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.

What’s behind the whooping cough epidemic?

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.

More respect for chickenpox, please

I was in grade school when I came down with chickenpox. I don’t remember much about it, other than being itchy and uncomfortable.

This was long before a chickenpox vaccine was developed. Back then, the majority of kids had the disease by the time they were in their teens. If a vaccine had been available, I suspect many parents would have gladly agreed to it in order to avoid the illness and misery.

It’s an entirely different ballgame now. Most younger adults have grown up with little or no firsthand experience of childhood diseases, such as measles, chickenpox and whooping cough, that once were common. There’s less trust in vaccines and more worries about vaccine safety.

When you put all these factors together, they can result in some questionable decision-making, of which so-called chickenpox parties are a prime example. In fact, health officials are so concerned about the pox-party trend that they’ve been speaking out; the latest warning came last week from the Minnesota Medical Association.

Chickenpox parties are nothing new. For those who don’t know, a chickenpox party involves bringing children together with a child who has the disease, in hopes the exposure will make everyone sick so they can get the disease over with and be naturally immunized for life. At one time, they were seen as somewhat of a convenience, allowing parents to plan for a child’s illness and to have their child contract the disease earlier in life, when chickenpox tends to be milder. But since the mid-1990s, when the chickenpox vaccine was introduced, another element has entered the discussion: fears about the vaccine and the belief that it’s safer for children to acquire natural immunity from the disease itself.

The chickenpox party is a controversial practice. Many people see it as unnecessarily risky. Others see nothing wrong with it.

What’s not exactly clear is why chickenpox doesn’t seem to inspire the same level of caution in many people as other infectious diseases do – influenza, for instance, or whooping cough.

A little background on chickenpox:

It’s caused by the varicella zoster virus, a member of the herpes virus family. There are records of it as far back as ancient Babylonian times. It was first formally identified by a 9th-century Persian scientist. Despite its name, it doesn’t have anything to do with chickens nor is it related to smallpox.

Modern-day Americans tend to regard it as a non-serious disease – and for the most part, it usually is. But this fact shouldn’t obscure the complications that can come with chickenpox. Teenagers and adults who get chickenpox can become severely ill. Complications include pneumonia, encephalitis and secondary bacterial infection of the soft tissues. The disease can be especially serious among women who are late in pregnancy or individuals who are immune-compromised. It’s worth noting that chickenpox, along with measles, smallpox and venereal disease, was among the diseases brought by early colonists to the Americas, decimating a native Indian population that had never been exposed and hence was defenseless.

Before the chickenpox vaccine became available in the mid-1990s, there used to be 4 million cases of chickenpox in the U.S. each year, according to the U.S. Centers for Disease Control and Prevention. Chickenpox resulted in 10,500 to 13,000 hospitalizations each year and 100 to 150 deaths. Vaccination has lowered the number of hospitalizations by 71 percent and the number of deaths among children and teens younger than age 20 by 97 percent. Public health officials worry this trend might be reversed if growing numbers of parents decide to skip the chickenpox vaccine.

For what it’s worth, you can find pediatricians and nurses who don’t think it’s essential to vaccinate children against chickenpox. Based on early experience, the vaccine was about 85 percent effective at preventing the disease. Many states now recommend a second dose of vaccine, which has been found to boost its effectiveness to better than 95 percent. But there continues to be debate on how well the vaccine truly works or how long it stays effective. In view of the fact that the vaccine has been in use for less than two decades, it will take time for research to help answer these questions more definitively. In the meantime, there’s bound to be confusion and conflicting opinions.

No one can force parents to vaccinate their children. Health decisions are among the most personal decisions we make. When infectious disease is involved, however, there’s a case to be made for protecting the health of the whole community. Chickenpox is not always the mild, harmless disease that many people think it is, and deliberate exposure at a chickenpox party can have unplanned, unintended consequences. Chickenpox could use a little more respect.

Photo: Wikimedia Commons

Health and geography

When it comes to being healthy, does it matter where you live?

Last week the University of Wisconsin Population Health Institute and the Robert Wood Johnson Foundation issued a county-by-county health ranking for every state in the U.S., measuring how each county stacks up on factors such as life expectancy, poverty, alcohol and tobacco use, and access to health care.

In many ways, the results weren’t all that surprising. Here in Minnesota, counties that ranked among the best in overall health status were mostly clustered in the Twin Cities suburbs and southern part of the state – areas where education and income levels tend to be above average. Those that fared the worst were mainly in northern and north central Minnesota, where the poverty rate is higher.

Multiple studies have demonstrated over and over again that two of the most important predictors for overall health are – you guessed it – income and education. Yet when you start digging more deeply into the county health rankings, it becomes clear there’s more to the story.

I was intrigued to come across a discussion about the health rankings in the state of Washington, where San Juan County was at the top of the list, despite the fact that it consists mostly of islands and is relatively remote from large hospitals. The commentators seemed rather surprised – but the online reaction wasn’t. “San Juan [C]ounty is probably the healthiest because people move away if they become sick or never move there in the first place if they have a pre-existing condition,” one person wrote. Others pointed to the peaceful lifestyle, the above-average income and the shortage of fast-food restaurants on the islands.

You could find similar contradictions in Lac qui Parle County, which holds the distinction as Minnesota’s healthiest county. Lac qui Parle County is somewhat off the beaten path, wedged south of the upper Minnesota River and along the South Dakota border. According to the 2010 Census, it has a population of slightly more than 7,200. It has no large cities. The nearest regional hospitals, in Willmar and Marshall, are 40 to 50 miles away.

It would be hard to single out any one or two factors that helped this county do well in the health rankings. Local residents think a countywide wellness effort, coupled with two small hospitals and clinics, are among the most critical contributors. Perhaps the rural lifestyle and a self-reliant rural culture have something to do with it. Or maybe it’s the population itself. Although Lac qui Parle County residents are older on average, they’re also relatively homogeneous and predominantly from white, northern European ancestry.

It’s interesting to note that Yellow Medicine County, which borders Lac qui Parle County to the south, is in the bottom tier for health outcomes in Minnesota. On the surface, these two counties aren’t that dissimilar – but Yellow Medicine County has a Native American community, and some of the biggest health disparities in Minnesota lie between its white residents and residents of color, especially for Native Americans who often fare worse on the majority of health indicators.

It’s also interesting to note that Kandiyohi County landed about one-third of the way down the list of Minnesota’s health rankings, despite its concentration of health care services and the fact that the county’s population skews younger than most of its neighbors. Then again, Willmar is a regional center, and regional centers tend to draw people who need services.

As with many statistics, the “why” of this latest edition of the county-by-county health rankings is more intriguing – and much harder to answer – than the “what.”

If there’s one thing highlighted by this report, it’s the multi-factoral nature of health. Where you live does seem to make a difference, but demographic, social and environmental issues are intertwined as well. According to the U of Wisconsin and the Robert Wood Johnson Foundation, social and economic factors account for 40 percent of overall health status. Health behaviors account for 30 percent, medical care for 20 percent and the physical environment, 10 percent.

Although many of us would like to think everyone can be healthy if they’d only take good care of themselves, it’s clearly a lot more complicated than this. If communities want to improve their health status, they need to start addressing more than just their inhabitants’ health choices and behaviors.

Image: Farm-fresh eggs from Earthrise Farm, rural Madison, Lac qui Parle County. West Central Tribune photo by Tom Cherveny.

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Rabies: a scary foe

My cat lives a pampered indoors-only existence. The only way she would ever come in contact with the great outdoors is if she accidentally escaped from the house, something I don’t plan to let happen. This kind of lifestyle puts her at extremely low risk of contracting rabies – yet she’s vaccinated against rabies and will continue to get her rabies shots lifelong.

Why vaccinate an animal (or a person, for that matter) against something that’s unlikely ever to be a genuine threat to them? Because rabies is an awful disease, that’s why, and I’m not willing to take even a minuscule risk.

There are any number of frightening zoonotic diseases, i.e. diseases that can be transmitted from animals to humans, and rabies is one of them. In North America, the rabies virus is endemic in the wildlife population, primarily bats, skunks, raccoons, foxes and coyotes. It’s generally transmitted through the saliva of an infected animal, namely through a bite.

Post-exposure vaccination will protect someone who’s been bitten from the possibility of developing rabies. Taking the right steps after any kind of animal bite is critical, because when left untreated, the rabies virus attacks the central nervous system and is almost always fatal. Once rabies has been allowed to progress, there’s no effective treatment for it other than supportive care.

I’d like to think most people wouldn’t get close enough to a wild skunk or raccoon to risk getting bitten. Our pets are a whole different story, though. They live with us, hang out in the yard and play with the kids. Occasionally they wander afield and perhaps tangle with a rabies-infected critter – then come home, setting the stage for possibly transmitting the rabies virus to someone in the family.

Vaccination of pet cats and dogs is in fact an important public-health strategy for buffering the human species from the rabies virus among the wildlife population. In this sense, the Humane Society of Kandiyohi County didn’t just do a good deed for animals this week by hosting a series of low-cost outreach vaccination clinics in Willmar; the neighborhood clinics also helped the community.

As scary as it is, rabies has become rare in the United States, among both pets and humans. As recently as 50 years ago, the majority of rabies cases among animals reported to the U.S. Centers for Disease Control and Prevention were among domestic animals. Now more than 90 percent occur within wildlife. At one time more than 100 Americans died of rabies each year. These days, with post-exposure vaccination available, it’s extremely unusual for this to happen. The few human deaths from rabies that do occur tend to involve undetected bat bites, as was the case with a Minnesota resident in 2007 who ultimately died.

What has happened with rabies is one of the more compelling success stories in vaccination and prevention. Great Britain has gone one better by managing to eradicate rabies, even among its wildlife. It helps, of course, if you’re an island nation – but internal policies and strict quarantines for imported animals also have played a critical role in controlling and preventing rabies in the U.K. When the Channel Tunnel, which links London with Paris and Brussels via high-speed rail, was constructed, Britons worried it would pave the way for rabies-carrying French rats to invade the country, a fear that so far has not materialized.

Rabies unfortunately remains a threat in the rest of the world, however, especially in developing countries where vaccination and surveillance are less prevalent.

When a vaccine-preventable disease isn’t very common, it can be easy to assume it’s not really a risk to us or to those around us. It can be easy to just skip vaccination altogether, using the rationale that it’s not necessary. When you weigh the risk vs. the benefit, though, I wonder how many of us would truly be willing to gamble in this fashion, whether it’s a rabies vaccination for our pets or a pertussis or Hib vaccination for our children. No matter how low the risk, many of the worst infectious diseases simply aren’t worth taking a chance on.

Image: Rabies virus. Courtesy of the Public Health Image Library, CDC

Health and geography

Does where you live make a difference in your health? There’s plenty of research to suggest it does, the latest being a new set of county-by-county health rankings issued this week by the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute.

It’s the first time anyone has attempted to show how each of the 3,000-some counties in the United States stacks up on a variety of health measures. A wealth of data, ranging from the U.S. Census to poverty and unemployment statistics, was used to come up with the rankings.

You can see here how Minnesota counties fared. All but two of the state’s 87 counties are included on the list. It’s clear from the map that many of the so-called healthiest counties are clustered around the Twin Cities and in southeast-central Minnesota, while those that fare worse are in rural central and northern Minnesota.

Some caution is warranted in interpreting the rankings. They were compiled with information that came from a wide variety of sources and may not have been measured in exactly the same way. Some of the statistics go back to 2000, making them a decade old. Information on premature death rates was collected from the National Center for Health Statistics for only two years, 2004 to 2006. Unemployment information came from the U.S. Bureau of Labor Statistics and only covered 2008, when the recession was just beginning to deepen in Minnesota. The Behavioral Risk Factor Surveillance System, which tracks health-related behavior such as physical activity, tends to rely on self-reported data from the public that might not be 100 percent reliable.

Without seeing the raw scores for each county, it’s also hard to know what separated the good from the not-so-good. Was it a difference of 10 or 20 points, or was it a difference of tenths of a point?

That said, this new report provides some interesting insight into the many contributing factors to what we think of as healthiness. Although we often view behavioral factors – for instance, eating fresh fruit and vegetables and avoiding tobacco use – as the most critical determinants in overall health, in reality they’re only part of the picture. Environment can make a difference; so can local culture and ready access to quality health care.

Many of the counties that ranked in the bottom tier also had higher rates of poverty and unemployment. This is no accident; two of the most important predictors for overall health status are income and education level. Income and education appear to have a significant influence on health-related behaviors, although it’s not totally clear why this is so. Smoking rates, for instance, generally are lower in the higher income brackets and among the college-educated. And across the board, the poor tend to be more vulnerable to being uninsured, having less access to health care services and suffering worse outcomes than those who are better off.

Geography matters in other ways as well. In highly rural counties and in inner cities, for example, it can be more challenging for people to consume fresh fruit and vegetables each day because there might not be a nearby grocery store that sells fresh produce. Access to medical care is more of an issue, especially in isolated rural areas where resources are thinly spread.

Barriers like these can be overcome, however, suggesting that local decision-making and priorities also have an important role. You’d expect Olmsted County, home of Rochester and the Mayo Clinic, to be one of the top performers on measures of clinical care provided by doctors and hospitals. But look who else scored well in this category: Kandiyohi County at No. 8 and Redwood County at No. 11. On measures of morbidity, or quality of life, the list was topped by small, rural Lac qui Parle County at No. 1, Swift County at No. 2 and Kandiyohi County at No. 9.

So now we know how we stack up, what do we do with the information? The authors of the county-by-county rankings view them as a call to action by health care and community leaders. It’s hoped that counties will be spurred to improve in the areas where they’re not doing well and reinforce their commitment in areas where they’ve been successful.

These kinds of initiatives are not a quick fix. It may take years to see improvements that are not only measurable but sustained. It’s probably going to take the involvement of community and business leaders and local government; after all, these aren’t issues that can be handed off to health care folks to solve themselves. Future report cards will tell the tale of who has responded to the call for action and who has not.

Mountains beyond mountains

True stories can be far more compelling than any fiction, which explains why I quickly became engrossed a few years ago in reading "Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World."

It’s the story of a public health doctor and infectious disease specialist who has devoted himself to one of the most poverty-stricken corners of the globe – rural Haiti. Here, in the central highlands, Dr. Farmer helped establish a hospital and health center that became the cornerstone of Partners in Health, the nonprofit organization he co-founded to bring needed health care to the poorest of the poor.

Pulitzer Prize-winning author Tracy Kidder was in Haiti in 1994, reporting on American soldiers who were in the country on a peacekeeping mission, when he met Dr. Farmer. Eventually he decided to write a book about this extraordinary doctor, his work in Haiti and the daunting issue of global health, especially among the poor. "Mountains Beyond Mountains" is the result. (The book’s title refers to a Haitian proverb that describes the never-ending hardships and challenges of life: "Beyond mountains there are mountains.")

It’s an illuminating book, not only for the light it sheds on Haiti and its history and culture but also for its examination of global poverty and the impact of poverty on health.

Here’s how Haiti fares in some of the most recent statistics collected by the World Health Organization: three physicians for every 1,000 people; one nurse or midwife per 1,000 people; less than one dentist per 1,000 people; 13 hospital beds for every 10,000 people. (Figures are for 2007, the most recent year for which complete numbers were available.) Given such a fragile health care infrastructure, it’s not hard to see why last week’s earthquake has had such a profound and devastating effect on the Haitian people.

Dr. Farmer’s organization, Partners in Health, is working to raise funds and coordinate donations and volunteers for earthquake relief. Follow the link to read more about the "Stand With Haiti" campaign, including reflections by Dr. Farmer, the personal account of a physician’s first 12 hours on the scene in Port au Prince, and a blog post by author Tracy Kidder. And I’d highly recommend reading "Mountains Beyond Mountains." A copy of the book is available at the Willmar Public Library.

Update: As the focus shifts from trying to rescue people to caring for the survivors, the health crisis in Haiti is deepening. This story, which appears today in USA Today, explains the challenges ahead. Doctors Without Borders also has posted a firsthand account and slideshow on its Web site.

Photo: Daniel Morel, Wozo Productions

A decade of health progress… or not

By some measures, Americans are healthier than they were a decade ago. But there’s still a considerable way to go, suggests a preliminary assessment of the Healthy People 2010 initiative.

Yes, it’s 2010 already, and the U.S. Department of Health and Human Services is starting to analyze the progress made over the past decade toward the goals set forth on the Healthy People agenda. The results are decidedly mixed: A series of reviews by the National Center for Health Statistics found that among 635 of nearly 1,000 Healthy People goals for the past decade, only 117 of the targets had been met, and there actually was backsliding on nearly one-fourth of the goals.

Although it’s too soon to know how the final report will look, it appears as if about 20 percent of the overall goals have been achieved. There has been backsliding here as well: In 1990, about 41 percent of the measurable goals were achieved; in 2000, it was 24 percent.

To back up for a minute, the Healthy People initiative was started in the late 1970s. The idea was to set a national public health agenda and provide a framework for developing health initiatives at state and local levels. Ultimately, the goal is to achieve longer, healthier lives for Americans and eliminate disparities in health status.

Needless to say, this is a pretty ambitious undertaking. Over the years the Healthy People objectives have morphed into an increasingly broad agenda that includes hundreds of targets in areas ranging from cancer and diabetes to occupational safety, mental health and family planning.

At first glance, it’s disappointing there hasn’t been more progress. For instance, one of the 2010 goals was to reduce the number of adults with high blood pressure from 28 percent to 16 percent. According to the most recent data, however, not only did Healthy People 2010 fail to reach this goal but the incidence of hypertension among American adults actually increased to 29 percent. The number of caesarean sections went up, not down, and the percentage of premature births also increased.

It’s not entirely clear how these numbers should be interpreted. For one thing, they’re an average. If you break down the data by individual states, differences in performance begin to emerge, with some states doing well on some of these measures and others doing not so well. The same goes for demographic subgroups such as rural Americans and populations of color.

I’d also be curious to know how the indicators tracked from one year to the next. If they worsened, as in the case of hypertension, was this a continual trend across the decade, or did most of the backsliding occur within the span of a year or two? The link between income levels and health status has been well documented, and it’s entirely possible that the recession of the past couple of years, coupled with unemployment, loss of health insurance and tight household budgets, may have undone whatever progress was achieved earlier in the decade. Indeed, many aspects of health are closely interwoven, and it’s often hard to make progress in a single area without addressing other things too, some of which may simply be out of our control.

There’s a certain amount of human behavior involved as well – and changing people’s behavior has always been notoriously challenging. Getting more Americans to be physically active, for instance, isn’t just a matter of telling them to be active and assuming they’ll do it. It requires people to make changes in their behavior that are not only conscious but sustained. It also generally requires a supportive environment; someone who lives in an unsafe neighborhood, for example, is probably going to be less likely to walk for daily exercise. Although many of us would like to think we’d all be healthier if we just tried harder, the reality is that it’s not always this easy.

If I have a criticism of the Healthy People initiative, it’s that it’s just too large and ambitious. A decade doesn’t seem long enough to accomplish hundreds of public health goals, let alone address how to sustain any progress that might be made. The initiative unfortunately comes with zero funding to implement any of it. It’s also fuzzy around the edges when it comes to explaining how state and local agencies and providers are actually supposed to achieve any of the targets.

That said, we all need goals, otherwise we have nothing to aim for and no way of measuring progress in the journey. Healthy People 2010 has in fact resulted in health improvements. The rate of childhood vaccinations is up, fewer Americans are dying of cancer and workplaces have become safer. All told, some degree of progress has been measurably achieved on 70 percent of the Healthy People 2010 objectives.

And we always have a chance to try again. Work has already started on developing the goals for Healthy People 2020. Most of the targets are unlikely to change, but many of the goals will be refined, expanded and perhaps modified to reflect emerging concerns and new evidence-based knowledge. There’ll be another new decade during which we can hope to keep doing better.

A healthy dose of statistics

With a major winter storm on our doorstep that’s threatening to wreck people’s Christmas travel plans, some of us might be wondering: Why on earth do we live in Minnesota?

Why, it’s for the quality of life, of course. The state has long had a good reputation when it comes to health. Life expectancies in Minnesota tend to be longer, there’s a lower incidence of tobacco use, fewer Minnesotans are uninsured, and the state generally scores well when it comes to the quality of its health care services.

A view of Minnesota by the numbers can now be found on the Web site of the National Center for Health Statistics, a division of the U.S. Centers for Disease Control and Prevention. This newly developed feature, dubbed "Stats of the States," offers a wealth of state-by-state data on measures ranging from teen births to diabetes and cancer mortality. You can click on any state to see the latest figures available. Statistics buffs could probably spend hours poring through the data.

Some figures gleaned from Minnesota’s collection of statistics: The state is among the top 10 at reducing the number of preterm and low-birthweight infants, both of which are risk factors for an infant’s future health status. Minnesota’s infant mortality rate in 2005, the most recent year for which figures are available, was 4.78 per 1,000 births, while the national average was 6.83. From 2004 to 2006, Minnesota also had one of the lowest percentages in the U.S. of individuals who were without health insurance.

Some of the most fascinating statistics on this new Web page have to do with causes of death. Heart disease is among the most prevalent conditions in the United States, and for decades it was the single biggest cause of death in Minnesota. But mortality from heart disease is slowly dropping (a similar trend has been occurring nationally for several years), and cancer is now the state’s leading cause of death. In fact Minnesota currently has the nation’s lowest death rate from heart disease.

There are probably several reasons for the decline in heart disease mortality – better early identification of risk factors, for one thing, and better prevention strategies, such as effective medication for lowering cholesterol, for another.

How might all of this translate to the local level? Let’s consider the significant effort that has been invested here in Kandiyohi County to evaluate and treat heart attacks as rapidly as possible.

Because heart muscle soon dies if it’s starved of oxygen, time is critical when it comes to treating a heart attack. Thanks to teamwork and training, local emergency medical services have managed to shave their response time down to an average of 90 minutes or less, from the time the patient arrives in the Rice Memorial Hospital emergency room until he or she gets into a cardiac catheterization lab – no small feat, considering the nearest cardiac cath lab is in St. Cloud, 60 miles away, and requires a helicopter flight. Local physicians say this aggressive protocol has been reducing deaths from heart attacks and reducing the likelihood that survivors will develop congestive heart failure.

Thanks to the work of a Kandiyohi County coalition, it’s becoming increasingly common to find automated external defibrillators in public places such as churches, malls and grocery stores. The Willmar Ambulance Service also is heading a countywide initiative to speed up the process for evaluating potential heart attacks while the patient is still in the ambulance.

Statistics have a reputation for being rather dry and dull but when you put them together with the stories behind the numbers, what emerges is a picture that can be very meaningful to individual consumers. Check back at the NCHS Web site in upcoming months for more new reports on birth and death vital statistics, health behavior surveys, health insurance coverage and hospital data.

Untangling the flu vaccine messages

Every year there’s some new angle on the influenza vaccine.

One year, I remember, it was discovered that the vaccine produced by one of the manufacturers wasn’t strong enough to offer full protection against the flu. Thousands of high-risk patients had to be called back in to receive a second booster dose.

Some years there have been vaccine shortages. Other years there have been delays in manufacturing and distribution.

The target audience for the vaccine has continually expanded. At first, flu shots were for the elderly. Then annual vaccination began to be urged for anyone with a chronic health condition – diabetes, for instance, or asthma or lung disease – who might be at risk of severe illness from flu or flu-related complications.

Within the last few years we’ve seen a bigger push to vaccinate children, after studies found this helps reduce the spread of flu viruses and increases what’s known as herd immunity. There also has been a push to vaccinate health care workers, partly to keep them healthy but also to lower the possibility of germs being transferred from patient to doctor or nurse and thence to the next patient they see.

If anyone is handing out prizes, though, the current influenza season takes the award for being the most complicated in recent memory. Not only do we have seasonal influenza to contend with, we also have the H1N1 novel virus. The arrival of the novel influenza virus this past April has meant we’ve been seeing flu cases through the summer and into the fall – months when flu is usually absent.

One of the biggest reversals: It’s children, not older adults, who are being hit hardest by the H1N1 virus. During the first six months of the pandemic, there were 98,000 hospitalizations and nearly 3,900 deaths. One-third of the hospitalizations were among children and teens 18 and under. Deaths also have been occurring at the highest rate among people younger than 65, the complete opposite of what we’re accustomed to seeing.

Now add in separate vaccines for seasonal flu and for H1N1, delays in manufacturing, and priority lists for who should receive the vaccine, and watch the complexity intensify.

Those who work in public health say it has been very challenging this year to craft their messages and to ensure these messages are accurate and that they’re reaching the right audience. (I’ll add here that it has been challenging for the news media as well.)

When we talk about flu vaccine, are we talking about the seasonal vaccine or the H1N1 vaccine? We’ve had to be specific because these are two different things.

When we’re describing the priority groups to receive the H1N1 vaccine, do we mean children, teens and young adults through age 24 or up to age 24? Even people who work with this every day tell me they’ve had to frequently stop and double-check to make sure the message is coming across clearly.

One thing we’ve all learned is you can’t assume anything. A new question cropped up just this past week: If a local medical clinic is offering the H1N1 vaccine, can anyone come in for a shot or is this only for established patients? I figured people pretty much knew this service is for established patients but clearly we need to say so directly.

It’s easy to take the whole process for granted. What most people don’t see is the work that happens behind the scenes – the planning, the coordination, the partnerships to help ensure local medical providers and public health are all on the same page. Without this coordination, there can be confusing and inconsistent messages to the public. Flu vaccine might not reach the people who need it the most.

The seasonal flu and H1N1 sagas are still far from over. There’ll likely be more confusion and questions as the weeks progress. But the process has been relatively orderly, and none of it has happened by accident. So the next time you talk to one of your local health care professionals, take the time to say thank you.

West Central Tribune file photo by Bill Zimmer