Combatting Defensive Medicine

By Alessandra Fodera (NHS ’16)

Growing up with arthritis and other medical issues, I was always a bit fragile. I very easily got hurt, and usually from simple activities. I sprained my ankles so much that I wore a medical boot on a different ankle every other month. I would go ice skating—sprain my ankle; walk on unleveled ground – sprain my ankle; play kickball at the field by the lake at my grammar school – completely miss the ball, watch my shoe fly into the lake and, good guess, sprain my ankle. My orthopedist, a family friend, was aware of my medical condition. He is a remarkable orthopedist who has been practicing for over thirty years. Yet, he needed an X-ray every time I came in. He clearly would state, “It’s another sprain, but let’s do an X-ray just in case.” In case of what? If I, a fifteen year old, knew it was a sprain; my doctor, with thirty years of experience, knew it was a sprain; and the ankle clearly looked like a sprain and not a fracture, why go through the trouble, costs, and harmful radiation of another X-ray? 

Defensive medicine is a direct result of medical malpractice. Medical malpractice occurs when a caregiver provides substandard care that results in injury or even death. This definition is extremely broad and the costs incurred therein are enormous.  For fear of being sued, many doctors practice defensive medicine to protect themselves. The practice of defensive medicine itself has many negative effects. Defensive medicine wastes the time, energy, and money of all parties involved. Extra testing is extremely expensive and adds to the United States’ high healthcare expense. Doctors are trained for years to diagnose and treat patients, but in defensive medicine, rely on technology instead of their own training.

Generally, there are two types of medical testing. The first level occurs when a doctor examines a patient and evaluates their symptoms and truly cannot render a valid diagnosis that they feel strongly about. Therefore, they order tests, for example, blood work on the three diseases they are considering, and use the results to differentiate the diagnosis. The second level of testing occurs when a doctor is positive of a diagnosis but, due to the prevalence of malpractice suits, needs testing to confirm the diagnosis. The first level of testing truly helps in diagnosis and treatment, but second level of testing serves practically no purpose except to rule out an incredibly unlikely diagnosis and legally safeguard a physician.

Numerous effects, some positive and some negative, can occur by having physicians pay for medical tests, X-ray studies, and consultations out of their own pockets.  Having doctors pay out of pocket may provide doctors with the incentive to more wisely choose testing measures. Doctors may more confidently make diagnoses by utilizing their medical knowledge and clinical skills instead of second-guessing themselves and conducting numerous and often unnecessary scans/tests. This would save significant money by reducing the high costs of testing. This also saves the patient from possible negative health risks, such as repeated exposure to radiation from X-rays.

A ten-year-old boy is rushed to the emergency room with high temperature, sharp stomach pain, and blood in his vomit – all clinical signs of appendicitis. He was then rushed into an operating room, where one member of the surgeon’s team asked about the sonogram. It then became clear that a sonogram had not been taken, since all the clinical signs were present. A portable sonogram machine was then brought into the room, minutes before anesthesia would be administered. Much to everyone’s surprise, the sonogram presented a perfectly healthy appendix. My ten-year-old brother almost had his healthy appendix removed because a doctor had thought that the clinical symptoms were enough evidence to cut him open. After evaluation by a urologist and additional testing, my brother was diagnosed with a kidney defect.

Although there are possible positive outcomes, there are also possible negative effects.  Physicians might not appropriately care for their patients due to the costs of tests. Doctors could misdiagnose, or fail to diagnose, by not appropriately using diagnostic testing. If parents bring in an infant who fell off a changing table, and a doctor examines the child who physically seems fine but cannot be analyzed for cognition because of its youth, the child can easily have unnoticed internal bleeding or other problems. If a doctor who doesn’t want to pay for the CT scan releases the patient and the child subsequently has a medical problem, then he may be completely at fault.

Physicians should be able to run numerous tests for confirmation and to see if they missed anything. Many diseases and/or illnesses are asymptomatic or have unclear symptoms, and therefore testing is necessary. For a doctor to have to decide which are necessary and which are not is not fair and possibly unethical.  A last to consider is that reducing testing by having doctors pay out of pocket is a barrier to preventative care and early detection. Preventative care reduces long-term costs. To make doctors bear this cost inhibits preventative care. Diagnosing cancer at the Stage One has much higher rates of success than at Stage Three.

Another possible and likely effect is that doctors will charge a higher rate for all patients (unless insurance companies don’t allow this). Due to the out of pocket expenses of testing, doctors will have to compensate and will shift the costs to the patients.

            Another possible situation is an entirely new insurance market: immediately, doctors will be more careful about ordering tests and will more closely examine patients to come up with firm diagnoses. Instead of ordering excessive tests just because insurance is covering it and because of fear of being sued, in this physician-paying world, doctors will carefully determine which tests are truly necessary for a complete and accurate diagnosis.  If physicians have to pay for testing, they will most likely shift the costs to other stakeholders, such as to the consumers by increasing their rates.

Doctors could increase their rates in one of two ways: Either they could adjust the rates according to what testing is performed, or they could increase their rates across the board. Following the former, depending on what tests were needed for a given patient, the doctor could charge them accordingly. On one hand, adjusting costs would not be fair for those not getting tests to overpay in order to compensate for others. On the other hand, if a doctor chooses a test and the patient can’t afford it, is it ethical for the doctor to not treat the patient?  Doctors can overcharge or undercharge according to incorrect criteria. Standardizing the rate seems the most efficient and rational. Across the board, doctors could increase their rates, having some patients pay more to compensate for others’ testing. Insurance companies would then either have to cover the whole or just a percentage of the costs, leaving the rest of the cost burden to the patients.

A change like this can have many different ramifications. The insurance system may completely be altered. If insurance companies aren’t paying for testing, they will then have to give a larger fee to the doctors who will be paying out-of pocket. They also can charge lower rates to enrollees due to lower costs of testing. Insurance companies may actually save money through this because the higher fee to doctors are minimal costs compared to the higher costs of testing. Doctors may also profit: by increasing their rates, all patients will be paying higher prices, whether or not additional testing is needed.  If 10 patients are seen at $200 per person, and only two patients need additional testing that costs $500 per person; the doctor is paid $2,000 from the 10 visits, with testing costs totaling $1,000. The doctor still profited $1,000. This new model may save or cost consumers: With lower rates from insurance companies, consumers would save money; depending on the rates of the doctor visits, consumers may have to pay additional costs.

This is a very controversial hypothetical situation. I do believe that defensive medicine and the high costs that it burdens patients with have become oppressive. The only reason defensive medicine occurs is because society is enabling it. Doctors should be able to make a diagnosis and only test if they think it is necessary to confirm a diagnosis; they should not be testing in fear of being sued. Doctors should be able to order tests and should not be limited by knowing the cost of a test is out of their own pockets. Tests save lives and diagnose issues that cannot be clinically determined. Doctors shouldn’t singularly bear the costs of testing. Having physicians pay out of pocket creates a dangerous scenario that could easily compromise patient care.  However, having doctors lose something through testing lets them have skin in the game: consider how insurance companies use copayments to ensure that patients are not overusing healthcare and causing unnecessary costs. Through copayments, patients share some of the financial burden and will hopefully choose wisely when it is necessary to seek medical attention. Doctors will be more cautious or prudent in ordering and performing diagnostic tests when they have a financial stake in the cost of such testing.

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AIDS in DC

By Alessandra Fodera (NHS ’16)

Despite a marked decline in the mortality and incidence rates of HIV/AIDS in DC, factors such as high prevalence rates, decreased HIV/AIDS attention and knowledge in the public, and disparities in the populations most affected by the disease, have contributed to the continuation of AIDS in the District of Columbia.

The rate of HIV and AIDS in Washington D.C. is six times higher than the national average, and in multiple countries in Africa, and is considered an epidemic by the World Health Organization. In addition to the devastating affects HIV and AIDS have on the health of the District’s residents, the possible economic effects are too severe to be overlooked[1].

The prevalence of HIV and AIDS in the District of Columbia poses the city’s largest social, economic, and health threat. When evaluating the impact of HIV and AIDS on an area, the three most important statistics to examine are the number of newly diagnosed cases of HIV and AIDS, the percent of the population that is living with HIV and AIDS, and the number of deaths from HIV and AIDS per year. When combined and examined in conjunction with breakdowns by sex and race, these three statistics present an accurate picture of the prevalence and consequences of HIV and AIDS in a given area.

The World Health Organization defines HIV epidemics as situations in which the frequency of HIV cases exceeds 1.0% of the total population.[2] The overall percent of the population of the United States afflicted with HIV and AIDS is just under 0.4%.[3] Despite the low national average, the percent of the population of the District of Columbia living with AIDS is a staggering 2.4%.[4] This percentage is nearly twice as high as the percentage in the Democratic Republic of Congo and higher than the percent of people living with HIV and AIDS in fifteen African countries.[5]

Additionally, the HIV and AIDS epidemic in the District of Columbia has disproportionately affected the African American community and the poorest sections of the city. Of the 4,919 newly diagnosed cases of HIV in Washington D.C. between 2007 and 2011, 77.4% of those diagnosed were Black.[6] Of the 251 HIV related deaths in the District in 2011, 232, or 92.4%, were of Black men and women.[7] Finally, the number per 100,000 persons living with HIV and AIDS and the number per 100,000 of new diagnoses of HIV between 2007 and 2011 were highest in Wards 5, 6, 7, and 8.[8] These wards have higher levels of poverty than all of the other Wards in the District.[9] However, there are very few services and programs targeting this population.

In a survey on HIV and AIDS conducted in 2011by the Henry J. Kaiser Family Foundation, just 7% of Americans were found to list HIV and AIDS as a top national health problem.[10] The report also found a decline in the number of people who has seen, heard, or read about the HIV and AIDS epidemic in the last year, from seven out of ten persons in 2004 to just four out of ten today.[11] But most importantly the report delineated the issue of a lack of leadership in the fight against HIV and AIDS.[12]

Counterarguments:

There are two major counterarguments to this view. Firstly, HIV/AIDS has become less of a problem in DC due to increased testing. Organizations such as the AIDS Healthcare Foundation (AHF) offer free HIV testing at various locations. “Come Together DC–Get Screened for HIV,” a campaign in DC that began in 2006, aimed to increase HIV testing, thus increasing people’s awareness of their status. Previously, patients had to personally ask their doctor to be tested during a visit. After this campaign was implemented, new protocol has patients automatically tested at any clinical visit; a patient has to specifically “opt out” of testing. The Fifth Vital Sign model, implemented for primary health care visits, requires rapid HIV testing for all patients; the rapid test is performed along with other vital tests (heart rate, blood pressure, weight, pulse-ox).[13] Because of these programs, more people are tested everyday. With increased testing, patients are diagnosed and receive treatment sooner.

Although testing has increased, HIV/AIDS in DC is still extremely high and has not decreased enough to not still be considered a major epidemic with many programs and initiatives to still be implemented. Also, although the previously mentioned protocol stated that patients should be automatically tested, this chart displays that this is not fully implemented. The statistic of 56.3% should be considered malpractice; only 56.3% of patients were offered an HIV test at any healthcare visit.[14] Approximately 1/3rd of the people in the city who have HIV aren’t aware of it. To miss this opportunity to reach this group of people is almost criminal, especially when the care provider only has to do a rapid swab test to patients that are already visiting. Also, Georgetown Hospital does not have a rapid HIV testing option. With Georgetown Hospital being closest to Ward 3, which has a higher risk of HIV than the national average, not having a testing location here potentially misses numerous testing opportunities.

 

HIV/AIDS has become less of a problem, with incidence rates decreased, in DC because numerous resources have been allocated to treatment. Figure 3 in the 2011 annual report displays a decrease in incidence and deaths and an increase in living HIV cases.[15] This proves that treatment plans are working and people are living longer healthier lives. The 2013 New Annual Report depicts the progress DC has made. DC has focused on increased testing and access to care. HIV incidence has decreased 46% from 2007 to 2011, while AIDS incidence has decreased 47% from 2007 to 2011. More people are being diagnosed and started on treatment sooner. Of patients diagnosed in 2011 with HIV, 80% accessed care for the disease within three months; when comparing this to those in 2005, 30% more people in 2011 got care. This proves that more people are accessing treatment. Other programs have been implemented and have been successful in targeting specific modes of transmission. A 10-fold increase of condoms were distributed in 2012 than distribution in 2007. Needle-exchange programs and increased health education in schools have been implemented.[16]

Resources are allocated according to people’s perceptions about risk of contracting HIV/AIDS. However, there are very few services that target black men in the city. Meanwhile, there are more services for white men and African American women. There are very few preventative services for African American men, even though new infections among men are significantly higher than women. DC needs to figure out how to reach this population without marginalizing them. Until then, they are inaccurately allocating many resources and failing to zoom in on the real risk population. Figure 4 depicts that in DC, the highest incidence is in the black and poverty-stricken population.[17] The quality of service in some parts of DC is extremely low. There are numerous differences between the black and white populations in accessing care, with some not receiving sufficient care and others not tested early enough.

Additionally, increasing prevalence requires more resources to be spent to treat people with the disease. With prevalence high and more people living with HIV/AIDS, more money and resources need to be allocated to treating patients for longer periods of time than before. Although our goal was always to have people who have contracting the disease to live longer, we might not be prepared for the amount of resources necessary to do this.

The HIV and AIDS epidemic has disproportionality affected Washington D.C. as a whole. HIV and AIDS is a complicated issue, affecting many different demographics is many different ways. Increased resources need to be allocated towards HIV/AIDS treatment, awareness, and outreach programs to truly combat this epidemic. The defeat of HIV and AIDS lies within our grasp, but without sustained, aggressive measures against it this disease will persist.

 


[1] District of Columbia Department of Health HIV/AIDS, Hepatitis, STD, and TB Administration (HAHSTA). (2012). Annual Epidemiology & Surveillance Report. 8 Washington, DC: U.S. Available online at doh.dc.gov

[2] HAHSTA,2012. 8

[3] “HIV in the United States: At A Glance.”HIV/AIDS. Centers for Disease Control and Prevention, 7 Nov. 2013. Web. 15 Nov. 2013. <http://www.cdc.gov/hiv/statistics/basics/at

[4] HAHSTA, 2012. 8

[5] “Democratic Republic of the Congo.”AIDS info. UNAIDS, n.d. Web. 17 Nov. 2013. http://www.unaids.org/en/regionscountries/countries/democraticrepublicofthecongo

[6] HAHSTA, 2012. 62

[7] HAHSTA, 2012. 28

[8] HAHSTA, 2012. 13, 8

[9] DC Fiscal Policy Institute. (2011, September 22). ACS Poverty Analysis. Retrieved from http://www.dcfpi.org/wp-content/uploads/2011/09/9-22-11-ACS-Poverty-Analysis.pdf

[10] “HIV/AIDS at 30: A Public Opinion Perspective” The Henry J. Kaiser Family Foundation.” HIV and AIDS. The Henry J. Kaiser Foundation, n.d. Web. 1 Feb. 2014. <http://kff.org/hivaids/report/hivaids-at-30-a-public-opinion-perspective/>.

[11] http://kff.org/hivaids/report/hivaids-at-30-a-public-opinion-perspective.

[12] http://kff.org/hivaids/report/hivaids-at-30-a-public-opinion-perspective.

[13] Greenberg, Alan E., Shannon L. Hader, and Henry Masur. “Fighting HIV/AIDS In Washington, D.C.” Health Affairs. N.p., n.d. Web. 01 Feb. 2014. <http://content.healthaffairs.org/content/28/6/1677.full>.

[14] “Heterosexual Relationships and HIV in Washington, DC.” Http://doh.dc.gov. Department of Health, 2010. Web. 30 Jan. 2014. <http://doh.dc.gov/sites/default/files/dc/sites/doh/publication/attachments/HET_BEH_STUDY.PDF>.

[15]District of Columbia Department of Health HIV/AIDS, Hepatitis, STD, and TB Administration (HAHSTA). (2011). Annual Epidemiology & Surveillance Report. Washington, DC: U.S. Available online at doh.dc.gov

[16] “New Annual Report Shows Continued Progress on Decreasing HIV/AIDS, STDs, Hepatitis and TB in the District.” Doh.dc.gov. Department of Health, 24 Sept. 2013. Web. 01 Feb. 2014. <http://doh.dc.gov/release/new-annual-report-shows-continued-progress-decreasing-hivaids-stds-hepatitis-and-tb-district>.

[17] HAHSTA (2011).

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A Proper Food Guide as a Solution to the Poor American Diet

By Sunny Parmar (COL ’14)

Abstract

Is there a way to improve the American diet? Nutritional trends in the United States have transformed dramatically over the years, contributing significantly to the poor overall health of Americans and increased prevalence of diseases such as obesity and diabetes. A recent survey demonstrates that Americans continue unhealthy diets without realizing that their diets are harmful.

 In tackling overall population health improvement, we must illuminate and prioritize public education about proper diet to instigate Americans towards healthier eating habits. Before this can be done, though, a reliable source on healthy eating guidelines is needed.

 The United States Department of Agriculture (USDA) created a Food Pyramid to serve as the official set of guidelines for the constitution of a healthy diet. However, it has been widely criticized by scientists and nutritionists for its lack of backing of actual research.

 In 2008, The Harvard School of Public Health formulated the Healthy Eating Pyramid, highlighting- along with exercise- limiting refined grains, red meats and dairy, and shifting to a plant-based diet. Those seeking to improve their own diet or those of fellow Americans could reliably turn to this food guide, which is backed by nutritional research, as their source.

A Proper Food Guide as a Solution to the Poor American Diet

As America’s diet has evolved, so too has its health declined. The result has been a stark increase in the prevalence of obesity among adults, which only continues to grow (Weight-control Information Network [WIN], 2014). Because obese individuals are at increased risk of diseases including but not limited to diabetes and cardiovascular disease, this issue remains a strong concern of health professionals. If poor diet contributes so evidently to poor health, why do Americans not change their habits? Evidence suggests that the problem is rooted in a lack of public awareness of the constitution of a healthy diet. In order to correctly educate the public, a reliable set of dietary guidelines based on nutritional research would be necessary. The official source, the USDA’s Food Pyramid, has been criticized for not accurately reflecting the findings of years of scientific research on nutrition. On the other hand, the Harvard School of Public Health’s 2008 Healthy Eating Pyramid contains many helpful changes relative to the USDA’s Pyramid, which are based on nutritional research. Those seeking to educate Americans should use Harvard’s food guide as an example of what constitutes a healthy diet. Such a food guide, if implemented properly, would likely contribute to the decrease in obesity-related diseases and the increase of overall health in Americans.

How has the American diet reached this state over the years? Kent Thornburg, Ph.D., Interim Director of Oregon Health & Science University (as of 2012) states that American meals traditionally consisted of meat, potatoes and vegetables, and meals were a family affair. As Americans began eating more fast food rather than home-cooked meals, consumption patterns became considerably unhealthier. Most food is now more likely to be determined by convenience and cost rather than considerations of nutritional value because of this new fast-paced lifestyle. Foods high in sugar, salt and fat stimulate pleasure centers in the brain, leading Americans to prefer these options over healthier, less tasty ones. In addition, cooking a dinner at home requires valuable time and effort, which could be spent at work instead. The negative consequences of this change—if they are indeed due to the change in diet as Thornburg argues—only became evident after a period of time. Obesity in U.S. adults has increased from 13.4 to 35.7 percent over the past fifty years (WIN 2014). In addition, more Americans than ever suffer from calorie malnutrition—an issue of getting too many calories and not enough nutrients. As a result, America is strapped with the highest costs of health care in the world and the unhealthiest population among Western countries. Thornburg believes the best solution lies in improving the American diet. What is preventing us from doing this?

It appears that Americans continue this unhealthy diet not because of a lack of concern for health, but because of a lack of knowledge regarding what is healthy. Northcut finds that nine in ten Americans claim to eat healthily, yet of the 1,234 polled, most made unhealthy food choices in their diet. For example, 43 percent drank one or more sugary sodas or sweetened drinks daily. Only one in four attempted to limit sweets, sugars and fats in their diets. A mere three in ten ate a recommended five or more servings of fruit and vegetables daily. Also, in terms of weight perceptions, a third of the responders reported healthy weights despite having the BMIs of overweight or obese persons. This data makes it evident that Americans lack an understanding of what constitutes a healthy diet and health in general, and could benefit enormously from proper education of a reliable food source.

The USDA’s Food Guide Pyramid, a tool showing much of different kinds of food Americans should eat, was instituted into school curriculums, media, brochures, and cereal boxes and food labels, yet health professionals widely criticized it as being based on questionable scientific evidence and not adapting to the latest research as it became available (HSPH, 2011). In response, the USDA instituted MyPyramid in 2005, which lasted six years until collapsing to criticism for being too confusing.  Its replacement, the much-simplified MyPlate (see Figure 1), continues to promulgate its shortcomings. MyPlate does a poor job of distinguishing junk foods from healthy ones. It does not distinguish harmful refined grains from whole grains, it places harmful salty processed foods in the same category as some unprocessed foods, and it does not highlight the danger of sugary foods. Some blame the USDA for being too influenced by lobbying efforts by organizations such as the National Dairy Council and the Wheat Foods Council, leading to poor recommendations in the new guide not accurately backed by nutritional research. A guide with better distinctions and backed by reputable research is surely needed.

choosemyplate
Figure 1: USDA’s official graphic of MyPlate. The sections of the plate represent the recommended portions of a daily diet. Grains and vegetables each take up over a quarter of the plate; protein, fruits and dairy each take up a little less than a quarter. Source: http://www.cnpp.usda.gov/Publications/MyPlate/GraphicsSlick.pdf

One potential solution is the Healthy Eating Pyramid, a food guide similar to the USDA’s, created by the Harvard School of Public Health in 2008 in response to a recognized need for a more accurate food guide for Americans (HSPH, 2011). The Healthy Eating Pyramid is backed by years of research on nutrition and health and is more descriptive. The findings from research led Harvard’s pyramid to elucidate on several significant differences than the USDA’s guide. The first, limiting dairy intake, is significant because of recent research’s indication that dairy does little to prevent osteoporosis or fractures. A second—limiting refined grain intake—is merited because grains are processed as sugars in the body and as such lead to the same health problems, such as diabetes. The USDA guide fails to highlight the dangers of red or processed meat, which are linked to increased rates of heart disease and diabetes. Harvard’s guide can also include more details that the USDA’s guide did not. For example, Harvard’s guide highlights the superiority of fish, poultry and beans alongside the avoidance of red meats. It suggests eating fish twice a week or shifting to a plant-based diet. With these changes based on nutritional research, the Healthy Eating Pyramid is a quality guide of what constitutes a healthy diet.

It is best to explore the exact details of Harvard’s Healthy Eating Pyramid in order to fully understand how it integrates food suggestions into dietary needs so as to improve well-being (see Figure 2). First and foremost, the pyramid highlights that exercise is intrinsic to healthy living. This activity helps one control weight by keeping in mind the simple fact that more or less calories are burned in relation to what one eats (HSPH, 2011). On the second level, the bricks are those of vegetables/fruits, healthy oils and whole grains. Simply, incorporating these components in the appropriate quantities would ensure that Americans get enough vitamins, fats and carbohydrates. On the third level are two bricks of nuts, beans and tofu on the left side, and fish, poultry and eggs on the right. The recommended plant foods on the left side provide fiber and additional vitamins and minerals valuable for the human body. The meat foods on the right side provide necessary protein, with a strong emphasis on fish for being rich in heart-healthy omega-3 fats, and some emphasis on poultry and eggs for being low in saturated fat. This distinction highlights how certain meats can be dangerous. On the fourth level is one brick, that of dairy, for which high intake has been associated with an increased risk of prostate and ovarian cancers but a low intake—which the pyramid recommends—can help one achieve enough calcium (vitamin D, on the other hand, can be fulfilled with supplements or more exposure to sunshine). Lastly, there is the “use sparingly” group, including red and processed meats, refined grains, sugary drinks and salt. In the Healthy Eating Pyramid, the comprehensive details paint a clear picture of the optimal diet.

thehealthypyramid
Figure 2: Harvard School of Public Health’s Healthy Eating Pyramid. Each brick within the pyramid reveals the suggested amount of each food group which should be consumed; larger bricks emphasize greater importance. Multivitamins and alcohol are included merely as light recommendations for their health benefits. Source: http://www.hsph.harvard.edu/nutritionsource/pyramid-full-story/

The state of American health is a serious concern. Whether lifestyle is to blame and it is difficult for people to switch to healthy foods, or they are simply not knowledgeable about what constitutes a healthy diet, an emphasis on education remains of prime importance in solving America’s health problems. We must address the misconceptions surrounding diet before people can begin modifying their lifestyles. In conjunction with our shift from primary to preventive care, diet must be addressed before people become so unhealthy that nutrition-related disease cripples them. The Healthy Eating Pyramid exemplifies how food guides can effectively provide information regarding diet to Americans. If reliable food guides can be made familiar to the public—be it through media, school billboards or even strategic placement of posters in restaurants—a healthier population will be closer to the American horizon than ever before.

 

References

 Harvard School of Public Health. (2011). Food Pyramids and Plates: What Should You Really Eat? Retrieved from http://www.hsph.harvard.edu/nutritionsource/pyramid-full-story/

 Northcut, T. (2011, Jan 4). Americans Falsely Believe Their Diet Is Healthy. Retrieved from http://news.discovery.com/human/health/americans-diet-weight-110104.htm

 Thornburg, K. (2012 Aug). The New American Diet. Retrieved from http://www.ohsu.edu/xd/education/schools/school-of-medicine/departments/the-moore-institute/about/message-22912.cfm

 Weight-control Information Network. (2014). Overweight and Obesity Statistics. Retrieved from http://win.niddk.nih.gov/statistics/

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The Stress of Poverty

By McCall Torpey (COL ’15)

As Georgetown students, it is pretty obvious that most of us experience stress on a daily basis. The pressure to perform well and exceed academically, socially, and financially is relentless. Recently, more and more research has been starting to focus on the fundamental origins of the “stress” that troubles our society. Interestingly enough, new findings indicate that stress and its effects tell us an awful lot about the state of American society.

Evidently, stress can have adverse effects on our health. New studies have shown that chronic stress increases your risk of contracting heart disease. In fact, just having the impression that you are experiencing an unhealthy level of stress increases blood pressure and heart rate, and may also lead to a higher likelihood of smoking and drinking (Bakalar). Furthermore, stress, as well as the negative emotions that usually accompany it, compromises the immune system, increases inflammation, and even intensifies one’s perception of physical pain (“How to manage stress”). Ironically, academic stress and the desire to perform well in school actually inhibit our capacity to handle daily educational rigors successfully (Shapiro).

You might be only slightly surprised to learn that a healthy amount of stress can be a good thing. It can put you “in the zone,” so to speak, and inspire us, in some instances, to reach that optimum performance level. When the body is put under pressure to perform well or take on an important task, the sympathetic nervous system, as well as the hypothalamus and the pituitary and adrenal glands, increase the levels of the stress hormones cortisol and adrenaline into the bloodstream, and the blood vessels dilate. Muscles tense and heart rate increases. This physiological response is desirable. It’s the “pumped up” feeling you might get right before participating in a sports game. The body reacts very differently, however, when placed under harmful stress. Blood vessels constrict and there is a big jump in blood pressure. Individuals under this type of pressure often experience lapses in judgment and reasoning abilities. They have lost their ability to re-engage their parasympathetic nervous systems, which are responsible for controlling the body’s everyday functions, like sleeping and digestion. This is an undesirable physiological response. It’s this type of body response to chronic stress that leads to insomnia, disease, and a shortened life span (Shellenbarger). Experts recommend that physical activity and mediation might be some effective ways to alleviate negative stress (Bakalar). Additionally, some techniques, such as biofeedback, in which patients learn to reduce anxiety levels and gain greater control over their own bodily functions, might also be valuable ways to reduce stress and anxiety. It is also believed that some treatments, for instance cognitive behavioral therapy, which is becoming increasingly popular, might be even more effective in combating the stress present in our daily lives since this remedy forces patients to confront the negative thoughts that are often the original source of feelings of stress and pressure (“How to manage stress”). While it is true that stress plays both a positive and a negative role in our daily lives, and we are preoccupied with finding ways to reduce our cortisol levels, recent investigations suggest that stress is a greater cultural problem than most people realize (NPR staff). Studying stress levels amongst the population gives us greater insight into the socioeconomic inequalities that exist within our society (Velasquez-Manoff).

Scientists now concur that the more powerless one feels when beset with a particular stressor, the more harmful are the effects of that stressor. This crippling feeling of helplessness and lack of control over one’s fate is much more prevalent amongst the less fortunate. Individuals at the lower end of the socioeconomic spectrum are more than three times likely to die prematurely compared to members of the affluent class. The stress impoverished children face has significant ramifications later in life and it is becoming more and more apparent that early-life hardships make one more susceptible to disease and illness in adulthood. In fact, a child’s nervous system and the strength of her immune system are highly influenced by the kind of environment in which she grows up. If her parents are members of the lower social class and do not receive a sustainable income, she will also soon begin to experience the stresses that afflict poorer individuals. The stress can be so acute that ultimately, a child who has been raised in impoverished conditions will be more vulnerable to degenerative diseases and infections later in life.  Inflammation due to early life stresses increases one’s chance of contracting heart disease as well as diabetes. Stress levels considerably affect the brain, too. Chronic stress has been related to a decreased volume of the hippocampus, a region of the brain that is crucial for both memory and learning. There are also differences in the pre-frontal cortex, which plays an important role in planning and self-control, amongst children who deal with the onus of poverty in early life. Thus, children stricken by poverty during their early formative years are also more inclined to have difficulty attaining educational achievements and won’t develop a healthy stress response. In reality, three-year old children from wealthier families have greater than twice the vocabulary skills of children whose families receive support from welfare. Scientists have discovered, quite recently, that the telomeres, or the ends, of chromosomes are significantly shorter in people who have experienced more adversity during early childhood. Having shortened telomeres critically hastens the aging process and is extremely difficult to reverse. Prosperous individuals simply have greater access to healthy resources, namely exercise and nourishing food. This phenomenon has been coined the “status syndrome.” There is a strong correlation between heath and socioeconomic status, and as the differences in income increase, class mobility also stalls (Velasquez-Manoff).

What’s needed to give disadvantaged children a better chance for future success is a reduction in the stress that they experience, greater access to education, and more sources of support for families in need. Not surprisingly, research into the nature of stress also offers some explanations for the differences in life spans amongst individuals belonging to different racial groups. In the Unites States alone, the life span of an African-American is on average five years shorter than the average white person. How can this be explained? Again, social and demographic circumstances are responsible. Once again, it was reported that income was one of the major sources of anxiety. Additionally, the stress inherent in the experience of racism, which some members of the African-American population still have to contend with, is also responsible for negative health effects. Discrimination is associated with fat accumulation amongst women. In males, there are reported increases in both blood pressure and cardiovascular disease. And while racism might be a contributing factor to these feelings of stress, it is the tendency that some African-American children are raised under money-tight conditions that is the real underlying cause for the discrepancy in life span between whites and African-Americans (Velasquez-Manoff).

Understanding how the actual stress of poverty perpetuates economic and social inequality in our society is key in recognizing that we must start to treat childhood poverty itself as a public health issue. I think that the information gathered from studies measuring stress among the American population gives fighting childhood poverty a new meaning. By reducing the number of children who grow up in stressful environments due to a lack of financial resources, we can prevent poor health in adulthood. This would actually save more money and save more lives. As a matter of fact, James Heckman, an economist at the University of Chicago reckons that investing in poor children could provide a 7 to 10 percent yearly return to society (Velasquez-Manoff). Culturally, we are very obsessed with finding ways to “fight” stress, when in reality, our conception of stress only serves to conceal the greater social and economic problems prevalent in American society (NPR staff).

 

 Works Cited

Bakalar, Nicholas. “Feeling stressed? It’s probably harming your health.” The New York Times. The New York Times, 1 July 2013. Web. 21 Mar. 2014. <http://well.blogs.nytimes.com/2013/07/01/feeling-stressed-its-probably-harming-your-health/?_php=true&_type=blogs&_php=true&_type=blogs&_r=1>.

“How to manage stress.” Wall Street Journal. Wall Street Journal, 6 Aug. 2009. Web. 21 Mar. 2014. <http://guides.wsj.com/health/wellness-and-diet/how-to-manage-stress/tab/print/>.

NPR staff. ‘One Nation Under Stress’, With To-Do Lists and Yoga for All. NPR. NPR, 11 Mar. 2013. Web. 21 Mar. 2014. <http://www.npr.org/2013/03/11/174043501/modern-interpretations-of-stress-place-focus-on-feeling-not-causes>.

Shapiro, Margaret. “Stressed-out teens, with school a main cause.” The Washington Post. The Washington Post, 17 Feb. 2014. Web. 21 Mar. 2014. <http://www.washingtonpost.com/national/health-science/stressed-out-teens-with-school-a-main-cause/2014/02/14/d3b8ab56-9425-11e3-84e1-27626c5ef5fb_story.html>.

Shellenbarger, Sue. “When stress is good for you.” The Wall Street Journal. The Wall Street Journal, 24 Jan. 2012. Web. 21 Mar. 2014. <http://online.wsj.com/news/articles/SB10001424052970204301404577171192704005250>.

Velasquez-Manoff, Moises. “Status and Stress.” The New York Times [New York] 28 July 2013, Opinion: SR1+. The New York Times. Web. 21 Mar. 2014. <http://opinionator.blogs.nytimes.com/2013/07/27/status-and-stress/>.

 

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Health Insurance and the Affordable Care Act

By Alessandra Fodera (NHS ’16)

Before President Barack Obama assumed office in 2008, he promised the American people that, if elected, he would fight for health care reform to increase access to health insurance. In 2010, the Patient Protection and Affordable Care Act was passed in Congress and signed into law. This act became the most profound reform to the health care system in America since the implementation of Medicare in 1965, and like its predecessor has proved itself one of the most controversial laws in American history.

The Affordable Care Act contains a number of provisions, some already implemented, that have the potential to bring quality healthcare to Americans who currently have none. One of these, effective September 2010, eliminates lifetime limits on insurance coverage.  Under the law, insurance companies will be prohibited from imposing lifetime dollar limits on essential benefits, such as hospital stays and care for chronic conditions.

Insurance companies cannot limit lifetime coverage for “essential health benefits.” Under the Affordable Care Act, insurance companies cannot set a monetary limit on spending for a patient’s essential care while under that plan. Essential health benefits include ambulatory and emergency services, hospitalizations, maternity and newborn care, prescriptions, laboratory services, preventive care, pediatric services, and mental health services.  Annual and lifetime limits are prohibited only on essential medical care; insurance companies can still set limits on services considered “nonessential.”

By 2014, annual dollar limits on a health plan will be completely eliminated. Before the Affordable Care Act, most health plans had both annual and lifetime limits. Limits were dollar limits on insurance spending per year or throughout a patient’s lifetime. If a consumer surpassed this limit, they would pay out of pocket for additional costs. Lifetime limits were banned in 2010, restrictions were placed on annual dollar limits- and are being phased out; by 2014, they will be completely prohibited.

This provision addresses a major issue that some Americans face every day: For people who have chronic conditions, needing multiple surgeries, piling up doctors’ bills because of recurring illness – how do they pay? How does someone who has a child who is born handicapped pay for all those medical expenses? When a person is diagnosed with cancer, they should not have to fear about the burden of bills, but rather use their energies to focus on getting well. Aside from people with long-term conditions, eliminating limits helps ease the minds of all healthcare consumers.

Having annual or lifetime limits for people with conditions such as long-term disease, cancer, or chronic disability, adds unnecessary stress on a patient with no other real concerns.  Patients might refuse care that they don’t absolutely need but can greatly benefit from. For example, a patient with arthritis might refuse continuous physical therapy because the cost of constant doctor’s visits, labs and drugs is too expensive; they’ve already met their limit or need to cut costs.  A person with recurring cancer who has to decide which option of treatment to choose might consider going untreated because of the costs of medications, chemotherapy, or radiation. This provision saves lives.

The potential costs associated with this are high. Insurance companies set limits to minimize their own spending.  When consumers know they will have to pay out of pocket, they choose their health services with more thrift. However, consumers shouldn’t limit their care due to costs. Not being able to afford preventive care now will cause more expensive bills later.

In theory, insurance companies assume the penalty of these costs. However, in actuality, the insurance companies will not technically pay these costs. Insurance companies will effectively be neutral about this provision.  Insurance companies will raise premiums, deductibles, copays, etc. to compensate for their own increased costs. As long as there are for-profit companies in the mix, insurance companies will prioritize stockholders; the goal is always to make a profit. In other industries, taxes, tolls, and price increases are a few examples of how consumers bear the burden of cost shifting.

The Affordable Care Act has numerous provisions, all geared toward the main goal of making healthcare more accessible and affordable.  However, with many of the provisions, including eliminating lifetime limits, insurance companies are essentially just reallocating the costs back to the consumers. The law bans insurance companies from imposing lifetime dollar limits on essential benefits; insurance companies will now just raise costs to consumers in other ways, such as premiums, copays and deductibles. Insurance companies need to find a source of revenue from some avenue and, due to for-profit goals and stockholder needs, we will always pay in some form or another.  Multiple stakeholders with different priorities make it extremely difficult to find a solution that benefits all, or at least the majority, of stakeholders. Although the Affordable Care Act’s provisions were needed and are on the right path, we still have much further to go to truly make healthcare more accessible and affordable for all.

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