Beyond the red dress

Think “pink” in relation to health issues, and breast cancer immediately springs to mind. Think “red” and… well, many people probably will recognize it as the symbol for women’s heart health, especially if it happens to be February, but plenty of folks might come up blank.

Are we so conditioned to fear breast cancer that we can’t fully recognize or appreciate the risk that heart disease poses to women’s health? It’s an intriguing question posed by cardiologist Dr. Lisa Rosenbaum in the New England Journal of Medicine last week.

In the past decade the American Heart Association’s Go Red for Women campaign and similar educational efforts have greatly increased women’s knowledge about heart disease, Dr. Rosenbaum writes. More recently, though, the gains have mostly leveled off. Gaps in knowledge also persist among minority women, who often are at higher risk of heart disease.

Dr. Rosenbaum wonders: What’s needed here – more facts or a greater effort to address women’s emotions?

There seems to be something visceral about breast cancer that taps into women’s fears in ways that don’t happen with heart disease, Dr. Rosenbaum writes. She speculates that maybe it’s connected with female identity and thus resonates with women very deeply. Against this, perhaps it’s harder for women to really engage with heart disease, she suggests.

Dr. Rosenbaum writes:

Have pink ribbons and Races for the Cure so permeated our culture that the resulting female solidarity lends mammography a sacred status? Is the issue that breast cancer attacks a body part that is so fundamental to female identity that, to be a woman, one must join the war on this disease? In an era when women’s reproductive rights remain under assault, is reduced screening inevitably viewed as an attempt to take something away? Or is the issue one of a tragic story we have all heard — a young woman’s life destroyed, the children who watch her suffer and are then left behind?

On the other hand, what is it about being at risk for heart disease that is emotionally dissonant for women? Might we view heart disease as the consequence of having done something bad, whereas to get breast cancer is to have something bad happen to you? In a culture obsessed with the “natural,” are risk-reducing medications anathema to our vision of healthy living? Or are we held up by our ideal of beauty? We can each summon the images of beautiful young women with breast cancer. Where are all the beautiful women with heart disease?

There’s certainly food for thought here. One way of encouraging women to rethink their perception of heart disease risk might be more emphasis on the message that heart disease isn’t always caused by unhealthy lifestyles, Dr. Rosenbaum suggests. Maybe women need to be reminded that a “natural” approach isn’t necessarily better than taking medication to reduce their cholesterol or blood pressure.

And maybe, she suggests, “we can try to move beyond disease wars toward the creation of communities of women in which stories about living with heart disease are as celebrated as stories of surviving breast cancer.”

Here’s a place to start: a collection of survivor stories from WomenHeart, a national coalition for women with heart disease. And from the excellent Heart Sisters blog by heart attack survivor Carolyn Thomas, here are several first-person stories from women who describe openly and frankly what their heart attack was like.

Flu shot options: a test of patient engagement?

Talking about the flu vaccine used to be straightforward. But with the proliferation of vaccine options, it has become much more complicated.

It isn’t even accurate anymore to call it a flu “shot”. The old-fashioned shot in the arm has been joined by intradermal and nasal spray versions of the vaccine. There’s now a quadrivalent form of influenza vaccine that protects against four strains instead of the usual three. Vaccines that used to mostly be available at the doctor’s office can now be obtained at community pharmacies, nursing homes, public health agencies, workplaces and even walk-in sites.

To add to this array, flu vaccine is not a one-size-fits-all proposition. The nasal spray can only be used among healthy children and younger adults. Ditto for the intradermal version. The new quadrivalent vaccine is thought to be more effective for children than adults.

More options for consumers = better for everyone, right? Well, yes. But here’s another way to look at it: With more choices that may or may not be appropriate for them, people increasingly need to take responsibility for educating themselves with accurate information.

This isn’t necessarily a bad thing. Patient engagement has become the Holy Grail of health care – desired, sought after, and the focus of intense effort by health care organizations. Care tends to be better and more reflective of the patient’s values when people are active participants.

The real question is whether we’re ready for this.

While some folks are eager to be more involved in their care, others need a strong nudge of encouragement. Some don’t really want to be engaged. Others are unable to be fully engaged. Nor can we underestimate how critical it is for people to have good information, the many myths about the flu vaccine – It’ll give you the flu! It’s full of toxins! – being a case in point.

This year’s flu vaccine season in some ways has become a real-world laboratory for the public’s ability to make informed decisions. People will have to ask questions and read the fine print. They’ll need to know which forms of the vaccine are available and which are appropriate for them and their family, and decide accordingly.

Are we up to it? We’ll find out.

Find the CDC flu vaccine guidelines here.

A health scare, but not enough to change their ways

A heart attack or a cancer diagnosis is usually life-changing, yet many people do little afterwards to alter their lifestyle or behavior in ways that might reduce their future risk.

Various studies have been cropping up lately, all with the same conclusion. One can’t help connecting the dots and wondering what it bodes for the long-term health picture.

The bigger question  here, though, isn’t “what.” It’s “why.”

The latest study comes from Canada, where researchers found that even when people had a history of coronary heart disease or stroke that put them in a higher risk group, they weren’t much more likely than the general population to adopt three key changes associated with reducing their risk of a second heart attack or stroke: smoking cessation, regular physical activity and a healthy diet.

The study used epidemiological data on more than 154,000 individuals from 17 countries. Of the 7,500 participants who reported a previous history of heart attack or stroke, about 18 percent continued to smoke and 60 percent didn’t follow the recommendations for a healthier diet.

Not surprisingly, those who lived in higher-income countries fared better on all three measures.

Here’s another study, this time from the cancer front: Researchers who looked at survivors of melanoma, the most serious form of skin cancer, found that about one in four skipped the use of sunscreen and 2 percent continued to visit tanning salons.

The study results “blew my mind,” Dr. Anees Chagpar, the study’s author, told CBS News.

Other studies have found that cancer survivors are just as likely as everyone else to be overweight and inactive, even though these two factors are tied to a higher risk of recurrence for certain forms of cancer.

Is this a huge collective failure of patients to heed the so-called teachable moment in health care? Or does it signal something deeper?

I suspect it’s the latter. As anyone who has attempted to adopt a healthier lifestyle can attest, changing your ways is often very difficult. It takes a high degree of motivation and support to persevere, and the stress of a serious health event can add complicating factors that might not be addressed or even recognized.

Depression, for example, is common among heart attack survivors, yet the possibility of post-heart attack depression is rarely discussed with these patients. Multiple studies have found that among those who develop depression after their heart attack, the majority are undiagnosed and untreated. That they may struggle and fail to adopt healthier lifestyle habits should not be surprising.

One survivor, responding to a frank entry on the Heart Sisters blog about depression and heart attack survival, put it this way: “Physically I am not the same person and don’t think I ever will be. Everyday life details are not important to me anymore. I see myself stepping further and further behind and no one understands.”

Ditto for the physical and mental toll of cancer treatment, which can leave survivors with long-lasting fatigue, cognitive impairment, nerve damage and more. Although efforts are underway to improve survivorship care in the U.S., progress is slow and uneven, leaving many survivors – perhaps the majority – still under the radar.

The health care system itself hasn’t completely figured out who should handle the “teachable moment.” Should it be the cardiologist? The oncologist? The primary care doctor? A rehab nurse? In the meantime, opportunities to talk to patients about making behavior changes are being missed.

Then there’s the question of who pays to help people change their habits after a major health event – and I’m assuming here that many will need some support, even if it’s only minimal.

It takes staff and resources to provide the education that may be necessary, and reimbursement is often low. Although many health insurance plans include coverage for smoking cessation, there’s considerable variation in what they offer, and some states don’t cover tobacco cessation at all for their Medicaid enrollees.

We could ask people to pay out of pocket for their patient education, nutritional counseling, depression screening and tobacco quit services, but this doesn’t mean they can afford it or that they would make it a financial priority – or, indeed, that they would recognize they might need all of these.

Maybe the whole notion that a health scare should be enough to make people change their ways is flawed. It might be motivation only for some. For others, the motivating factor may be something very different. If we hold the tsk-tsk’ing long enough, we might start to figure out what really lies behind the seeming lack of lifestyle change and what can be done to have a more positive impact.

Health care’s new paternalism?

Is the patient’s blood pressure at 120 over 80 or below and controlled with one or more medications if necessary? Check.

Normal body mass index? Check.

Recommended screenings carried out according to the recommended schedule? Check, check, check.

But here’s the real question: Are all of these goals important to the patient, or does he/she see them as frustrating, burdensome and perhaps impossible to achieve?

The push toward better health care has organizations and clinicians focusing a tremendous amount of energy these days on patient outcomes. Few policymakers seem to have asked, however, where patients fit into this and how they feel about having their health goals – appropriate weight, appropriate blood pressure, glucose and cholesterol levels, appropriate prescription medications and so on – essentially dictated to them.

Is it going too far to call it a new form of health care paternalism?

If you listen closely, you can hear the beginnings of some pushback from people like Dr. Victor Montori of the Mayo Clinic, who last week talked to the Star Tribune of Minneapolis about hitting the pause button on all the checklists and having a heart-to-heart conversation with patients about what they really want.

An excerpt from the newspaper’s interview with Dr. Montori:

He argues that doctors must take into account the patients’ “values and preferences.” If one drug can bring their blood sugar down a notch, but doesn’t make them feel better, is it worth taking? “It’s making sure we don’t make any decisions about them without them,” he said. It’s a strategy that stops demanding perfection from patients and focuses on the treatments that are most important to them. “So they only get what they need and what they want.”

This is squarely at odds with the current approach of setting goals and measures and expecting all the players to reach these targets in order to achieve quality care.

There’s much at stake. By fiscal year 2015, fully 30 percent of Medicare payments to hospitals will be based on outcomes. Medical practices are dealing with similar pressure to reach specific goals in patient care.

This isn’t to say health care shouldn’t be held accountable for results. Outcomes do matter. But when an organization’s fiscal health and people’s livelihoods are on the line, it’s not hard to see why there would be a rising tide of all-around frustration when patients can’t – or won’t – meet the prescribed goals.

Meetings of the Rice Memorial Hospital board here in Willmar are normally rather subdued, but one of the most animated discussions I’ve seen in months erupted this week over the issue of patient adherence.

The doctors in the room spoke of the challenge of persuading their patients to adhere to the standard, and the frustration of being penalized when they don’t.

The hospital leaders in the room spoke of the unenviable task of being asked to meet goals that may hinge on patient decisions and behaviors beyond the hospital’s control.

The implications go deeper than this, though. What about hospitals who care for high numbers of elderly, frail and medically complex patients who may not have outcomes as favorable as that of a younger, healthy population? What about the 90-year-old who has been living with congestive heart failure for a decade and has decided it’s time to stop with aggressive management of the condition?

Should hospitals and medical practices become more selective about the patients they’re willing to take and start turning away those deemed to be too sick or too complicated or less likely to be compliant? Most Americans would agree it’s unethical (or at least unfair) to cherry-pick the “best” patients, but there’s no denying this looms as one of the unintended consequences of outcome-based payment. Left unanswered in all of this is who, exactly, will care for the sickest and most vulnerable when the reimbursement model is rigged against them.

Finally, there’s the issue of patient autonomy. The patient’s right to make his or her own medical decisions is one of the core tenets in American health care. This basic value seems to mesh uneasily, however, with performance-based payment. What happens to patients who don’t want to take a particular medication because the regimen is too burdensome or the side effects are intolerable? What about the patient who simply wants to feel better and function better rather than meeting specific target numbers?

To make things even more complicated, all of this is taking place simultaneously with a growing emphasis on patient-centered health care and shared decisionmaking.

It’s far from clear how this is supposed to fit together, or the extent to which the average consumer is aware of the push-pull between giving patients more say in their care, while at the same time deciding on their behalf what the measure of their health should be.

Don’t look for this to be resolved anytime soon. No one ever said health care was simple.

The exercise conundrum

We all know physical activity is supposed to be good for us, yet approximately 40 percent of the American population reports not exercising at all. How come?

The New York Times reported a couple of days ago on some intriguing research that might shed a little light on this riddle: When people avoid exercise, maybe it’s because some forms of physical activity leave them feeling bad rather than good.

How this works seems to be complicated. In a series of studies, the researchers found that people had different reactions to the increasing intensity of exercise. Some felt better the harder they exercised; others felt worse. The majority of them felt bad when they surpassed their “ventilatory threshold,” or the point at which they were breathing too hard to talk – and this threshold was different for everyone.

In another study, volunteers were asked to exercise for 20 minutes at a level that felt unpleasant to them. In one session they were given a five-minute cool-down afterwards that restored their sense of well-being. In the other session, they were told to stop exercising without cooling down. When asked later which of the two workouts they preferred, most chose the one that left them feeling more pleasant.

In some ways this shouldn’t come as a surprise. People tend to pursue activities that make them feel good and avoid those that don’t.

The more intriguing part is that we seem to be learning that exercise, like weight management, may not be a one-size-fits-all matter of “just do it.”

While the vast majority of people derive health benefits from regular physical activity, there clearly are differences in how it’s perceived and experienced.

Some people seem wired to enjoy exercise more than others do, and research suggests there indeed may be individual variations in how the body responds physically and emotionally to exercise. Some runners, for instance, experience the fabled “runner’s high,” while others don’t. Then again, perhaps individual behavior is largely to blame for why so many people don’t engage in exercise.

Or is it more complicated than this? Reader responses to the New York Times article provide a wider perspective on what might be going on in people’s lives to make the recommended 30 minutes of daily physical activity so difficult for many of them.

One person lived in San Francisco for many years, didn’t own a car and walked everywhere. Then he moved to Florida, to a town where “a car is needed for even the smallest errand,” and watched his weight, cholesterol and blood pressure soar. Others described neighborhoods with no sidewalks, streets that are poorly lit at night, bike paths littered with glass, and gyms and fitness centers that are either unaffordable or only open during the day.

Some commenters wrote that for many non-exercisers, the problem is in getting started. What they need is help, patience and encouragement, one person wrote. “There is so much anxiety tied up in this issue for people who are out of shape, they don’t know where to start and the idea of exercise feels overwhelming and genuinely terrifying.”

And what about the tendency for issues such as arthritis, chronic insomnia, low-level depression or long, stressful work hours to undermine people’s willingness to be more physically active? One commenter, who had frequent severe migraines and also worked long hours, wondered, “How is one supposed to exercise?!?! and eat? and sleep? and be a person… of sorts?”

Several commenters also complained about the sniffy elitism that can pervade the conversation about exercise – for instance, value judgments about what constitutes “real exercise.” Don’t shame people for not being able to engage in a high-intensity workout, wrote one woman, who said she’s over the age of 60 and has painful arthritis. “Judging other people’s exercise habits doesn’t make them want to exercise more, it just makes them feel bad.”

Someone else pointed to the unrelenting hideousness of phys ed classes in junior high that were rigid and competitive rather than fun. “Maybe that is why I came to hate exercise and it still feels like punishment,” she wrote.

So what’s the answer? It seems to come down to making physical activity more rewarding and less of a struggle. How this is supposed to be accomplished might be different for everyone – and, as with the national effort to reduce the incidence of obesity, some of the solutions will likely have to take place in the environmental and policy sphere. Figuring out why some people genuinely enjoy exercise and find it pleasurable and why others don’t might be a good start, though, at understanding these differences and coming up with effective strategies to help.

Tobacco use: still a problem

It’s safe to say that over the past few decades, billions of dollars have been spent in the United States on reducing tobacco use.

It has had an impact. The number of adults who smoke has declined steadily, from about 43 percent in 1965 to the current rate of approximately 20 percent. Among high school students, the age group in which tobacco use most often starts, the smoking rate has fallen as well. Smoke-free workplaces and eating establishments are widespread.

This should be reason to reflect on the progress that has been made. But to those who work in the field of tobacco control, it isn’t enough.

ClearWay Minnesota launched a new campaign this week whose title conveys a blunt message: “Still a Problem.”

Some facts from the website:

- Smoking is linked to health problems that range from coronary artery disease and high blood pressure to lung cancer, oral and neck cancer, chronic bronchitis and increased risk of type 2 diabetes.

- More than a quarter-million children in Minnesota are exposed to secondhand smoke at home.

- Almost half of the adults who responded to the 2010 Minnesota Adult Tobacco Survey said they were exposed to secondhand smoke within the past week.

- Progress in reducing tobacco use among adolescents in Minnesota appears to have stalled. According to the 2011 Minnesota Youth Tobacco and Asthma Survey, 77,000 middle school and high school students are current tobacco users; collectively they will buy or smoke 13.4 million packs of cigarettes this year – enough when stacked sideways to span the entire state from north to south.

- Smoking costs $3 billion in excess health costs annually in Minnesota. This works out to $554 per individual Minnesotan.

None of this information should come as a surprise. The American public has been exposed to public health messages about the physical and economic toll of tobacco use for decades, perhaps to the point of tuning it out.

Tobacco control efforts can be at odds with individual rights and interests, as any smoker forced to huddle outside the company loading dock for a cigarette break might tell you. When a federal appeals court struck down the U.S. Food and Drug Administration’s graphic new warnings for cigarette labels earlier this year, the decision came down to free speech protection.

Yet the other side of this is that for every smoker who doesn’t wish to quit, there’s someone else who does. Last year the U.S. Centers for Disease Control and Prevention analyzed data from the 2010 National Health Interview Survey involving more than 27,000 adults over the age of 18. Among those who smoked, seven out of 10 said they wanted to quit, and half had attempted to quit during the previous year.

Despite long-standing anti-tobacco campaigns, it’s somewhat startling to realize how pervasive tobacco use still is. A new small-scale study, to be published in the upcoming issue of the Pediatrics journal, found that many parents who smoke do so in their car in the presence of their children, and only a minority had a smoke-free policy for the family vehicle.

In another recently published study, researchers observed patients at a large urban hospital and found that among those who smoked, nearly one in five continued to light up during their hospital stay – even though the hospital had a smoke-free policy.

Tobacco smuggling also remains a significant global issue that robs Third-World governments of tax revenue and is thought to contribute to the funding of organized crime. An in-depth report developed by an international team of journalists concluded that the illicit tobacco trade is so widespread and so lucrative that tobacco has become “the world’s most widely smuggled legal substance.”

So is tobacco use “still a problem”? Let the public look at the evidence and judge for themselves.

For treating high blood pressure, more is more

If you have high blood pressure that’s under control, you’re in good company. According to a new report from the American Heart Association, just under half of American adults with high blood pressure now have the condition well managed with medication.

This is a major improvement compared to 10 years ago, when only one out of three hypertensive adults had their blood pressure under control. The gains also underscore a growing body of evidence that when it comes to successfully treating high blood pressure, more is more: Most patients just do better when they’re taking more than one medication for hypertension.

The report appears in the Circulation journal and is based on data collected from 9,320 participants in the National Health and Nutrition Examination Survey from 2001 to 2010. High blood pressure was defined as 140/90 mm Hg or greater (130/80 mm Hg for those with diabetes or kidney disease).

As chronic conditions go, high blood pressure is common, especially in people who are middle-aged and older. Although there’s often a perception that hypertension is becoming more widespread, the overall prevalence has been more or less unchanged for many years, hovering at around 30 percent overall of the American adult population.

What does seem to be changing is that people who are hypertensive are more aware of it. They’re increasingly likely to be told by a doctor or other health care professional that they have high blood pressure, and they’re increasingly likely to be prescribed medication to treat it.

Some telling figures from a brief published in 2010 by the National Center for Health Statistics: The overall percentage of adults with high blood pressure who were aware they had the condition rose from 69.6 percent in 1999-2000 to 80.6 percent in 2007-2008. And the percentage of those being treated with medication for it grew from 59.4 percent to 71.6 percent over the same time period. (The figures come from NHANES, the same source as the new American Heart Association report.)

Important as these measures are, however, what matters most is whether these people have their high blood pressure actually under control. This metric is what the Heart Association report examines, and despite the fact that there’s still often a gap between aspiration and success, the picture is encouraging.

What accounted for all this progress? The authors single out what appears to be the key factor: the growing use of multiple drugs for treating high blood pressure. Overall, the number of study participants taking multiple drugs for high blood pressure increased from 36.8 percent in 2001 to 47.7 percent in 2010. Outcomes tell the tale: The participants were much more likely to meet their blood pressure goals when they were prescribed two or more medications for hypertension.

Significantly, the survey also confirms progress in blood pressure control in the wake of new treatment guidelines, published in 2003 by the Joint National Committee, that call for greater use of combination drug therapy to achieve and maintain acceptable blood pressure levels. In other words, doctors have been taking these evidence-based guidelines to heart when managing their patients with hypertension.

There’s room for improvement, though. In the bigger picture, about half of Americans with high blood pressure still don’t have it under control. The researchers found that thiazide diuretics, recommended as initial treatment for uncomplicated hypertension, still aren’t being prescribed often enough.

The study authors also noted some worrisome disparities: Older adults, African Americans and people with diabetes or chronic kidney disease were more likely to fall short of blood pressure goals despite treatment. “More efforts are needed to close the gap between treatment and control and to maximize the public health and clinical benefits among those high-risk subpopulations,” the authors concluded.

A (flu) shot in the arm

When I rolled up my sleeve last week for my annual flu shot, I was given a new option: an intradermal injection, using a microneedle to deliver the vaccine into the skin instead of the traditional intramuscular stab in the arm.

Who knew the choices for receiving a flu shot could multiply so quickly in just the past 10 years? First there was the introduction in 2003 of FluMist, an inhaled version of the flu vaccine that does away with shots altogether. Now there’s the microinjection – still a shot, technically speaking, but with considerably less of the ouch factor; it involves an ultrafine needle that’s 90 percent smaller than the usual flu vaccine needle and penetrates no deeper than the top few layers of skin.

Many of us could use a guide to what’s available in the world of flu shots these days, and who’s eligible for what. Here’s a quick rundown, courtesy of the U.S. Centers for Disease Control and Prevention:

Regular flu shot: Suitable for most people; not approved for infants younger than 6 months. The regular vaccine accounts for most of the flu vaccine administered in the United States each year. It is given as an intramuscular injection, usually in the upper arm. The vaccine contains inactivated, or killed, influenza viruses. Side effects can include soreness, redness or swelling where the injection was given, muscle aches and low-grade fever.

Nasal spray flu vaccine: An aerosol form of the vaccine that’s given as a spray into the nose. Because it’s made with a weakened form of the flu virus, it’s recommended only for healthy individuals between the ages of 2 and 49. Anyone older or younger than this or who has a chronic condition or other risk factor should not receive the inhaled version of the influenza vaccine. The most common side effects among children include runny nose, headache, wheezing, vomiting, muscle aches and fever. Typical side effects for adults include runny nose, headache, sore throat and cough.

Intradermal flu shot: Administered with a prefilled microneedle into the top layers of the skin. This version of the influenza vaccine was introduced in the 2011-12 flu season. It was offered on a limited basis last year but has become more widely available this year. Besides being somewhat gentler than the traditional flu shot, it contains 40 percent less antigen, meaning it requires a lower amount of active ingredients to deliver the same flu protection as the traditional vaccine. Otherwise, the intradermal flu shot works in the body the same way as a regular flu shot and protects against the same three strains of flu as other yearly versions of the flu vaccine.

Intradermal flu shots are FDA-approved for adults ages 18 through 64. Side effects include redness, swelling, pain, toughness and itching at the injection site. These side effects seem to be somewhat more common with this form of the flu vaccine than with regular flu shots. Other side effects that have been noted include headache, muscle aches and fatigue.

High-dose flu vaccine: Designed for adults 65 and older. The high-dose vaccine contains four times the amount of antigen as a regular vaccine and is intended to provide greater protection for older adults whose immune systems have waned with age. It’s given as an intramuscular shot, the same as the regular flu vaccine.

High-dose flu vaccine is not recommended for older adults who have had a previous severe reaction to a flu shot. As with the intradermal vaccine, side effects seem to be reported more frequently; they include pain, redness and swelling at the injection site, headache, muscle aches, fever and overall malaise.

Although it’s a welcome development to have more options, it puts more burden on the consumer to make an appropriate choice. Aside from eligibility, one of the key questions is this: Regardless of which form of the flu vaccine you choose, will it be effective?

By now, the nasal spray has accumulated a substantial 10-year track record of safety and reliability, especially among children. Some research suggests it’s less effective in adults, however, and the recommendations for who can receive it remain limited to healthy individuals ages 2 to 49.

Because the intradermal vaccine is newer, there are fewer studies that have examined its effectiveness. But most of the researchers’ conclusions are positive, and one study even found that this form of the flu vaccine worked better in older adults. As intradermal flu shots gain wider use, stay tuned for more information evaluating their safety and effectiveness.

One thing on which there’s a clear consensus among the researchers: Whether it’s a shot in the arm, a spray up the nostrils or an injection into the skin, the flu vaccine only works in those who actually receive it.

The most dangerous health occupation

Occupations in the U.S. with the highest rate of work-related fatalities are primarily physical: commercial fishing, logging, mining, farming.

But if you concentrate on the incidence of nonfatal injuries that happen in the workplace, health care is far more injury-prone than perhaps the public realizes – and the highest rates of all for getting hurt on the job are among certified nursing assistants who work in nursing homes, a category that also happens to be the lowest-paid among the health professions.

A report published earlier this year contained some eye-opening statistics. Using data from the National Nursing Home Survey and the National Nursing Assistant Survey, the researchers found that 60.2 percent of CNAs who participated in the survey had experienced a work-related injury in the past year. Three out of five had been hurt more than once and about one-fourth had to quit working because of their injury.

There’s more: Although scratches and cuts were the most commonly reported injury, back injuries and strained muscles were frequent, accounting for almost two in every 10 work-related injuries. Workers who were younger or older (those under age 30 and those older than 45) also had higher rates of injury.

In one of the more startling facts contained in the report, the incidence of nonfatal injuries among nursing assistants was one of the highest of any occupational category, including trucking and construction.

Here’s another concerning statistic: Nursing care assistants working in skilled care facilities often experience violence from the residents they’re trying to help. A report by the U.S. Centers for Disease Control and Prevention found that 12 percent of the CNAs in a nationally representative sample had sustained a human bite wound within the past year. The incidence of assaults and bites was greater for those who worked in units caring for people with dementia.

I was reminded of this when I visited Johnson Memorial Health Services in Dawson, Minn., this past week for the staff’s celebration of earning MnSHARP status from the Minnesota Department of Labor and Industry. The program recognizes organizations that go above and beyond the standard in creating a workplace that’s safe for their employees.

One of the things I learned was that it’s not easy to qualify for this designation. In fact, very few health organizations have made the cut. Johnson Memorial is the first nursing home and only the second hospital in Minnesota to earn certification.

It took three years and continual hard work to get there. As the staff readily admitted this week, it’s going to take ongoing hard work to stay there. But the payoff is fewer work-related injuries for everyone who’s employed at Johnson Memorial, employees who are happier, more productive and better able to provide good care, and lower costs for workers’ compensation, leaving more money to plow back into other priorities.

There’s a growing sense that occupational injuries among nursing assistants have been underrecognized in the past and that more needs to be done to reduce their likelihood of getting hurt at work.

Research has identified a number of factors that seem to make a difference. Nursing assistants are more likely to get hurt when there’s a shortage of staff or when the workload is highly demanding. The probability of injury also tends to be higher among nursing assistants who are new on the job and/or feel they weren’t adequately prepared for the job.

Why does it matter? The U.S. population is aging and it’s becoming increasingly critical to have a good workforce to provide direct care to older adults, many of whom need intensive daily help. Occupational safety, notes the CDC report, “is an important factor for retaining trained, motivated, and capable nursing assistants in long-term care… It has been shown that nursing personnel who were subjected to work-related violence on at least a monthly basis reported higher intent both to leave the nursing profession and to change institutions.”

It might be impossible to achieve zero work-related injuries for certified nursing assistants, but supportive policies and better training – in short, creating an institutional culture that fosters a good workplace environment – seems to go a long way toward making this riskiest of health care occupations more safe for the workers.

New flu, old lessons

It feels as if we’ve been here before: New type of influenza is identified, virus begins to spread, public health officials sound the alarm.

This time it’s influenza A (H3N2), which apparently is being transmitted from pigs to humans. As of Thursday, more than 120 cases had been confirmed in the United States since July. The new form of swine flu has been found in four states and is overwhelmingly occurring among young people. A common denominator seems to be state and county fairs where teens are handling or in contact with hogs. Some farmers and veterinarians also have fallen sick.

Should we be worried? By all accounts, at least so far, this new type of influenza virus doesn’t appear to cause severe illness. It seems to have been around for awhile; the first human cases actually were identified a year ago.

Naysayers might write it off as a big deal over nothing, the same way some felt the H1N1 pandemic of 2009 was vastly overblown. Perhaps we shouldn’t be too quick to dismiss it, though – if for no other reason than the reminder it provides of the wily nature of the influenza virus and microbes in general.

Some years ago I attended a crash course on pandemic influenza that included an overview of how readily the flu virus mutates, circulating among various species, swapping bits of genetic material and shuffling the deck in a perpetual evolutionary process. It’s the main reason why flu vaccines need to constantly be updated and why the flu shot you received five years ago might not be very effective anymore against the flu viruses currently in circulation.

For an illustration of just how crafty the virus can be, here’s CNN’s explanation of how the H3N2 swine flu variant arose:

What makes this new version of the H3N2 flu virus different is that it has picked up a gene from the novel H1N1 flu virus that became a pandemic three years ago. This can happen when a person or an animal is exposed to two different viruses at the same time.

Somewhere along the line, H3N2 and H1N1 viruses were present in a mammal at the same time, and the “matrix-gene” (or m-gene) from the H1N1 pandemic virus was picked up by the H3N2 swine flu, creating a new variant version of H3N2.

It is this m-gene that has experts on the lookout, because the presence of the m-gene can make it more easily transmissible to humans.

See what the virus did there?

Even if it’s not an especially severe form of influenza, H3N2 nevertheless has the potential to make many people sick. A vaccine that would offer protection is in development but hasn’t hit the market yet. Widespread flu can lead to absenteeism at work and school and overflowing doctor’s offices. Inevitably, some of the people who get the virus will be particularly vulnerable and could end up becoming extremely sick.

We have only to look around us to see that the battle against infectious diseases is still going strong: Whooping cough. HIV. Ebola. Tuberculosis. Methicillin-resistant staphylococcus aureus. Although people don’t die of infectious diseases in anywhere near the numbers seen 100 years ago, microbes remain very much a global presence to be reckoned with.

They’re incredibly tenacious and adaptable. In a weird sort of way, you almost have to admire the influenza virus for being so ingenious, so mutable. In spite of all the tools constantly being developed to fight them, flu viruses and their companions in the germ world have figured out how to outwit humans over and over.

The early lesson from the new H3N2 swine flu variant? Where microbes are concerned, it’s not a good idea to get too complacent.