Category Archives: prevention

Health care’s new paternalism?

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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

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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

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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

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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

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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

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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

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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.

What’s behind the whooping cough epidemic?

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Many people in the western Minnesota communities of Dawson and Boyd must have been surprised when pertussis, or whooping cough, broke out in 1998. I remember it well, especially for the concern it caused. By the time the outbreak was over, more than 30 people, mostly school-aged children, had gotten sick.

From the vantage point of nearly 14 years later, it seems to have been an early warning sign – in our own back yard, no less – of things to come.

An alarming increase in whooping cough cases in the United States has caught everyone’s attention this summer. For those in the public health field, however, there’s nothing new about it. Pertussis has been climbing in incidence for several years and it’s not completely clear why.

What we’re seeing with pertussis seems like a good illustration of how easy it can be to mistakenly assume we’ve eradicated most of the formerly common childhood diseases, such as whooping cough, and how challenging it is to maintain whatever progress has been made.

Many have been quick to blame the anti-vaccine movement for what’s happening. But although this is probably one of the contributing factors, it doesn’t seem to be the whole story.

The real issue could well lie with the vaccine itself. It’s now known that even among those who were vaccinated as children, the protective effects begin to wane by adolescence. Essentially this creates an enormous pool of teens and adults who may have become a reservoir for the pertussis bacteria and are unwittingly aiding in its spread, especially to infants and the very young who aren’t yet fully immunized. (Children need to be at least 2 months old to receive the vaccine, and it takes a series of shots to acquire full protection.)

Questions also have been raised about the vaccine formula. In the late 1990s the formula was changed from a whole-cell form of the pertussis bacteria to an acellular, or inactive form. Did this make it less effective? Did it somehow alter the control of the disease? On the other hand, evidence suggesting the vaccine lacks long-term effectiveness has been around longer than this, so a change in the formula might not adequately explain what’s happening. Although researchers have been exploring these issues for several years, the answers so far have been unclear.

Other research has found that the Bordetella pertussis bacterium may be evolving and perhaps is no longer well matched to the existing vaccine formula.

It was encouraging to hear this week that Affiliated Community Medical Centers here in Willmar has joined a project by the Minnesota Department of Health to increase the surveillance of whooping cough and collect more data. With more information, the public health community is in a better position to address the growing problem of whooping cough.

A couple of other points bear mentioning. First, although teens and adults do get sick from pertussis, their disease tends to be less severe – and as a result, it can go undiagnosed, allowing them to unknowingly spread it to others who might be much more vulnerable. The very young are usually hit the hardest; indeed, half of babies under the age of 1 year who develop pertussis end up being hospitalized.

Secondly, it’s critical for health providers to keep whooping cough on their radar screen. They may not see it often and they may assume that the vaccine has made it a non-issue. But as we’re learning, whooping cough is still very much present, and a persistent, hacking cough in an adult or severe cough in a child signals the need to look closer.

(For audio of what whooping cough sounds like, click here. Warning: Some may find it disturbing. Also, keep in mind that the characteristic high-pitched whoop at the end of the cough is not always present.)

Despite the tangle of issues surrounding the effectiveness of the whooping cough vaccine, it’s pretty clear that it’s still far better and safer to get vaccinated – and with the full series – than to skip it. Since we know that the vaccine wears off by adolescence, teens should get the recommended booster shot. Adults whose last pertussis vaccination was years ago and who’ve never had a booster shot should get one too, especially if they spend any time around young children.

It may not fully stem the tide, but there’s uniform agreement in the public health community that appropriate vaccination will go a long way toward closing some of the gaps in the immunity safety net and starting to bring down those alarming pertussis numbers.

The facts about drowning

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Maybe it’s the early start to the warm season this year, or the hot summer that’s driving everyone to seek relief at lakes and swimming pools. Whatever the reason, Minnesota is seeing a dismaying spike this summer in drowning deaths.

There’s no trend that seems to stand out. The drownings this year have claimed the lives of both children and older adults. They’ve happened in lakes and pools. They’ve involved boaters and swimmers.

There’s been considerable research on the risk factors that contribute to drowning, and it all points to the same conclusion: Many, if not most, drowning deaths can be prevented.

Among the facts:

- Children are the most vulnerable to drowning – and this seems to be true worldwide, not just in the United States. According to the U.S. Centers for Disease Control and Prevention, drowning is the second leading cause of injury-related deaths in the U.S. among children ages 1 to 4.

- The majority of drowning deaths among American children happen in swimming pools, not lakes or rivers.

- Most – although not all – drowning victims are male.

- One of the risk factors for drowning is, not surprisingly, exposure to water. Others that most of us are likely aware of include alcohol use, risky behavior and lack of supervision.

- There are less well known risk factors as well: lower socioeconomic status, less education and rural residency.

- Some demographic groups also seem to be more at risk than others. A study done in Canada a couple of years ago found that new immigrants are more vulnerable to drowning, probably because many of them never learned how to swim. Other studies have found similar issues among African-American children.

An article published this spring in the New England Journal of Medicine concluded that if you adjust for exposure to swimming vs. exposure to traffic crashes, drowning deaths are 200 times more common than deaths from crashes.

Knowing what many of the most influential risk factors are, how can we avoid becoming one of the statistics?

Learning how to swim is at the top of the list. But experts say there are other important steps that can be taken as well.

For parents, keeping an eye on kids in the water and not allowing themselves to be distracted is key, Susan Grundeen recently told the Pioneer Press of St. Paul. “Leave the cellphones, the magazines, the books aside,” said Grundeen, who is the beach safety coordinator for the Three Rivers Park District. “When you’re with that one person, have your eyes on them at all times.”

One of the myths about drowning, abetted by television and the movies, is that people who are drowning will splash around and yell for help. The reality is that drowning oftentimes is silent; indeed, someone who’s going under often isn’t even capable of waving or yelling. Many swimmers who get into trouble are never noticed until they’re found submerged in the water.

Water safety experts also point to the importance of swimming where there’s a lifeguard and sticking to beaches and lakes with which you’re familiar.

Finally, don’t assume that good swimmers never drown. Fatigue, cramps and even unexpected injuries or a medical emergency can overwhelm the strongest of swimmers. I’ve heard anecdotally of skilled swimmers who got into trouble because they hyperventilated in order to hold their breath under water and ended up blacking out.

Of all the activities to be enjoyed during the summer, swimming combines some of the best – physical activity, hanging out with friends and family, and a chance to cool off. Rather than being fearful of the water, swimmers can be prudent yet still reap all the benefits.

The case for motorcycle helmets

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On a road trip to the Twin Cities last weekend, a couple on a motorcycle passed me on Highway 7 east of Hutchinson. They were wearing T- shirts, shorts and flip-flops. No helmets.

I know how fast I was driving, and given how rapidly they flew by and disappeared into the distance, I’d estimate their speed (conservatively) at 70-75 mph.

I didn’t hear about any fatal motorcycle crashes afterwards that fit their description, so presumably they arrived safely at their destination. But the science and the statistics unfortunately are stacked against this kind of risk-taking.

A new study by the U.S. Centers for Disease Control and Prevention concludes that motorcyclists are less likely to die in a crash if they’re wearing a helmet – and that states with universal helmet laws incur lower costs associated with motorcycle crashes.

A few key points from the study, which analyzed National Highway Traffic Safety Administration data on fatal crashes from 2008 to 2010:

- Although motorcycles accounted for less than 1 percent of all vehicle miles traveled, 14 percent of U.S. traffic deaths in 2010 involved motorcyclists.

- Of the 14,283 fatal motorcycle crashes that occurred during the three years analyzed in the study, 42 percent of these bikers weren’t wearing a helmet. In the 20 states with a universal helmet law, however, just 12 percent of the fatalities were among motorcycle operators and passengers who weren’t wearing a helmet. For the three states that didn’t have a helmet law of any kind, 79 percent of the fatalities occurred among motorcyclists without a helmet.

- Helmet laws were estimated to save $3 billion in medical costs and lost productivity in 2010.

The report was issued at almost the exact same time as Minnesota officials reported an unexplained spike this summer in motorcycle deaths. As of mid-June, 17 motorcyclists have died on Minnesota roads this year; a year ago it was 10. It’s not clear why, although the mild winter of 2011-12 and an early start to the motorcycle-riding season might be part of the reason.

Whatever the case, it has sparked a new round of debate about motorcycle safety and helmet vs. no-helmet laws. Does it impinge on individual freedom to enact universal helmet laws? Or are these laws necessary to help save lives and reduce the societal cost of motorcycle crashes?

The Star Tribune of Minneapolis didn’t mince words with an editorial this past weekend about the inadequacies of the state’s partial-helmet law, which requires helmets only for those with instructional permits or under age 18. The editorial points out that of the 574 Minnesotans who died in motorcycle crashes over the past 10 years, the majority weren’t wearing a helmet. “Minnesota should be a leader, not a laggard, on this critical public health issue,” the editorial concludes.

There was a speedy response today in the form of a letter to the editor from Mark Backlund, safety coordinator for ABATE of Minnesota, which promotes safety awareness and training for motorcycle operators.

Rather than heavy-handed regulation, the focus should be on preventing crashes in the first place, Backlund argues. “These are not ‘accidents,’ and whether or not one is wearing a piece of equipment has no bearing on why or how the crash took place.”

The motorcycle crash rate undoubtedly could be lower than it is. Whether all crashes are 100 percent preventable is debatable, though, and it seems a multi-pronged effort – crash prevention, operator training and protective gear – would be a more effective strategy at saving lives than relying on prevention or training alone.

To be sure, a helmet does not guarantee someone won’t be seriously injured or killed in the event of a crash. Nor do motorcycle crashes reflect negatively in some way on the operator’s driving ability; all drivers need to learn to share the road safely and watch out for the motorcyclists among them.

But who has a better chance of self-preservation in a crash: Someone on a motorcycle clad in shorts and not wearing a helmet, or someone encased inside a metal vehicle fortified with seatbelts and airbags? The freedom of riding a motorcycle is also the factor that puts operators and passengers most at risk if a crash were to happen.

I’d like to know what readers think. Should helmets be mandatory for all motorcycle operators and passengers? What’s the best way to keep motorcycle riding as safe as possible?