a lot more about cholesterol. He first tried his best at changing his diet—it helped a little, but just did not do the trick.

Ken’s doctor told him: “For some people, there is a strong genetic component to high cholesterol levels, and while diet is still important, it just cannot always reduce LDL cholesterol enough by itself. Exercise helps, especially by increasing the good cholesterol, but it does not do much for the bad cholesterol. Medication may be needed and there is now evidence that if taken regularly, it reduces the chances of having a heart attack or at least delays its occurrence.”

Taking medication every day was not so easy for Ken, but he stuck with the plan. His doctor asked him to have his cholesterol levels checked every few months for the first year. Ken was amazed at how well the medicine worked. His LDL fell from 165 to less than 100 on only a modest dose. In addition to routine cholesterol checks, Ken had his blood tested for potential side effects from the medication, such as impacts to his liver, and he was told to report any long-lasting muscle aches and pains. The good news was that he could not tell he was taking the medication—he felt just fine.

Now that the cholesterol levels had dropped, he thought maybe he could go off the medication if he just watched his diet closely. His doctor let him try that for a month, but after the 30 days were up, his LDL level was back up to 160.

“Looks like you are hooked on medication for life,” his doctor said with a wry smile, adding, “At least the extra cost is worth the extra benefit.”

Ken and his wife were told the high cholesterol levels were a genetic condition. Not only did Ken need to take the medication on a permanent basis, but the pediatricians began testing his kids.

The doctors said, “We are beginning to understand the genetics behind this condition and would like to do some genetic testing on the children, including that new baby of yours.”

Ken wondered if the information on his children’s cholesterol levels would be part of their medical records for the rest of their lives. “You are not planning to put that on the Internet, are you?” Ken joked nervously as they drew blood from his newborn son.

Discussion Questions

1. How are the range of normal and desirable-range approaches to establishing a reference interval and defining a positive and negative test illustrated in this case? Explain.

2. What arguments are presented in this case that fulfill the criteria for screening for high LDL cholesterol? Explain.

3. What definition of cost-effectiveness is being used to justify screening and treatment of elevated LDL cholesterol?

4. What ethical issues need to be considered in screening for conditions such as elevated LDL cholesterol? Explain.

H. PYLORI AND PEPTIC ULCERS

Duodenal ulcers and benign stomach ulcers are frequently referred to as peptic ulcers. Peptic ulcers are among the digestive diseases with the highest incidence. Approximately 10% of the population experience a peptic ulcer at some point in their life, though a substantial proportion, perhaps a majority, are not medically diagnosed. Peptic ulcers generally heal even without prescribed treatment in 4 to 6 weeks. Approximately 1% of those with peptic ulcers experience complications, with potentially life-threatening perforation of the stomach or duodenum being the more serious complications. The disease often recurs, with a probability of recurrence in the range of 50%.

For many years, peptic ulcers were believed to be exclusively the result of excess acid production due to such factors as alcohol, aspirin and other anti-inflammatory medications, spicy foods, and stress. The stomach and duodenum were known to be highly acidic, and it was believed that bacteria were unable to survive in this high-acid environment.

In the early 1980s, investigators observed a spiral-shaped bacterium, which they named Helicobacter pylori, or H. pylori, in a number of pathological specimens from patients with disease of the stomach and duodenum. Most scientists doubted the relationship to disease, often concluding that the organism must be a contaminant because of the belief that bacteria could not grow in highly acidic environments.

After many unsuccessful attempts, Australian researchers Barry J. Marshall, MD, and J. Robin Warren, MD, were able to culture the bacteria from the stomach and became convinced that the bacteria were actually the cause of peptic ulcers. They were frustrated in their attempts to demonstrate that H. pylori was the cause of the disease because of the absence of good animal models. To attempt to establish causation, Marshall drank a flask of the cultured bacteria. He became ill and developed acute ulceration of the stomach. H. pylori was cultured from his ulcerations. This dramatic effort brought attention and extensive investigations to address whether H. pylori is a contributory cause of duodenal ulcers.

Subsequent studies in the United States and other countries established that H. pylori is a frequently occurring organism that increases with increasing age. Overall, over 20% of people in the United States have H. pylori, that is its prevalence is over 20% in the United States, with a higher prevalence beginning at an early age in many developing countries, as well as Japan. In case-control studies, H. pylori was found to have a strong association with duodenal ulcer, with over 70% of peptic ulcer patients having H. pylori at the time of their diagnosis.

Randomized controlled trials examined the recurrence rates of duodenal ulcers after treatment of the bacteria with antibiotics shown to eliminate H. pylori. In one study among those randomized to placebo, the recurrence rate was over 10 times as great as among those randomized to antibiotic treatment directed against H. pylori. This research led to a search for biological mechanisms. Extensive research established a greater understanding of the physiology of peptic ulcers, including identifying the production of an enzyme by H. pylori that reduces acidity and thus facilitates its growth in an acid environment.

New tests demonstrated that H. pylori is associated with the great majority of duodenal ulcers among outpatients. Randomized controlled trials and extensive clinical follow-up established the effectiveness and relative safety of antibiotic treatments of H. pylori. These investigations led to evidence-based recommendations for routine testing for H. pylori among outpatients diagnosed with peptic ulcers and treatment of H. pylori with antibiotics when it was detected.

Discussion Questions

1. Describe the negative and positive roles that biological plausibility played in establishing causation.

2. Discuss what would be required to demonstrate that H. pylori is a cause of duodenal ulcers and stomach ulcers using Koch’s modern postulates. Were these postulates established for H. pylori?

3. Discuss how the evidence linking H. pylori and peptic ulcers using randomized controlled trials fulfill the contributory cause criteria of association, prior association, and how altering the “cause” alters the “effect.”

4. What grade (A, B, C, D, I) would you give the recommendation to treat H. pylori among those diagnosed with peptic ulcers and having a positive test for H. pylori? Explain based on the strength of the evidence and the magnitude of the impact.

WHAT TO DO ABOUT LYME DISEASE?

You have just moved into a new subdivision—your first home with your young family. The first week you are there, a neighbor tells you that her son has developed Lyme disease and now has chronic arthritis that requires extensive treatment.

Lyme disease is an increasingly common disease that can cause acute and chronic arthritis if not treated early and correctly. In rare instances, it can cause life-threatening heart disease and temporary paralysis often to one side of the face due to nerve damage. The disease is caused by an organism known as a spirochete, which is spread from deer ticks to humans via tick bites. Lyme disease is especially common in communities with large deer populations, which today includes much of the suburban United States as well as rural areas.

Ticks must remain in place on the human skin at least 12 to 24 hours in order to extract human blood and inject the spirochete organism at the site of the bite. Complete removal of the small but visible tick within 24 hours usually prevents the disease. Deer ticks are most abundant in the late spring and tend to live on tall grasses from which they can easily move to the bare legs of children and adults. The disease frequently first appears as a circular red rash around the site of the bite. At this stage, early diagnosis and treatment with antibiotics is usually successful. Several weeks or months later, the onset of arthritis may occur and can be difficult to diagnose. A missed diagnosis may result in severe arthritis that is difficult to treat. A vaccine has been developed and briefly marketed to prevent the disease, but it was quite expensive and only partially successful.

In your new hometown, the local health department is charged with developing a plan for control or elimination of Lyme disease. As an informed and concerned citizen, you are invited to give input on the plan, identifying possible interventions.

Discussion Questions

1. What primary interventions would you consider? Explain.

2. What secondary interventions would you consider? Explain.

3. What tertiary interventions would you consider? Explain.

4. What educational interventions do you recommend? Explain.

5. Can Lyme disease be eradicated? Can it be controlled? Explain.

SHARMA’S VILLAGE

Sharma lives in a small farming village in south Asia, but she could just as well be living in Haiti, Ethiopia, Ghana, or several dozen other countries classified by the World Bank as low-income economies. Her home is a small hut, and she works daily with her mother to gather firewood for their small indoor fireplace, which acts as the kitchen stove. The smoke often makes her eyes water because there is no chimney or other ventilation. At night, she sleeps with her extended family in a room where mosquitoes bite her regularly. Despite the fact that Sharma lives in a rural community, the villagers live in crowded quarters. The water the family drinks is carried by the women from a well several hundred yards from their home. The water sometimes tastes bad, but it is all they have to drink.

The family farms a small plot of land on the hillside, which had become eroded from years of cutting trees. The last big monsoon to hit the area created a landslide, which left the village underwater for several weeks, creating mold in nearly every home. Most of the adults have goiters from the lack of iodine in the soil. The addition of iodine to salt has prevented goiters in the children. Pesticides are used widely to control mosquitoes and agricultural pests, but the farmers receive little education on their safe use. Recently, a new road was built, connecting her village with the neighboring towns. Despite the advantages of having the new road, cars and trucks now speed through her village, rarely stopping to let people cross the road.

In Sharma’s village, the life expectancy is 49 years. Babies often die of diarrheal diseases in the first year of life and mothers occasionally die in childbirth. Malaria is widespread and hookworm disease is present among those who farm the fields and in children, whose ability to learn is often affected. Malnutrition is also widespread despite the fact that farming is the major occupation in the village. Chronic lung disease among adults and asthma among the young is surprisingly common, even though cigarette smoking is rare. Tuberculosis is widespread and a major cause of death, despite the fact that until recently, there have been few cases of HIV/AIDS in the area. Unexplained neurological diseases among farm workers occur regularly. The most common cause of death among teenagers is motor vehicle injuries along the new road, even though there is only one truck in the village.

Discussion Questions

1. What environmental risk factors contributing to disease and other health conditions are illustrated in this case? Classify each as an unaltered, altered, or built environment factor.

2. Discuss at least two examples of how disease or other conditions found in the village can be explained by the environmental risk factors.

3. Identify at least two interventions that would make a large difference in the health of this village.

4. What changes do you expect to occur in this village as social and economic development take place?

LEGAL DRUGS THAT KILL—DEATH FROM PRESCRIPTION DRUG OVERDOSES

Katie found herself flat on her back in pain after falling off her bicycle as she swerved to avoid a collision with a car. She was taken to the emergency department, where she was examined, X-rayed, and given a five-day supply of a prescription pain-killer along with a note saying, “Make an appointment to see your doctor as soon as possible.”

Though no one asked, Katie had a history of regular alcohol use and occasional binge drinking on weekends. Her father died of liver disease after many years of heavy drinking. Katie stayed away from most illegal drugs, though she tried marijuana a few times.

Katie had trouble filling her prescription after she left the emergency room late at night. Her nearest 24-hour pharmacy told her they do not carry narcotic pain medicine because they are a target for robberies. When she finally was able to fill her prescription, the pain was so bad that she took double the prescribed dose of medicine. She was running low before she could get an appointment with her doctor, but she found that if she took it with alcohol, it did the trick.

Her doctor agreed that her injuries were bad enough to require additional narcotic pain medications, which he prescribed for a month followed by a couple of refills. Katie quickly filled the prescription. On her way out of the pharmacy, she was stopped by a young man who offered to buy her medication for twice what she had paid. Katie turned the other way and rushed home to take her medication.

Katie could hardly get out of bed, the pain was so bad. After a few pills and a little alcohol, she was able to get going. Getting her work done was an ordeal and she mostly looked forward to the weekends. Partying took on a new meaning now, as it was an escape from constant pain.

One Saturday night, several months after her injury, Katie’s friends planned a party to celebrate her 30th birthday. Katie tried her best to get herself together to go to the party despite the pain. She thought a little extra medication and a few drinks were what she needed. She soon felt so tired that before getting ready for the party, she decided to lie down for a little nap. She never heard the knock on the door by her friends, who wanted to know why she did not show up at the party. By the time they had called the rescue squad and the responders had broken in the door, she was found lying in her bed without a heartbeat, a victim of an unintentional prescription overdose.

Katie’s friends were astonished to hear that unintentional prescription overdoses now rival motor vehicle injuries, suicides, and firearms as causes of death among young people, far exceeding deaths from illegal drugs. Traditionally a cause of death among young males, deaths from unintentional drug overdoses are rapidly increasing among females. Drug overdoses often occur from a combination of prescription narcotic pain medicine with alcohol, which together form a common and deadly combination that is widely available.

Discussion Questions

1. What underlying factors led to Katie’s death?

2. What educational interventions would you recommend to prevent unintentional overdoses? Explain.

3. What motivational interventions directed toward prescribers or patients would you recommend to prevent unintentional overdoses? Explain.

4. What obligation or legal interventions would you recommend to prevent unintentional overdoses? Explain.

5. What changes in the rates of unintentional overdoses in the United States do you expect in the absence of the types of interventions that you identified in questions two, three, and four? Explain.

SECTION IV

Cases and Discussion Questions

© Leah-Anne Thompson/ShutterStock, Inc.

WHEN NURSING MEETS MEDICINE

Maureen felt she had no other choice but to let the hospital administrator know when a physician had repeatedly prescribed the wrong dose of medication. How many times could she double-check with Dr. George Ludwig just to be sure that she had understood his orders? Orders, they still call them, she thought to herself. That is certainly what they want them to be.

The days of obeying orders were over for Maureen. She had been through nursing school, and after five years working in the hospital, she went back to get her doctor of nursing practice degree to become a nurse specialist so she could work in an intensive care unit. Now she was doing the weekend 12-hour nursing shift to make ends meet and finish her doctoral degree. Nurses were in short supply, so she could now for the first time speak her mind without fear of losing her job. Nursing, she realized, was by its very name designed to nurture and take care of patients, but that did not apply to physicians. Their arrogance was so deep, she did not think they saw it.

Hospital policy required nurses to follow the orders after first checking with the head nurse and then double-checking with the physician who wrote the order. Complaints could be filed with the hospital quality assurance committee, but the process took months and the nurse who initiated the process could be reprimanded if the committee found his or her complaints to be unfounded or trivial. Trivial, this was not, but when she confronted the hospital administrator, he confided, “Do not put me in the middle of this.” The pharmacist finally agreed to call the doctor and check on whether he preferred the “standard dose” of medication or the “unusual dose” he had first ordered. Dr. Ludwig agreed that the standard dose was “worth a try,” so Maureen went ahead and followed the doctor’s new orders.

Not too many months later, Maureen found herself confronted with new decisions in her first job as a nurse specialist in the intensive care unit. She now worked under “standing orders,” which allowed her to make many decisions on her own. For the first time, she felt like she was calling the shots and making the decisions that made a difference for patients.

On one shift, late in the middle of the night, she was running from bed to bed covering the intensive care unit when she realized that she had given a patient the wrong medication. Fortunately, it was not a life-threatening mistake. She sighed with relief. Checking the chart carefully, however, she winced when her eyes fell upon the name of the attending physician, Dr. George Ludwig.

Discussion Questions

1. How is Maureen’s situation affected by the structure of the nursing profession?

2. How is Maureen’s situation affected by the changes in roles of women that have occurred in the United States in the last 40 years?

3. How is Maureen’s situation affected by the changes that have occurred in the delivery of health care over the last 10–20 years?

4. What changes do you think are needed in the healthcare system to prevent the types of mistakes illustrated in this case?

JACK AND CONTINUITY OF CARE

Jack was told that he had high blood pressure and high cholesterol when he was in the army. Because the conditions did not bother him, Jack paid little attention to them. His job did not provide health insurance, so he decided to take his chances rather than spend his last dollar paying for insurance through an exchange. Anyway, he was strong and athletic. Over the years, Jack gained weight, exercised less, and developed a “touch of diabetes.”

When the diabetes produced symptoms, he went to the emergency room, where they did a good job of diagnosing his problem and sent him off with a prescription and a few pills to get started. The pills seemed to help, but Jack could not afford to fill the prescription or follow up with his “family doctor” because he did not have one. Jack did not understand all the terms the doctors and nurses used to describe his condition, but he knew it was serious and could get worse.

It was not long before he was sick again, so this time, he sought care at a community health center. He did not qualify for Medicaid, but the treatment was affordable. For a couple of months, he followed up and was feeling better, but on the next scheduled visit, they told him, “You need to be in the hospital—you are getting worse.” They got him to the hospital, where he was admitted to the university service and assigned to a young resident who had just graduated from a well-known medical school. The resident reviewed his condition, developed a treatment plan, and explained to Jack what needed to be done. He ordered a TB skin test and collected sputum to check for TB because of Jack’s chronic cough. Unfortunately, before the treatment could be implemented, the resident rotated to another service and Jack’s new resident did not seem to pay much attention to him.

Jack decided to leave the hospital against medical advice and left no forwarding address. His TB skin test was never read. When his positive sputum culture for TB came back, the laboratory alerted the local health department. Not knowing where Jack lived, the health department was not able to follow up.

Before he left, the hospital made sure that Jack had signed all the forms to receive Medicaid payments for the hospitalization. However, Jack did not complete the forms because he did not plan to get any more medical care. That changed one day when the pain was more than he could stand. He decided to try another emergency room. This time, the place was very crowded and he had to wait hours to be seen. Once he was examined, the physicians and nurses tried to get information from him on his condition and treatment, but Jack could not provide much useful information.

He was prescribed pain medicine and sent home. He was told to follow up with a doctor in the next few days. By then, it was too late. One morning as he was getting up, Jack’s left leg was weak and numb and he had lost his speech. He struggled to call 911. Despite the fact that he could not speak, the operator was able to send an ambulance by tracing his telephone location. The EMTs rushed to Jack’s home and got him to the nearest hospital. Once again, the emergency room clinicians evaluated him, but this time, it was too late to be of much help. Jack was admitted for a stroke.

He stayed in the hospital for a week and made some improvement, but he needed help with the activities of daily living and could only speak a few words. The hospital was able to place him in a rehabilitation center because Jack, now 65, qualified for skilled nursing care under Medicare. He was transferred to the facility and received intensive rehabilitation services for the next month, until he no longer improved. At that point, Jack was no longer eligible for skilled nursing care. He was transferred to a Medicaid nursing home closer to his only relatives. The new facility had a large number of patients needing “custodial care.” It provided all the services required by law, but Jack soon realized that he was just another stroke patient.

Discussion Questions

1. How does this case illustrate the lack of institutional continuity?

2. How does this case illustrate the lack of continuity between the healthcare and public health systems?

3. How does this case illustrate the lack of financial continuity?

4. What role does the lack of information play in this case? How can information technology serve to reduce or eliminate these lapses in continuity?

5. Which lapses in continuity require other types of interventions?

DONNA’S DOCTOR—TO ERROR IS HUMAN

Donna’s heart was racing again and there just did not seem to be a reason for it. She was not upset and had not been exercising. She was only 48, and no one seemed to take her seriously when she told everyone that something was wrong with her heart. She knew it was more than her recent divorce and raising a couple of teenagers. Not even the diagnosis of menopause satisfied her.

She decided to change primary care doctors, having heard that Dr. Stein actually listened. He did listen and examined her carefully, but did not find anything. He ordered a 24-hour test to monitor her heart. Donna did her usual activity and the portable device recorded a basic electrocardiogram. She had one brief episode of racing heart. She recorded the time and length of the episode just as requested, and sure enough, she was having a brief episode of what the doctor called “atrial fibrillation” at the recorded time.

A week later, Donna got the results—episodes of atrial fibrillation. The upper chambers of her heart, called the atria, were beating very rapidly. Her lower chambers, called the ventricles, which pump the blood out of the heart, were doing just fine, so she was not in immediate danger.

“The real danger is blood clots and potentially a stroke,” Dr. Stein told her, “and we should thin, or anticoagulate, your blood.”

The thought of a stroke was enough to convince Donna to go ahead.

Anticoagulation can be done economically using a drug called Warfarin, often known by the brand name Coumadin, she was told, but it has to be done carefully. It can cause bleeding if it is not checked often. Taking Coumadin, Donna felt protected. She went back for the tests to adjust the dose. She felt better and now had lots of energy, but she still had some of those episodes of rapid heart rate.

When the hot flashes began, she knew that menopause had in fact arrived, but she felt better than ever and found herself skipping her blood tests because she wanted to be sure that she had time for her exercise routine. She did not realize that anything was wrong until she fell off her bike one day, hitting her head. Fortunately, she was wearing a helmet, so the injury did not seem too bad. However, she did feel dizzy afterward. And then a few hours later, her son told her that her speech was slurred.

“Have you been drinking, Mom?” he asked.

The look of disdain on his mother’s face was enough to worry her son, who now insisted on taking her to the emergency room.

Dr. Stein met Donna and her son in the emergency room. He arranged an emergency MRI scan, which showed evidence of a small bleed, and the blood test showed her anticoagulation level was too high. The doctors rapidly reversed the level, and over the next few days, Donna’s mental state returned to normal.

What a relief, she thought, but there has to be a better answer than going back to anticoagulation. Her doctors in the hospital asked for a consultation. First, the medical student, then the resident, and finally the professor came to look her over, examined her carefully, and then talked about her just outside her door, where she could hear bits and pieces of their conversation. “Dr. Stein sure missed the diagnosis”…“If she had only been compliant, none of this would have happened”…“An obvious case of hyperthyroidism”…“No need for Coumadin.”

“The blood tests confirm overactivity of your thyroid, which is a condition called hyperthyroidism,” the resident told her. “This caused your atrial fibrillation and your increased energy. You need treatment, but we do not do that here—we will give you a referral.”

Donna could hardly absorb everything and did not get a chance to even ask questions.

She went back to Dr. Stein, who told her how badly he felt about missing the hyperthyroidism—he too had learned a lesson and he apologized for what had happened. He told her that there was very good treatment for hyperthyroidism and he would be pleased to take care of her after consultation with a specialist. Donna knew that doctors make mistakes, but she did not know that they admitted them. She knew that Dr. Stein was a good doctor and that he would pay extra attention to her. Donna hoped that things would go well and was confident that she was in good hands with Dr. Stein.

Discussion Questions

1. Did Dr. Stein’s care fulfill the duty, breach, causation, and damages criteria for medical malpractice?

2. What additional aspects of Dr. Stein’s care affected whether a malpractice case resulted?

3. What role do you think the disclosure of error played in preventing a malpractice suit?

4. What attitudes toward decision making in health care on the part of Donna influenced the approach she took to her health care?

HEALTH CARE IN THE UNITED STATES—FOR BETTER OR WORSE?

The final hours came as no surprise to his wife and family, who made daily visits to the hospital where Sam had been treated on and off for the final year of his life. His doctor had spared no expense to give him the most effective treatments available.

But wouldn’t it have been nice if he could have died at home? they thought to themselves as they gathered at the funeral. At least he held out until after the baby was born.

Sam’s diagnosis of colon cancer did not shock him. His father had died of colon cancer, and he had been thinking for some time that it was time to be checked. Surgery went well and he and his doctor were optimistic about the future. The surprise came about 18 months later, when during a follow-up examination, he was told that there might be a recurrence.

Chemotherapy seemed to do more harm than good. There did not seem to be a good answer. Sam’s physician sought out the newest treatment, but it did not seem to help. The final shock to his system came after he received a dose of the wrong medicine administered by a nurse who was new to the unit. She was hired in response to the recent accreditation review, which criticized the hospital for understaffing.

Though his death was no surprise, the bills from the hospital and physician were an unexpected burden in the months and years that followed. The health insurance that was offered through Sam’s employer did not pay for screening for the colon cancer that killed him. In addition, its loopholes, caps, and copayments left the family with bills that would require years to repay. It was not just the uncovered expenses that they had to pay out of pocket; it was the mountains of paperwork that arrived in the mail.

Nonetheless, the family understood. The doctors had done everything possible, treated Sam and them with respect, and responded quickly to their calls and continuous questions. Maybe things were not ideal, they concluded, but at least they did everything they could.

Discussion Questions

1. What strengths of the U.S. healthcare system are illustrated in this case?

2. What limitations of the U.S. healthcare system are illustrated in this case?

3. How would the Affordable Care Act affect the services provided in this case?

4. What steps would you recommend to improve the delivery of preventive and curative services to better serve patients like Sam?

5. How might Sam’s health care have been different in other developed countries, such as Canada and the United Kingdom? In what ways might it have been better and in what ways might it have been worse?

EXCESS COSTS—HOW MUCH CAN BE SAVED?

Doris, an 80-year-old white female, had been previously healthy. Her mother had a history of hip fracture. Doris was told to take extra calcium to prevent osteoporosis, but she was never tested or prescribed any treatment.

One Saturday morning, Doris fell in her home and landed on her hip. She lay in pain for about an hour before she was able to reach the telephone and call for help. The ambulance took her to the nearest hospital rather than the hospital she had requested. The doctors at the hospital had none of her medical records and did not realize that she was allergic to penicillin, which they prescribed because of the deep skin abrasions she suffered in the fall. Within minutes after receiving a shot of penicillin, she experienced anaphylaxis, a severe allergic reaction, and required an emergency team to be called to provide immediate resuscitation.

Doris was admitted to the intensive care unit on a Friday night. She underwent X rays and was seen by five teams of doctors over the weekend. The doctors determined that she had a hip fracture and needed surgery as soon as possible. No surgeons were available to see her until Monday morning, at which time surgery was scheduled for Wednesday morning.

While Doris was in the hospital, the physicians decided to do a work-up for gallbladder disease because gallbladder disease is very common in her age group. The scans did show gallstones, and she was initially advised to have surgery for her gallstones. A consult recommended that rather than surgery, she seek health care if she ever had pain in the area of the gallbladder.

The physicians who took care of Doris in the hospital decided to treat her aggressively for osteoporosis using the newest and most expensive medication. The medication was covered by Medicare because Doris was in the hospital. The medication could be given by an injection and lasted for a year.

After discharge, Doris was supposed to receive physical therapy to be sure that she was ambulatory and did not develop blood clots in her legs. Unfortunately, the wrong telephone number and address were provided to the physical therapy team, and it took a week before the physical therapists were able to locate Doris to begin physical therapy.

Doris began the therapy, but on the second day in the middle of the treatment, she became short of breath. The physical therapist recognized the signs of a pulmonary embolism, or a blood clot traveling to the lungs. She immediately called the ambulance, which took Doris to the same hospital where she stayed before.

The hospital staff recognized that Doris had been discharged less than one month earlier and were concerned that Medicare might not pay the bills for her readmission. They decided to transfer her to the hospital that she had originally requested. She was successfully treated for pulmonary emboli and was followed up as an outpatient on a weekly basis for several months.

Doris received over 40 mailings related to the billing for her hospitalization, many of which said, “This is not a bill.” She did receive 10 separate bills, including ones from the two hospitals, three laboratories, the physical therapy group, and four different doctor groups. The bills for her care totaled $215,000, $212,000 of which was covered by Medicare or her Medigap policy. The bills included a $50,000 bill for the orthopedic surgery, which was fully covered, and a $1,000 bill for transportation to the second hospital, which was not covered by Medicare.

When Doris inspected the 10-page bill from the hospital, she noticed a bill to Medicare for equipment for three blood transfusions. “No one told me about that,” she said to herself, so she called the hospital to confirm whether she in fact had had blood transfusions. The billing clerk checked with the hospital administration, let Doris know that this was a mistake, and apologized. A week later, Doris read in the newspaper that a large number of Medicare patients were being charged for equipment for blood transfusions they never received.

Discussion Questions

1. Identify ways that each of the IOM categories of excess costs played a role in this case.

2. Identify ways that excess costs could be reduced in this case.

3. Discuss ways in which a reduction in the costs of health care in the United States could affect the quality of health care favorably.

4. Discuss ways in which a reduction in costs of health care in the United States could affect the quality of health care unfavorably.