Project follows the race to make bagged salad safer

The latest investigation by California HealthCare Foundation Center for Health Reporting’s Deborah Schoch will make you think twice before ripping into a sack of spring mix, but her work about the myriad food safety challenges posed by bagged salads examines the industry’s struggle to develop technology powerful enough to overcome the existential threat posed by E. coli and friends.

The industry has made great strides since a 2006 outbreak linked to tainted spinach, she writes, but “It’s impossible to stop all pathogens from landing on lettuce and spinach leaves.” And once they’re on the leaves, it seems as if their spread is almost inevitable. They hide in gooey biofilms and resist powerful washes.

Thousands upon thousands of salad leaves are taken to a central plant, washed together, bagged and shipped. Even if only a few leaves are tainted, harmful pathogens can spread in the wash water — the modern salad version of the old adage that one bad apple spoils the whole barrel.

“I would think of it as swimming in a swimming pool in Las Vegas with a thousand people I didn’t know,” said William Marler, a prominent Seattle-based food safety attorney.

Plenty of public and industry money has been aimed at the problem, Schoch writes. “The Center for Produce Safety at UC Davis, founded in response to the spinach outbreak as an industry-public partnership, has pumped more than $9 million into 54 research projects at 18 universities.”

Even the best research can’t reduce the risk of contaminated greens by 100%, scientists said. At Earthbound, Daniels says the ultimate goal is to achieve what scientists call a “5 log reduction,” the equivalent of pasteurizing milk. In short, if an unwashed lettuce contained 100,000 pathogens, the perfect wash system would knock off five “0s” and reduce the pathogen count to 1.

An added bonus? Schoch’s column on whether she (and the experts she talked to) feel like it’s important, or even salutary, to wash their bagged greens.

Leaded aviation fuel a threat to public health, children

KUOW’s John Ryan used federal data and a few key sources to delve deep into issues surrounding one of the few remaining sources of airborne lead in the United States, a leaded aviation fuel known as “avgas.” In the process, he reveals damage that even low levels of lead exposure could be doing to children.

Avgas accounts for less than 1 percent of the nation’s liquid fuel use. Yet enough piston–engine planes fly enough miles on avgas to belch out half of all the lead going into the nation’s air.

Lead paint in old buildings remains a bigger threat, but even low levels of childhood exposure, one source tells Ryan, can manifest itself in “Decreases in IQ, changes in test scores, changes in attention, hearing threshold, all sorts of things like that.”

Earlier this month (January), an expert panel advising the Centers for Disease Control and Prevention cut in half the levels of lead in children that should alarm parents or doctors. Researchers have yet to find any level of lead exposure that doesn’t cause harm.

Michael Kosnett, a medical toxicologist at the University of Colorado, told Ryan, “In any one child, it’s not something that’s going to necessarily cause them to display any kind of signs and symptoms. But if you can lower the lead exposure of a population of children, you’re going to give that population more of an opportunity to have gifted children and to have children who have higher IQs, and that’s certainly a desirable public health goal.”

Marie Lynn Miranda, an environmental health scientist and a dean at the University of Michigan, points out that “Living close to an airport can increase your blood lead level anywhere from 2 to 4 percent,” acknowledging that is a small amount but that evidence indicates even small amounts of lead are bad. She also notes that “lead is especially a problem for the low–income families that are most likely to live near airports.”

Pilots who still use avgas say their businesses would be dead in the water if they couldn’t get the leaded fuel, an argument Ryan contrasts with quotes from a Europe-based lead-free avgas producer, who sells it for 40 cents less a gallon, but hasn’t been able to break into the U.S. market “Because no one thinks that there will be demand for an unleaded–grade aviation gasoline.”

The federal database Ryan used, The National Emissions Inventory, is posted online by the EPA.

Investigation delves into Wash.’s prescription drug problem

Everything time we think prescription drug abuse stories have peaked, something comes along to push the story further. This time, InvestigateWest’s Carol Smith sets herself apart by starting from square one and clearly explaining the origins and dimensions of Washington’s particularly nasty drug issues, tracing back each facet of the problem to its source and spotlighting what makes the Evergreen State unique.

Washington has been one of the hardest hit states in the country, in part because of aggressive prescribing practices. That, coupled with lack of oversight of doctors who over-prescribe, has led to the spectacular run-up in the number of deaths from prescription overdoses.

The backdrop for her work is an epidemic that shows no signs of abating, despite a recently implemented state law Smith calls “a bold attempt to reduce overdose deaths by launching the first-ever dosing limits for doctors and others who prescribe these medicines.”

Prescription drug abuse is at epidemic levels throughout the state, and elsewhere in the country, despite lawmakers’ attempts to get a grip on it. Washington now has one of the highest death rates in the nation. Deaths from prescription drug overdoses in this state have skyrocketed nearly twenty-fold since the mid-1990s, and now outstrip those from traffic accidents.

Why caused it to leap so quickly? Smith tracks down several key tipping points. “There’s plenty of blame to go around for what caused the epidemic,” she writes. “Aggressive marketing of opiates by drug companies, nonexistent tracking of overprescribing, lack of insurance coverage for alternative treatments for pain, and demand by patients for quick fixes, to name a few.”

She drills down into many of those causes, with my personal favorites being two key origin stories:

• How marketing by OxyContin maker Purdue Pharma led to relaxed guidelines for chronic pain treatment and a “1999 law specified ‘No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opiates prescribed,’” both of which helped cause a jump in prescriptions.
• How “the rise in the death rates of Medicaid patients tracks along with the state’s cost-saving decision to move many of its poorest residents to the cheapest, most potent pain reliever available: Methadone.”

See the upper right-hand sidebar for more stories from the six-month investigation.

Article looks at reform concepts put into practice

Here’s a recent story that touches on a whole lot of themes in health reform – without getting bogged down in a lot of jargon. Value-based purchasing. Evidence-based medicine. Shared decision-making.

Jackie Crosby of the Minneapolis Star-Tribune writes about how a Minnesota insurer, HealthPartners, has introduced a new approach for patients with low back pain. Before they get surgery, they have to get a consult on nonsurgical alternatives.

If they still opt for surgery, they can have it. But the thinking is (based on what other health systems have learned) that many will opt for physical therapy and rehabilitation once they learn more about the pros and cons, risks and benefits, of all their options.

“Patients can still see a surgeon if they wish. But after this visit, they’ll be better informed about all of their options, and can make decisions more aligned with their own values,” the story quoted  Dr. Thomas Marr, HealthPartners’ medical director of clinical relations as saying.

“In general, it’s a bad thing when the doctor and patient can’t determine the treatment without interference from the insurance company or the government,” spine surgeon Jeffrey Dick was quoted as saying. But this is an exception, he said. Surgery is appropriate for only about one out of eight low back pain patients he sees. Getting them into appropriate care from the start can save money – not to mention years of lingering back pain.

“These aren’t HealthPartners criteria,” he added. “These are treatment algorithms for low-back pain that we all should be following – but maybe haven’t been by all practitioners.”

The story also noted how HealthPartners is working with stakeholders and monitoring patient reaction and satisfaction to minimize criticism and misunderstandings.

So what are those health reform themes?

Value-based purchasing – loosely translated – is paying for what works.

Evidence-based medicine is what it sounds like – and the evidence is that a lot of back surgery is unnecessary. Sounds simple but it’s not always practiced – even in those cases where the evidence is strong. Sometimes it’s even derided as “cookbook medicine.” Financial incentives are certainly one big impediment: surgeons, hospitals, etc., make money from procedures that may not always be the best choice for the patient. Practice patterns – how physicians are taught and what’s done in the medical culture of a given hospital or community – play a role. And patients often want treatments they don’t need because they don’t understand that it’s not necessary, or they think surgery is a reliable quick fix.

Some researchers exploring medical decision-making have found that physicians are a lot more likely to talk about why to have a certain procedure, including back surgery, than why not. Clinicians and researchers are beginning to develop models for “shared decision-making” and there’s even a bit of language in the health reform law to promote it.

So are there programs like this rolling out in your local hospitals or health plans? We’d like to hear more. It will be interesting, too, to watch how people react to the HealthPartners and similar ventures. Will patient/beneficiary attitudes begin to change? Will they come to understand that more isn’t always better? Will they be glad to find out they really don’t need surgery? Or will there be a backlash about choice and control. The answer may depend on whether patients feel the decision is shared, or imposed.

On balance: Lazar explains a little-discussed fundamental fact of aging

It’s not easy to write well about the nitty-gritty details of aging – the wear and tear on bones and joints, the deterioration of seeing and hearing, the gradual onset of frailty in barely observable increments.

But everyone encounters this when they’ve lived long enough; physical decline is a fundamental part of the aging experience.

That’s why Kay Lazar of The Boston Globe deserves kudos for her story on balance problems in older adults, a common, seemingly mundane condition that hasn’t received much attention.

The consequences can be serious: when balance is compromised, seniors become at risk of losing their mobility or falling, potentially precipitating a cascade of other medical problems.

Lazar’s explanation of why older people become unsteady on their feet is graceful and easy to understand:

“A person’s sense of balance relies on an exquisite interplay of three regions, your vision, a maze-like structure in the inner ear which includes microscopic cells that resemble little hairs, and the muscles and joints running from your feet, up through your spine, that sense your body’s position.

All three areas send signals to your brain, which processes the information, and helps give you a sense of spatial orientation - your balance.

As we age, eyesight fades, as do our muscles’ ability to sense surroundings. Meanwhile, the hair cells in the inner ear die off and do not regenerate. These declines combine to throw off the signals to your brain about your balance.”

Her description of “four flavors of dizzy” - the feeling of blacking out, unsteadiness, spinning, or lightheadness - almost surely will help older adults and their families recognize symptoms that may require medical assistance.

That’s why a story like this is valuable. By talking openly about a problem that usually passes under the radar screen, it expands our sense of alertness to older people and difficulties they may experience. It makes seniors visible, not invisible as they so often seem to others.

Next time I see an older person hesitate at a curb before stepping down or stand stiffly in a crowd, nervous about moving in tight, confined spaces, I’ll think about Lazar’s article.

Survivor goes undercover in Tijuana cancer clinics

Reporting for Al Jazeera English’s People & Power, Sarah Macdonald tells how her own battle with breast cancer led her to shave her head, hide a camera and go undercover to investigate south-of-the-border clinics touting alternative cancer therapies.

The thriving sub-industry of alternative Tijuana cancer clinics relies primarily on palliative care licenses to operate, a end-of-life-care-focused designation that seems somewhat sinister when it’s hidden behind promises of miracle cures. In looking beyond those promises, MacDonald’s investigation finds an interesting mix of chicanery and genuine good intentions, but ends on a familiar, cautionary note.

I have been fortunate in that I have successfully emerged from my own treatment for breast cancer, so I completely understand the desperation that people will feel when they are told their condition is terminal. It is a death sentence. I understand why many patients or their families will begin to scour the internet in search of a cure and will seize on anything that offers hope. However, as our investigation has shown, at least some of the Tijuana clinics are offering nothing but false hope. There is little or no evidence to support their claims that their strange therapies actually work and there is plenty of evidence that vulnerable people have parted with large sums of money for no reason.

Web outlet pumps out dozens of stories on prescription drug abuse

In partnership with USC’s Annenberg School for Communication & Journalism and a number of other organizations, Santa Barbara online news outfit Noozhawk (about), put together “Prescription for Abuse,” an exploration of the misuse and abuse of prescription drugs in the Santa Barbara area. In the extensive, online-only series, the reporters take a look at the problem and its underlying causes, then go a step further by exploring possible solutions as well.

In a uniquely meta twist, the series even looks at how journalism such is advancing public health goals and explains how the project came together. The series features at least 36 individual articles, by my count, and every health journalist who takes the time to browse the full catalog will come across at least a few easily localizable ideas, but in this space I’ll just highlight those stories that deal directly with the series itself:

• USC, California Endowment Unite to Support Health Journalism at the Source
• Bill Macfadyen: Prescription for Abuse Project Is a Series of Opportunities
• Santa Barbara Teen News Network Adds Another Dimension to Prescription Drug Abuse Series
• Annenberg Fellowships Take a Diverse Approach to Community Health Journalism
• Bill Macfadyen: Noozhawk Earns a USC Annenberg Health Journalism Fellowship
• Noozhawk Journalists Recount Lessons Learned from Prescription Drug Abuse Series

NYT series digs into overprescription and developmentally disabled adults

In the series Abused and Used, New York Times reporter Danny Hakim and a host of his colleagues have been investigating how public resources are used to treat developmentally disabled New Yorkers. The series is ongoing, but hit an inflection point with the publication of Hakim’s piece on the few-strings-attached use of very powerful drugs to treat some of the state’s most vulnerable adult residents.

Developmental disabilities, Hakim writes, often manifest themselves in ways that are easily mistaken for mental illness, and these misdiagnoses can lead to unnecessary or improper medication. “In fact,” Hakim writes, “developmentally disabled residents of group homes in New York are more likely to be given Ativan, an anti-anxiety drug that has a tranquilizing effect, than multivitamins, the records show.”

Hakim’s reporting is rich with both anecdotes and data. These paragraphs from the series will give you an idea of how he approached the issue.

Tens of thousands of powerful pills created to treat serious mental illnesses like schizophrenia are given to developmentally disabled people in the care of New York State every day.

…a review by The Times of previously unreleased records, as well as interviews with state employees, clinicians, family members and outside experts, reveals that the psychotropic medications, which alter the brain’s chemistry, are often dispensed sloppily, without rigorous or regular review, by general practitioners with little expertise in the area.

And low-level workers at state group homes are frequently given discretion to increase the medication “as needed,” despite their lack of significant training.

Psychologists who have worked inside the system describe a culture in which the drugs are used to control the disruptive behavior of the developmentally disabled — people with conditions like autism, Down syndrome and cerebral palsy — an approach increasingly discredited in the field.

Reuters shows how shell companies hide Medicare fraud in plain sight

Reporting for Reuters, Brian Grow and Matthew Bigg used an analysis of public data to investigate the practice of using shell companies to defraud Medicare of millions while staying a step or two ahead of federal investigators.

While the specific damage inflicted by shell companies has not been tracked, “Last year, ‘improper payments’ resulted in $48 billion in losses to the Medicare program, nearly 10 percent of the $526 billion in payments the program made, according to a Government Accountability Office report last March.”

“Simply by reviewing the incorporation records of Medicare providers in two buildings” in Miami, they write, “reporters uncovered information that one government official said could prompt “a serious criminal investigation” of some of the companies.”

The fraud rings merge stolen doctor and patient data under the auspices of a shell company and then bill Medicare as rapidly as possible. Other shell companies are often layered on top to camouflage the fraud, law enforcement officials say.

Some of the shells purport to be billing companies; they form a buffer between the sham clinics and Medicare. Others pay kickbacks to doctors and patients who sign off on bogus medical claims or sell their Medicare ID numbers to enable the shell company to bill the government. Still other shells act as fronts to launder the profits.

The key to this kind of fraud, known as a “bust-out” scheme, is for each of the fake companies to bill as much as possible before authorities catch on. Shell companies become a tool that helps keep the crooks ahead of the cops.

The Armenian crime ring whose fraud made headlines last year used 118 shell companies in 25 states and bilked the feds out of at least $100 million. Varying incorporation rules make state-hopping and obfuscation “easy,” they write, especially since states don’t check to see if records are legit before they allow a company to incorporate. The reportes found that even a few simple safeguards would go a long way to detecting the boldest frauds.

In Florida, FBI agents say almost every Medicare fraud scheme involves shell companies. There, Reuters scrutinized incorporation documents for firms located in two buildings near the Miami International Airport. In a building with dimly lit corridors, a rickety elevator and almost no one in sight, a host of companies purport to provide services to Medicare recipients. But telltale signs of fraud abound.

Many of the 26 companies in the buildings had replaced corporate officers at least once in the last four years. Some had changed ownership, or their corporate executives represented more than one medical-related company. Law enforcement officials consider such activities to be red flags for fraud.

For its part, CMS told the reporters it simply didn’t have the resources necessary to conduct the widespread audits needed to catch fraud, though the $350 million allocated to such efforts under the 2010 health reform law should help.

Health journalists who will certainly want to review the “methodology” subheading at the end of the story.

Why are rural Westerners killing themselves?

Writing for ABC News, Alan Farnham seeks to explain the jump in suicide rates in the rural American West, particularly in Intermountain states such as Idaho, Wyoming and New Mexico.

Historically the suicide rate in rural states has been higher than in urban ones. According to the most recent national data available, Alaska has the highest rate, at 24.6 suicides per 100,000 people. Next comes Wyoming (23.3), followed by New Mexico (21.1), Montana (21.0) and Nevada (20.2). Idaho ranks 6th, at 16.5. Suicide is the second-leading cause of death for Idahoans aged 15-34. Only accidents rank higher.

Farnham focuses on the Gem State, where suicide rates are rising alongside unemployment and related economic hardship. In addition to economic factors, including cuts to Medicaid funding, and a regional lack of resources for the initial diagnosis of mental illness, local experts point to demographic and cultural factors.

Kim Kane, executive director of Idaho’s Suicide Prevention Action Network in Idaho says other factors explain the high rate of suicide in western mountain states. One is the greater prevalence of guns: In 2010, 63 percent of Idaho suicides involved a firearm, compared with the national average of 50 percent.

She and Garrett also say the West’s pride in rugged individualism can prevent people from seeking help. Their feeling, says Kane, is that they ought to be able to pull themselves up by their mental bootstraps. Idaho is the only state not to have a suicide-prevention hotline.

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  • Controversy over breast implants spreads across Europe
  • Project follows the race to make bagged salad safer
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