PUBLIC HEALTH
Global Climate May Affect Health, Disease
Can El Niño be blamed for health problems? A growing number of researchers are studying how global climate changes affect health and illness, according to a recent issue of American Medical News. Through this emerging field, scientists are looking beyond the traditional focus on single exposures to harmful agents or microbes. "It's forcing us to focus on the climate's effects on many health outcomes and on points of prevention way upstream," said Dr. Jonathan Patz, director, Program on Health Effects of Global Environmental Change, Johns Hopkins University School of Hygiene and Public Health.
How can climate changes impact public health? Increased and more intense rainfalls can affect sections of the United States that have high amounts of the pathogen Cryptosporidium in agricultural waste, Patz said. The hard rains can drive runoff into the water system, increasing the likelihood of waterborne disease, which can be chronic and life-threatening in immunosuppressed individuals, particularly AIDS patients.
Climate change interacts with other factors affecting health. For instance, 1995's Chicago heat wave intensified the socioeconomic problem of the elderly living alone and without air conditioning, resulting in hundreds of deaths.
To study the weather-health link, the National Assessment of the Potential Consequences of Climate Variability and Change, a multidisciplinary project of the U.S. Global Change Research Program, will focus on five key areas affecting public health: heat, air pollution, waterborne and foodborne illness, diseases often carried by insects and rodents, and extreme events. Congress will receive a report on the results in January.
HEALTHCARE ACCESS
Managed Care a Threat to Charity Care?
The coming of managed care would appear to bode ill for charity care in the United States, according to an article by Peter J. Cunningham, PhD, et al., in JAMA.
In 1996-97 Cunningham and his colleagues conducted a yearlong survey of 9,871 direct-care physicians at 60 sites around the nation. The researchers hoped to discover whether managed care has affected the amount of free or reduced-cost care those physicians provide to uninsured and underinsured patients.
Of the physicians surveyed, 77.3 percent had provided some charity care in the month before they were interviewed. Those who had provided such care that month spent an average 10.3 hours doing so.
The survey showed that doctors whose practices were most dependent on managed care for revenue were significantly less likely to provide any charity care. When they did give indigent care, such physicians spent fewer hours doing so than doctors with less managed care involvement.
The survey also indicated that physicians who practiced alone or with a single partner were more likely to provide charity care than those in large group practices and staff or group model HMOs. Physicians practicing in areas with low managed care penetration were more likely to give indigent care than those in high-penetration areas.
Cunningham and his colleagues concluded that as managed care imposes greater price discipline on the healthcare market, many doctors face increased competition for paying patients and, at the same time, find it difficult to shift the costs of charity care onto other payers. The researchers fear that, as a result, many physicians may reduce their indigent care or eliminate it altogether.
The researchers warn that, since physicians now provide care for about one-third of uninsured Americans, a reduction in charity care will further restrict access to healthcare in general.
In an accompanying JAMA editorial, Robert H. Fletcher, MD, notes that approximately 45 million Americans are currently uninsured. He recommends the formation of a pool into which all insurers would be required to contribute funds for medical research, teaching, and indigent care.
Long-Term Care
Hearing As Well As Listening
Many residents of nursing homes and assisted living facilities have neither friends nor family members to visit them, provide emotional support, and listen with a sympathetic ear. To lessen the loneliness that such residents may feel, the pastoral care staff of Bayley Place, a long-term care facility sponsored by the Sisters of Charity of Cincinnati, trains volunteers in what they call "reflective listening."
Volunteers in the reflective listening program are matched with residents according to personality traits. In weekly meetings, they listen as the resident leads the conversation to any topic that may be on her mind, from life concerns to spiritual needs to confidences. Many residents talk about their emotional problems as well as their physical infirmities. They also share their happiness at life's celebrations.
When the visit is over, the volunteers record the date, the length of the conversation, and a brief confidential summary of what the resident said in a pastoral care log book. The pastoral care staff members review the summaries for indications of any problems that may warrant professional help.
The staff at Bayley Place has found that residents are more willing to discuss their feelings and concerns with one other person than in large group gatherings. The program offers the residents friendship, assurance, and an opportunity to share their experiences. Both the residents and the volunteers develop a deep sense of satisfaction and connection that comes from the heart.
— Kristen Laska, Director of Marketing and Public Relations, Bayley Place
PUBLIC HEALTH
Obesity Linked to Increased Heart Disease
In an effort to curb the escalating rate of obesity, the Interdisciplinary Council on Lifestyle and Obesity Management has urged health officials from the private and public sectors to take greater steps in helping Americans manage the battle of the bulge. More than one-third of all Americans have been classified as obese or overweight.
The council has recommended the following steps:
- Considering body weight index, waist circumference, and weight as standard vital signs physicians use to measure patients' overall health and their risk for high cholesterol, high blood pressure, and diabetes
- Developing a team-supervised approach to manage obesity, including diet, exercise, lifestyle changes, and, for some patients, pharmacotherapy
- Eating a healthy diet which derives no more than 30 percent of its total daily calories from fat
- Increasing emphasis on education and prevention
The American Heart Association has added obesity to its list of major risk factors (including smoking, high blood pressure, sedentary lifestyle, and high blood cholesterol) that people can control to prevent heart disease. "Obesity is causing a disproportionate amount of coronary heart disease, which remains the number one killer in the United States," said Dr. James M. Rippe, a cardiologist who chairs the Interdisciplinary Council.