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October Awareness: Breast Cancer and Hispanic Heritage

Tina asked for bloggers to participate as guest bloggers for October, on the theme of Breast Cancer Awareness, in honor of her Mother, a breast cancer survivor.  Here is my cross-listed post.

October is Breast Cancer Awareness Month.  It is also Hispanic Heritage Month.

And breast cancer is the leading cause of cancer death among Hispanic women.

The Hispanic population is the largest minority group in the United States.  Hispanic Americans make up roughly 14 percent of the U.S. population, but they are the fastest growing segment, estimated to reach 20 percent or more by 2050.

Even when access to health care is adequate, for Hispanic women in the United States, breast cancer is more often diagnosed at a later stage, when the disease is more advanced.   Further, approximately two-thirds of breast cancer found in Hispanic women is discovered by accident – not by screening or mammogram.

Actually, according to a Kaiser Permanente study, the news gets worse.  When compared to non-Hispanic white women, Hispanic women are more likely to be diagnosed at a younger age, have cancer that has already spread beyond the breast, have tumors with cell type that have a poorer prognosis, have larger tumors, and have tumors that cannot be treated with some of the most effective medicines.

What’s the public health response?  Interventions aimed at increased screening, access, and education.  But is it enough?

If early detection and survival is the goal of Breast Cancer Awareness Month – then there has to be a conversation about an individual’s ability to access health care information and services.  Central to that conversation is the reality that those very life-saving information and services are unjustly linked to one’s racial, ethnic, socio-economic, and immigration status.

How do these dynamics play out?  Here is a local example.  If a woman cannot demonstrate access to or eligibility for some type of insurance (or have the ability to pay) – programs can deny her a screening for breast cancer.  Why?  The argument is that it is unethical to provide a screening for a disease when the patient will not be able to access treatment for it.  In the past year, one of the screening programs in New Orleans was shut down for this reason.

What is more unethical?  Denying screening?  Denying treatment?  Or needing any of coverage or eligibilities in the first place?

The bottom line is that women in our largest ethnic minority group do not have a good outlook when it comes to breast cancer.   And improving the outlook is about more than screening programs and access to medicines.  Striking at the heart of a serious disease means a serious look at our entire system of care and asking where treatment for breast cancer and survival of women lie within our values.

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Get it! Got it? GOOD.

It’s flu season and as predicted and anticipated, H1N1 is back and stronger than before.  This extra nuisance gives little indication over who it will strike down and who it will simply inconvenience… but it does seem to have a particularly strong affinity for children.  And one way or another, every single one of us is going to be exposed to it.  We are all potential host of this virus and we all will have the opportunity to unknowingly passing it along until the virus has neutralized itself within our collective systems.

Sound scary?  Well, it should.  Let’s say that 25% of us come down with those uncomfortable flu systems.  And let’s say that of those 25%, half will need IVs for dehydration, a common side effect of flu.  What would happen in your city’s hospital system if more than 10% of the total population needed some sort of medical assistance?  That’s a 10% excess rate — a percentage of people needing services over the usual load of illnesses and injuries.  And what if your child is the one of the ones who becomes REALLY ill?   What will it be like to get them care within a system that is that overburdened?  If the situation turns life-threatening, does your medical facility have the resources, equipment, and experience to handle advanced flu-related symptoms and infections?  And can they carry all of that out with a significant increase in patient demands on the system?

But good news!  WE HAVE A VACCINES!  One for seasonal flu and (impressively!) one specific to H1N1.  It’s effective.  It’s safe.  It’s being made in large numbers and supplies are available or en route to your city!  WOW.

So seriously.  I respect individual rights to make decisions.  I do.  Truly and honestly.  And while there ARE good reasons for a few people to think about passing up a life-saving vaccine that not only protects them, but everyone around them — for the vast majority of us hemming and hawing and doubting and worrying, the decision is a really easy one to make.

You get the damn shot.

I’m not your doctor and I’m not open to any liability, so I’m not going to sugar-coat it.  Here is the advice from the Center for Disease Control and the American Academy of Pediatrics.  Here is what your doctor would say if they weren’t obligated to neutral, open, and supportive bedside manner:

Get the damn shot.

Okay, okay, there IS a caveat.  Some people are considered priority in the vaccination recommendations.  If you’re young and not around kids and don’t work in medicine and have no other health issues and have little history of getting seasonal flu ever… well, maybe y’all could hang out for awhile.  Just until we use our supplies to those more likely than you to get sick and pass it around.  But the rest of us?  Let’s get in line.

But let me back up a bit.  This is NOT judgmental or crazy or blaming.  I’m a straight up person and I’m calling the spade a spade.

I understand that it is hard to make a choice about things like vaccines and viruses and strains all over an illness that we’ve all had, or we think we’ve had, at one time or another.  The fact that it is so familiar (what’s a little flu?) minimizes it’s importance in our minds.  When faced with a “choice” to vaccinate, we take on the responsibilities that come with it whatever we decide.  We must weigh the cost of the inconvenience, the fee, the appointment… and any risk, no matter how minuscule.  The perceived risk of flu seems less innocuous than the unidentified maybes and pseudo-scientific rumors of getting a shot.  After all, we’ve all had flu risk in the past.  Why not just take flu risk again?  Save myself the hassle?

The “decision” of whether or not to get a flu shot, particularly with a novel virus spreading, is not just a personal decision.  It’s not just about you.  The decision, your decision, impacts not only you and your family — it impacts EVERYONE AROUND YOU.  Personally, I feel that part of considering the responsibility of whether or not to vaccinate includes considering the responsibility we have to our communities, friends, neighbors, and relatives.  The plain and simple reality is that vaccines save lives.

An excerpt from Slate:

One of those who died in Colorado was 8-year-old Joseph Williams. He had been perfectly healthy before the sudden onset of a stomach ache and high fever. His parents took him to the emergency room, believing they would bring him home quickly, but a brain inflammation brought on by the influenza killed him in hours.

The day after Joseph’s death, his parents held a tearful news conference to beg everyone in the community to get flu shots. If more people had been vaccinated, they argued, their child might have never contracted the infection in this first place.

Damn straight.

One of us — you, me, my kid, your kid, the woman at the deli, the UPS delivery guy, your newborn niece — anyone of us could be the next one who falls suddenly and irreversibly ill.  And the risk of that happening is much, much greater than any risk from a vaccine.

To address some common concerns:

Worried about thimerosal?  Read this.  There are different kinds of flu vaccine, some without preservative.  Vaccine for children under age 2 is preservative-free — just as all routine vaccines have been since 2001.  If you’re concerned, find out which vaccines are being given, to whom, and at which locations.  Ask questions.

Have a homeopathic treatment?   If it makes you feel better, great.  Just don’t think you’re protected, or that you’re protecting anyone else.

What about antivirals?  Antivirals (oseltamivir = Tamiflu, or zanamivir = Relenza) are recommended for folks who have serious symptoms.  A recent British study recommended extreme caution in it’s use, as the side effects of the antivirals are often worse than the actual flu.  Antivirals temporarily prevent a virus from doing what it needs to do to reproduce in your body… it doesn’t stop you from getting the flu forever.  It’s not a substitute for vaccine.

Think a shot gave you or your kid the flu?  Young children are more likely to have mild side-effects from a vaccine (things like fatigue) because their bodies have a lot more work to do to build immunity.  Those side effects will minimize as the kids grow older and have more illness exposure and greater immunity.  But no, no, no, for heaven’s sake NO — you cannot get the flu from the flu shot!  If you developed the flu after a shot, it was because you already had it.

How many to get?  For the novel H1N1 virus, 2 doses are recommended for young children because they are not “immunologically primed” — this means that they have had limited flu exposure in the past and therefore do not have a lot of antibodies built up in their systems.

What’s the whole thing about paralysis and flu vaccine?  In 1976, 35 million Americans were vaccinated against a flu that broke out in New Jersey (a H1N1 swine flu) which ended up not having the mutations necessary to cause an epidemic, despite a widespread public health warning campaign.  Those vaccinated were tracked very closely and seven cases of Guillian-Barre Syndrome were reported within 10 weeks of the vaccine.  Just because you are diagnosed with something after a vaccine does not mean that the relationship is causal (that one caused the other), it means it’s temporal (one happened to come before the other). If you have a car accident at noon and happened to eat breakfast that morning, your eating breakfast didn’t necessarily have anything to do with your car accident.  Nonetheless, the cases of GBS were studied to great degree.  No evidence of causation has ever been shown, despite research which included an active GBS surveillance program through the early 80s that showed no association and no risk of GBS from vaccinations.

For those in New Orleans:

To my knowledge, supplies of the 2009 H1N1 vaccine are not yet available in our community.  However, the seasonal flu vaccine IS… and it’s not too late to head it off.

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Thoughts on Rising Tide 4

I’m so glad Harry Shearer gets it.

He spoke compelling at today’s Rising Tide, poignantly describing the how New Orleans lost the media battle regarding the city’s story of Katrina, the Flood, and recovery.  He’s absolutely right, of course.  Read any article about New Orleans’ recovery and go to the comments; they are ripe with misinformation, sweeping falsehoods, and complete hatred towards this city and the people within it.  The reason it’s important for the people of New Orleans to continue to tell the story is because, somehow, the facts are still not understood: that this city was destroyed in a man-made disaster, a Flood that occurred when a Federally-funded agency failed to perform as it had been designed to perform because it was never built correctly.  And I can’t believe we still have to say this, again, but FOR THE LOVE, this city is NOT below sea level!  Can we move on now, please?

(See some video of Shearer’s speech here.)

A last minute cancellation resulted in my being a member of the Health in New Orleans panel (versus its moderator) — along with two well-known, established mental health professionals.  One is consistently named a Top Female Achiever in the City for her well-respected work with the police mental health crisis unit; the other, a psychiatrist and medical director for a large local non-profit.  I was an out-of-left-field addition to this group… I don’t have one primary affiliation with one organization, my scientific perspective is a bit different (public health), and I’ve spent nearly 4 years volunteering and researching how clients and health promoters navigate the waters of New Orleans social systems.

I wasn’t intimidated by the other panelists, but I definitely wanted to take the conversation to other places that I didn’t feel it was going (or maybe could not go).  Instead of sticking to questions and topics that had been pre-arranged, the my fellow panelists opened the talk to the floor to do a large Q&A.   What followed were a lot of discussions about local services, which I don’t find particularly useful in this type of venue: the panel wasn’t envisioned as a laundry list of mental health services for a reason, because people tend to not remember those sorts of specifics.  (If you want to list services or achievements or whatever, bring a resource guide and pass out copies.)  Panels, I feel, should build on that sort of available information.  A more productive conversation may be one that discusses how we can supplement existing programs.  As an example: what can be done to better support families to care for their loved ones transferred to facilities an hour or more away with the closure of NOAH?   Or maybe a discussion of the sorts of a strategies we all can use to handle our own stress and mental illness outside of seeking professional providers?   In my thought, the power of a group like RT is when you excite the room — after all, these are folks who write and read and write some more — so I think it’s important to try and throw out big issues.  Let people get charged up and see what types of good actions come out.

I did try to throw in a few cents — pointing out that health is so much more than access, more than doctors and medicines.  We are resource-poor in New Orleans, without a doubt, but focusing on access and getting more providers and opening more clinics and getting more people health insurance is ultimately a disservice to the people of New Orleans.  I’m not saying these things aren’t important.  I’m saying that in the end, these are not the factors that create healthy lives.  What does create healthy people are the more difficult, more sensitive, more POLITICAL realities of our lives.  Our physical living environments (FEMA trailers, polluted properties, abandoned structures, proximity to blighted areas), our work environments (are we respected? do we have benefits and fair pay? do we feel useful?), our school environments (are our children eating healthy lunches? are they learning? do they have pride in who they are?), our streets (can we exercise without fearing for our safety? are children safe walking home?), and our neighborhoods (can we buy affordable healthy foods close to our home? is there a clinic nearby to see a doctor for non-emergencies? can we get a medicine when we need it?)  All of these factors contribute to our health: they create stress, they weigh on our hearts and minds, and when not addressed in comprehensive ways, they make us sick.

And, since the feeling of having no control over your life is a key part of mental illness, (as mentioned by a panelist) perhaps involvement in some of the issues above on a community level would help individuals find more purpose and agency in their lives.  Just a thought.

But that’s not all.

And here is where I am embarrassed.  My one note, the one thing I most wanted to discuss, maybe even the most important thing to discuss within the context of health and New Orleans, did not get mentioned.  I didn’t know where to put it in without sounding like the crazy loon in the armchair throwing off the conversation… so I waited for a question from the audience that would let me bring it up.  Unfortunately, it didn’t come.  So I didn’t say anything about the issue of race and class… and neither did anybody else.

Which is a shame because we cannot consider the scope of health challenges of any kind within our city — access, stress, mental health, behavioral concerns, nutrition, whatever health issue one can think of — without discussing race and class.  Race and class shape any health experience regardless of the location.  But in New Orleans, it is a paramount issue.  For one, before 2005, New Orleans was the only city in the country that had a defined two-tier system with separate and (un)equal medical facilities for the haves and have-nots.  What has not returned post-Flood are those services for the have-nots.  So what isn’t being said is that the reason these services aren’t here, or are being taken away, is because they are for a population that many do not want here in the first place.  The rest of us work away at putting money and resources into community clinics (whose funding is not indefinite) and outreach and signing individuals up for public services — but how effective can we be in the long run if we never take a step back and look at the big picture?

In the panel that preceded ours, John Slade mentioned that the movement to re-open Charity Hospital was gaining support because Uptown whites were having to wait longer in medical facilities for treatment and were unhappy with the current desegregation of the system.  Although flip, I think his comment speaks to an important truth… at the heart of our health concerns about access, treatment, and who gets care are long-held ideas about race and class.  Until we address those base realities and histories with honesty, I’m not sure we can build a solidly healthy community — no matter how many top-of-the-line medical facilities we open.

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Recovery and Rebirth

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Why does New Orleans have different moral rules of conduct?

My silence on the issue is not because of lack of interest, thought, or evidence.  Either I’ve become so apathetic that I’ve lost the ability to hold faith in anything (a distinct possibility) or I’ve smartened up — after awhile, you just have to face the fact that the dining room table is never going to respond.

Then, this past week, we were faced with situations that necessitated medical attention. The first occurred while in Pensacola, where we visited a walk-in clinic that was part of the medical center Kate was unexpectedly born in 3 years ago; the second took us to an urgent care center favored by many in our area as one of the best around.

The differences were distinct and pronounced in every respect.

At Pensacola’s Baptist Medical Center, both Kate and I were seen by a friendly, good-natured, respectful, and competent provider who gave both of us very thorough exams with no ounce of hurry.  Kate had a chest x-ray to check out some wheezing heard in her lungs.  We had several pharmacy prescriptions filled.  The kids played in a children’s area.  And, all of the above happened within a 2-hour time frame.

Then, over the weekend, one of the kids who was staying with us at the beach tested positive for Type A influenza (aka: H1N1 flu).  The testing occurred on Sunday, with Will’s first day of school Monday, the next day.  We couldn’t send him to school until we knew that he was without flu — and in the interest of due diligence, needed to show that the rest of our family were not harboring flu as well.  Both Kate and Will had some fever on Sunday afternoon, and on Monday morning, all four of us were showing fever.

Despite pre-arrival calls to the one clinic that would see all four of us, and despite filling out all paperwork before our arrival, we waited for over an hour and a half in the open waiting area.  It was not particularly busy.  When we did see a nurse, she was secretive in her assessments (if you take a measure, you share it with the client, and you most certainly do not hesitate in reporting it), and was incomplete in her evaluation.  I had good reason to believe that some of the equipment was showing measurement error and one of the machines even broke during use.  We heard the doctor insulting us from the other side of the door.  When we finally did get seen, they did not provide the service we requested, I had to correct an inaccuracy the physician made regarding influenza, and in the end, they prescribed medicines the CDC specifically advises against for H1N1 flu treatment and prevention.  From start to finish, the whole thing took about 4 hours.  Note: we did not take the extra 2 hours it would have taken to fill the prescription.  (Buying a house is faster and involves less paperwork than filling a prescription in New Orleans.)

In short, we tried to do the right thing so that Will could be cleared to attend school.  In the process, we paid a gross amount of money, lost precious work hours, were insulted, and came away with poor treatment advice.  Such is the nature of health care in New Orleans.

Yes, without question, the health care system in the United States is incredibly broken and dysfunctional.  Our country is among the worst in the developed world in virtually every indicator of health.  Without question, it’s bad.

And in New Orleans?  Whether from lack of providers, lack of resources, lack of compassion, or apathetic frustration (all of which are factors) — it’s even worse.

A few months ago, I was asked to help on a survey that a local agency wanted to do regarding experience with the health system.  It was being put together last minute, by well-intended people who were driven by a need to show the dysfunctions within our medical services.  Surveys in New Orleans are incredibly difficult post-Katrina (if not impossible) because we simply do not know how many people are here, particularly within marginalized, minority populations.  Still, this organization had a group of health students coming from a respected northeastern University during their spring break, and these students wanted to “help” by doing whatever “survey” this group could concoct.  Upon investigation, I discovered that the students were under no supervision from their institution, had no IRB approvals despite the sensitive nature of the questions they were wanting to ask within high-risk groups, and (most alarming) felt no ethical conflict about any of the above.  These things would be in-excusable for work done in their own city, but in New Orleans, a place known to be low on resources, it was seen as perfectly acceptable by both these students (who, frankly, should have been trained to know better) and the local organization.  In short, the idea was that it was fine for New Orleans to accommodate lower standards of research and be accepting of unethical inquiry simply because we are resource-poor.

I withdrew from the survey and advised the organization to put the students to work finding information that was needed for an area benchmarking of services.  The students protested that it wasn’t a good enough use of their time and proceeded with the survey… which grew into a monster so unethical and alarming that I pondered reporting it to their home institution.

All people deserve ethical treatment in research, no matter how resource-poor they or their communities may be.  I do not feel that this is negotiable on any level.  What does that say about us when we decide which kind of people get respect and value in a health inquiry and which do not?

How we can talk about health without talking about ethics?  About what it means to be human and the ways in which our society should reflect how we define humanity?  Isn’t that the point?

I do not know how ethics have left the conversation of health care.  How, in our debate of it, we have forgotten to discuss what is right, what is the most human response.  But it isn’t there.  And in New Orleans, ethics is not only ignored but deliberately surpassed as an annoying step one can causally eliminate.  As if the people here are so desperate and pathetic that we should be thankful for any “help” we can get.

It is beneath us to compromise ourselves, no matter where our community stands in recovery, no matter where our society stands in development.

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Recovery and Rebirth

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Of Two Minds

In class on Tuesday, I showed students part of a documentary film called SASA! about the interplay of violence and HIV in women’s lives in Uganda and Tanzania.  Sasa means “now” in Kiswahili (the Bantu language most of us know as Swahili) and was chosen as the name of the film to emphasize the need for knowledge building about how violence, disease, and cultural power dynamics impact women.  The organization that worked to create the film, Raising Voices, is a respected NGO working in non-violence, specifically regarding women and children. The film itself was made by The People’s Picture Company in partnership with Raising Voices.

The film follows the stories of women who have been personally impacted by violence and HIV.  Their lives illustrate the common barriers women face to health and personhood.  The issues are not particularly unique to this one place nor are they revolutionary in terms of what we already know about women, poverty, and heath — but they are still tremendously tragic.  Bride prices, cultural expectations, personal beliefs of a woman as economically dependent, social acceptance of plural marriage… when these are combined with violence and poverty, disease is not far behind.

(Quicktime 30 minute film here.)  SASA (30 minutes)

I was surprised at how much of the material discussed in the film came as a surprise to students, or at least, that they showed such great pain at the realities in the film.  I had been taking it for granted that these were things everyone knew about women in poverty: that their lives are characterized by great abuses and limitations that are unthinkable to women raised in the West.  In fact, I usually am frustrated by the over-characterization of ALL women, particularly AFRICAN WOMEN, of living these oppressed lives.  Films like this often frustrate me because I feel it gives us wealthy Westerners reason to pity women who aren’t like us, infantilizing their lives and experiences in patronizing, imperialist ways.  I’m more comfortable talking about strengths, resistance, community building, and learning.  These sort of films and stories can paints the picture that women, even women within these terrible circumstances, are completely passive — controlled by the whims of their fathers and husbands — providing no self-directed action toward any part of their lives.  In depth research into these issues shows us that women who we view as the most “oppressed” by our definitions of oppression still act in resistance in ways that we might not see or appreciate.  Those are the sorts of conversations I like to have.  Let’s talk about what works and build on it.

But this class is an overview class.  Many students within it have never been outside of the United States, least of all to a non-OECD country.  First, then, they learn of the realities of poverty.  Thus, the film.  Thus, the discussion.

It was a good class, a fine, interesting discussion.  But it left me a bit raw.  I’m not sure how to teach an introduction to the realities of global poverty without painting the “woe is me” picture.  Is there a way to tell a tragic, terrible story, showing relevant barriers and challenges without painting a picture of a passive victim and active perpetrator?  I tried my best to break up that binary dynamic, about how the limits on one equally limits and defines the other – if you define one as black, then by definition the other one is completely white, leaving no room for gray.  I tried to walk that line of breaking thought out of submission versus aggressive, masculine versus feminine, victim versus perpetrator… but who knows how far that was absorbed.

Maybe it’s just that easy to believe that men are assholes?  Or, maybe it’s easier to believe that women are passive, submissive, and silent.

Donors do like a good victim story, after all.

Still, I like this film.  I think it does a good job of showing the problems and gives focus to how the community is coming together in their own terms to deal with them.  It does an excellent job of showing the ridiculousness of the “ABC” approach and how utterly useless it is in women’s lives.  (The ABC approach is the “Abstinence, Be faithful, use Condoms” approach to HIV prevention.  You might as well tell women that drinking Kool-Aid will prevent HIV.  Actually, the chemicals in Kool-Aid are probably more effective in limiting HIV infection than ABC.  But I digress.)

It ends in a positive light, showing the impact of peer counseling and community work.  And of course it does!  Because ultimately the film needs to show interest and build compassion.  Ultimately, this is an agency that relies on donations.  It is a wonderful organization doing work I respect and admire.  The sort of place I’d love to work, actually.  When you think about it, they tread a fine line in this film: showing just enough compelling story for donors and then showing the proactive ways a good organization can be capable of improving even the most difficult of lives.

So why do we focus so much on all that terrible, victimizing stuff?  What is it that is so compelling?  Is it the same thing that makes us listen harder when the neighbors start to fight, or slow down to look at the scene of a traffic accident?  Do the realities of living in poverty provide good voyeur material?

I can’t help but feel a little frustrated.  Maybe it’s that I’m jaded and tired of the essentializing of ‘women in the developing world’.  Maybe I’m tired of seeing the same solutions for problems that seem never-ending.

In the end, I felt that putting it here might be a way to work it out.  Maybe I’m wrong and there are very surprising things to be found in this film.  Maybe I’m alone in my frustrations.  And maybe there is more we can do?

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What’s that smell?

Dear Dow,

WHAT in the world DID YOU DO THIS TIME?

(From the T-P : )

The strong chemical-like odor blanketing the metro area this morning is coming from the Dow chemical plant in Hahnville, according St. Charles Parish emergency officials.

Rodney Mallett, a spokesman for the Louisiana Department of Environmental Quality, said the plant released the chemical ethyl acrylate.

So.  My husband is breathing ethyl acrylate as he carries out the trash?  My children are breathing ethyl acrylate as they run and huff and puff and play outside in the sun?  I am breathing ethyl acrylate as I walk to campus?

You down play it, sure.

(From same T-P : )

St. Charles Parish spokeswoman Renee Allemand Simpson said parish officials were told by Dow that a crack had developed along a seam in a tank at the plant, which released the odor at about 6:40 a.m.

Simpson said a Dow technical advisor [sic] said a blanket of foam had been sprayed over the roof of the tank, reducing the volume of leakage, and that the chemical was being pumped from the tank.

Some people may experience headaches, dizziness and vomiting, Simpson said. Two deputies were made ill by the release and were treated at St. Charles Parish Hospital, according to Sheriff’s Office Spokesman Capt. Pat Yoes.

“It’s not toxic at the levels that it’s at right now, but it is noxious,” Simpson said.

The plant has not shut down and is operating as usual, Dow spokesman Tommy Faucheux said.


Not that you have any history of downplaying chemical leaks or anything.

(Again, T-P : )

The chemical may cause toxic effects if inhaled or absorbed through skin, and it can irritate or burn the skin and eyes. The chemical is listed as a possible carcinogen by the National Institute of Occupational Safety and Health. Officials, however, say the mixing of the chemical in the air has resulted in levels too low to be a health threat for those outside the immediate area of the plant.

Hahnville resident Ida Martin said her son woke her up early Tuesday after smelling the odor, but when she called the parish Emergency Operations Center, the person who answered the phone seemed to downplay the matter.

“She said it was just an odor,” Martin said.

Sorry, DowBUTIDON’TBELIEVEYOU.

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NOLA

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April Just Posts for a Just World

Kate has been dealing with diarrhea for almost two weeks. It’s been a pain. She has an incident at school and is home for a day and nothing happens, then she goes back and the whole thing happens again… with an occasional blow out at home that results in floor, clothes, and bed washings. I’ve been able to take her to the doctor for tests, give her fluids, and not for a moment worry about any of it. The inconvenience of it all was in the back of my mind when I read Robin’s post for assistance. My friend, Robin (whom you may remember from her amazing Mama-multitasking) lives and works in Bangladesh. She works for ICDDR, B and recently posted a plea for support for her agency, which is struggling to get re-hydration salts to an impoverished population that will die without them. One of this month’s Just Posts is about poverty in Bangladesh and offers an interesting backdrop to the reality that Robin sees in her work — and what went on in my own head when I thought about how “inconvenient” diarrhea was for our family while others are facing it as a life and death situation.


Also? A package of oral rehydration salts costs about ten cents.

Just a thought. And on to Just Posts.

Thank you thank you thank you thank you to this month’s readers and writers and especially to the new folks who contributed to the April Roundtable… thank you. Be sure to stop by and say hi to my Just Posts Partner, Alejna, too!

April Just Posts:

THANK YOU to April Just Post Readers:

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You don’t want to meet the new boy in town.

Jazz Fest has graciously occupied all extraneous space in our lives over the past two weeks, allowing only minimal time for me to feed my inner-epidemiologist with all of the emerging news related to H1N1 flu.  In the mean time, New Orleans has come into the flu pandemic fold with an 8-year old testing positive for H1N1 at a local elementary school. That school has voluntarily decided to shut down for a few days for thorough cleaning and for good reason. Because it’s the smart thing to do, and by relation, I believe the right thing to do.

One confirmed case triggering a three-day school closure does not suggest panic, imminent doom, or apocalypse.  Some may wonder, then, that if there were more confirmed cases, would it be reason for us to panic?  Well, no. There is never a time to panic.

It is, however, a good time to gather up a few smarts.

The mis-information is all over the place, and the backlash from the efforts of public health authorities to minimize disease is complaint topic du jour. I don’t profess to be a flu researcher or an expert on pandemic disease, but I am a public health professional and I get the basics.

Here is what I can do:

– clarify what pandemic is

– explain why flu is a big deal, and

– provide some background to why things like school closures are important.

The term pandemic describes spread of disease and has nothing to do with severity. Stages of a pandemic tell us where we are in our planning and preparedness – issues like whether we have time to stockpile vaccine (if one is available), if we should consider quarantine, or knowing whether the illness has run it’s course or if the number of new cases are expected to accelerate. So when WHO or the CDC declares a pandemic, they are saying that a new illness has spread across continents. The stages tell us where we should be in our mitigation strategies.

Understanding why flu is a big deal is a bit more complicated. We are all very familiar with seasonal flu. Seasonal flu is threat to individuals with low immunity – particularly young children and the elderly. Our immune systems are building until about age 20 and then begin to develop weaknesses at around age 40. The seasonal flu takes advantage of the developing or weakening immune systems to cause illness. When people die of influenza, the most common reason is actually bacterial: influenza weakens the system and an opportunistic bacteria takes hold. Deaths from pneumonia are therefore sometimes understood as deaths attributed to seasonal influenza. In general, we expect roughly 36,000-40,000 Americans to die each year of seasonal influenza. The exact numbers are a little shaky because every person who dies each year isn’t tested for influenza; causes of death are not so cut and dry. Death certificates reflect this by allowing for a list of factors that lead to death.

Seasonal flu is somewhat predictable in pattern. It worsens in the winter months and is of a repetitive strain of flu that has already been through a population, meaning that there will already be some type of natural immunity. Flu vaccines are made from the best predictions of the type of mutations and strains that will be seen over a flu season. A pandemic flu is one that has not previously been seen and therefore, the population has no naturally immunity (usually this implies a direct animal-to-human transfer).

H1N1 is alarming to the health community because it’s never been seen in this particular genetic composition before.  What was surprising about this particular strain is it’s composition: it holds genes from human, avian, and swine flu viruses. Further, it showed the ability to spread human-to-human through causal contact. Thankfully, the strain is not virulent. However, with each new host (whether mammal or avian) the virus gets another opportunity to mutate.

Mutation is what makes flu such a big deal.  It means that it can change over and over again, keeping whatever characteristics are the most effective at being spread over large numbers of hosts.

The influenza pandemic of 1918 killed more people in less time than any other disease before or since.  The 1918 flu was swift and vicious. It claimed the healthiest of people (mortality in the 20-40 age group far exceeded that of other groups who would typically been seen as the most vulnerable) and took them within days, killing them through suffocation as they bled into their lungs. The reports from survivors are gruesome.  The trauma of the event is blamed to be the reason we know so little about it now: because the survivors simply had to force themselves to forget it in order to function. Current estimates are that 50-100 million people died in the pandemic. In the United States, 28% of the population is estimated to have been ill with 500,000 to 675,000 people dying.

Until 2005, we didn’t know what type of virus was contained in the 1918 flu. Now we know it was H1N1 and that it was avian in it’s source. Scientists believe that the 1918 flu struck after several seasons of related flu – flu of the same type that simply needed a few years of mutation in order to acquire the gene characteristics for it cause a pandemic.

Unlike bacteria, viruses are not alive. They are strands of DNA and RNA encased in protective shells that require live cell hosts. Most viruses have a consistent shape, but flu can exist in many shapes. One characteristic shared by all flu viruses are little spears that come up from the surface of the protective shell. There are two type of spears. One is protein called hemagglutinin and the other is an enzyme called neuraminidase. We know of 16 varieties of hemagglutinin and 9 of neuraminidase, and these are how influenza strains are identified… as H1 to H16 and N1 to N9. Until 1997, it was believed that only H1, H2, and H3 could infect humans.

In 1997, children in China who had contact with birds died from flu that was identified at H5N1. Birds all over Asian were culled in an effort to halt bird-to-human spread of disease. Human-to-human spread was very limited, happening only in situations between individuals with direct, care-giving contact. In other words, the virus (while virulent) had not acquired the ability to spread easily and has thus far been containable.

We know that the flu of 1918 and H5N1 have some similar characteristics.  They are both avian viruses, for one.  But the most striking is that they work by turning the immune system against the host provider, causing an inflammatory response.  Hence why they are so efficient in destroying the internal organs of otherwise perfectly healthy people in the prime of life.   However, here is one important difference: as devastating as the 1918 pandemic was, the case fatality rate was thought to be about 5%.  The outbreaks of H5N1 have had case fatality rates of over 50%.  Not even the worst outbreaks of Ebola (at 40% case fatality) can match that terrifying level.

The question that keeps health scientists up at night is when and where H5N1 is going to mix with other strains of flu… ones that have the qualities of being spread through causal contact.  It’s not IF it does this.  It’s WHEN.

So. Back to our current H1N1. The good news is that it doesn’t seem to be particularly virulent. But how virulent would a flu have to be in order to cripple the medical infrastructure of a community? In a city like New Orleans, with a scarcity of hospital beds, a widespread case of mild flu over that of the expected seasonal flu disease burden could easily become a disaster.  One of the best ways we know to prevent the spread of disease is to limit opportunities for contact — especially within schools.  Particularly in the early days of an outbreak, when we are still trying to understand the etiology of a disease, closing a school due to a confirmed case of the new flu type is a good idea.

It doesn’t mean that anyone is panicking. It doesn’t mean that the health department is going overboard. It means that people are paying attention and acting accordingly.

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Photohunt: Purple

Purple has been a big color in the Internets this week.  First, twitter pages started going purple in honor of little Madeline Spohr.  Then in dual purpose of supporting another tragedy with the loss of baby Thalon.

Like so many others, I have spent time and tears this week lurking in the unexplainable, unimaginable loss of a child. I remember the losses of children within my own family and friends and it makes me appreciate the internet a little more… that we can share and educate and act.

These pictures of Kate, wearing purple, seemed an appropriate fit to this week’s theme.

I’m hugging my kids extra tightly. I feel very, very lucky.

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Where I ponder Charity.

Right after All Things Considered, just moments before the classical hour begins, our local public radio station has the owner of a consulting firm give advice in minute’s time.  They call it “The Louisiana Rebuilds Minute.”  We call it “The WWOZ Minute.”  (A friend coined the term, meaning that this is when he switches the radio to the local music station for that minute).

The idea of the Minute is that the people of Southeast Louisiana are too stupid to realize that it just takes a web search to find the answers to all problems related to an unprecedented rebuilding of an American city.  Since we’re too idiotic to figure it out, The Minute does it for us.  Paul and I have been joking for years that we would make a “Louisiana Rebuilds Minute” Generator — you just add in a common post-Katrina problem, throw in some patronizing ‘pull yerself up from yer bootstraps’ talk, and suggest that one consulting firm’s website has alllll the answers.  Insert those few tidbits, press enter, and BOOM, you’ve got your manufactured minute.

The point that The Minute doesn’t get is that JUST BECAUSE there is one organization out there with funds to build playgrounds, doesn’t mean that every school that needs one and applies will get it.  JUST BECAUSE one bus is available to a few folks who have the magic combination of ills and scripts to qualify for reduced medicines doesn’t mean that everyone who needs meds can get them.  And JUST BECAUSE The Road Home offered funds to some families doesn’t mean they have all that they need to rebuild their homes and lives.  Just because there are programs and grants and applications and dollars out there doesn’t mean that they are thought through, that they are honest, that they actual reach the people that they are meant to reach, and that they make any impact at all in the outcomes of our daily lives.

It is easy to get mislead.

It is easy to think that ideas are either good or bad.

I’m not so sure.  If I have learned anything from being a part of New Orleans’ recovery, it is that EVERYTHING is mired in thick, silty gray.

And in the middle of all that mess sits Charity Hospital.

One of the big discussions flying around Southeast Louisiana surrounds Charity Hospital.  Until Katrina, Charity was the second largest hospital in the country and one of the oldest continuously operating hospitals in the world.  It was the primary source for health care for many of New Orleans’ poor.  Actually, considering that many of Charity’s former patients have not seen a physician since Katrina, technically, Charity is still their source for health care… it’s just not open for them to receive it.

In fall 2007, Jim Aiken, the LSU University Hospital Chief of Emergency Medicine who worked the Emergency Department through Katrina and the aftermath, came to a class I was assistant teaching.  His fascinating lecture included discussion of Charity’s pre-storm emergency plans, his experience of the storm and flood from within Charity, how he helped coordinate emergency care in the extended aftermath, and finally some of the issues involved with long-term planning for health care for the city.  At every step, the issues are overwhelming at best — but what struck me was his passionate and pointed arguments for medicine, good medical care, and services to the community.  He left me convinced that we need to rebuild a top-tier medical facility in this city, one that serves the poor within it, both because it draws good doctors to gain experience within it and because providing care to those who wouldn’t otherwise receive it is as important in this community as drinkable water and drivable streets.

A little over a week ago, the Schweitzer Fellows held our second symposium.  This one was on “The State of Health in Louisiana” and Dr. Larry Hollier, chancellor of LSU health sciences center (encompassing the training programs for all allied health fields at LSU), was one of the speakers.  His presentation was about the new LSU health sciences center — a center which is desperately needed, but is incredibly controversial in how it plays out.

The issue is that Louisiana’s doctors come from LSU graduates… by no small amount.  The physicians practicing in the State are close to retirement age by overwhelming numbers, and the physicians coming out of LSU are not the type to stick around and take their places.  Even before Katrina, LSU was seeing a substantial increase in the numbers of foreign-trained medical students who were ‘matched’ to attend LSU for their residencies — these are students who tend to go back to their home countries after residency.  There were also increases in ‘matches’ with students for whom LSU was not a top choice… indeed, has not been a first choice for many in recent years.  In addition to bringing in students who are not necessarily going to stick around… LSU has not been attracting the best talent, who are going to get picked up by the more desirable residency programs.  Post-Katrina, these enrollment numbers have been even more dire, suggesting that the outlook for Louisiana to have competent, young physicians to support the State’s medical needs into the future is grim.  Dr. Hollier argued that plans for a new science center were in place long before Katrina, and that the need for an expanded, updated center for treatment, training, and research was critical to the survival of health care in Louisiana.

And I believe him.

Don’t get me wrong: my impression of the guy was that we’d have some seriously different views on just about any medical or social issue… but the numbers and his argument was compelling.  More than that, it completed echoed my experience as a student: my peers don’t stay.  Heck, *I* am having trouble figuring out how we’re going to stay.  Even if Paul had gainful employment, the fact is that the research dollars to study health inequalities in our city don’t go to researchers in New Orleans.  If I want to stay involved in research here, it seems like I need to move to Chapel Hill or Ann Arbor or Boston or wherever in order to do it.  (I’ll save this rant for a later date.)

I think that we need a commitment to a new, state-of-the-art facility to attract new talent, house research programs, and rebuild health infrastructure in the city.

Dr. Hollier spoke ONLY of the LSU plans — NOT the combined VA plans.  In the LSU plan, only 33 homesites are impacted over an area that encompasses more empty parking lots than businesses or homes.  (The VA plan, as outlined in a wonderful advocacy website, impacts many more people and historical properities.)  He argued rationally that the Charity hospital building could not be retrofitted to the needs of the new center and any expansion did not include parking or other supportive infrastructure necessary for that sort of facility.  He suggested the renovation of Charity as apartments for residents.

Everything that I know about New Orleans and the way things work make me question people in power — question their motives, question their reasoning, wonder about what they haven’t considered.  (In contrast, it also has shown me that New Orleanians are some of the most change-resistant people on the planet… but possibly for good reason.)  Yet, I am compelled to WANT this new center.  I WANT a place where I can collaborate and build and learn and serve.  I’m EXCITED about the possibility of this center… it makes me want to be here, stay here, work here.

Those first couple of blocks closest to I-10?  The ones that are predominantly occupied by empty parking lots?  I can’t think of a better use than to build a new science center.

But.  The rest?  Well.  I’m uncertain about this.  Because I feel that Dr. Hollier would drive through a community like lower Mid-City and not see a community worth saving.  He wouldn’t necessarily see a pattern of New Orleans rolling over yet another predominantly African-American community for the sake of progress.  Or, maybe he would — maybe he would but he would argue it was necessary for the common good.  And sometimes?  Sometimes I believe in the common good, even if it stomps all over individual rights.  Early public health efforts involved holding people down for immunizations against their will… and that is WHY we were able to control disease.  Sometimes common good is a good answer.

BUT!  Common good should come out of insight and input from the community.  That’s what it’s all about. I’m not convinced that LSU are taking alternative plans seriously.  I don’t understand why the RMJM Hillier plan isn’t feasible and while I am not convinced it is the right place to go, I do think it signals to LSU that it needs to look for compromise.

And I’m worried that this will be locked in years of debate and at the end, the people of New Orleans will continue to suffer for lack of a comprehensive medical center and a generation of medical talent will slip through our fingers.

There is no easy answer here.  And I’m sort of all knotted up inside over it because it involves my field (public health) and my passion (community-level advocating/organizing) — with one tromping on the other in the name of common good.

Got anything good for this one, Louisiana Rebuilds Minute?  What website of yours solves this??

(If anyone still reading has thoughts, comments, insight, or ideas… I’d love to hear them.)

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