Health Worries Rising for D.C. Latinos; Proposed Clinic Closure, New U.S. Rules Put Pressure on Providers - The Washington Post

At the Clinica del Pueblo (the People's Clinic) in NorthwestWashington, the telephone rings every few seconds, but thereceptionist tells callers in Spanish that no appointments areavailable for six weeks. Patients have to climb three flights to getto the clinic, where nurses and volunteer medical students examinethem in closet-sized cubicles among stacks of files and shelves ofmedicine.

'We are open six days a week, 12 hours a day, and we use upevery available space,' said Andrew Schamess, the private, nonprofitclinic's only full-time physician. 'But we have to turn away farmore people than we can see, often with serious problems. It breaksyour heart every time.'

Health Canada "passes the buck" on diabetes drug, researcher charges - CMAJ: Canadian Medical Association Journal

Health Canada's decision to restrict the use of the diabetes drug rosiglitazone (Avandia) does not go far enough and simply places the responsibility for its safe usage on doctors, a leading critic charges.

'My take is that Health Canada passed the buck to front-line clinicians,' says Dr. David Juurlink, a scientist with the Institute of Clinical Evaluative Science and the head of clinical pharmacology and toxicology at the Sunnybrook Health Sciences Centre in Toronto, Ontario.

Health Canada posted a 'Dear Doctor' letter from rosiglitazone's manufacturer GlaxoSmithKline Inc. on Nov. 19 which advises physicians to restrict the use of Avandia to those patients for whom all other treatments to control their blood sugar have failed or are not appropriate. In addition, Health Canada now requires doctors to get patients who continue to take rosiglitazone to sign a consent form stipulating that they are aware of the potential risks.

'They've complicated the lives of patients and doctors with a consent form,' says Juurlink, who had urged suspension of the drug (www.cmaj.ca /cgi/doi/10.1503/cmaj.109-3268). 'To me, it's an ineffective and weak-kneed response.'

Health Canada's advisory mirrors that of the United States Food and Drug Administration (FDA), which after conducting hearings into the safety of rosiglitazone in September voted to allow the drug to remain on the market, although with similar tight restrictions. The drug has been implicated in increased cardiovascular events, such as heart attack and stroke.

The FDA also halted a clinical trial, known as TIDE (Thiazolidinedione Intervention with Vitamin D Evaluation), which was to have compared rosiglitazone to pioglitazone and standard diabetes drugs.

Juurlink believes Health Canada should have followed the lead of the European Medicine Agency, which pulled rosiglitazone off the market.

'The Europeans did the right thing,' says Juurlink, who conducted a large study comparing rosiglitazone with pioglitazone, another diabetes drug. 'What we have is a regulator that's unwilling to take decisive action, in this case on a drug that not a single Canadian patient needs. Why can't they simply have the guts to pull a drug from the market?'

Health Canada declined interview requests but in a written response states that 'no decision to remove a product from the market is taken lightly; it is based on a thorough review of the scientific evidence and scientific evaluation of the product's benefits and risks to Canadians.'

Health Canada reviewed scientific data and Canadian adverse reaction reports, as well as 'other information,' the department added.

'Should new safety information arise, Health Canada will take appropriate action as necessary,' the department writes, adding it is tracking adverse cardiovascular events associated with rosiglitazone, as well as doctors' prescribing patterns.

Many doctors are unaware of the Health Canada restrictions and are continuing to prescribe rosiglitazone, says Juurlink. 'I've had three patients in the last month come in on a formulation of rosiglitazone. Clinicians are too busy to read everything that comes across their desk from Health Canada. They don't listen to what Health Canada has to say unless Health Canada actually does something.'

Juurlink's contention that physicians' do not uniformly react to regulatory advisories is supported by data from IMS Health's National Prescription Audit and the Xponent Database. The data was published in an opinion piece that asserts there were regional variations in rosiglitazone prescribing following the FDA's 2007 'black box' warning about increased cardiovascular risks associated with use of the drug (N Engl J Med 2010; 363:2081-84). While overall use dropped dramatically, rosiglitazone was still prescribed more in some states, such as Oklahoma, than others, such as North Dakota.

Meanwhile, the FDA and Health Canada's restrictions on rosiglitazone use strengthen the position of plaintiffs in a class action lawsuit against Glaxo- SmithKline, says Saskatchewan lawyer Tony Merchant. 'We're feeling better about the case and the strength of the case as a result of Health Canada's decision.'

Of the 500 patients or their families who have contacted Merchant's firm, about 50 cases have involved a death, Merchant says. Although the drug company has settled some rosiglitazone lawsuits in the US, they have not made settlement offers in Canada. - Laura Eggertson, Ottawa, Ont.

[Sidebar]

Studies have linked the use of rosiglitazone with increased cardiovascular events, such as heart attack and stroke.

[Author Affiliation]

Laura Eggertson, Ottawa, Ont.

Mental Health Care Scarce in Rural Areas; Traveling Social Workers and Psychologists, New Technology Bring Services to Far-Flung Clients - The Washington Post

When Margie Whichard looks out the windows of her centralVirginia trailer just beyond the Appalachians she sees miles oftrees and fields. The loudest sound she hears is the clucking ofchickens from her barn. The nearest town, Dillwyn, is 15 miles awaydown a narrow, windy highway.

Months ago, events in Whichard's life triggered a depressionthat made her feel her world was collapsing. She sought counseling,but the nearest mental health professional was more than an hour'sdrive from her home. The time and expense of traveling made regulartherapy impossible, and Whichard struggled on her own.

Child health and human capital.(Research Summaries) - NBER Reporter

When economists use the phrase 'human capital' it generally means 'education.' But one's health can also be viewed as a form of capital. Both education and health are strongly influenced by 'family background' which is commonly measured using parent's education and income. Much of my research over the past decade seeks to evaluate the effect of public programs designed to improve the outcomes of children from disadvantaged backgrounds. In my forthcoming book, The Invisible Safety Net: Protecting the Nation's Poor Children and Families, I argue that while the cash welfare system receives more attention, elements of a largely invisible safety net of in-kind programs have proven remarkably effective in improving the lives of poor children. (1)

Intervention Programs

For example, my work with Eliana Garces and Duncan Thomas shows that Head Start (a pre-school intervention for poor children) improves long-term outcomes for disadvantaged children, although it does not bring these children up to the level of their more advantaged peers. Using a special supplement to the Panel Study of Income Dynamics, we ask whether children who attended Head Start had better outcomes (on a range of measures) than their own siblings who did not attend. We find that among whites, children who attended Head Start were about 25 percent more likely to have completed high school than their siblings who did not. Among African-Americans, the Head Start children were half as likely to have been booked or charged with a crime. This is the first study to show a lasting effect of Head Start. (2)

Still, programs like Head Start remain 'black boxes' in that we know little about exactly why they work. It is possible that much of the beneficial effect of Head Start is not through explicitly educational interventions but rather through mandates to improve nutrition, link families with community services, and increase utilization of preventive health care. (3)

Head Start's emphasis on getting children into care remedies an important limitation of programs that focus primarily on extending health insurance via such programs as Medicaid or the State Child Health Insurance Program (SCHIP). Lack of health insurance remains an important issue, but is not the major determinant of child health. One reason is that providing eligibility for health insurance does not always lead people to use care appropriately. In a broader review of the 'take up' of social programs, I discuss the low take-up rate among individuals eligible for public health insurance; this is an important social problem that reduces the use of preventive care and may increase the use of expensive palliative care. (4)

SES and Child Health

Maternal education is one important determinant of take-up and of other health behaviors. However, it has been difficult to demonstrate this relationship empirically because maternal education is a choice. To tackle this problem, Enrico Moretti and I compiled data on openings of two- and four-year colleges between 1940 and 1990. We used data about the availability of colleges in the woman's county of residence in her seventeenth year as an instrument for her education at the time of her child's birth. We found that higher maternal education does improve infant health, as measured by birth weight and gestational age. It also increases the probability that a new mother is married, reduces parity (birth order), increases use of prenatal care, and reduces smoking, thus suggesting that these are important pathways for the ultimate effect on health. (5)

In subsequent work, Moretti and I created a unique longitudinal dataset of California births from the 1960s to the present in order to investigate the relationship between maternal income (measured at the time of the mother's birth and at the time of the child's birth), maternal birth weight, and the child's birth weight. We used names and birth dates to link the records of mothers and children and also identified mothers who were siblings. We showed that there is a strong inter-generational correlation in the birth weight of mothers and children, but that a measure of household income at the time of the mother's birth is also predictive of low birth weight in her child. Our most interesting finding is that there is an interaction between maternal low birth weight and maternal poverty in the production of child low birth weight. Together these findings suggest that inter-generational correlations in health could play a role in the inter-generational transmission of income. Parent's income affects child health, and health at birth affects future income. (6)

The relationship between family income and child health starts at birth but grows stronger as children age, even in countries with universal health insurance such as Canada. Using a panel of Canadian children, Mark Stabile and I show that the health of poor children relative to that of richer children worsens with age, just as it does in the United States. We argue that this deterioration may be related to a higher 'arrival rate' of negative health shocks among poor children. For example, poor children are more likely than richer ones to have new chronic conditions diagnosed at virtually all ages, and they are also more likely to be hospitalized. (7) Perhaps surprisingly, in our data, both rich and poor children were equally likely to recover from any given health shock. Identifying the sources of these health shocks and policies that may prevent them is an important avenue for future research.

Threats to Child Health

One example of a negative health shock not prevented by conventional medical care is unintentional injuries. Such injuries are a leading cause of death among children over the age of one in the United States. Joseph Hotz and I show that accident rates are responsive to child care policy--they are lower among children in care when the care givers are more educated--although stiffer child care regulations may also increase accident rates among children pushed out of regulated care by higher prices. (8)

Pollution is another factor that affects disadvantaged children disproportionately. In our study of the effects of air pollution in California on infant health, Matthew Neidell and I find that the most polluted zip codes have 50 percent more mothers who are high school dropouts than the least polluted ones. This complicates our attempts to identify the causal effect of pollution. We use individual-level vital statistics data to investigate the effects of criterion air pollutants on infant mortality, fetal deaths, low birth weight, and prematurity. Our models are identified using within-the-zip-code level variation in pollution levels that remains after controlling for seasonal patterns and weather. We find that the reductions in carbon monoxide (CO) and particulates (PM10) that occurred over the 1990s saved more than 1,000 infant lives in California. (9)

Nutrition is a key determinant of health that is receiving increasing attention, given an 'epidemic' of obesity and obesity-related diseases such as diabetes. I have examined the determinants of child nutrition in a series of studies with Jayanta Bhattacharya, Steven Haider, and Thomas Deliere. We find that poverty is an important predictor of nutritional outcomes among preschool children, but not among school-aged children. However, 'food insecurity' (missing meals or being afraid that there will not be sufficient money to buy food) is not predictive of poorer nutritional outcomes among either group of children (although it could be viewed as a bad outcome in itself). Nevertheless, there are many children with nutritional deficiencies, even among those who consume too many calories. (10)

Using data from the National Health and Nutrition Examination Surveys, we also find that poor families reduce expenditures and calories consumed in response to cold weather shocks (a 'heat or eat' effect), although we find no evidence that this affects the quality of the diet. Despite recent concerns about inadequacies in child nutrition programs, we find that the School Breakfast program improves the quality of children's diets. (11) Taken as a whole, these studies suggest that there is a link between poverty and poor child nutrition that is mitigated by the food safety net that is in place, particularly for school aged children.

While most of the economic research on child health focuses on physical health, mental health may be much more important. The majority of workdays lost among adults are attributable to mental health problems, and many such problems have their roots in childhood. The best available estimates suggest that mental health problems may be much more prevalent among poor than among non-poor children, confounding attempts to measure the effects of mental illness per se. Stabile and I use nationally representative samples of U.S. and Canadian children to examine the medium-term outcomes of children with symptoms of Attention Deficit Hyperactivity Disorder (ADHD), the most common child mental health problem. (12)

Rather than relying on diagnoses, we use 'screener' questions administered to all children, and we use sibling fixed effects to control for omitted variables such as poverty. We find large negative effects on test scores and schooling attainments, and positive effects on the probability of being placed in special education. The effects are remarkably similar in Canada and the United States. Moreover, the effects are approximately linear, suggesting that even moderate symptoms have costs in terms of educational attainment. In contrast, physical health problems such as asthma are found to have insignificant effects. These results indicate that mental health conditions might well prove to be a 'missing link' between family background, child health, and educational attainments.

The Role of Health Insurance

Despite the key role of family background and non-medical threats to child health, most discussions of disparities in child health focus not on more general interventions, such as Head Start, but rather on the role of health insurance. I have continued to study Medicaid, the main system of public health insurance for poor women and children. Using individual-level vital statistics data, Jeffrey Grogger and I find that state welfare reforms prior to 1996 were associated with reductions in the use of prenatal care and with negative impacts on infant health, presumably because women who went off the welfare rolls were no longer automatically eligible for Medicaid coverage. (13)

Over the 1990s, most states switched their Medicaid caseloads from traditional fee-for-service to some form of Medicaid managed care (MMC). Like the managed care programs that cover most privately insured Americans, MMC restricts access to services in order to reduce costs. In the case of Medicaid patients, though, it has been argued that managed care might have some offsetting benefits for patients. For instance, it would guarantee access to providers who were contractually obligated to treat Medicaid patients, whereas under the fee-for-service system, many providers did not accept Medicaid.

However, incentives facing providers are complex and may result in many consequences that were not intended by legislators. John Fahr and I find that the introduction of MMC in California was accompanied by shifts in the composition of the Medicaid caseload away from black children, and that black children who lost coverage were subsequently more likely to go without doctor visits. Using a panel of all California births among mothers in the 1990s, Anna Aizer, Moretti, and I are able to follow mothers who were required to join MMC plans between births. We find that mothers forced to switch to MMC were more likely to delay prenatal care and to suffer adverse birth outcomes than other mothers. (14)

Aizer and I also examine estimates of 'network effects' in the utilization of public prenatal care services provided under the Medicaid program. We find that these effects are similar for first-time mothers and for second-time mothers who have already used prenatal care services. This suggests that the measured effects do not represent transmission of information about the services between network members, because mothers who have already used the services presumably know about them. Moreover, the estimated effects are much reduced when we control for the hospital of delivery. Perhaps surprisingly, women who live in the same neighborhoods, but who are from different ethnic groups, tend to deliver in different hospitals. These results suggest that it is the enrollment services provided by hospitals, and not the woman's 'network,' that facilitates access to Medicaid-sponsored prenatal care services. (15)

In summary, my research points to a holistic view of child human capital development that encompasses educational attainment, physical, and mental health, and seeks to explore the feedbacks between them. Interventions to reduce the transmission of poverty from one generation to the next could perhaps be improved if we understood these linkages better.

(1) Forthcoming from Princeton University Press, Spring 2006.

(2) E. Garces, D. Thomas, and J. Currie, 'Longer Term Effects of Head Start,' NBER Working Paper No. 8054, December 2000, and American Economic Review, 92, 4, September 2002, pp. 999-1012.

(3) J. Currie and M. Neidell, 'Getting Inside the 'Black Box' of Head Start Quality: What Matters and What Doesn't,' NBER Working Paper No. 10091, November 2003.

(4) J. Currie, 'The Take-up of Social Benefits,' NBER Working Paper No. 10488, May 2004, forthcoming in A. Auerbach, D. Card, and J. Quigley, eds. Poverty, the Distribution of Income, and Public Policy, New York: Russell Sage.

(5) J. Currie and E. Moretti, 'Mother's Education and the Intergenerational Transmission of Human Capital: Evidence from College Openings,' NBER Working Paper No. 9360, December 2002, and Quarterly Journal of Economics, VCXVIII, 4, November 2003, pp. 1495-532.

(6) J. Currie and E. Moretti, 'Biology as Destiny? Short and Long-Run Determinants of Intergenerational Transmission of Birth Weight,' NBER Working Paper No. 11567, August 2005.

(7) J. Currie and M. Stabile, 'Socioeconomic Status and Health: Why is the Relationship Stronger for Older Children?' NBER Working Paper No. 9098, August 2002, and American Economic Review, 93, 5, December 2003, pp. 1813-23.

(8) J. Currie and J. V. Hotz, 'Accidents Will Happen? Unintentional Injury, Maternal Employment, and Child Care Policy,' NBER Working Paper No. 8090, January 2001, and Journal of Health Economics, 23, 1, January 2004, pp.25-59.

(9) J. Currie and M. Neidell, 'Air Pollution and Infant Health: What Can We Learn From California's Recent Experience?' NBER Working Paper No. 10251, January 2004, and Quarterly Journal of Economics, CXX, 3, August 2005, pp. 1003-30.

(10) J. Currie, J. Bhattacharya, and S. Holder, 'Poverty, Food Insecurity, and Nutritional Outcomes in Children and Adults,' Journal of Health Economics, 23, 2, July 2004, pp. 839-62.

(11) J. Bhattacharya, J. Currie, T. DeLiere, and S. Holder, 'Heat or Eat? Income Shocks and the Allocation of Nutrition in American Families,' NBER Working Paper No. 9004, June 2002, and American Journal of Public Health 93 (7), July 2003, pp.1149-54. J. Bhattacharya, J. Currie, and S. Holder, 'Breakfast of Champions? The Effects of the School Breakfast Program on the Nutrition of Children and their Families,' NBER Working Paper No. 10608, July 2004, and Journal of Human Resources, forthcoming.

(12) J. Currie and M. Stabile, 'Child Mental Health and Human Capital Accumulation: The Case of ADHD,' NBER Working Paper No. 10435, April 2004, forthcoming in Journal of Health Economics.

(13) J. Currie and J. Grogger, 'Medicaid Expansions and Welfare Contractions: Offsetting Effects on Prenatal Care and Infant Health,' NBER Working Paper No. 7667, April 2000, and Journal of Health Economics, 21, March 2002, pp.313-35.

(14) J. Currie and J. Fahr, 'Medicaid Managed Care: Effects on Children's Medicaid Coverage and Utilization of Care,' NBER Working Paper No. 8812, February 2002, Journal of Public Economics, 89, 1, January 2005, pp. 85-108. A. Aizer, J. Currie and E. Moretti, 'Competition in Imperfect Markets : Does it Help California's Medicaid Mothers?' NBER Working Paper No. 10430, April 2004, forthcoming in Review of Economics and Statistics.

(15) A. Aizer and J. Cuttle, 'Networks or Neighborhoods? Correlations in the Use of Publicly-Funded Maternity Care in California,' NBER Working Paper No. 9209, September 2002, Journal of Public Economics, 88, 12, December 2004, pp. 2573-85.

Janet Currie *

REP. WALBERG OP-ED: 'GOP HEALTH CARE CARD' - US Fed News Service, Including US State News

Rep. Tim Walberg, R-Mich. (7th CD), has issued the following news release:

Families in Michigan and throughout America are concerned about the rising cost of health care. Costs continue to rise, emergency rooms are filled with the uninsured, and many Americans continue in jobs they may not enjoy just to keep their health insurance.

Our current health care system is fatally flawed, and right now more than 47 million individuals find themselves without coverage and millions more are underinsured. Now is the time to step forward with solutions that make health care more affordable and accessible, and place health-care decisions with medical professionals and patients.

For too long, according to polling data, the Republican Party has been 'losing' the health-care issue to the Democrats. This should not be the case, as Republicans are pushing for real common-sense solutions and credible reforms.

I for one will not allow the Democrats to claim health care as their issue, especially since most Democrats support a government-run and taxpayer-funded single provider system in which Washington, D.C., bureaucrats would have ultimate decisionmaking authority over every American's medical coverage.

Supporters of this government-run health care approach claim it will provide every American with a level of health care coverage, but fail to elaborate on the actual quality of care that will be provided.Government-run health-care programs all over the world are failing to meet the needs of those who need coverage. According to Britain's Department of Health, nearly 900,000 Britons were waiting for admission to National Health Service hospitals at a given time in 2006. In other European countries with government-based health care, people can wait for weeks, months and even years for important, specialized treatments, such as heart surgery or chemotherapy.

Empowering bureaucrats through a 'Hillary-Obama Care' approach would provide the same level of compassion and customer service we have come to expect from the Internal Revenue Service. This kind of one-size-fits-all, Washington-based approach is wrong, and America needs a patient-centered health-care system that gives consumers direct control and choice over their health-care decisions.

With that goal in mind, recently I introduced the Making Health Care More Affordable Act (H.R. 5995). We hear a lot of radical promises from the other side, this bill offers common sense solutions that ties together six core reforms to make patient-centered, market-driven health care more affordable and accessible to all Americans:

(1) Provide a health-insurance tax credit: If Congress provides such tax credit of up to $2,500 for individuals and $6,000 for a family of four, health insurance will become more affordable for more Americans, and families will be able to take their health insurance with them when they switch jobs. Providing these tax credits will expand the health insurance market, make the current system more equitable, reduce the number of uninsured Americans and increase the available options, while using the market to bring down health insurance costs.

(2) Create association health plans: These plans allow small businesses to band together to increase buying power in the market. Such a reform would lower overhead costs for small businesses and reduce health care prices for employees.

(3) Make insurance purchasable across state lines: This will help create a national market for health insurance by having consumers, not bureaucrats, find the coverage that best suits consumer needs. Consumers should have access to all benefits and services available throughout the United States and this reform will allow a more efficient individual market.

(4) Build on Health Savings Accounts: These HSAs allow people to take control of their health-care decisions, make health insurance more affordable and increase choice. Though relatively new, HSAs offer consumers a wide range of benefits and are becoming increasingly popular as more Americans learn about how this individual ownership plan works. The number of Americans with HSAs increased 35 percent last year, meaning more than 6 million Americans are now seeing the benefits of consumer-based health care. HSAs will let more families build health care 'nest eggs.'

(5) Stop lawsuit abuse: Frivolous lawsuits are driving up costs of health care, thus limiting the number of physicians pursuing careers in certain specialties and forcing doctors to practice defensive medicine. My bill places a $250,000 cap on noneconomic damages and provides guidelines on how punitive damages are determined. For too long, trial lawyers have lined their own pockets by driving up health-care costs.

(6) Encourage health information technology: High-tech efficiencies, such as electronic health records, increase health care productivity, lower costs and reduce the potential for medical errors. In fact, a study by the nonpartisan Rand Corp. revealed widespread implementation of Health IT could save $162 billion in health-care costs and prevent 2.2 million undesired adverse drug reactions.Democrats are not the only party discussing the lapses in coverage, high costs and bureaucratic red-tape American families are dealing with every day. Republicans are offering real reforms so important health-care decisions can be made by families, not HMOs or the whims of Washington, D.C., bureaucrats.

The GOP should rally around a consumer-based heath-care plan like the one I introduced to counter the draconian command-and-control plans of Barack Obama and Hillary Clinton. My legislation will improve quality of care, empower people to take control of their own health care and create a positive, consumer-driven alternative to free up our health- care system from heavy handed government mandates.

Passing the Making Health Care More Affordable Act will bring necessary reform to our broken health-care system and provide needed, high-quality health coverage to more Americans.

Despite Flaws, Health Care Law Is Needed - St. Joseph News-Press

(CNN) -- With the Supreme Court set to hear oral arguments aboutthe constitutionality of the President Obama's health care law, morepatients than ever have been asking for my thoughts about healthreform.

I practice primary care in southern New Hampshire near theMassachusetts border, which gives me a firsthand look at how healthreform has impacted my neighboring state. Despite flaws with theMassachusetts approach, and the president's Affordable Care Actwhich is modeled after it, I believe that health care reform needsto move forward.

Over the years, I have encountered too many cases of patients whoare inadequately served by our current health care model. Some oftheir stories are heartbreaking, others are deeply worrisome.

Some time ago, I had one middle-aged patient with diabetes, whomI'll call Mark, requiring high doses of insulin to control his bloodsugar. He faithfully saw me every three months, where I made carefulinsulin adjustments so his sugars wouldn't go too high or low. Butall of a sudden, he stopped coming. I didn't hear from him until ayear later, when I received a call from the emergency departmenttelling me Mark was found in a coma because of a critically highsugar level. Thankfully, he survived his hospital stay, and when hecame for a visit afterward he explained how he had lost his job, andthus, his health insurance. He couldn't afford to see me or buy hismedication.

According to the 2010 Commonwealth Fund survey, 72% of joblessAmericans said they couldn't afford to fill a prescription or obtainneeded medical tests. Worse, 40% said that medical bills forced theminto difficult financial decisions, such as depleting their savings,or being unable to pay for necessities like food, heat or rent.These are choices patients should never be forced to make.

But it's not only patients without insurance who suffer. Othersare in a situation like another patient of mine, whom I'll callLinda. She recently told me that her sister was diagnosed with coloncancer, a disease with a strong genetic component. I recommendedthat Linda have a colonoscopy. Unfortunately, her health insuranceplan had a deductible in the thousands of dollars, making acolonoscopy prohibitively expensive.

Last year, a study from the RAND Corporation, a nonprofit,nonpartisan research organization, found that families enrolled inhigh-deductible plans like Linda's cut back on health care that wasclearly beneficial, like cervical cancer, breast cancer and coloncancer screening. According to the study, 'these cutbacks couldcause a spike in health care costs down the road if people end upsicker and need more intensive treatment.'

The Affordable Care Act would help patients like Mark, byproviding him a way to obtain affordable health insurance regardlessof his job status. Beginning in 2014, health reform would expand theeligibility of Medicaid and provide federal tax credits to help buyprivate insurance. On average, 17% of the nonelderly populationnationwide would be helped, with numbers as high as 36 to 40% inparts of Florida, New Mexico, Texas, Louisiana and California. Andfor patients like Linda, health reform would prohibit cost sharingfor many preventive screening tests, including colonoscopies.

My support of the Affordable Care Act is tempered, however, by aserious flaw: Its benefits cannot be fully realized without a strongprimary care foundation. In the United States, the number ofspecialists to primary care doctors is about 70-30, a ratio that'sreversed in the rest of the world. That primary care deficit is afar bigger threat to health reform than if the Supreme Court were torule President Obama's law unconstitutional.

Having health insurance doesn't necessarily mean that you'll beable to see a doctor. In Massachusetts, more than 95% of residentshave health insurance, the highest in the country. However, a 2011Massachusetts Medical Society survey found that more than half ofprimary care doctors were not accepting new patients, while theaverage wait time for an appointment exceeded one month. When youconsider that health coverage will expand to 32 million Americans in2014, whether our strained primary care system can handle thatburden is a serious question. An inability to see a primary careprovider will force patients to already crowded emergencydepartments, where health care is often the most expensive.

The Affordable Care Act doesn't do nearly enough to make primarycare enticing, despite the anticipated shortfall of primary careproviders approaching 30,000 by 2015. Medical students, concerned bytheir average school debt approaching $160,000, often eschew primarycare in favor higher paying specialties. And the bureaucraticburdens of primary care, including paperwork and spending time onthe telephone refuting insurance company denials, are overwhelming.According to an Annals of Internal Medicine study, 30% of primarycare doctors considered leaving the field entirely, citing burnout,time pressures and administrative hassles.

These concerns, however, shouldn't stall health reform. Instead,they need to be addressed as the Affordable Care Act is modified andimproved on in the coming years. Far too many patients can no longerafford to obtain basic care. It's their stories that have made merealize we desperately need to fix our broken health care system,and accept health reform despite its shortcomings. We cannot let thepursuit of perfection become the enemy of doing the right thing.

Patients like Mark and Linda need help now.

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PATIENT-CENTERED HEALTH CARE NEEDED TO FIX BROKEN SYSTEM - US Fed News Service, Including US State News

Rep. Tim Walberg, R-Mich. (7th CD), has issued the following column:

For years, Americans have looked to Congress for answers about the way health care is delivered in our country. Our current system is fatally flawed, and right now more than 47 million individuals find themselves without coverage and millions more are underinsured.

Two vastly different answers to our current health care crisis have emerged. One side is advocating for a single provider system in which Washington, D.C. bureaucrats would have the ultimate decision-making authority over every American's medical coverage.

Supporters of this government-run health care approach advocate its ability to provide every American with a level of health care coverage, but fail to elaborate on the actual quality of care this approach will provide. Government-run health care programs all over the world are currently failing to meet the needs of those who need coverage.

According to England's Department of Health, nearly 900,000 Britons were waiting for admission to National Health Service hospitals at a given time in 2006. In other European countries with government-based health care, people can wait for weeks, months and even years for important, specialized treatments, such as heart surgery or chemotherapy.

Empowering bureaucrats through a 'Hillarycare' approach would make visiting the doctor or going to the hospital similar to a trip to your local license branch. This kind of one-size-fits-all, Washington, D.C. based approach is wrong, and America needs a patient-centered health care system that gives consumers direct control over their health care decisions.

With that goal in mind, today I am introducing the Making Health Care More Affordable Act. This bill is a comprehensive solution that ties together six core reforms to make patient-centered health care more affordable and accessible:

1) Provide Health Insurance Tax Credit - If Congress provides a Health Insurance Tax Credit of up to $2,500 for individuals and $6,000 for a family of four, health insurance will become much more affordable and people will be able to take their health insurance with them when they switch jobs. Providing these tax credits will expand the health insurance market, make the current system more equitable, reduce the number of uninsured Americans and increase the number available options, while using the market to bring down the cost of health insurance.

2) Create Association Health Plans - These plans allow small businesses to band together to increase buying power in the market. Such a reform would lower overhead costs for small businesses and reduce health care prices for employees.

3) Allow individuals the option to purchase health insurance across state lines - This will help create a national market for health insurance by having consumers, not bureaucrats, find the coverage which best suits consumer needs. Consumers should have access to all benefits and services available throughout the United States.

4) Build on the success of Health Savings Accounts - HSAs allow people to take control of their health care decisions, make health insurance more affordable and increase choice. Though relatively new, HSAs offer consumers a wide range of benefits and are becoming increasingly popular as more Americans learn about how this individual ownership plan works. The number of Americans with HSAs increased 35 percent last year, meaning over six million Americans are now seeing the benefits of consumer-based health care.

5) Stop lawsuit abuse - Frivolous lawsuits are driving up costs of health care, thus limiting the number of physicians pursuing careers in certain specialties and forcing doctors to practice defensive medicine. My bill places a $250,000 cap on non-economic damages and provides guidelines on how punitive damages are determined. For too long, trial lawyers have lined their own pockets by driving up health care costs.

6) Encourage Health Information Technology - High-tech efficiencies, such as electronic health records, increase health care productivity, lower costs and reduce the potential for medical errors. In fact, a study by the RAND Corporation revealed that widespread implementation of Health IT could save $162 billion in health care costs and prevent 2.2 million undesired adverse drug reactions.

Unfortunately, many Americans do not have health coverage, and if they do, they often experience lapses in coverage, high costs and bureaucratic red-tape. Individuals and families need to be able to make important health care decisions without being denied by HMOs or the whims of Washington, D.C. bureaucrats.

Sexual Health Education Disparities in Asian American Adolescents - Journal for Specialists in Pediatric Nursing

Column Editor: Betsy M. McDowell

Ask the Expert provides research-based answers to practice questions submitted by JSPN readers.

Question: I have noticed that there are increasing numbers of Asian American adolescents in the United States. Even though Asian American youth are doing great academically, their level of sexual health-related knowledge is not explicitly known or understood because of the differences in their cultural backgrounds. What do I need to know in order to ensure that my assessment of their sexual health knowledge is culturally responsive?

Tsui-Sui Kao responds: Asian Americans comprise close to 4.2% of the total U.S. population. Research on the health status of Asian Pacific Americans (APA) often analyzes the population as one homogeneous group; however, the APA community includes more than 30 diverse ethnic subpopulations that vary by national origin, language, culture, citizenship, and economic status. The main subgroups include Chinese, Japanese, Korean, Filipino, Vietnamese, Asian Indian, and other cultures from Southeast Asia (U.S. Department of Commerce [USDOC], 2000). Even though as a whole, Asian Americans seem to have comparable educational backgrounds and median family incomes with Caucasian Americans, Asian Americans tend to have more family members working at the same time to maintain their financial status and lifestyle. It is important to note that 14% of the APA population lives below the poverty line, compared to 13% of the U.S. population, and that Asian Americans are less likely to use federal or state-funded health care programs such as Medicaid (National Asian Pacific American Women's Forum [NAPAWF], 2005).

Asian Americans often are perceived as a model minority, appearing to have abundant resources. In reality, their health is compromised by this misconception, and their health problems are often blamed on the conservative nature of their cultures. Healthcare disparities exist not only in new immigrants but also in the subsequent generations of Asian American children. Most Asian American children are immigrants themselves or are children of immigrants who straddle two cultures. Few studies are available to help nurses see some of the problems that Asian American adolescents encounter as a result of this bicultural identification. Nurse professionals confront increasing challenges to care for this vulnerable population, especially with the cultural sensitivity to sexual health issues (Kibria, 2002).

Nurses must be cognizant of the importance of Asian Americans' family-centered cultural values, more specifically the taboo against sex education, and the possible impacts of biculrural straddling. Grunbaum, Lowery, Kann, and Pateman (2000) noted that Asian American adolescents tend to delay sexual intercourse, but that once sexually active, they were as likely to have used alcohol or drugs or fail to use a condom during intercourse as any other ethnic group. These factors put them at greater risk for compromised sexual health; therefore, it is important for pediatric nurses to assess the sexual health of all Asian American adolescents.

Asian American Adolescents' Sexual Health

Studies show that Asian American adolescents tend to delay the onset of sexual intercourse compared to other ethnic groups (Grunbaum et al., 2000; Horan & DiClemente, 1993; Schuster, Bell, & Kanouse, 1996; Schuster, Bell, Nakajima, & Kanouse, 1998; Upchurch, Levy-Storms, Sucoff, & Aneshensel, 1998); however, they are less likely to receive sexual health-related services prior to and even after becoming sexually active (National Asian Women's Health Organization [NAWHO], 1997; Schuster et al., 1996) than other population groups. As a result, Asian American women tend to be diagnosed with more advanced stages of cervical cancer and breast cancer than Caucasian American women (Frisch & Goodman, 2000; Hedeen, White, & Taylor, 1999), and cervical cancer is the leading cause of death for Vietnamese American women (Ishida, 2001). Furthermore, new technology and research show that cervical cancer is actually caused by the human papillomavirus (HPV) (Ordonez, Espinosa, Sanchez-Gonzalez, Armendariz-Borunda, & Berumen, 2004), one of the most prevalent sexually transmitted infections (STIs). Therefore, when focusing on the sexual health of Asian American adolescents, nursing professionals should target cervical cancer detection at the same time.

Many obstacles deter Asian American adolescents from receiving proper sexual health care, such as healthcare providers' misconceptions, stereotyping, racism, sexism, and bicultural gaps between the adolescents' home culture and environmental culture. The disparities in receiving sexual healthcare services exist not only in Asian American women, but are also found in Asian American men. In a survey conducted by the National Asian Women's Health Organization, 89% of the 802 Asian American men surveyed had never received sexual or reproductive healthcare services, even though 87% reported having had at least one sexual partner in the past year (NAWHO, 1999).

Bicultural Straddling

Some research suggests that Asian Americans' reluctance to utilize sexual health-related care is rooted in their conservative cultural background (Horan & DiClemente, 1993; Okazaki, 2002; Schuster et al., 1998). Still, other research has linked health behaviors with the mistrust of healthcare providers (NAWHO, 1999). A survey of 669 Asian Americans found that despite their comparatively higher socioeconomic status (as measured by income and education), Asian Americans reported having a poorer quality of health care than the overall population. Compared with 62% of the overall population, only 45% of Asian Americans were very satisfied with their health care (USDOC, 2000).

One of the reasons for the growing problem of sexual health disparities might be associated with Asian American families' reluctance to talk about sexual health-related issues at home. According to a survey of Asian American women, one-third of the women surveyed never discussed pregnancy, STIs, birth control, or sexuality in their households (NAWHO, 1997). More than half of the women were uncomfortable discussing reproductive health with their mothers and even more uncomfortable discussing these concerns with their fathers and brothers. As a result of this cultural taboo, Asian American girls are often at increased risk for engaging in compromising sexual health-related behaviors. For example, Asian American women have the highest increase in certain STIs, such as gonorrhea and HIV/AIDS (Foo, 2002), yet they are the least likely of all minority groups to believe they are at risk and the least likely to receive sexual health care (Foo, 2002; National Council of Negro Women, 1992; USDOC, 2000).

One possible reason that sex education is a taboo subject in Asian American homes may be the fact that in the traditional Asian culture, sex education was minimized in the schools, and parents, as well as health professionals, were reluctant to discuss sexuality and sexual information (Chan, 1986). Hence, it is possible that Asian American parents lack sexual knowledge themselves, and that may discourage them from approaching the subject with their children. Even though there is no documented study to validate Asian American parents' lack of knowledge, nurses must be aware of this possibility and be more attuned to assessing the Asian American parents' and their adolescents' sexual health-related knowledge, as well as their respective comfort talking to each other about sexual health-related issues and/or concerns.

A recent study of Asian American adolescents linked adolescents' sexual activity with gender, acculturation, and parental attachment (Hahm, 2005). Among Asian American girls, the most acculturated group was three times more likely to have reported sexual intercourse than the least acculturated group. For both boys and girls, a high level of parental attachment was associated with lower odds of sexual intercourse. Hence, nurses need to give particular attention to assessing the level of acculturation among Asian American girls and build on the strengths of a healthy parent-child relationship (Hahm).

Culturally Responsive Interventions

Even though second-generation Asian Americans might have less trouble adapting to American society in terms of language, they are not necessarily without difficulties. Straddling between two cultures is not an easy task for these teens because they also are struggling with adolescent development. It is important for nurses to understand that living within two cultures in one society can profoundly affect the growth and development of the Asian American adolescent (Noda, 1989).

In order to provide culturally responsive care to Asian American adolescents, nurse professionals must first be sensitive to their cultural differences and be nonjudgmental in order to build trust with both parents and adolescents. Nurses must approach taboo subjects such as sexual health carefully and respectfully. If possible, a same-gender healthcare worker is preferred when discussing sexual health issues with an Asian American teen to minimize embarrassment.

Additionally, nurses need to educate Asian American parents about sexual health before their children reach adolescence. With the conservative nature of Asian culture, parents' lack of knowledge might become an obstacle for adolescents to develop or learn correct information related to sexual health. This in turn may compromise the adolescents' health development. Providing sexual health knowledge for Asian American parents in a culturally sensitive manner would empower them to help their teens make healthier choices.

Nurses also need to understand that Asian Americans' family-centered values may be utilized as a protective factor for the adolescents' sexual health if nurses can facilitate communication between parents and adolescents. Research has indicated that Asian American parental expectations of their adolescents is a factor in preventing alcohol abuse (Hahm, Lahiff, & Guterman, 2003) and promoting academic achievement (Hall, 2002). One can assume that parental expectations have the potential to be a protective factor against engaging in risky sexual behaviors. Nurses, therefore, should promote bonding and effective parenting skills in Asian American families, which in turn can inject parental expectations into adolescents' decision making regarding sexual health.

To summarize, the Asian American adolescent's sexual health has been ignored for a long period of time. Even though there are general beliefs that Asian Americans are model minorities, they are not without difficulties. Healthcare disparities exist not only in populations with low socioeconomic status, but also in the populations who are under-utilizing healthcare systems for various reasons. Nurses need to realize that healthcare disparities exist in the Asian American population despite the fact that their Asian American patients have presentable appearances, good educational backgrounds, and/or families with fairly good incomes. Once healthcare disparities in sexual health knowledge are acknowledged, pediatric nurses can provide care that is culturally responsive to the needs of Asian American adolescents, a growing segment of the American population.

If you would like to submit a question for consideration in the Ask the Expert column, please e-mail your question to the column editor at bmcdowell@lander.edu.

Search terms: Adolescence, Asians, Healthcare disparities, sexuality

[Reference]

References

Chan, D.W. (1986). Sex misinformation and misconceptions among Chinese medical students in Hong Kong. Archives of Sexual Behavior, 19, 73-93.

Foo, L.J. (2002). Asian American women: issues, concerns, and responsive human and civil rights advocacy. New York: The Ford Foundation.

Frisch, M., & Goodman, M.T. (2000). Human papillomavirus-associated carcinomas in Hawaii and the mainland U.S. Cancer, 88, 1464-1469.

Grunbaum, J.A., Lowery, R., Kann, L., & Pateman, B. (2000). Prevalence of health risk behaviors among Asian American/Pacific Islander high school students. Journal of Adolescent Health, 27, 322-330.

Hahm, H.C. (2005, January). Gender and acculturation differences in Asian American adolescents' sexual activity. Paper presented at the Society for Social Work and Research, Celebrating a Decade of SSWR, Miami, FL.

Hahm, H.C., Lahiff, M., & Guterman, N.B. (2003). Acculturation and parental attachment in Asian American adolescents' alcohol use. Society for Adolescent Medicine, 33, 119-129.

Hall, G.C.N. (2002). Asian American psychology. Washington, DC: American Psychology Association.

Hedeen, A.N., White, E., & Taylor, V. (1999). Ethnicity and birthplace in relation to tumor size and stage in Asian American women with breast cancer. American Journal of Public Health, 89, 1248-1252.

Horan, P.P., & DiClemente, RJ. (1993). HIV knowledge, communication, and risk behavior among White, Chinese-, Filipino-American adolescents in a high-prevalence AIDS epicenter: A comparative analysis. Ethnicity & Disease, 3, 97-105.

Ishida, D. (2001). Making inroads on cancer prevention and control with Asian Americans. Seminars in Oncology Nursing, 17(3), 220-228.

Kibria, N. (2002). Becoming Asian American: Second-generation Chinese and Korean American identities. Baltimore, MD: Johns Hopkins University Press.

National Asian Pacific American Women's Forum. (2005). Medicaid and Asian Pacific American women. Retrieved April, 19, 2005, from http://modelminority.com/article279.html.

National Asian Women's Health Organization. (1997). Expanding options: A reproductive and sexual health survey of Asian American women. San Francisco, CA: Author.

National Asian Women's Health Organization. (1999). The Asian men's health survey: Sharing responsibilities. San Francisco, CA: Author.

National Council of Negro Women. (1992). The 1991-1992 women of color reproductive health poll (Vol. 55). Washington, DC: Communications Consortium Media Center.

Noda, K.E. (1989). Growing up Asian in America. Boston, MA: Beacon.

Okazaki, S. (2002). Influences of culture on Asian Americans' sexuality. Journal of Sex Research, 39(1), 34-41.

Ordonez, R.M., Espinosa, A.M., Sanchez-Gonzalez, D.J., Armendariz-Borunda, J., & Berumen, J. (2004). Enhanced oncogenicity of Asian American human papillomavirus 16 is associated with impaired E2 repression of E6/E7 oncogene transcription. Journal of Genetics and Virology, 85(Pt 6), 1433-1444.

Schuster, M.A., Bell, R.M., & Kanouse, D.E. (1996). The sexual practices of adolescent virgins: Genital sexual activities of high school students who have never had vaginal intercourse. American Journal of Public Health, 86, 1570-1576.

Schuster, M.A., Bell, R.M., Nakajima, G.A., & Kanouse, D.E. (1998). The sexual practices of Asian and Pacific Islander high school students. Journal of Adolescent Health, 23, 221-231.

Upchurch, D.M., Levy-Storms, L., Sucoff, C.A., & Aneshensel, C.S. (1998). Gender and ethnic differences in the timing of first sexual intercourse. Family Planning Perspectives, 30, 121-127.

U.S. Department of Commerce. (2000). U.S. Bureau of Census data 2000. Washington, DC: Author.

[Author Affiliation]

Tsui-Sui (Annie) Kao, MS, RN

Doctoral Student

University of Michigan

Ann Arbor, MI

Multicultural Medicine and Health Disparities - Journal of the National Medical Association

Multicultural Medicine and Health Disparities David Satcher, Rubens J. Pamies and Nancy N. Woelfl, eds; New York: McGraw-Hill, 2006; ISBN 0-07-143680-4; $59.95

Health disparities are an acknowledged fact in American life, so much so that reducing health disparities is one of the two overarching goals in Healthy People 2010. Multicultural Medicine and Health Disparities presents 34 chapters written by a variety of guest experts which function as stand-alone essays on different aspects of health disparities in the United States. The first chapter, by Hani K. Atrash and Melissa D. Hunter, is an excellent introduction to the subject of health disparities (as defined by this volume). Topics covered include an overview of health disparities, sources of data, problems with racial and ethnic classification, factors which may be related to the observed disparities, and a review of some programs and interventions addressing health disparities. Subsequent chapters vary somewhat in content and approach but most follow the same general format: they introduce the topic, summarize relevant information and conclude with an ample reference list; many also include recommendations for reducing disparities and some include case studies. Many of the chapters cover standard topics such as black/white differences in morbidity and mortality, and the importance of cultural competence for healthcare workers. Others are more unusual, including chapters on disparities in bioterrorism preparedness, faithbased initiatives to improve health and the role of community health centers in minority health. A complete list of the chapters may be found at: http://books.mcgraw-hill. com/getbook.php?isbn=00714368 04&template=#toc.

This is an excellent reference volume and textbook. Given the definition of 'health disparities' and 'multicultural' used by the volume's editors, it's hard to think of topics which have not been included. The presentation of information is straightforward and makes excellent use of tables and graphics. My main criticism is the limited range of subject material in terms of what is considered a 'culture' and what groups are considered in defining a disparity.

A health disparity is a difference in occurrence or outcome in some health condition or health behavior among =2 groups of people. The number of possible ways to define groups for this type of comparison is virtually endless: race and ethnicity, age, gender, disability status and geographic residence are just a few of the possibilities. Multicultural Medicine and Health Disparities concentrates on disparities among population groups as defined by race and ethnicity. In this choice, it follows the frame of reference used by the Institute of Medicine's Committee on Understanding and Eliminating Racial Ethnic Disparities in Health Care, formed in 1999. Similarly, 'multicultural' within this text refers to cultures defined primarily by race and ethnicity, rather than, for instance, deafness or sexual preference.

The investigation of racial and ethnic health disparities is a worthy subject and is the easiest type of health disparity to study because of the wealth of national data available that links racial and ethnic classifications to information about health behaviors, access to healthcare, and morbidity and mortality. Because Multicultural Medicine and Health Disparities does an excellent job summarizing information concerning racial and ethnic disparities in healthcare, it will probably be the definitive statement on that topic for years to come. Unfortunately, because of its excellence, it may be seen by many as defining not just the field of racial and ethnic health disparities-but health disparities in general-so that topics omitted (for instance, inequality in healthcare for gay men and lesbians) or treated only briefly (for instance, urban/rural differences) will not be included in future discussions of health disparities.

[Author Affiliation]

Reviewed by

Sarah Boslaugh, PhD, MPH

BJC HealthCare

Health Right sees more patients than ever: ; City clinic provides free health care - Sunday Gazette-Mail

Charleston's free health clinic sees more and more patients eachyear, a trend that both gratifies and dismays executive director PatWhite. Last year, the Washington Street East clinic treated morethan 14,000 patients, encompassing 44,000 clinic visits. Volunteerstaff filled 91,000 prescriptions, worth about $8 million. Abouthalf of those medicines went to people 65 and older.

'Our patients are appreciative of the service,' says White, aformer state legislator who has headed Health Right since its 1982inception. 'I love my job. I can't imagine doing somethingdifferent. But it also makes you wonder about the richest nation inthe world having so many people fighting for their lives, withoutaccess to medical care.'

In 1984, a total of 1,620 people visited Health Right. The clinicaveraged 29 patients a day. Now it sees more than 160 a day in amodern, brick building that opened in November of 1999.

Those patients seem to grow sicker each year, she said. They showup with progressed chronic ailments, including heart disease anddiabetes.

'It takes longer to get them stabilized than it used to,' saidWhite. 'It's a lot more labor intensive.'

Federal welfare reform enacted a few years ago has also driven upHealth Right's numbers, White says. The approximately 75,000 statefamilies no longer on welfare assistance are going somewhere forhealth care, White says.

'Where they're primarily going is to free clinics,' she said.'We're finding that in many instances their health status isn't asgood as we might have hoped.'

But in the face of the increased demand, Health Right isexpanding its services. White and her volunteer staff are drawing upplans to offer free adult dental care, recruiting volunteerdentists.

They have applied for funding from the greater Kanawha ValleyFoundation, United Way and the Benedum Foundation. White said HealthRight is also trying to offer more health education services, suchas smoking cessation classes.

Health Right already offers free eye exams and glasses throughthe optical supply business Lens Crafters.

The clinic is open two evenings a week, including every otherTuesday night. It is also open some Saturdays. White said itsaverage service time is about 62 hours a week. Health Right uses theservices of 106 physician volunteers.

'Even when you go to a hospital emergency room it's not the sameas having a doctor,' White said. 'And here a nurse practitioner cantell you 'This is how you take insulin, this is why you're onmedication for your heart condition.''

Health Right's budget ran $650,000 last year, White said. Itsmedicines and physician labor are donated, of course.

The clinic draws money from a West Virginia Department of Healthand Human Resources line item, United Way, and other charities andfoundations. Health Right's board also conducts an annual fund-raiser that produces about $100,000, she said.

US health-care dissatisfaction rated high 3-nation study finds Americans less likely to permit government efforts at solutions - The Boston Globe (Boston, MA)

Americans are among the world's most dissatisfied people when itcomes to health care systems, but they are the least disposed to letgovernment try to solve the system's problems, according to athree-nation survey published today.

The survey also found that Canadians and Germans are increasinglydissatisfied with their health care systems.

The new findings suggest it is less likely than ever thatAmericans will soon look to other nations with government-led healthcare systems for answers to growing US problems with costs andgrowing numbers of uninsured citizens.

The survey, which involved nearly 4,000 adults in the threenations, found a sharp drop in recent years in the proportion ofCanadians and Germans who think their health systems work well. Theproportion of Canadians who were satisfied with their health systemplummeted from 56 percent in 1988 to 29 percent in 1994. In Germany,the drop in satisfaction was less drastic during the same period,from 41 percent to 30 percent.

In the United States, the proportion who said they were satisfiedwith the health system rose slightly, from 10 percent in 1988 to 18percent in 1994.

The rise in dissatisfaction, the authors said, reflects thosecountries' recent struggles to control health costs in the face ofnew technology and aging populations.

'There's no medical Shangri-La out there,' said Robert J. Blendon,chairman of health policy and management at the Harvard School ofPublic Health and principal author of the survey, which appears inthe journal Health Affairs. 'When you start to constrain costs,people don't necessarily want to abandon their health system, but thebloom is off the rose.'

That impression was ratified by Dr. Mimi Divinsky, a Torontogeneral practitioner who is active in efforts to keep Canada'sgovernment-financed health system intact.

'My sense is that people are really apprehensive about losing thesystem we've known since the 1960s,' Divinsky said in an interviewyesterday. 'My older patients, who remember the days beforeMedicare, are calling me and saying, `Maybe I should have my hipoperated on now, because perhaps in five years the system won't payfor it.' '

While Canada and Germany are cutting back drastically on healthcare spending, there is considerable evidence from the survey that,as Blendon put it, 'people in the other countries have fewer problemswith their health care' than Americans do.

For instance, one in eight Americans said in 1994 that theycouldn't get needed medical care in the previous year -- a measure ofthe millions of people who do not have health insurance here. Bycomparison, one in 13 Canadians and one in 17 Germans said theycouldn't get needed care.

Twenty percent of Americans said they had a problem paying doctoror hospital bills in 1994, versus only 6 percent of Canadians and 3percent of Germans. (The survey involved only people living in theformer West Germany, since the former East German states wererebuilding their health system.)

Americans didn't fare any better than Canadians in the length oftime they had to wait to see a doctor. About one in seven people inboth countries said they waited more than a week for an appointment,versus only one in 17 in Germany.

As jobless lose health care, it's often devastating, 'scary' - AZ Daily Star

Forty-three-year-old Ruben Alvira's last day of work in PimaCounty's Development Services Department was Jan. 17.

Now the married father of two is without health insurance.

'I had heart bypass surgery in 2000, and I saw the bill - it costmore than $100,000,' Alvira said. 'I have no idea what I'd do ifsomething like that happened to me now. Heart bypass surgery is nota forever thing. It's scary.'

Alvira's situation is not unique. A national report releasedFriday says that more than half of unemployed workers in Arizonawith low or moderate incomes have no health insurance. The same istrue on a national level, says the report by Families USA, anational non-profit organization that advocates affordable healthcare.

The report came out the same day that the federal governmentreleased data showing the United States lost 3.6 million jobs since2007, with half of those losses occurring in the last three months.A total of 11.6 million Americans are unemployed, the governmentsays.

Many health-care advocates say that for every percentage-pointuptick in unemployment, another 1 million people will go withouthealth insurance.

Local hospitals and health-care clinics are bracing for anonslaught of 'bad debt and charity care' write-offs in the nextyear, when the full impact of the country's recession is expected tobe felt in the health-care industry.

Bret Hicks, finance director at Tucson Medical Center, wrote offmore than $24 million in bad debt and charity care last year - afigure that's expected to grow in 2009.

Hicks said: 'There's no question with the economic downturn andpeople being uninsured or having high-deductible plans, there'salways going to be a problem. Almost everyone has some kind of a co-payment or deductible. If it's a question of keeping the heat on orthe electricity on in the house,' a hospital bill is not one of thetop priorities for people to pay.

Many lower- and middle-income workers such as Alvira say theycan't afford to pay for health coverage through the ConsolidatedOmnibus Budget Reconciliation Act of 1985, better known as COBRA. Itextends health insurance coverage from former employers for 18months.

Alvira said that to cover himself and his two children, COBRAwould cost him nearly $700 per month. In most cases, COBRA costsjust as much as the company's subsidized insurance plan, except thatthe individual pays the entire premium without the company's help.

'The average COBRA premium consumes on average 84 percent ofunemployment benefits,' said Ron Pollack, executive director ofFamilies USA. 'It is really difficult for people to get any otherkind of coverage - so-called Medicaid programs are not generous,particularly with adults.'

Indeed, because Alvira's wife works for the Tucson Unified SchoolDistrict, Alvira said the family makes too much money to qualify forthe Arizona Health Care Cost Containment System, or AHCCCS. But hesaid her health insurance is so expensive that Alvira and the kidsare going without for now, while the family tries to stayfinancially afloat.

Other unemployed Arizonans don't qualify for AHCCCS because theyown too many assets, such as a house or car.

AHCCCS, which added more than 70,000 people to its rolls in 2008 -including nearly 10,000 in Pima County - is for extremely low-income individuals and families in Arizona. In general, it's forpeople living at or below the federal poverty level, an annualincome of less than $10,400 for an individual or less than $21,200for a family of four.

Alvira, who is diabetic, had a doctor's appointment on Wednesdaybut decided to skip it to avoid the expense.

Tucsonan Arnold Moreno, 48, also is opting to go without healthinsurance because the construction work he does has been sporadic,and his income has dropped.

'To pay for health insurance is expensive, but I'm overqualifiedfor AHCCCS,' he said. 'My wife has insurance for her, but not for meand my kids.'

Moreno is diabetic, and his medications cost $500 per month. Hehas been dividing them in half to save the money. But this week heapplied for prescription-drug assistance and hopes to be taking hisfull dosage soon.

'I'm getting some work, but it's slow,' he said. 'We just allhave to hang in.'

Pollack, of Families USA, said only one in five unemployedworkers with income of 200 percent of the federal poverty level orbelow has private insurance or military coverage. And only one infour receives health coverage through Medicaid or other publicprograms.

'It is clear this is a group of people that will have enormousdifficulty retaining private health coverage,' he said. 'Losing ajob often means losing health insurance and as a result, millions ofmiddle-class and lower-income people become uninsured.'

Arizona shed 12,400 jobs in December, and the unemployment raterose six-tenths of a percentage point from November to 6.9 percentin December. Researchers at the state Department of Commerce predictthe unemployment rate will top 7 percent and might even hit 8percent before the state economy turns around.

Some relief for laid-off workers may come from Congress, whichis considering passing legislation to offset the high costs ofCOBRA.

Contact reporter Stephanie Innes at 573-4134 or atsinnes@azstarnet.com.

WHAT TO DO

Some health-care options if you lose your job:

* Find out if you can get coverage through your spouse's ordomestic partner's employer.

* Find out if you can continue your coverage through COBRA, theConsolidated Omnibus Budget Reconciliation Act of 1985.

* Find out if you or your family members are eligible forMedicaid, the Children's Health Insurance Program or any other stateor local programs, or coverage through the Department of VeteransAffairs.

ARIZONA BY THE NUMBERS

* Number of unemployed workers with incomes below 200 percent ofthe federal poverty level ($44,100 for a family of four): 92,123

* Unemployed workers who are uninsured: 50,721

* Percent uninsured: 55 percent

The Highest Possible Health Status for Indians - Human Rights

In 1976, the United States undertook in the Indian Health Care Improvement Act (IHCIA), 25 U.S.C. � 1601 et seq., a commitment to provide 'the highest possible health status for Indians.' That commitment, which was preceded by many treaties promising health care to Indian tribes, was reaffirmed in 1992. Portions of the act expired in 2001. While the authorization to provide federal funds for Indian health problems still exists in a broad 1921 statute providing for federal health care for Indians, the failure of Congress to reauthorize the health care act (including amendments to strengthen the Indian health program) for the past five years has clouded the federal commitment.

In some sections of the public, a view apparently exists that the entire federal effort to improve the health status of Indians has failed and should be abandoned. For example, Dr. David Eichler, the president of the Alaska Dental Society, has denounced the entire concept of a federally funded health program for Indian and Alaska Native peoples in the January 2006 Alaska Dental Society newsletter.

'One reason for failure.' he commented in a version of his article available on the Internet, 'is because the socialist model removes any responsibility from the client and breeds resentment because of dependency.... We establish the Natives as de facto slaves... The most effective action we could take would be to remove all special federal assistance for all American Indians' in order to allow 'their integration into American society as dignified citizens.' see Posting of Dr. David Eichler, northpoledentist@gci.net, to owner-dental-publichealth@list.pitt. edu (Mar. 1, 2006) (copy on file with author). Eichler's lack of knowledge about the origins and reasons for the federal commitment to Indian and Alaska Native health care is revealed by his statement, 'For some reason in the 1920s [sic] the federal government decided to establish by legislation that it would take upon itself the role of health care provider for American Indians.'

His point of view ignores both the federal obligation to provide health services to Indians in exchange for the relinquishment of vast tracts of Indian land and the impressive improvement in Indian and Alaska Native health care that the Indian Health Service (IHS) has made since it was founded in 1955. For example, between the early 1970s and 2002, the tuberculosis mortality rate for Indians and Alaska Natives was reduced by 80 percent, the cervical cancer rate by 76 percent, the infant mortality rate by 66 percent, and the maternal mortality rate by 64 percent.

Eichler asserts that abolishing the IHS program would improve Indian health status. Yet many Indians and Natives live in remote areas where access to non-IHS health care is very limited or nonexistent. And, notwithstanding the accomplishments of the IHS, Indians remain afflicted by many diseases at higher rates than other Americans.

In addition, since native people now live longer, they face increasing risks from certain diseases that come with age. They are in greater need of nursing care, long-term care, and home health care, which the IHS has provided rarely and reluctantly. In addition, diabetes is one of the fastest growing threats to native health. The Indian death rate from diabetes is 3.3 times that of non-1 lispanic whites. Cervical cancer death rates are still 3.8 times higher.

I have been actively involved in the administration of Indian health programs, serving as chair of the board of the Bristol Bay Area Health Corporation, a tribal organization that provides health services to Natives in the 45,000-square-mile Bristol Bay region of Alaska. I have also been chair of the Alaska Native Health Board, and I am currently chair of the Alaska Native Medical Center Joint Operating Board and the National Indian Health Board. It boggles my mind that anyone can describe the agency that has accomplished so much to improve Indian health status as 'enslaving' native people. While I have been involved in addressing Indian health problems, a major innovation has been the decentralization of the IHS program through the transfer of responsibilities from the federal bureaucracy to Indian tribes and tribal organizations. In Alaska, the entire delivery of federally funded health care to Native villages is in the hands of the villages themselves or their designees.

The United States needs to stay the course. The pending Senate bill to reauthorize the IHCIA broadens authorization to meet contemporary healthcare needs in Indian Country, including strengthening the present diabetes program and express authorization for long-term care, home health care, hospice, and assisted living. The latter are especially important in remote rural areas because the elderly should be able to stay home among their friends and family during their last years.

The bill also includes provisions to address the deterioration of federally owned Indian health facilities, including water and sewer facilities. In Alaska Native villages, due to minimal water facilities, the infant pneumonia hospitalization rate is eleven times the national average. The shocking state of many of the buildings in which Indians receive the federal health care to which they are entitled is a particularly appalling feature of the contemporary scene in Indian Country.

Congress not only needs to authorize these programs, it also needs to fund them. There is at present a backlog of $429 million for essential maintenance, alteration, and repair of Indian health facilities. This has not been a priority with the budget people in the Bush administration, who asked Congress for $52,668,000, an increase of only $1 million, an adjustment for inflation, in the 2007 budget request.

The pending bill also includes provisions designed to increase the number and effectiveness of health-care professionals in Indian Country. Building on the experience with the effective community health aide program in Alaska, it would authorize the extension of that program to Indian Country throughout the United States. The bill would also encourage the government to expedite the construction of new health-care facilities, including water and sewer facilities, to serve Indian and Alaska Native communities, addressing the serious deficiencies in both the number and condition of existing facilities, and it would strengthen the ability of Indian people to recover reimbursement for the costs of healthcare from nationally available programs such as Medicare and Medicaid, in which they are entitled to share but frequently encounter barriers to enrollment.

Without diminishing the federal commitment to health care in Indian Country, the bill would also address the availability of health care for some 650,000 Indians who live in urban areas in the United States by eliminating some of the disparities between programs for reservation Indians and urban Indians.

Indians are grateful to the American Bar Association for calling on Congress to pass the IHCIA reauthorization in 2004 and again in 2005. While gains in Indian health over the past fifty years are evident, the shortages in both staffing and facilities call for a renewed legislative initiative. Even as the United States faces the many challenges of the twenty-first century, Indian and Alaska Native health care should not be relegated to the back burner.

[Sidebar]

An elderly Navajo woman is treated at the Montezuma Creek Community Health Clinic on a reservation near Bluff, Utah.

[Author Affiliation]

Population health's tipping point.(the interview)(Interview) - H&HN Hospitals & Health Networks

MAUREEN BISOGNANO, president and CEO of the Institute for Healthcare Improvement, recently co-authored Pursuing the Triple Aim, which highlights partnerships among hospitals, employers and their communities that aim to improve population health and the individual patient experience while reducing the cost of care. Bisognano will receive the American Hospital Association/Health Research & Educational Trust TRUST Award at the AHA-Health Forum Leadership Summit this July in San Francisco.

What are the key takeaways from your book?

BISOGNANO: I'm seeing leaders who have moved beyond the vision of taking excellent care of patients--in an office visit or during a hospitalization--and see the Triple Aim as their mission. That involves not only excellent care that's safe, effective, efficient, as least costly as possible and timely, but also seeing beyond the care experience to the health of the population, and bending the cost curve. Ten years ago, when we began to talk about the Triple Aim, it was a rare executive who said, 'I can take that on for my community.'

Why do you think providers are finally embracing population health?

BISOGNANO: I think reform opens peoples' eyes to looking at their work in a very different way. The notions of bundled payments and ACOs pushed a lot of people in this direction. But the people we write about didn't mostly motivate through financial reconstruction. At Bellin Health in Green Bay, Wis., when [CEO] George Kerwin faced financial challenges at his hospital, the normal pathway would have been to cut costs or close beds. But George looked at the health of his own workforce. The health of the workforce in the United States is pretty dreadful. Many of us are ignoring the complications of chronic disease and are eating too much and working too many hours. So George went to his own workforce first, and [as they] improved in health and their ability to work, he found that his premium costs were lower. That gave him credibility to go out into his community and say to other leaders, 'You can save money by making a healthier workforce.' It not only strengthened his workforce, it strengthened Bellin as a whole.

You also talk about hospital/employer partnerships.

BISOGNANO: The great opportunity when you're working with a company like Intel or Starbucks or Boeing is that the company knows its workforce. It's a little bit more challenging when a CEO in a hospital is trying to get his or her hands around the health of the community when nobody really owns that whole community. So it's a great place to start.

These companies have very good profiles on their employees. They know how many times employees are out with back injuries, headaches or carpal tunnel syndrome. Having that data allows them to dive deeply into the key problems that are preventing their employees from being fully functional human beings. Combining that with the medical knowledge in the health care community, you can create a value stream. You get a sense of the best way to care for a patient who is newly diagnosed with diabetes, or a woman who has just found out she's pregnant. What's the best way to deal with that, and how do we put all the pieces together in a new design? It's very exciting to see the employers and the health care community redesigning care, because the cost benefits to the company are immediate. The hospital likely will see some shifts in its business model. You are going to see, perhaps, fewer MRIs and more office visits, but [the patients] are going to need managing. I call it building a bridge to a different model of care, where [providers] are seeing downsizing in some parts of their business and increases in others. It's a management requirement to be able to predict those changes and move the staff and technology to the future.

And that gets back to the idea of population health.

BISOGNANO: Right. I see proactive anticipation and new designs as key leadership challenges. When you move from managing an organization to really capturing the data in a community and building a coalition, it's not management, it's governance at a community level. You're bringing together people who come from well outside of health care--local ministers, people who run 24-hour barbershops, school nurses, mayors--and moving away from the paternalistic view of health care, which is 'We'll take care of you when you get sick,' to really co-creating health in a community.

Where does patient-centered design fit into that model?

BISOGNANO: In the book, there is an example from Memphis, where there are health care professionals, but also ministers and other people, around the table. They have their data, they know what the total population is, they know minority representation, they know how many people have diabetes and undiagnosed hypertension. All that data drives very different conversations. We see a minister talking to a physician, saying, 'You see these diabetic patients twice a year for 15 minutes. How can you possibly expect to improve their health with such brief interactions and encounters?' [The minister] said, 'I see them twice a week for two hours, so I'll take diabetes.' And he started changing the food they were serving in the church, and in his sermons, talking about the sanctity of your health and how you have an obligation to God and your family to know your health status.

The CMS shared savings pilot focuses heavily on the Triple Aim. What's your take on the program so far?

BISOGNANO: In some communities, the conversation is mostly about money. I don't have a whole lot of hope with the idea of shared savings being a part of financial negotiation. I have tremendous hope when I see the conversation being around health and health care producing the savings, and then, what [to] do with those savings. I'm seeing people really wrestle with their population--What does it look like? How many asthmatic children do we have here? What is the status? Is it getting better or worse? Some of these shared savings now are being invested into improvements in health. It's a different conversation than the financial bartering.

Finally, are you optimistic the current focus on the Triple Aim and population health will continue regardless of how the Supreme Court rules on health reform?

BISOGNANO: I was in Salt Lake City and Seattle [recently] having this very conversation and I'm optimistic. It really worries me if the legislation is repealed, that in some communities people will revert to business as usual. But the visionaries, the people whom I wrote about in the book, the people I am visiting, clearly are on a pathway to the Triple Aim. I don't see that reversing very easily.

[ILLUSTRATION OMITTED]

THE BISOGNANO FILE

C.V.

Started career as a nurse at Quincy City Hospital in Massachusetts. Joined the IHI in 1995.

On the Road

'I get to learn from the very best in health care, as I travel to teach from Africa to Sweden and across the United States. I will often visit clinics and hospitals to see things as a patient would.'

Quality Swings

'I play golf with my husband every Saturday morning at 6:09 a.m., and use QI methods to improve my game!'

Red Sox Nation

'I have a bet with [IHI Senior Fellow] Rick Norling each year on the Red Sox vs. his Yankees. I'm out quite a few more dinners than Rick is!'

PODCAST

To listen to a podcast of this interview, go to www.hhnmag.com.

VIDEOCAST

Health care reform hurts business in U.S. - Long Island Business News

Two years after President Barack Obama signed the PatientProtection and Affordable Care Act into law, America's health planis once again at a crossroads.

And as the nation's top judiciary readies to hear challenges tosome of the act's key components, detractors say health care costscontinue to rise for companies and most individuals.

The Congressional Budget Office, meanwhile, says the legislationwill cost $1.76 trillion over a decade, nearly twice earlierfigures, making the Affordable Care Act far less affordable for thenation.

'All we've realized so far is more paperwork and higher costs,'said Lou Basso, president of Farmingdale-based Alcott Group, whichmanages benefits and human resources for more than 300 companies.'One of the points of health care reform was to cover more people.The other was making a more competitive market, so the cost ofhealth care would go down for everyone - businesses, employees.Unfortunately, that hasn't happened.'

While many provisions have yet to take effect, leaving hope thatreform will eventually lower costs, the act is so far taking aneconomic toll on companies and individuals.

'Two years into it, I think employers saw this as setting thestage for increased access, which is a good thing for members andthe population's perspective,' said Steve Logan, president ofAetna's New York market. 'But it has added to their costs.'

Logan said health insurance rates are rising 8 to 12 percent, inpart due to mandates to provide coverage for dependents up to age26, which he said added 2 percent to Long Island premiums.

'That doesn't sound like a lot, but it's significant,' Bassosaid. 'Although that's a young population, even normal health careadds some costs.'

Ignoring the culprits

The big reason for rising costs, however, isn't new mandates.It's the continuing increase in health care procedures, tests andmedications, which cause an annual 10 to 12 percent rise in claimcosts, which the legislation so far hasn't addressed, Logan said.

'The overwhelming driver of premiums is medical costs,' he added.'The act does much in the area of access. But the act has donenothing to address the underlying health care costs up to now.'

North Shore-Long Island Jewish Health System CEO Michael Dowlingpointed to other cost drivers the legislation doesn't address.America's aging population, for instance, drives up demand, as doesobesity and obesity-related diabetes. The generally held belief thatmore care is better also inflates spending.

'The idea that you can have a piece of legislation passed thatwill reduce the cost of health care in the United States isludicrous,' Dowling said, 'unless you change all of the otherstuff.'

In addition to costs related to mandates and health carespending, companies are being hit with compliance costs that aren'tincluded in most calculations.

'There is record keeping and compliance that companies need todo,' Logan said. 'Many are working with vendors, payroll companies.But it's added consulting costs an employer would have to incur.'

Basso is concerned that the hidden cost of compliance will makehealth care more expensive for companies, regardless of the act'soverall impact on care.

'My sense is between administrative and regulatory burden and thecomplication of trying to comply with it, the costs are going to goup, not down,' Basso said.

The mandate about to be reviewed by the U.S. Supreme Court, whichrequires companies with 50 employees or more to provide 'affordable'insurance or pay a $2,000 fine per worker, may also increase somecompanies' costs. There is also the problem that the fine is lessexpensive than the cost of insurance, said Mark Bogen, vicepresident of finance at South Nassau Communities Hospital inOceanside.

Another provision, which would create insurance exchanges, isintended to allow people to compare insurance plans and find cheaperpolicies, but the legislation doesn't specify how states shoulddesign them.

'A lot of the compliance regulations were intentionally vague,'said David Sturdivant, senior executive officer in charge of healthcare at MindSHIFT Technologies, which manages information systems.'There's no magical solution that's going to enforce thesestandards.'

Others said if New York doesn't devise an exchange soon, thefederal government will create one that residents may not like.

'New York state needs to pass legislation related to a stateexchange,' said Dr. Stacey Rosen, vice president of clinicalservices at the Katz Institute for Women's Health. 'If everythingstays intact and New York state does not have an exchange in place,the federal government takes control.'

Incentivizing wellness

The great hope of health care, however, may be a shift frompayments per procedure to paying for the continuing care of thepopulation.

In these models, providers are paid for managing care andprevention and for reducing readmissions and other costs, ratherthan simply for procedures. The idea is to pay for true 'healthcare' rather than 'sick care.'

'Volume-driven health care has a bull's- eye on it,' said Dr.Simon Prince, CEO of Beacon Health Partners. 'It's going to die atsome point.'

Kevin Dahill, CEO of the Nassau-Suffolk Hospital Council, a tradegroup, said shifting from payments for services to value-basedpayments, by incentivizing efficient care as opposed to more care,could lead to big savings.

'The hypothesis came forward,' he said, 'that the only way we'regoing to bring down health care costs in this country is to get awayfrom a fee-for-service system where all the incentives are aroundvolume.'

Some, however, worry that incentivizing providers to do lesscould leave patients vulnerable if providers withhold care to boostprofits.

'You've got to protect against that,' said Thomas McAteer, seniorvice president for the East Region for Aetna Medicaid. 'If you wantto move to thoughtful, rational delivery of care, you need torealign the incentives.'

Meanwhile, some people are seeing benefits from specificprovisions. More than 250,000 senior citizens benefited to the tuneof $160 million when the so-called donut hole, the gap in Medicaidprescription coverage, was closed. An added 150,000 young people nowhave health insurance coverage in New York and 2.5 million have itnationwide.

But others say coverage for many is deteriorating as prices rise,while companies and insurers offer policies with higher co-paymentsand deductibles.

Environmental health and the media, Part 2: beyond get the message out/put the fires out.(Inside the Profession) - Journal of Environmental Health

'I switched on the TV,' NEHA first vice president Rob Blake told JEH, 'and I couldn't believe it.'

[ILLUSTRATION OMITTED]

Blake, who serves as environmental health director for the Dekalb County Board of Health in Georgia, was on a visit to the United Kingdom and was stunned to discover that a British television series features the work of environmental health officers. The program is called Life of Grime.

Environmental health as fodder for reality TV? Apparently so: Each half-hour installment narrates the adventures of environmental health officers at work on problems ranging from food safety to sewage issues. Readers can find synopses of upcoming episodes on the UKTV Web site (http://www.uktv.co.uk/index.cfm?uktv=tv.series&tvSid=8).

Personality profiles of environmental health officers serve as interludes in the storyline. 'They were breaking up the story within the half hour to show all kinds of different angles around the people who work in environmental health,' Blake said. 'We've got some really neat people.'

Drama, comedy, striking visuals, human interest--when one stops to think about it, environmental health activities have all the ingredients of good television.

And perhaps Life of Grime also has what many environmental health professionals dread about media coverage--a touch of sensationalism? Synopses of some of the episodes, for instance, read as follows:

    The entertainingly stomach-churning exploits of environmental health  officers in London's East End. Hot temperatures mean hot heads and  high emotions as the officers face a bad cockroach epidemic....    .... A tenant's dogs are stinking out a council block, a woman is  attracting rats by leaving food out for the pigeons, and a food  inspector is cracking down on illegal street traders. It's enough to  put you off your TV dinner!    Environmental health officers double up as ghostbusters when they  help a woman who is being terrorised by ghostly activities in her  council home--could an exorcist be the only answer?.... (UKTV, n.d.)

JEH put it to Blake: Was there ever anything on the show that environmental health professionals might not have liked?

'Oh, I'm sure,' he said. 'And I know some of the folks in the U.K. thought--maybe they felt the same way.' But he believes the net effect is beneficial, because it raises the public's consciousness 'that ... hey, we are invisible, but we're doing this every day for every person.'

But could it happen on American TV?

'I don't know, I don't know,' Blake said. He acknowledged that the television market in Great Britain offers limited choices. On the other hand, he's not ready to give up hope: 'This was on one of the major networks that goes out across the country, and it came back by popular demand. It's interesting to people.... It affects their health, every day, and they're interested in what's going on in their community that they might otherwise be oblivious to.'

Could It Happen Here?--A Pep Talk

Before succumbing to the 'realism' of 'can't'--it can't happen on American TV, American viewers can't handle substance, a big market can't innovate the way a smaller market can--JEH thought it might be worth asking a couple of American television professionals whether something like Life of Grime would be possible in the United States.

A producer at a major TV network, who asked to remain anonymous, said.

  We like that [accompanying someone on the job]. Especially my  documentary guy doing the specials. We love that. I mean, you want to  get to know the people who do the work and are passioante about it. We  follow doctors all the time; I've followed police detectives, that  kind of thing. Somebody who's passionate about their work can show you  something. That's always good television.

'The way you've just described it, it sounds like it ought to work in the American context,' said Greg Dobbs, who corresponded for 23 years for ABC and then for National Geographic Television and HDNET Television. He warned, however, that it's hard to know for sure: 'I've long since learned not to trust my own judgment about what the American people are going to be interested in.'

So: maybe.

In fact, something along these lines is being tried in a modest way in Charleston, South Carolina, where the local NBC affiliate has worked with the Trident Public Health District to develop a three-minute segment on public health issues that airs once a month (Pranger, 2005). The first segment described the investigation of a possible foodborne-disease outbreak. Despite its brevity, it gave viewers 'a glimpse of the roles these public health workers play' (Pranger, p. 4).

Part of the challenge is to interest the gate-keepers (editors and news directors), who may have some untested convictions about what will and won't appeal to the American public.

A freelance health reporter writes: 'There is evidence that, contrary to the instincts of many news managers, people are actually more interested in health policy stories than in 'disease of the week' blurbs' (Holtz, 2003, p. 9). He bases this conclusion on an analysis of polls taken by the Kaiser Family Foundation and the Harvard School of Public Health and pointedly notes that 'The findings seem to contradict the gut news instincts about what stories draw an audience' (p. 9).

'I think the interest is there,' said David Ropeik, a former television environmental journalist who now teaches risk communication and working with the media at the Harvard School of Public Health. 'I think the interest is there because they realize it's the ... physical world in which they live--the air they breathe, the food they eat, the water they drink. And, specifically, I think, the world in which their children live, breathe, and eat.'

Journalists are always looking for stories that have personal implications for their audience. Michael Hawthorne, environment reporter with the Chicago Tribune, said, 'Personally I like to read about it [environmental health]. I'm biased, obviously, since that's a subset of what I do for a living. But I find that even other people who have nothing to do with journalism ... have questions about it.... Because this is one area in which in many cases there's much closer effect on many people. Or a direct effect.'

The American news media has traditionally seen public health stories as 'dull but important,' but as one reporter notes, there is nothing inherently dull about 'the fascinating personalities who practice it [public health] and the extraordinary stories it reveals' (McKenna, 2003, p. 11). She describes watching 'a scientist empty a refrigerator of a week's worth of groceries to search for clues to a foodborne disease that was causing a rash of miscarriages while she ignored the risk to her own first-trimester pregnancy' (p. 11).

The visuals are often good: 'We look for pictures,' the anonymous television producer told JEH, and 'luckily [with] environmental stories often you're out in nature, in beautiful spots or disgusting chemical spills, all of which are very good.'

Mel Knight, director of the Sacramento County Environmental Management Department in California, pointed out that other kinds of environmental health stories--'tattoos, piercing, that kind of thing'--also offer good visuals.

The first step in capturing the interest of media gatekeepers is to be convinced oneself that environmental health activities make good material for journalists. Many members of the profession may also need to get past a reflexive fear of sensationalism. For one thing, sensationalism may sometimes be a price worth paying. For another, it is not the only way to a journalist's heart: 'The media tells stories that are of interest to the public,' said June Livingston, communications and media officer for the Sacramento County Environmental Management Department. 'People are very interested in food--people eat out a lot, people go to grocery stores.'

'The public seems to have a sustained interest in restaurant inspections,' Knight added.

The Rising Interest in Environmental Health--Challenge and Opportunity

Indeed, some environmental health professionals see public interest in their work increasing. 'These environmental issues have been the hot topics,' said Emily Gresham, health communication specialist for the Northern Kentucky Health Department. 'You've got your West Nile virus, you've got your lead in soil, and those have really been things that are out there in our local media.'

Mark Robson, of the Department of Environmental and Occupational Health at the University of Medicine & Dentistry of New Jersey (UMDNJ) School of Public Health, said, 'I think it [environmental health] is becoming less invisible. I think--it's terrible to say this, but--since the 9/11 issue, everybody has kind of understood now about environmental health.'

The result is increasing interest on the part of the media. That circumstance presents another important challenge for professionals in the field.

'The first thing is that the media are calling more,' Robson observed. 'They expect you to be crisp.... The second thing is that the media are more savvy than they used to be. Large papers are more specialized. Unless it's a really tiny outlet, you don't have people who are covering everything from the social pages to the business section. They really are environmental professionals.'

Tracy Regan a reporter for the Times of Trenton, does not believe that all health departments have risen to the challenge yet. 'I think these folks are getting up to speed.... There are increasing numbers of articles about health issues. And so I think they're kind of under fire now.'

A Culture of Caution

'Most environmental health professionals would avoid the media like the plague if given a choice,' believes Robert Emery, associate professor of occupational health at the University of Texas School of Public Health.

'We tend to be, as a group, in the aggregate, afraid of the media,' said Robert Harrington, director of the Casper-Natrona County Health Department in Wyoming. 'Because they might expose us in some of our shortcomings,... we just don't reach out to the media. If I don't see the TV truck in front of my office, phew! It's a good day.'

Denzil Inman, a former FDA regional food specialist, sees this phenomenon as a function of personality types: After studying the Myers-Briggs system (often used in career counseling), Inman has concluded that the following traits are predominant among environmental health professionals: hardworking, honest, dependable, modest, cautious, and introverted. The trend is self-perpetuating because people tend to hire people like themselves. He believes the profession could benefit by consciously broadening its hiring practices.

But reticence and distaste for the media may also have structural causes related to the medical and regulatory implications of the work. 'From Day 1, you're taught not to discuss things that you're working on,' said Laura Strevels of the Northern Kentucky Health Department. 'I think we've tended to say, 'Don't answer it--or don't give too much information--because you don't want to hold yourself open to liability for ruining a business.''

'And [another] thing that's occurred,' Emery of the University of Texas pointed out, 'is that many of us maybe have endured some sort of media training in preparation for the 60 Minutes sort of ambush tactic.'

As a result, many of the media tactics environmental health professionals have adopted are defensive in nature. Barry Drucker, environmental health supervisor for the St. Charles County Department of Community Health and the Environment in Missouri, said he was once told that ''the thing to do is be as boring as possible.'' This method, he believes, doesn't favor the interests of the profession in the long term.

Blake thinks that 'we as a profession, if we are in a personality type--whatever is going on--we just need to be able to get out of that comfort zone.'

Environmental health professionals have traditionally worried that a sensationalized story will give the public distorted ideas about health threats and--in a worst-case scenario--create panic. But several people pointed out that even sensationalistic or negative stories can be helpful in the long run.

'I'll give you [a] very applied example,' said Knight of Sacramento County:

  The San Jose Mercury did an article in which they actually took  inspectors and compared the differences among them. And they would say  [Inspector A] seems to always find temperature violations. But  Inspector C never finds temperature violations. And what they showed  was inconsistency or other things, which helped I think highlight to  program managers and others that these were important things that  ought to be dealt with. And I think it also made it easier for  professionals in the field to realize that the work they were doing  was both appreciated and being looked at.

So it helps, I think, on everything from grammar to handwriting to whatever it is. Knowing that people are going to look at your work.

'The general public and policy makers don't read the Journal of Environmental Health,' pointed out Lori Dorfman, director of the Berkeley Media Studies Group at the University of California-Berkeley School of Public Health. 'Neither do most reporters. Policy makers, in particular, need to know the implications of the research and practice in environmental health--news attention is one of the most effective ways to get the issues on their agendas.'

In recent years, many environmental health departments have engaged media consultants and have adopted tactics that--to put it bluntly--have been so long in use elsewhere that much of the public has developed immunity to them. That is not to say that these traditional methods of dealing with the media have no value. (For more on the advantages and pitfalls of some familiar media-handling tactics, see the sidebars on pages 38, 40, 41, and 42.)

The usual tactics tend to be tailored to 'getting the message out' (i.e., educating the public on some specific health or safety issue) or 'putting the fires out' (i.e., 'handling' the media when controversy erupts). But as the British Life of Grime series suggests, other relations with the media are possible. The rest of this paper will consider some ways the profession can step outside the usual games.

Be a Media Resource (And Be Flexible About It)

'You get some odd questions every once in a while,' observed Gresham of the Northern Kentucky Health Department. The questions may not relate to everyday environmental health work. Or they may be questions a reporter could easily answer for him- or herself by visiting the Centers for Disease Control and Prevention (CDC) Web site. But the point, said Gresham, is that 'they basically just want a person they can ask those questions to--basically stand there and give them back the information in an interview.' She considers meeting the media's needs in this way to be 'a public service, a health service.'

'It's just a matter,' added Strevels, 'of 'Can we come out, put some trees behind you? We're putting you once again on TV, in the public's eye, so that they know if they have questions to call you.' I know a couple of times, it was like: 'Man, that's not what we do.' But you do it anyway. Because they'll build on that relationship.'

Gresham said journalists also call her because they know the health department has contacts in the community--even if the issue has nothing to do with public health.

The right answer, in cases like that, is never 'not my area, sorry.' Gresham makes sure to provide a referral. 'I think that we have to be willing to go the extra step,' added Strevels. 'I know we're all busy, but ... [it's good to] do a little legwork so that we are more visible.'

Steve Jenkins, health director of Summit County Public Health in Utah, told JEH, 'We've had them call us about different things: 'Do you think bicycle safety in Summit County is a concern?' We said, 'Well, we're not sure, but let us research it out.' We researched it out and sent him two or three articles we got off the Internet and stuff from the state health department. He said, 'Thanks for the information. I think we're going to be able to put together a pretty good article about that.''

Emery told a story about boning up on fireworks safety, then laughed: 'I can't tell you the number of items I've been considered to be an expert in....'

Be an 'Expert'

To become known to journalists as an 'expert' is to ensure that your voice will be heard over and over. Because of the way journalists conduct their research, one's influence can grow exponentially.

Reporters generally start work on a story by going to secondary sources. They search Google, LexisNexis, or other databases to find out who the 'players' are, said Len Ackland, who teaches journalism at the University of Colorado-Boulder. 'You're trying to understand the issues, and you're writing down names of people.'

So, he said, 'There is a mechanism that people who get quoted once may get quoted again.'

Richard Maas, co-founder of the Environmental Quality Institute, is one of those people who gets interviewed repeatedly. 'My experience has been that ... one place would publish it, and then it would get picked up by the AP and Knight-Ridder, and then there'd be another hundred newspapers calling me.'

Being a neutral--and forthright--expert can earn lavish gratitude from journalists: 'I love Mark Robson [of the UMDNJ School of Public Health]' reporter Regan told JEH. 'Were I to hold someone up as someone who really is a scientist and really is interested in simply, you know, telling the truth and not shying away because it's controversial, I would point him out.... When I speak to him, I know I'm going to get the honest truth and what he knows--and the limits of what he knows.... It's very refreshing.'

Unfortunately (or fortunately for environmental health professionals looking to be heard), there seems to be a shortage of neutral experts. Traditionally, reporters have looked to university professors to fill this role. 'But I don't think they're as neutral today as they were when I was a journalist--because of the grants,' said Ackland. Also, said Maas, 'Most of them [academics] are doing very theoretical research inside the ivory tower. They actually don't have practical information that you need if you're a media person.'

One reporter JEH spoke with was skeptical that employees of health departments could step into this role. Todd Bates of the Asbury Park Press draws a distinction between 'neutral,' which he does not think academics necessarily are, and 'independent.' When he calls university professors, he is 'looking for independent sources of information.... But if you're calling up the state health department, they're not an independent source; they're the state health department.'

Ackland, however, thinks that 'a lot of people' at the health department could qualify as knowledgeable but neutral. 'It depends on the issue,' he said. 'If somebody at the health department is called on the phone about a story, and the story comes out well, and this person responds well to the questions and really clarifies what's going on, then a good reporter will try to get to know that person. I tell my students: 'Befriend an epidemiologist.''

Blake pointed out that in the United Kingdom, NEHA's sister organization, the Chartered Institute of Environmental Health (CIEH), is often quoted in the national media. He would like to see a network of experts that the media could access through NEHA. 'For the national papers, for CNN, for some of the national TV stories.'

Found an Independent Institute

The Environmental Quality Institute (EQI), which Maas and colleague Steven C. Patch cofounded at the University of North Carolina--Asheville, is specifically designed to 'conduct technically rigorous and unbiased research to help interested parties gain accurate technical understanding of complex environmental issues,' according to EQI's Web site (http://orgs.unca.edu/eqi/mission.htm). Because of its reputation for independence, the institute attracts proposals for research projects--funded proposals--from entities ranging from Greenpeace (on mercury exposure) to a jewelry-piercing association (on lead in jewelry) to news organizations (on issues like surface-water quality).

Maas said EQI has so many ongoing research projects that media coverage and appeals to his expertise are now 'almost continuous.' The Greenpeace project allows anyone in North America to send in a hair sample for mercury-exposure testing. 'Greenpeace offers the test,' he explained, 'and then we do it as a research project where they [participants] have to fill out a questionnaire.'

This kind of work accomplishes two things at once: 'We're helping the public understand the dynamics of the problem, but we're also providing specific information for each family that enables them to protect themselves from the hazard.' In other words, EQI's work helps make the connection between public health issues and personal health concrete.

The only problem, said Maas, is that 'we are absolutely so overwhelmed right now. I'm trying to do my thing of raising public awareness, but it's actually scary to think about more samples coming to the lab.'

So there is room for more entities like EQI. Maas acknowledged that setting up a research institute is 'easier said than done,' but he believes that doing so could significantly raise the public profile of environmental health. EQI was established under the umbrella of a university, which is one model of independence, especially practical since some of the infrastructure and equipment would be in place. Another possibility might be for a trade association like NEHA or a NEHA affiliate to sponsor such an institute.

Have Coffee with a Reporter

Once the media is working on a story related to environmental health--especially if controversy is involved--environmental health staff in many jurisdictions may be prohibited from speaking to reporters. The battle lines are drawn--PIOs and attorneys take over, and it's too late for the personal touch. Getting beyond the defensive stance involves foresight.

'It involves personal relationships with the media in your locality,' said Michele Morrone, who teaches environmental health science at Ohio State University, 'so that you can call the reporter and say, 'Here's what's going on today.''

'If you work with the media well ahead of time,' said Tom Bennett, bioterrorism coordinator for the Clayton Health District in Georgia, 'the slant can be very good for environmental health. If you don't work with them ahead of time, then you get caught--kind of blindsided by it; normally the slant is going to be whatever they want.' He told JEH that this kind of preparation served his department well on the issue of recreational-water safety. The issue suddenly rose to the fore when an E. coli outbreak was traced to a sick child who'd had an accident at a water park. Many illnesses resulted from the outbreak, a death was involved, and the media covered the issue intensively.

'The incident changed a lot of things in the pool industry,' Bennett noted. 'It changed things from the government regulatory end, and it changed the way people handled themselves in pools both private and public. And it changed the way a lot of pools are being managed.'

Thus, in what could have been a public relations disaster ('Why isn't the health department doing its job?') media coverage helped the health department achieve some policy objectives.

One way to establish rapport with journalists is to invite them to observe departmental activities. Jenkins of Summit County, Utah, told JEH that when his jurisdiction held tabletop terrorism preparedness exercises, it invited the media, 'and they loved that.' Bennett thinks 'the biggest thing environmentalists can do is to probably start with their little local newspaper reporter and say: 'How about coming in and doing this story on the environmental health part of the health department and what we do?'... Talk to them over a beer.'

Everyone--not just PIOs--'can be proactive.'

'But you have to be proactive before there's an incident,' Bennett warned. '[Otherwise] you'll be tightened down on so that you may not be able to say anything. You can talk to people casually. They can't stop me from talking to my next door neighbor who happens to be a reporter.'

The idea here is not to release sensitive information, just to pitch ideas; if the reporter decides to follow up, Bennett said, he goes back to his PIO and gets permission for an official interview.

Pitch Stories

'I wish they [health departments] were more proactive about getting information--and possible news tips--to me,' said Matthew Leingang, formerly of the Cincinnati Enquirer and now an Associated Press writer. 'I find that environmental health officers and public health officials are very happy to have reporters paying attention to the work they do. But I don't think these officials are very media savvy. They don't always think to call me when they have something that could be news.'

Like every other reporter JEH spoke with for this story, Leingang said that he often finds things out 'by going through back doors--tips from readers, tips from other sources.'

What kinds of stories should one pitch to journalists? More kinds than one might think.

'Sensation' isn't the only criteria for running stories,' said Dorfman of the Berkeley Media Studies Group. 'There are news values as well. After all, many reporters ... went into the business for the same reason I went into public health: They wanted to make the world a better place. They get constrained by their institution just like we in public health get constrained by ours.'

'We want to have people watching,' said a producer at a major TV network who asked to remain anonymous, 'but we also think we're doing our job if it maybe wasn't the highest-rated show but it really sparked some debate among policy makers and lawmakers.'

Press Releases--Tips and Pitfalls

When journalists say they want to hear from health departments, they don't necessarily mean mass distribution of routine press releases.

'Something that people quite often do, especially in health departments,' complained John Ferrugia of Channel 7 News in Denver, 'is send me an e-mail with statistics in it and references to Web pages or Web sites ... Well, I don't have time to go through [that].'

On some occasions, however, there's no getting around the use of a press release. The following tips emerged from conversations with journalists:

* 'Personally?' said the anonymous TV producer, 'a press release? Should-be-short. You don't want to give someone 10 options. Here's what's important. And then let them ask questions.'

* Dobbs, formerly of ABC, suggests being selective about what you put out. 'Don't flood them--I mean, I used to get hundreds. Every day. Hundreds of news releases. I mean: A new photocopy secretary has taken a job at such and such--and they'd put out a press release. I learned to just about ignore them.'

* Ferrugia of Denver Channel 7 said press releases should tell a story: 'Put it in narrative form.'

* 'Personalize it,' he added. One way is to 'find a family' that's been affected by the issue or has benefited from the program being discussed. 'Dig into your great resources and find a family that's willing to come forward.'

* Or write a headline that invites participation: 'If You Go to a Restaurant and You Get Sick, We Want to Know About It. And We're Setting Up a Hotline.'

* 'Tell me why I care,' said Shauna Bales assistant news director of KCWY, an NBC affiliate in Casper, Wyoming. 'Tell me how it's going to affect me.'

Even if your press release is brilliant, however, it's important to remember that competition for journalists' attention can be intense. Dorfman describes it this way:

  All you have to do is walk into a newsroom to see that reporters,  producers, and editors are completely inundated by news. They have TVs  on their desks tuned to news; the assignment desk is listening to all-  news radio and police and ambulance scanners simultaneously; there are  TVs mounted to the ceilings or walls that can be seen from every  vantage point in the newsroom; on each person's desk computers are  hooked up to wire services that beep every few minutes to alert them  of a new story; phones are ringing with people pitching stories; and  they are talking to each other about the news.... In this environment,  it's no surprise that it takes something extraordinary to get  reporters' attention.

Beyond the Press Release

'You can e-mail things to reporters,' observed Livingston of Sacramento County Environmental Management, 'but sometimes they won't pick up your story. Sometimes what they want is for you to pitch a story and have one person tell that story.'

It's a question not only of pitching the right story, but also of finding the right person to pitch it to. 'I've found out,' Livingston added, 'that sometimes they [reporters] get a little annoyed when you pitch stories to the wrong people. They expect for you to do a little bit of background work yourself to know who to pitch the story to.'

What kind of material are journalists looking for?

* Todd Bates of the Asbury Park Press said, 'Whatever seems most timely is what I try to focus on--an issue that's in the news or [conversely!] an issue that nobody else has written about.'

* He's also, as a reporter for a local paper, interested in stories that have a local or regional angle. 'If we're writing about national issues, we'll try to focus on what the local impact is.'

* Michael Hawthorne, a reporter for the Chicago Tribune, said he's looking for 'some kind of pending decision being made.... A new finding. If it's explaining something differently than has been explained before. If it's something that we took for granted and actually it's still a problem....' In other words, he's interested in something that wasn't foreseen. 'Or the questions just weren't asked. Scientists didn't ask the questions. Journalists didn't ask the questions. The government didn't ask the questions.'

* A producer at a major television network is looking for material that makes him say, ''Huh, I didn't know that' or 'Gee, that's a lot of people.''

* 'Certain things are going to make people's ears perk up,' observed Livingston. 'If it's something that's going to have to do with [them] or if it's something that's in an unregulated industry. People are very interested in that.'

Also, Livingston pointed out, 'sometimes when you get in on one story, and they're writing it, you pitch them another one.'

Beyond the News

Not everything that appears in the media is news. Dorfman recommends the use of letters to the editor and op-ed pieces. Of course, contributions of this sort are more likely to run if they 'piggyback' on issues currently in the news.

But environmental health could also have a presence in a style section or a food section. The Sacramento County Environmental Management Department, for instance, has worked with the food and wine editor of the Sacramento Bee.

In fact, the example this article began with, the British Life of Grime series, is not really news. It's a human-interest documentary, with a touch of comedy thrown in. And that raises a tantalizing thought: environmental health as fodder for the American entertainment industry? Sitcoms and dramas have been set in law firms, police departments, high schools, and 'neighborhood' bars. Why not in an environmental health department?

Making it happen would mean pitching like crazy. It would mean a lot of work and a lot of creative thinking. Above all, it would mean relinquishing some dignity--accepting that on occasion one might be seen in a melodramatic or comical light. Script writers are likely to emphasize different issues and different aspects of the work than environmental health professionals might want to see. But the point of getting beyond the news in this way would not be to offer up a perfect rendition. It would be to make viewers familiar with the profession, to bring the concept of environmental health into the everyday vocabulary of the American public.

Conclusion--Media Relations Is a Lot of Work

Pranger of Trident Public Health District provides significant help to the Charleston television station running the Disease Detectives series. 'Be ready to coordinate locations for filming and line up people to be interviewed,' she writes. 'Our goal at Trident Public Health District is to make the Disease Detectives segments as easy as possible for the television station to produce' (Pranger, 2005, p.4).

'A lot of people, when they talk about marketing environmental health, they talk about it like it's an event: 'We're going to have a campaign,'' said Peter Thornton, environmental administrator for the Volusia County Health Department in Florida. 'It's not an event. It's a way of life.'

The work is endless: Pitching stories that turn environmental health statistics into 'narratives.' 'Personalizing' the stories. Finding people who are willing to come forward and talk publicly about their experiences. Doing legwork for reporters. Figuring out which journalists to pitch to (which means reading their articles). It's simply too much to do as an aside to other duties.

And so, for the department that wants to transcend the get-the-message-out/put-the fires-out dynamic, the first step is inescapable. You have to have a PIO--a good one, a real creative thinker.

Acknowledgements: JEH is grateful to the journalists and environmental health professionals who were interviewed for this story, all of whom were extremely generous about taking time out of busy schedules. Special thanks are due to Alicia Green, Journal project specialist, who shared her contacts among journalists. As always, discussions with NEHA Executive Director Nelson Fabian provided background, direction, and intellectual focus for the inquiry.

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REFERENCES

Hartz, J., & Chappell, R. (1997). Worlds apart: How the distance between science and journalism threatens America's future. Nashville, TN: First Amendment Center.

Holtz, A. (2003). Frustrations on the frontlines of the health beat: News organizations need to find spaces to be homes for stories that are now often orphaned. Nieman Reports, 57(1), 7-9.

McKenna, M.A.J. (2003). The public health beat: What is it? Why is it important? Nieman Reports, 57(1), 10-11.

Pranger, L. (2005). 'Disease detectives' spread the news. NACCHO Exchange, 4(2), 1,4.

UKTV. (n.d.). What's on. Retrieved October 13, 2005, from http://www.uktv.co.uk/index.cfm?uktv=tv.series&tvSid=8.

Wallack, L., Woodruff, K., Dorfman, L., & Diaz, I. (1999). News for a change: An advocate's guide to working with the media. Thousand Oaks, CA: Sage Publications.

Editor's note: NEHA is committed to providing its members with information specific to the profession of environmental health. The Journal of Environmental Health has taken a major new step in this direction by employing a staff reporter. Rebecca Berg, who has long copy edited the Journal, will be writing in-depth reports on trends and events in the field. Her reports will provide Journal readers with important insights into the profession. They will also be designed to encourage discussion of controversies, challenges, and big-picture issues facing the profession. Readers are invited to participate in these discussions through letters to the editor: Please send your responses, opinions, or comments to Joanne Scigliano, Content Editor, jscigliano@neha.org.

Rebecca Berg, Ph.D.

RELATED ARTICLE: Get a PIO

JEH heard a combined sense of discovery and relief from department managers who have hired public information officers (PIOs).

'Most of that stuff [writing articles or press releases for the media]--it'd take me all day,' said Steve Jenkins, health director of Summit County Public Health in Utah. 'It takes her like 30 minutes.'

There are, however, disagreements about just how far one should lean on the PIO. Some departments use the PIO as their primary spokesperson. Certainly, for environmental health professionals who might be very busy--or a little shy--it is tempting to let someone else do the talking. Others believe this approach can be counterproductive.

'The face of the media has changed,' said Robert Emery of the University of Texas School of Public Health. 'When they put the public affairs person on TV, the immediate assumption is that they're hiding something.... [The public] doesn't want to see the tagline 'Joe Blow, public affairs person.' They want to see 'Joe Blow, environmental health director.''

'If you're the PIO and you're out there talking instead of the director of the health department or the director of environmental health,' observed Peter Thornton, environmental administrator of the Volusia County Health Department in Florida, 'that becomes a problem. Because everybody knows that the information has now been filtered, reviewed with attorneys, etc.' He added: 'If the public perceives--and this does happen a lot--that the PIO is setting policy for the department, that's a very negative reaction.'

Comments from media professionals confirm that a reaction has set in: 'Flakism is rampant,' said Len Ackland, who teaches journalism at the University of Colorado-Boulder. He believes it is a problem 'when the institutions try to funnel everything through a spokesperson and don't let journalists talk to their sources. That ... does a disservice to everybody.'

Indeed, the bottleneck approach to controlling one's message can backfire, since reporters will be looking for ways around the PIO. 'I work in the investigative unit,' John Ferrugia of Channel 7 News in Denver told JEH. 'So if I want to know something, I'm not going to go to the PR person. Every good reporter is going to have sources in every department.'

David Ropeik, who teaches risk communication and working with the media at the Harvard School of Public Health, thinks 'it's a bad idea that anybody but the expert does the interview directly.'

So some departments prefer not to use the PIO as a primary spokesperson. The PIO may be seen as a facilitator, arranging interviews and drafting press releases. Sometimes the PIO does sit in on these interviews. 'We just help facilitate things,' said Emily Gresham, health communication specialist for the Northern Kentucky Health Department. 'If there is a question that maybe the reporter hasn't asked, we might say, 'Hey, this is something else that you might want to know about.''

Some reporters may perceive the PIO who sits in as a 'minder,' which is why, said Ropeik, 'the press officer needs to make clear at the beginning and throughout that he or she is there to facilitate,' not to 'rein in' the interviewee.

Not take over?

'Not speak,' he said, unless the reporter tries to take the conversation outside the interviewee's area of expertise, in which case, the PIO can intercede 'as a facilitator: 'I'm sorry to interrupt. The scientist ... is not an expert in that.' What that says is: 'Journalist, the stuff you'll be getting after this isn't from an expert....' It's facilitating for the journalist.'

Ropeik also thinks PIOs can serve as coaches:

  In general, the press officer's job should be to prepare the  scientist. First of all, it should be to convince the scientist to do  the interview in almost all cases. Say yes.... And having a press  officer around can help you do that. A scientist--or a policy person--  can be more reassured that it will go better since he's got this  person to help him. Then [the PIO's role is] to prepare the scientist  or policy person for that interaction.

Richard Sanchez, director of environmental health in Sacramento County, confirmed that the presence of a 'coach' can be tremendously helpful, especially for environmental health professionals who might feel shy or nervous in front of reporters. 'I always speak to June [June Livingston, communications and media officer] before I go on the media,' he said. 'She gives me the mantra. Get your message across. Keep in mind that you know more than they do. And you know what? That one was a key one for me. Just realizing that I know more about this than they do. That gave me a little boost of confidence to speak to them more effectively.'

RELATED ARTICLE: Stay on Message--Sometimes!

For years now, environmental health professionals have been hearing 'stay on message' from media consultants. This tactic is one way of coping with, say, a reporter who's looking to manufacture trouble. Wallack and co-authors suggest using 'pivot phrases' as 'quick transitions away from your problem questions' (1999, p. 100). They also advocate an approach they call 'reframing.' For an example of appropriate and effective reframing, see the sidebar on page 41.

But it's important to note that 'stay on message' is now old advice. It has been implemented so insistently by politicians and corporate media relations offices--and often so cynically--that journalists and the public have learned to be skeptical.

'I hate it,' said Michele Morrone, who teaches environmental health science and risk communication at Ohio State University. 'I think it's probably effective in some situations. But it goes against sound risk communication principles.'

'Yes, when appropriate, reiterate your main point,' said David Ropeik, who teaches risk communication and working with the media at the Harvard School of Public Health. 'But only when appropriate. Because to do so when out of context is to be defensive and manipulative--and waves a red flag at the reporter that we are now in battle.... It's terrible advice. It's inflammatory. It's disrespectful. It's defensive, it's hostile.'

Greg Dobbs, who corresponded for 23 years for ABC, told JEH that in the case of a potentially negative story, 'If the reporter's brought it up, that's because the reporter knows there's an issue. And if you just try to put that happy face on it, then the reporter's going to go to somebody who's going to paint an even darker picture than you might be willing candidly to paint.'

'To me, 'staying on message is code for 'spin,'' said Matt Leingang, who was a reporter for the Cincinnati Enquirer at the time and now writes for the Associated Press.

  Staff who 'stay on message' come across as robots who can't think for  themselves.... [They] use this technique to deflect questions.... They  essentially talk in circles. This is pathetic. Weak reporters will let  these people get away with that, but I won't. If someone won't answer  a question, I will say so in my story. I won't regurgitate their spin.

'One of the key things you have to do to be an effective communicator is to be honest, frank, and open,' Morrone said. 'And be responsive, too. And if you are creating a message and not being responsive and honest, it might work short term, but if it turns out that people do some more digging and they discover you weren't honest, frank, and open, there goes everything. It's all about building trust.'

Still, said June Livingston, communications and media officer for the Environmental Management Department in Sacramento County, California, 'We're knowledgeable, and we have information to share. It's my obligation to turn to [the reporter] and say: 'That may be an interesting question when it comes up, but what the public needs to know is this....'

'I'm not talking about spin,' she added, 'which I think is the negative part of staying on message. I'm talking about what--if you are a responsible public health official--what is it that the public needs to know.'

Emily Gresham, health communication specialist for the Northern Kentucky Health Department, offered the following advice: 'Answer their question as best you can, but then try to tie it back into your message.... You can't just have your one message and keep saying that over and over again.'

So effective communicators do not necessarily throw 'stay on message' out the window, but they do apply it in a nuanced and context-sensitive way.

RELATED ARTICLE: Reframing--Advice from Some Public Health Advocates

If an interviewer seems to be digging a trap, how do you keep from falling in? Wallack and co-authors suggest the use of 'pivot phrases' as 'quick transitions away from your problem questions' (1999, p. 100).

They offer the following example:

Q: ''Are our schools failing to prepare students for work, or are young people just not trying hard enough to find good jobs?''

A: ''Neither of those is what's most important. Let me tell you what is'' (p. 100).

Especially with television, the pivot and the subsequent reframing have to be fast and succinct.

RELATED ARTICLE: How to Be Interviewed

Scientists often complain about how frustrating it is to be interviewed by journalists who are not prepared, have not read their articles, and know nothing about the field. But preparation is equally important for the interviewee.

'Don't do it ad lib!' said David Ropeik, who teaches risk communication and working with the media at the Harvard School of Public Health. 'Even if you have been interviewed on the same topic before.... Think through whom you'll be talking to, what they want to know, how you say it.' In other words, either the interviewee or the PIO should research the journalist, read the journalist's previous articles, and find out, as Robert Emery of the University of Texas School of Public Health put it, 'What's the angle for the story?'

'Ask the deadline and respect it, but say you cannot do it immediately,' advised Ropeik. '[Say] 'I'll call you back in five minutes, three minutes, ten minutes.' Take time to prepare.'

Hartz and Chappell (1997) recommend engaging the journalist 'in dialogue.' Although media consultants often urge interviewees never to forget that an interview is not a conversation, taking this advice too literally can lead to defensive behavior. Hartz and Chappell think one should 'avoid if possible the 'ping-pong' interview--question/answer, question/answer....'

  A more rewarding method is to draw the reporter into a genuine  conversation, much as one might a colleague. Find out how much  background he/she has in your area, how much of the literature, if  any, has been digested, who else the reporter has spoken to, opinions  he or she might hold. (p. 94)

The give and take is important because, Ropeik said, 'an interview with a senior newspaper reporter is different from an interview with a local radio station reporter on the same topic. You would use different words. You would use different levels of detail.'

June Livingston of the Environmental Management Department in Sacramento County, California, has found that journalists can be surprisingly forthcoming: 'A lot of times they will tell you whom they've talked to. They may not tell you exactly what the whole story is, but mostly they do answer your questions. Some of them are very surprised that you asked.'

After researching the interviewer, the next step is to write down one's main points.

Robert Blake, environmental health director for the Dekalb County Board of Health in Georgia, keeps files on various issues. Each file contains a sheet spelling out his 'single overriding communication objective' for a given issue. 'When a media person comes, I pull that out, and I tweak it and adapt it to the slant of the story. And then I usually pull a couple of staff people in to fire the usual questions at me. And then I say, 'Fire a couple of off-the-wall questions to keep me on my toes.''

'Figure out what else they're likely to ask you,' said Ropeik.

'Think about what's the worst possible way this story can be portrayed,' suggested Michele Morrone, who teaches environmental health science at Ohio University. 'And then have a plan for how you're going to respond.'

Once the interview is under way, the following tips may be helpful:

* Start with your conclusions--this is especially important in TV interviews.

* Repeat important points (but see the cautions in the sidebar on page 40).

* Avoid jargon and acronyms.

* Don't answer questions you're not qualified to answer.

* Pick a location where you're comfortable. 'Don't be bullied into--for example--a TV interview outdoors,' said Bob Harrington, director of the Casper-Natrona County Health Department. 'Don't do it! It never looks good. The wind's always blowing, there's always noise.'

* Make sure the reporter will not be quoting you from memory. 'If a reporter comes here and they're not taking notes [or running a recorder], that's pretty much the end of the interview,' said Peter Thornton, environmental administrator for the Volusia County Health Department in Florida.

* Emery recommends giving reporters a 'media brief': a one-page summary of the issues, with the important facts at the top and a summary of one's comments below.

* If a reporter presses you for information you can't give (confidential medical information, for instance), be polite and explain why you can't give it.

* 'We're frank and honest, but we're cautious.' Harrington said. 'We consider how our statements might be misinterpreted.'

* Never say 'no comment'! 'It's like taking the Fifth,' observed Barry Drucker, environmental health supervisor for the St. Charles County Department of Community Health in Missouri.

RELATED ARTICLE: The Elephant in the Room: Nerves

The interviewing tactics and the cautions outlined in the sidebar on the facing page might seem like a lot to keep in mind on the spot. JEH asked several environmental health professionals if they felt nervous the first time they spoke with the media.

'Oh yeah,' said Robert Emery, who teaches occupational health at the University of Texas School of Public Health. 'You just don't [anticipate] things like the camera only being two inches from your nose.'

Tom Bennett, bioterrorism coordinator for the Clayton Health District in Georgia, told JEH that during his first interview, he was 'so nervous that it was almost like it was canned--responses with no emotion, just monotone.'

  So finally they told me they were just turning the [recording  equipment] off and were just talking to me about what they were going  to ask me. And I didn't realize they were actually recording it. And  the difference it made.... What they did was play it back and say,  'Now, can we go with this?'

Few people are born knowing how to be interviewed. And ultimately, Emery thinks, 'you can't tell someone how to ride a bicycle. They've got to go out and ride the bike and crash.'

Bennett thinks that for some people who might not be comfortable with the media, 'the biggest thing you can do is say. 'No, I can't do that.' Instead of getting in front of the camera and acting like a bundle of nerves. You'd be better off to say, 'No, let my PIO do that.''

Ropeik, however, believes that 'in almost all cases the answer should be yes. With caveats, but yes.' He acknowledges that there are exceptions. 'There were a couple of scientists at my center who were really lousy at being interviewed. And it was mutually agreed that they were so poor at it that I ought to do it.' But in this case it was made clear to the reporter why the PIO was speaking in place of the expert.

June Livingston, communications and media officer for the Environmental Management Department in Sacramento, California, believes that most people can do interviews, even those who think they're not cut out for it. 'Sometimes people don't realize: When a reporter comes to you for information, it's because they need information from you.... It's a powerful feeling, once you realize that. Once you get over the initial fear.'

Livingston's colleague Richard Sanchez, the department's environmental health director, added:

  I come from a science background. Most of the staff in our field come  from a science background. It's not necessarily in our nature to be  effusive or be ready to jump up when it comes to being in front of a  camera.... [But] I have actually come to almost a 180 on these things,  where June can attest to the fact that I'm almost kind of the  mouthpiece now for all these environmental health issues.

RELATED ARTICLE: Nothing to Fear but Fear Itself

Assuming that journalists are out to get you can result in a defensiveness that hurts your cause. It's hard to speak freely, intelligently, and flexibly when you're afraid that every word will be snatched up and twisted. To elucidate what can happen when an interviewee sounds wary or unforthcoming, Michele Morrone of Ohio University turned the conversation and began to interview the journalist:

Morrone: You smell blood, right, Rebecca?

JEH: I don't have that reaction, actually. I suspect that there are reporters who do. But I just get a little frustrated. It just makes my job a little harder.

Morrone: And how does that affect what you write?

JEH: It does color my perception of the trustworthiness of what the person's saying. I do suspect that there may be more to the story than what they're saying. Or that they're somehow censoring themselves a little. I'm not necessarily going to write something just based on that hunch, but it might affect how I conduct an interview with somebody else who's involved with the issue in some way. I might think of asking them questions that I might not otherwise ask.

Morrone: There you go.

JEH: It's a subtle effect, and it really varies by the situation, but there's no doubt that it has some kind of effect.