Clearing the Air: Addressing Asthma Disparities in Maryland

This morning I had the pleasure of addressing a group of health care professionals at the Asthma and Allergy Foundation’s Clearing the Air: Addressing Asthma Disparities in Maryland conference in Linthicum, Md.

In Baltimore City, over 60,000 adults and nearly 20,000 children have been diagnosed with asthma at some point in their lives. There are considerable disparities in the burden of asthma by age, race, ethnicity, and geography. Young children, African-Americans, those with low income, and urban residents carry a disproportionate burden of asthma in Maryland. Access to quality care is thought to be a significant factor contributing to disparities. Disparate populations may lack insurance, asthma education, or access to quality primary or specialty care providers. These and other barriers to quality care have significant impacts on asthma morbidity and mortality.

One of the key ways that the Health Department is addressing asthma disparities in Baltimore is through Healthy Baltimore 2015, our comprehensive health policy agenda. This agenda aims to explore the root causes that drive health inequities, break down silos between various sectors of our society. To this end we’ve created an interagency task force to examine potential health implications of policy decisions.

To date, the asthma home visiting programs have reached over 500 children and have documented significant reductions in asthma symptoms, roach and mouse infestations, and school absences. Among a sample of 94 clients, 94.7% had a reduction in emergency department visits and 100% had a reduction in hospitalizations after completing three home visits. School-age participants also reported an increased attendance rate.

To address asthma disparities in Baltimore City Schools, we are working with the state to implement the Asthma Friendly School Initiative. More than 30 Baltimore City Schools that are Asthma Friendly. This Initiative requires schools to meet a set of criteria to be considered Asthma Friendly including:

• Identifying and tracking students with asthma;
• Maximizing asthma management through the use of asthma action plans and case management;
• Coordination of asthma management with parents/guardians and health care providers;
• Supportive policies regarding access to asthma medication;
• Proactive maintenance of buildings and school facilities to reduce asthma triggers and improve indoor and outdoor air quality; and
• Asthma education for students and staff

Additionally, the Health Department’s EPA-funded Healthy Environments Healthy Kids program will provide training of and direct services to community-based partners engaged in improving environmental health for children in Baltimore. Through this grant, the BCHD will improve child health outcomes in Baltimore through:

o   inspecting and training for city-based Head Start Programs and child care providers focused on environmental and health hazards in those settings;

o   training of key home visit staff (e.g., community health workers and nurses, Healthy Start staff) on healthy home fundamentals;

o   training for WIC and other community-based partners; and

o   integrating healthy homes and community principals into training and certification programs for licensed child care providers.

BCHD will continue to collaborate with its partners to improve asthma disparities, working toward our goal of turning Baltimore into a city where all residents realize their full health potential.

I’m curious to hear what other public health workers are doing around asthma and schools. What are some of your success stories?

Cigarettes Get Graphic New Warning Labels

Today the FDA announced a major leap forward in the ongoing struggle of educating the public about the dangers of smoking. 

Beginning in September 2012, every pack of cigarettes will be required to have a graphic warning label reminding the public about the real life consequences of smoking.  Thanks to the Family Smoking Prevention and Tobacco Control Act signed into law in June of 2009, each pack of cigarettes will contain one of the following images:

One of the FDA's new warning labels.

• A mouth full of gross teeth with a lip ulcer - early signs of oral cancer
• Before and after picture of lungs exposed to smoking
• A cute baby about to be engulfed by a cloud of poisonous tobacco smoke
• A gentleman smoking through a hole in his throat
• An overweight man on oxygen presumably having a heart attack – a consequence of smoking
• A cartoon of a premature infant – prematurity a consequence of smoking during pregnancy
• A distraught woman next to the caption “WARNING: Tobacco smoke causes fatal lung disease in nonsmokers.” 
• A corpse with his chest sewn up
• A dude proudly sticking his chest out with an “I Quit” logo on his shirt

These images range from the gross to the sentimental to the uplifting.  I applaud this effort because we need all the help we can get when it comes to helping people stop smoking. 

Cigarettes have been designed to be one of the most efficient ways to deliver one of the most addictive substances on this planet – nicotine.  Packaged with slick advertising cigarettes have worked their way to being the number one cause of PREVENTABLE death.  Regrettably, I don’t think there’s a graphic for that.

In Baltimore City, smoking rates are as high as they are in states such as Kentucky, one of the highest producers of tobacco plants.  There are no safe tobacco products, nor is there a risk-free exposure level for adults, children or pregnant women. Tobacco is a major contributor to early heart attacks, strokes, chronic lung diseases and cancers. There is also compelling evidence of the harmful impact of secondhand smoke to nonsmokers and children who suffer from respiratory infections. Smoking is also associated with preterm births, still­births, and low birth weight.

That’s why Healthy Baltimore 2015 identifies tobacco as a priority area for action. Over the course of the coming year, we will collaborate with partners across the city to help our residents stop smoking, or better yet – never start.  One of our most important resources is 1-800-QUIT-NOW.

Which graphic do you prefer?

Take Care Baltimore!

National Prevention Strategy mirrors efforts in Baltimore to improve health outcomes, eliminate disparities

Today I had the pleasure of taking part in a stakeholder panel discussion as part of the release of the National Prevention Strategy. I was representing the National Association of County and City Health Officials (NACCHO), the group that represents the nation’s more than 2,800 local public health departments.
These city, county, metropolitan, district and tribal departments work every day to protect and promote the health and well-being of all people in their communities.

Local health departments are essential to seeing that the strategic directions and priorities of this Strategy result in improved health outcomes. The central role for local health departments will be to do what we do best: Emphasize preventive and quality health care, expand access to care for all populations and engage communities.

In Baltimore City there is a 20 year gap in life expectancy between 2 neighborhoods less than 5 miles apart. Statistics like these give great urgency to the work we do to improve the health of our city, our neighborhoods and our residents. That’s why in April, Mayor Stephanie Rawlings-Blake and I released Healthy Baltimore 2015, an aggressive plan for improving health outcomes and eliminating health disparities.

Healthy Baltimore 2015 highlights 10 priority areas for action that account for the greatest morbidity and mortality in Baltimore City.  These priority areas mirror the National Prevention Strategy. Within each of the 10 areas, we identified aggressive benchmarks for improvement because they help to set the level of urgency in addressing ongoing disparities and inequities. 

In addition to reporting citywide data for each of the leading indicators, we include the greatest subgroup disparities.  In some indicators this is based on race, but in other indicators the greatest disparities are based on gender, educational attainment or income.

Our leading indicators go beyond traditional health measures and explore the root causes that tend to drive health inequities such as access to healthy foods, liquor outlet density and vacant building density.

We’re adopting a health in all policies approach because it’s clear that addressing these long-standing inequities can no longer be accomplished via traditional medical models or even traditional public health models. We’ve convened a cross-agency health task force that has senior level representation from all city agencies. 

Our job will be to look at what each agency is currently doing in service of HB2015 and what we can do above and beyond. We’re working with Hopkins School of Public Health to develop evaluation metrics to determine what difference this process makes on the ground.

We’ve also convened a similar group for our clinical providers.

Lastly, we have an innovative private public partnership aimed at reducing disparities in access to healthy foods. It’s our virtual supermarket known as Baltimarket.

The National Prevention Strategy represents an unprecedented commitment by the Obama Administration to the idea that prevention of illness and disease should be a national goal, not just for those of us in the health field, but for every sector of society that touches people’s lives. I stand with other local health departments in applauding federal government leaders represented here today for recognizing that improving the quality of life for all Americans needs to incorporate the influences of where we live, learn, work and play.

Have you had a chance to look at the Strategy? What are your initial thoughts? How can we all work together more efficiently to achieve these goals?

Health Department Testing Reveals Items of Children’s Jewelry With Excess Lead

Many parents are aware of the health risks associated with lead poisoning. The federal government limits the amount of lead in children’s toys. But what they may not know is our inspectors continue to find some products – especially children’s jewelry – with off-the-charts lead content being sold in Baltimore City retail stores.

Lead is toxic to the nervous system. It can cause severe illness and even death at high doses and cognitive impairment and other neurological problems at lower doses. These health risks are the reason the Baltimore City Health Department tests products for lead levels every month. This morning, we issued violations to three businesses selling items of children’s jewelry that contained dangerous levels of lead. Lead contents below 300 parts per million (ppm) are considered safe. However, these items tested by an independent certified laboratory for as much as 280,000 ppm of lead.

Perhaps the most disturbing aspect of these test results is that one of the products was labeled “lead compliant,” and yet it contained 18,000 ppm of lead – that is 6 times the regulated limit.

All products of the same style and manufacturer to these items are being considered a nuisance to public health. These products may not be offered for retail sale in Baltimore City. Please be on the lookout for these products:

Item: 4pc Pink & Rhinestone Flower Set (Rhinestone flower clip on earrings)

Total Lead Content: 18,000 ppm

Item: Strawberry Charm Bracelet (Big Strawberry Charm)

Total Lead Content: 180,000 ppm

Item: 3 piece Pearl Set (Pearl Necklace)

Total Lead Content: Clasp – 3,800 ppm; Chain – 280,000 ppm

This and other recent toy recalls due to unsafe lead levels should serve as an important reminder for parents to remain vigilant. Dangerous lead levels have recently been found in a Toy Story 3 bowling set, an American Girl’s craft kit, even articles of children’s clothing.  In fact, a quick glance at the CPSC’s toy hazard recalls will illustrate that the sale of children’s items containing high levels of lead remains a stubbornly difficult problem to combat.

For more information on Baltimore’s regulation on lead in children’s jewelry, visit our website.

Goodbye Food Pyramid, Hello MyPlate

First Lady Michelle Obama has been a powerful advocate for ending childhood obesity. Her Let’s Move campaign is aimed at raising a generation of American youth who are healthier and more active than those before them.  While her initiatives are directed at kids, Mrs. Obama’s message is an important one for all of us.

We live in a time when two-thirds of Americans are overweight or obese. In Baltimore City, 1 in 3 children is overweight. Additionally, 37% of Baltimore City high school students are overweight, compared to 29% of their counterparts in Maryland.

As we all know, obesity is associated with numerous health problems, including heart disease, stroke, and diabetes. And while sedentary lifestyles play a significant role in the country’s obesity epidemic, so too do poor food choices.

Enter MyPlate. This new tool from the USDA replaces the outdated food pyramid. MyPlate provides a clean visual representation of how our meals should look: half of the plate is fruits and vegetables, with the other half split between grains and protein. Dairy sits in a saucer on the side. This is a far more logical symbol for consumers to make food choices than a pyramid – what could be simpler than a plate?

The old food pyramid primarily instructed consumers to eat a certain number of servings from each food group. However, what constituted a “serving” was not especially easy or convenient for people to figure out. As the First Lady said, "We can't be expected to measure three ounces of chicken or look up a portion size of rice or broccoli." In contrast, MyPlate places a much higher emphasis on portion size and proportion.

It is important to know that MyPlate will not single-handedly end the obesity epidemic – it does not encourage physical activity; explicitly decry slathering vegetables in butter; or address the fact that in many households and restaurants, plates can be the size of small dinner tables. However, news outlets, nutritionists, foodies, and academics agree that MyPlate is a great first step toward educating consumers about smart food choices in a relatable, common-sense way. And just like its predecessor the pyramid, people are encouraged to visit www.choosemyplate.gov for more in-depth information on nutritional food choices.

If we are to meet the aggressive goals we set in Healthy Baltimore 2015 for combating obesity, we must utilize a variety of approaches to educate and change the behavior of our residents. Common-sense tools such as MyPlate can be an important resource for the average family looking to improve their food choices.

What do you think? How does MyPlate compare to the food pyramid? Do you think it will succeed in getting people to eat healthier?

Health Department Observes World No Tobacco Day

In 2009, the percentage of adult smokers in Baltimore City (28.3%) was higher than Kentucky and West Virginia – the two states tied for the highest percentage of smokers (25.6%) in the country. Although Maryland has one of the lowest smoking rates in the country, significant disparities exist among Baltimore smokers with high and low income and educational attainment levels. The smoking rates for city residents with an income of less than $15,000 is 36 percent (compared to 15.1 percent for the highest income group). Likewise, the rate for college graduates is 14.8 percent, compared to 33.9 percent for those with a high school education or less, according to the 2009 Baltimore City Community Health Survey.

These are troubling numbers, especially because tobacco use remains one of the most preventable causes of death and disease.

Today, I am calling on all city residents to join us in commemorating World No Tobacco Day. This day is an excellent opportunity to raise awareness about the harmful effects of tobacco use on the health and well-being of Baltimore City residents.

The negative health effects of tobacco use are well known. It contributes to early heart attacks, strokes, chronic lung diseases and cancers. There is also compelling evidence of the harmful impact of secondhand smoke to nonsmokers and children who suffer from respiratory infections. Smoking is associated with preterm births, stillbirths and low birth weight, all of which can cause infant mortality. Eighty percent of all fire deaths occur in the home; careless smoking is often to blame.

This year, more than 5 million people worldwide will die from a tobacco-related heart attack, stroke, cancer, lung ailment or other disease. Having killed 100 million people during the 20^th century, tobacco use could kill 1 billion during the 21st century, according to the World Health Organization.

If you or a loved one is ready to take the step of quitting tobacco, we want to help. Every day, the Health Department and our partners provide the following educational outreach and treatment support for tobacco users:

• Residents may call 410-361-9765 for a referral to a cessation program.

• The Health Department’s SmokeFree Baltimore Tour Bus will provide tobacco use and quitting information from 10:00 a.m. to 2:00 p.m. at Baltimore Medical System at Orleans Square health center at 2323 Orleans St.

• The department’s Tobacco Use Prevention and Cessation Program provides pharmacotherapies to Federally Qualified Health Centers (FQHC) for uninsured clients in their cessation programs. Free patches are distributed to clients – either through one-on-one counseling by a health care provider or during cessation classes. To find the FQHC nearest you, call 311, the city’s service line. 

• The national Quit Line – 1-800-QUITNOW – provides counseling to callers who want to quit. Qualifying callers are provided with a month’s supply of patches and gum.

Being tobacco free is a high priority area for this department. Earlier this month, we unveiled Healthy Baltimore 2015, our five-year health policy agenda for improving health outcomes and reducing health disparities in Baltimore. In it, we set ambitious goals for realizing our goal of a tobacco free Baltimore. I hope you’ll take a few minutes to review this important document and sign up to partner with us on these and other important efforts to improve public health in Baltimore City.

University of Medicine and Dentistry of New Jersey Commencement Speech

This past Monday, I had the honor of delivering the keynote address at commencement ceremonies for my alma mater, the University of Medicine and Dentistry of New Jersey – New Jersey Medical School. What do you think are the biggest challenges facing the next generation of young physicians and dentists? How can we better bridge primary care and public health?

Dean Johnson, esteemed colleagues, parents and family, and class of 2011.

It is an honor to be your commencement speaker. 

It’s astounding to think it was just 20 years ago when I was in your seat.  My medical school graduation was one of the most momentous days of my professional career.  Personally, I was humbled by the honor of having my grandfather travel from a rural town in Puerto Rico to see his granddaughter become a doctor.  As for many of you, this accomplishment was not just my own, it was - and still is - my family’s accomplishment as well.  Professionally, I saw it as the beginning of a journey I had always dreamt about.  It was real and I had the paper to prove it!

One of my internal motivations has always been hearing my mom’s voice in my head saying “don’t forget where you came from and make sure you give back to the community”.  I’m certain that many of you may have that same tape running in your head because we all come from somewhere and we all get to where we are with the support of others.  And even if we don’t share similar upbringings, we share the fact that we had the privilege and honor of being from New Jersey Medical School.

Newark, New Jersey and its people have become a part of you - same as you have become a part of the lives you have touched in this city.  The patients and families I cared for and learned from here helped to shape my views when I went to Washington, DC to work in a community health center.  They also helped to inform my decisions when I went into public health in NYC and now in Baltimore City as health commissioner.

And so MY first point to you is to “remember where you came from and make sure you give back to the community” wherever that community may be.

In preparing for this speech, I searched the internet for just the right quote to impart words of wisdom and I pretty much gave up until I came across a quote that reminded me of what my mom said. It’s a quote from the 18^th century German philosopher, Immanuel Kant:

“Always recognize that human individuals are ends, and do not use them as means to your end.”

By remembering that individuals are ends, we then come to the second point: Each of our patients has something to teach us.  All too often this point in medical school has been made within the context of learning about the body and natural course of disease.  As you progress in your careers, my hope is that this point will take much greater dimension to learning and integrating how social determinants of health – things that impact where we live, work and play - affect the patients you see and the way you practice medicine.

As physicians we have the privilege of being let into our patients’ lives.  Some times by choice and other times in spite of their objections.  This privilege should never be taken for granted.  With this privilege comes the responsibility of bearing witness to the social conditions that affect individual health outcomes, as well as community health outcomes. 

One of the most important things we can do is not ignore the power of the white coat.  I encourage each of you to be more than just physicians.  I challenge each of you to be physician advocates.  To be outraged by the health inequities that are driven by social determinants of health such as education, housing, access to healthy foods and transportation.  There are opportunities that will be afforded to you by virtue of the power of the white coat.  Use this to the advantage of your patients.

According to the Institute on Medicine as a Profession: 

Physician advocacy extends beyond the provision of good clinical care and advocacy on behalf of individual patients to include collaborations with people and organizations that combat interpersonal, structural, and systematic inequities and abuses in our society. Advocacy is the bridge that links patient care with efforts to address social determinants of health, institutionalized prejudices, and structural dislocations that patients and communities face. Physicians are especially qualified to advocate upon behalf of social change. The prestige and credibility that they command may serve as valuable resources in advocacy efforts. 

When I was just out of training I worked in a community health center in inner city Washington DC.  Day in and day out I saw children that were being lead poisoned by their housing environment.  It was frustrating to be treating outcomes that were so easily avoidable.  I was at a loss of what to do until I did what we as scientists have been trained to do – document what we see. 

I created a very simple database that tracked the addresses of children with elevated lead levels.  This simple tool demonstrated that there were identifiable units that were serially poisoning the children of our community. Just as I finished the first phase of the database, I was connected to a young lawyer in the Department of Justice who came to our clinic working on another project, but who was also interested in housing justice. 

To make a long story short, he was able to use the database to make his case against delinquent landlords even stronger and levy heavier fines against those landlords.  In the end, then-Secretary of Housing Andrew Cuomo came to our clinic to highlight the work that had been done.

The power of the white coat lies in the ability to apply your diagnostic skills to identifying trends in a community.  It lies in your ability to translate medical data into everyday language that illustrates that acuity with which things such as housing policy, educational policy and even land use policy affect communities such as the one we have served here in Newark. 

As John F. Kennedy said, “the goal of education is the advancement of knowledge and the dissemination of truth”.

Births and deaths and the dignity with which they occur remind us of why it is we do the work we do and that there is urgency to creating a healthcare delivery system that makes healthy choices the default choices.

You will be among the first group of doctors finishing their residency training when the majority of the provisions within the Affordable Care Act go into effect in 2014.  None of us know exactly what this beast will end up looking like, but one thing is certain:  It won’t be what it is now.

The question is “Will it be what we want it and need it to be?”

Not one of us should have the delusion that an insurance card will be a game changer when it comes to addressing health disparities and health inequities. But we should all have the courage to advocate for a healthcare system that values preventative care, makes it easier for doctors to do the right thing with the use of electronic health records and provides a quality feedback loop at the systems level so that we can know when what we’re doing isn’t giving us the outcomes that we anticipate. 

As I end, I am reminded of a visit I made to South Africa shortly after apartheid had fallen.  I had the privilege of visiting Kwazulu-Natal, the birthplace of Community Oriented Primary Care.  COPC is a way of practicing primary care that incorporates the social determinants of health.  It was started in the 40’s by Sidney and Emily Kark, first in Israel and then in South Africa.  It gave rise to the community health center movement here in the 1970’s. 

During that trip I also had the privilege of spending time with young doctors who were studying at the newly formed school of public health.  To this day, I have never forgotten what one young doctor said to me about her class - “We are excited to heal our country”.  I hope that you too are excited about healing your country and your community. 

We come to medicine out of love – love for science and the purity of reason; love of our fellow man and the wellness of communities.  Be the best you can be at whatever specialty you choose because your patients deserve it.  Be advocates - whether you are an interventional radiologist or a general pediatrician – because your patients and their communities need you.  Understand social determinants of health and how they affect your daily practice and the outcomes you can attain with your patients.  Also be mindful of the fact that where we live, work and play oftentimes play as big a role in making us sick as they do in keeping us healthy.  But most of all strive for health equity.

Thank you and Godspeed.