Category: Public Health

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General MSPress Announcements Public Health Reflection

“Fulfillment in Practice”: Dr. Howard K. Koh, 2015 Commencement Address of the Yale School of Medicine

We are excited to publish the final contributor to this year’s Commencement Archive, Dr. Koh’s 2015 commencement speech to the Yale School of Medicine, “Finding your calling.”

Howard Kyongju Koh is the former United States Assistant Secretary for Health for the U.S. Department of Health and Human Services (HHS).  

Screen Shot 2015-10-06 at 8.08.49 PMDr. Koh oversaw the HHS Office of Public Health and Science, the Commissioned Corps of the U.S. Public Health Service, and the Office of the Surgeon General. At the Office of Public Health and Science, he spearheaded programs related to disease prevention, health promotion, the reduction of health disparities, women’s and minority health, HIV/AIDS, vaccine programs, physical fitness and sports, bioethics, population affairs, blood supply, research integrity and human research protections.

Dr. Koh graduated from Yale College and earned his medical degree from Yale University School of Medicine. He has earned board certification in four medical fields: internal medicine, hematology, medical oncology, and dermatology, as well as a Master of Public Health degree from Boston University. 

Dr. Koh previously served as the Harvey V. Fineberg Professor of the Practice of Public Health, Associate Dean for Public Health Practice, and Director of the Division of Public Health Practice at the Harvard School of Public Health.  

Dr. Koh begins his speech by advising students to find meaning and fulfillment in medicine, regardless of external expectations,

“Please listen carefully to your inner soul so that you can discover your own sacred calling.  Doing so will help you express yourself, not just prove yourself. Doing so will help you determine in your life what is ultimate versus what is merely important.”

He continues by reminding students that patients will be teachers as well, and may be key factors in finding that calling,

“One way to learn more about meaning through your journey is to respect how your patients find meaning in their own. They can teach you in unexpected and profound ways. Sometimes the patients who will educate you the most will be the ones you couldn’t cure, no matter how hard you tried.”

He concludes and advises students to enjoy every step of the way,

“So please pay great attention to how you live your lives, not just as doctors, but as individual human beings.”

Visit the Medical Commencement Archive to read Dr. Koh’s full speech here

Categories
Clinical Opinion Public Health

It’s Time to Take Responsibility for our Unimmunized Patients

There is an old parable about a tree that falls onto an old dirt road in the forest. On the day the tree falls, the daughter of a rich king is passing through the forest in her carriage. The carriage runs over the tree, loses control, and crashes. A passing lumberjack sees the overturned carriage and carries the princess to safety. Her father, the king, throws a great celebration in honor of the lumberjack, and rewards the hero with riches.  In the next village, another tree falls on the road.  In this village, the lumberjack sees the fallen trunk and with great difficulty carries it off of the road.  The princess never crashes and she continues on her way, none the wiser.  A hero all the same, there is no celebration and no reward for this lumberjack.  This allegory wins no awards for its subtlety.  While life-saving and innovative treatments are often lauded by the general public, the praises of preventive measures often go unsung.

Vaccines are considered among the safest and most effective public health interventions. [1] There is no dispute among the scientific community, and repeated peer-reviewed studies have detailed the value of vaccines as preventive health measures. These studies collectively support the conclusion that the benefits of using vaccines to minimize illness outweigh the potential risks.  It is precisely because of the overwhelming success of immunizations that people have little or no personal experience with diseases like smallpox, or chickenpox, or polio.

Parental autonomy suggests that parents have the right to raise their children as they see fit.  As a result of this benign belief, however, more young parents believe that vaccination should be a choice. [2] To combat the anti-vaccination movement, health care providers have traditionally relied on their role as medical experts and discussed the scientific data, expecting patients to trust in evidence-based medicine. But the inability of overwhelming evidence to quell controversy and resolve debate has led to greater polarization—biased reasoning has made discussion counterproductive and has led to the intensification of beliefs for many of those opposed to vaccination.  As a result, there are groups of under-vaccinated children which increase the risk of an outbreak in the general population. [3]

There are patients who will continue to refuse to accept research and statistics, even when presented by a trusted family physician. These patients have fallen victim to misinformation and fear-mongering. Their concerns include side effects, immunization schedules, financial incentives, and “Big Pharma”, but more broadly represent suspicion of biomedical research and healthcare providers.  [1]

Physicians often suffer from the curse of knowledge—an inability to recall the lack of understanding that came before learning a new concept. This may play a role in the notoriously poor communication skills of doctors.  For example, watch a third year medical student discuss a clinical subject with a first year medical student and notice the difference in the use of clinical jargon.

Learning how to read a research paper, understanding how and why the study was performed, and recognizing the implications of its conclusions are skills taken for granted by those in the scientific community. These skills take years to learn, yet clinicians reference data and statistics to their patients indiscriminately.  If we want patients to trust us, we have to admit when what we are doing is not working, and be willing to change. For some patients, citing facts and figures is not an effective tactic.

It can be easy to vilify those opposed to vaccination, but new parents continue to be drawn to the movement every day. In a culture of blame, when there is an outbreak of an infectious disease, we instinctively search for someone to condemn and hold culpable. We would be better served by identifying what makes individuals skeptical and how we can change misconceptions and behaviors. The issue at hand involves trust.  Some patients will not trust what we have to say as providers. We have to consult the experts—we must refer them to their grandparents.

Grandparents can discuss the ominous nature of diseases that many of us, due to vaccination, are not frequently exposed to.  They can explain what it means to have a cousin under quarantine or a sibling living with the complications of an infectious disease.  They can express what it means to lose an infant child to a vaccine-preventable illness. Anti-vaccination parents have had the impact of their decisions mitigated due to many years of previous vaccination and herd immunity—a community’s general protection from disease because of a high proportion of immunity in its members.  It is time for us, as medical professionals, to admit that we must change our tactics.  Some patients may not understand the consequences of many of these infectious diseases, but I bet their grandparents do.

References:

  1. http://iom.nationalacademies.org/Reports/2013/The-Childhood-Immunization-Schedule-and-Safety/Report-Brief011613.aspx
  2. http://www.pewresearch.org/fact-tank/2015/02/02/young-adults-more-likely-to-say-vaccinating-kids-should-be-a-parental-choice/
  3. http://www.reuters.com/article/2015/08/27/us-usa-vaccine-exemptions-idUSKCN0QW2JY20150827
Featured image:
Clipart edited by Ilya Aylyarov
Categories
Lifestyle Public Health Reflection

Giving Blood

When my cousin mentioned that she wanted to give blood, I was happy because she voiced a wish of my own. I had wanted to donate blood for years, but I never met the eligibility criteria: either I didn’t weigh enough or I was anaemic. I had been fully eligible for over a year, but I kept postponing my donation for no reason other than the fear of facing the unknown alone. Having found another person to share the experience with, I was finally brave enough to follow through and donate.

I am a medical student, an aspiring Emergency Medicine specialist, an advocate of blood and organ donation, and I am fully eligible to give blood. Who better to donate than me? How can I expect other people, who are less aware of the need for blood products or the process of blood giving, to volunteer for this seemingly unpleasant act, without serving as an example?

Let me tell you, it was not a big deal. The whole experience was actually quite different from what I expected. I expected to be in pain, to feel dizzy and to have to spend a whole day preparing and recovering from giving blood. Here is what actually happened:

After a usual day of classes and a light lunch, we walked to the Croatian Institute for Transfusion Medicine, nervous but excited. We were met by very friendly staff, who responded to my nervous humour with witty jokes. I have to give them credit, because they made a big difference in my first experience. While they joked and kept the mood light, they were professional and reassuring.

The nurse who welcomed me didn’t believe I weighed enough, but a quick consult with the scale proved him wrong. After a quick check of my haemoglobin level and a small routine examination, I was given a questionnaire to fill out about my medical history, medication use, lifestyle and traveling.

It was encouraging to see that quite a few donation beds were taken. A few people seemed to be regular donators, as they chatted between themselves and with the staff, looking completely at ease. While waiting for a donation bed to clear, the staff chatted with me about medical university workload and our health system. After a very short wait, I was shown to a donation bed and got comfortable in a head-and-feet-up position. My cousin couldn’t give blood herself as she was anaemic, so she kept me company. I have to admit my eyes did widen at the sight of the 16 gauge needle, but a nurse inserted it in my cubital vein quickly, and I can’t say that it hurt.

I squeezed my stress ball to keep the blood flowing, had sips of water, and chatted with my cousin and the staff. As I watched the red fluid flowing from my vein to the bag, I didn’t feel faint, as I expected. I did have a weird sensation I can’t describe, which was probably psychological, but there wasn’t pain, sweating, dizziness or any other symptom I expected I would have due to my low blood pressure. It didn’t last more than five minutes, which is a lot quicker than I thought it would be. Even though I felt completely fine, I was advised to stay on the bed for a few more minutes just to rest.

After a friendly goodbye from the staff, and a present of a pen that looks like a syringe, I was shown to the cafeteria where I got a drink, a warm meal and a doughnut. I left the site feeling happy knowing my blood will help someone else, and elated with the enjoyableness of the experience.

For the rest of the day, I made sure to keep hydrated and have healthy meals, but otherwise I went about my usual business: I walked my dog, studied and went to the gym (exercise isn’t recommended straight after giving blood, but I was careful not to strain myself).

I realise that giving blood isn’t the first thing to pop into your mind when you imagine a perfect day, but it’s a quick and easy thing to do. It doesn’t take a lot of time and effort on your part, but it can make a big difference in someone’s life.
Find out more about donating blood, eligibility criteria, and how to get ready for a donation, with special notes for first time donors.

A few facts from the American Red Cross:

  • Every two seconds someone in the U.S. needs blood.
  • More than 41,000 blood donations are needed every day.
  • Although an estimated 38% of the U.S. population is eligible to donate, less than 10% actually do each year.

Give blood, save lives.

Featured Image:
Blood Donation Appointment in Calendar/Journal by Oliver Symens

Categories
General Opinion Public Health

Are You Prepared For the Walmart Storm?

Clouds, storms and sunsets

Ten years ago, the idea of going to Walmart for a primary care check up would have seemed completely foreign. Walmart, as the largest American employer, previously seemed to limit itself when it came to health care. Currently, it is branching out into the discount drug industry, owning roughly 100 retail clinics and working in conjunction with a few large hospitals. Now it appears that they’re ready to branch out with more clinics. Since they already have a number of clinics, it begs the question: why are many major television networks and newspapers only now showing alarm over the idea of Walmart becoming a serious contender in the healthcare market? There are several reasons: first, the clinics that Walmart are now endorsing are completely owned by them. Furthermore, they are being branded as “one stop shops” for primary care. Second, the new clinics are run solely by nurse practitioners and are open longer and later than their competitors (such as, private practice physicians), thus launching a full front assault on the family medicine practitioner. Thirdly, due to the reach of the company, its potential as a disruptive innovator and giant in the industry is unparalleled. Experts are now saying that Walmart can single handedly change healthcare as we know it.

What does this mean for us as medical students, soon to be working in the medical field?  It seems to me that the greatest thing that Walmart is offering customers is choice.  Rather than simply offering healthcare at a lower cost, they are offering customers a simpler way of dealing with their health concerns. They also seem to be veering away from the procedural based medicine that physicians seem to practice currently. Instead, patients are allowed to buy doctor visits in bulk— thus the “retail” if you will. Though this inevitably means more competition for contenders, it may also prove useful. With cheaper, more readily accessible primary care, emergency rooms will be less full with repeat offenders. People who would greatly benefit from primary intervention (those suffering from diabetes, obesity and high cholesterol) –those who typically slip under the radar due to lack of insurance – could get covered for a cheap cost. Finally, extraneous hospital costs would be cut down, allowing patients a certain amount of control over insurance and their insurance provider. With Walmart entering the industry, other companies will be forced to offer more competitive and reasonable rates.

Who knows, Walmart might be the thing to make healthcare equitable in this country.

Featured image:
Clouds, storms and sunsets by MattysFlicks

Categories
General Innovation Lifestyle Public Health

The Seedfolk Store | An Urban Agriculture Project

I recently had the privilege of visiting The Seedfolk Store in Rochester, New York. The store is run by the non-profit ProperRochester, Inc. which focuses on community engagement through urban agriculture with a focus on healthy food availability, youth empowerment, and entrepreneurship. The shop takes some inspiration from the book “Seedfolks”, a children’s novel by Paul Fleishman, in which an ethnically diverse community in Ohio works together to transform a vacant lot into a garden. I visited the shop as part of an activity for a medical humanities course I am currently taking, entitled “Death by Zip Code”, taught by Katrina Korfmacher, Ph. D. This course explores the importance of the environment on population health, focusing on epidemiology. The Seedfolk Store provides some vegetation in an area that is otherwise a “food desert”. These areas usually have fast food restaurants and convenience stores/corner shops. The Seedfolk Store has a refrigerator full of vegetables that are often requested in the area by neighbors. As a new organization, they are working on spreading the word about their efforts and services. While a full-fledged vegetable market would be unsustainable and unprofitable, this hybrid-shop is a great compromise and is catered to current demand. The shop gains some profits by selling granola from Small World Bakery, selling coffee for Coffee Connection, and selling potted plants and green tea bags that they make.

photo 4

The staff’s experiences with ProsperRochester, Inc. is inspiring−it is clear to me that this team is daring and ambitious. They are dedicated to teaching youth about the specifics of food planning, processing, and distribution (selling and educating). These youth are employees and volunteers who work at the Seedfolk Store, green house, and in community gardens. They are actively involved with cooking education, small-scale food production, urban farming and learning about the local food system. The Seedfolk Store provides nutrition workshops, cooking classes, soup for the general public on Tuesdays, potted plant sales at the Rochester Public Market, and a rentable kitchen space for cooks. On April 12th, the team began planting at the M.K. Gandhi Institute for Nonviolence, a community partner which provides ProsperRochester, Inc. with space to widen in-ground gardening. In many locations, ProsperRochester, Inc.’s concerns about lead in soil has led to their use of raised bed gardening. ProsperRochester, Inc. also works closely with In the City Off the Grid, with which they are creating an aquaponics agriculture system at the Gandhi Institute and expanding a hydroponic greenhouse on Rochester’s East Main Street.

Most inspiring is that The SeedFolk Store’s team truly lives the message of health that they promote. Three members lost large amounts of weight and they told us their secret−namely they changed their diet, eliminating refined grains and processed sugars while increasing their intake of fruits and vegetables. One of the cooks renting the kitchen is a cheerful immigrant from Africa who wrote a children’s book about nutrition. She brought her own cooking supplies to The Seedfolk Store’s kitchen and waited in the rain for her ride home. This determination to further the health of one’s community through nutrition, no matter the obstacles, is very much necessary in all urban areas in the United States. I hope to help spread the word about this initiative and soon see similar projects pop up across the country to empower youth with the ability to make healthy life choices.

To visit The Seedfolk Store online or in person:
The Seedfolk Store
540 West Main Street, Rochester, NY, 14611  
(585) 279-9943

Categories
Clinical General Opinion Public Health

Parents fight Croatian law enforcing mandatory child vaccinations | We don’t need no vaccinations, we don’t need no thought control

Photo courtesy of https://www.flickr.com/photos/zsoolt/

The Croatian constitutional court has made the vaccination of children a legal obligation. Their reasoning behind this law is that “a child’s right to health is more important than a parent’s right to choose (wrongly)”. Their words, not mine, although I do agree.

Vaccination has been a part of paediatric care in Croatia for years, and children have regularly been vaccinated throughout their education, although it has never before been officially mandatory. Now, parents have the potential of being prosecuted if they do not to vaccinate their children. In Croatia, children are vaccinated against the following: tuberculosis, diphtheria, tetanus, pertussis (DTaP), polio, measles, mumps, rubella (MMR), and hepatitis B. It was always said that vaccination was mandatory, but whenever I asked what to do with unvaccinated children, I was given vague answers. Nevertheless, the law now states that a parent’s failure to ensure the vaccination of their child will result in a fine and a visit from social services. A large group of parents, accompanied with some medical professionals, disagree with this and have called for a public discussion.

Photo courtesy of https://www.flickr.com/photos/jaccodeboer/
Photo courtesy of https://www.flickr.com/photos/jaccodeboer/

“Nobody wants to take the responsibility.”

This is an argument many parents have repeated when asked why they don’t want their children vaccinated. The majority of “modern” parents are best pals with Doctor Google, who has told them stories about apparently unnerving side effects of certain vaccinations. Furthermore, media dramatization and sensationalism add another factor in the vaccine debate.  Although the Internet and media in general can provide strong patient education, it can also provide highly biased information thereby providing harmfully improper patient education. Even though they are dramatic and stand out, articles reporting on a child developing a long term and/or life changing disorder or condition are quite rare. Reading such an article invokes fear in readers. Statistics are what matter in possible negative outcomes. How many stories about serious problems arising from a vaccinations exist? And how many children are vaccinated every day? And what are measles, mumps, rubella, polio, pertussis, and the other diseases like when they take hold of a child’s body?

Understandably, parents want to protect their children and don’t want their little ones to suffer any life changing side effects, short or long term. Before allowing for any vaccination, they want doctors to tell them with absolute certainty that no harm will come to their children from a vaccine. Surely parents would also like completely safe transport, but they are willing to put their children in a car, train, or plane because of the benefits of fast travel outweigh the small chance of an accident happening. It is impossible to expect doctors to claim that anything is completely safe, and “take responsibility“ if anything at all goes wrong. This is why there are patient consent forms and small directions in all medication boxes explaining possible side effects. If a parent asked me whether I would take responsibility for any possible side effects of vaccination, I would reply with another question: Would you, as a parent, take the responsibility of your child getting an infectious disease that could leave them with life changing consequences, or even possibly be a cause of death?

Although I would try and talk to people who refuse vaccination, if they continued to refuse I would respect their decision. In the end, I appreciate it is your right to decide what you want to do with your body. A friend of mine has pointed out to me that this law might limit the right of choice; therefore not allowing parents to make a choice about their children. I can see his point, and as I said, everyone should have the right to decide what to do with their body. However, this is a choice parents aren’t making about themselves, but about their children, who are too young to make an informed choice. Are their parents making an informed choice though? Do they have enough information to go against medical advice? Many countries don’t have a law about mandatory vaccination, and maybe those fighting against this law will manage to win, but I hope this whole debate will at least raise awareness and make people think about the importance of vaccination.

Featured photo courtesy of zsoolt

Categories
Clinical General Innovation Opinion Public Health

A Quick Guide to HPV Vaccination

Photo courtesy of Agência de Notícias do Acre (https://accounts-flickr.yahoo.com/photos/fotosdoacre/13065655185/?rb=1)
ThinPrep of CIN 1/HPV Photo from Ed Uthman
ThinPrep of CIN 1/HPV
Photo from Ed Uthman

Human papillomaviruses (HPV) are non-enveloped, double-stranded DNA viruses which infect human mucosal and epithelial tissues. They survive well in the environment and can be spread through direct contact with a wart, a fomite (ex. doorknob or toilet seat), or when an infant passes through the birth canal.  HPV is now the most common sexually transmitted infection in the US1. Even though most infections resolve spontaneously without further progression, it can lead to the formation of skin warts and has been associated with cervical cancer since the 1990s. HPV-6 and HPV-11, two types of HPV, are known to cause genital warts and low-grade cervical abnormalities, while HPV-16 and HPV-18 cause about 70% of cervical cancers. Despite the prevalence and potential severity of this viral infection, there is no specific treatment for HPV. Medical intervention involves treating clinical manifestations of the infection, including removal of warts or cervical neoplasias.

The spread of HPV can be reduced, but not prevented, through the use of condoms and other methods of physical barrier protection. In addition, two new inactivated subunit HPV vaccines, Gardasil and Cervarix, were recently approved by the FDA. The vaccines have no therapeutic effect on those who are already infected and the duration of vaccine protection is unknown, but studies are underway to determine if immunity wanes as time goes by. Both vaccines use the L1 capsid protein, which is produced through recombinant technology. This capsid protein then self-assembles into noninfectious virus-like particles (VLP), which function to elicit a memory immune response.

In 2006, Gardasil, a quadrivalent vaccine (HPV4), was approved by the FDA for both males and females of ages 9 to 26. Gardasil is composed of HPV6, HPV11, HPV 16, and HPV 18 and is administered in a 3 dose course. If a patient has not had all 3 vaccine doses by the age of 26, the remaining rounds can still be administered. HPV4 vaccination is also recommended for all immunocompromised males and men who have sex with men under the age of 26. In 2009, Cervarix, a bivalent vaccine (HPV2) containing HPV 16 and HPV 18, was approved by the FDA. HPV2 is approved for females ages 10 to 25, but is not approved for use in males. Neither HPV4 nor HPV2 contain any preservatives or antibiotics, and more than 99% of those who are vaccinated produce an antibody response to the viral types present in the vaccines.  Prior infection with one of the virus types does not diminish the protection against the other types of HPV present in the vaccine.

The vaccines should not be administered to those who are allergic to any vaccine components, are acutely ill, or pregnant women. If a woman becomes pregnant prior to completing the 3-dose vaccination, the remaining doses should be postponed until the completion of the pregnancy. Side effects of HPV vaccination include pain or swelling at the site of vaccination and fever. Overall, no serious adverse reactions have been documented.

Dr. John Kreider's son and grandson with a historical marker recognizing Dr. Kreider and Dr. Mary K. Howett's work which lead to the development of the HPV vaccination. Photo courtesy of PennStateNews.
Dr. John Kreider’s son and grandson with a historical marker recognizing Dr. Kreider and Dr. Mary K. Howett’s work which lead to the development of the HPV vaccination. Photo courtesy of PennStateNews.

Despite the fact that HPV-16 and HPV-18 are highly associated with cervical cancer, controversy has surrounded the HPV vaccines. In general, parents are understandably reluctant to vaccinate their children against a sexually transmitted infection at such a young age, perhaps because the duration of the protection resulting from vaccination is still unknown. Dr. Diane Harper of the University of Missouri-Kansas City School of Medicine does not believe the vaccine should be mandated by law since only 5% of women infected with HPV develop cervical cancer2. While that seems valid logically, the basic principle of vaccination is to prepare the body’s immune defenses for eliminating virulent agents before they can lead to harmful medical conditions. As an example, consider poliovirus. Poliovirus affects each individual differently, with up to 95% of the total cases being inapparent or asymptomatic3. Only a small percentage of those who are infected with poliovirus get paralytic polio, the condition which was seen in the public eye so often.  Even though infection with poliovirus rarely leads to paralytic polio, parents do not usually hesitate to vaccinate their children in order to prevent this outcome. So, both vaccines prevent a serious outcome which rarely occurs as a byproduct of viral infection, yet polio vaccination has general support around the globe. Despite the fact that the HPV infection doesn’t always result in cervical cancer, parents should not overlook this vaccine, as it drastically reduces the risks of this serious complication even further.

Sources:
1) http://www.cdc.gov/vaccines/pubs/pinkbook/hpv.html
2) http://www.npr.org/2011/09/19/140543977/hpv-vaccine-the-science-behind-the-controversy
3) http://www.cdc.gov/vaccines/pubs/pinkbook/polio.html