Lara Croft: Cancer Activist

In an Op-Ed piece published in Tuesday’s New York Times, actress Angelina Jolie revealed publicly that she had undergone a prophylactic double mastectomy — removal of both breasts — in order to reduce her risk of developing cancer.

Ms. Jolie had a reason to be concerned. Genetic tests showed that she carried a mutation in a gene known as BRCA1, a change in her DNA that greatly increased the likelihood that she would develop breast or ovarian cancer sometime during her life. Cancer-causing mutations in the BRCA1 gene (or a related gene known as BRCA2) are rare, but account for a majority of familial cases of breast and ovarian cancer seen in the US.

Ms. Jolie likely inherited this mutation from her mother, who died of cancer at 56. Based on her test results, doctors estimated her lifetime risk of developing cancer at approximately 87%, probably at an early age. By contrast, the average woman in the US has a lifetime risk of 12%, with diagnosis usually coming later in life.

The decision to remove both breasts could not have been an easy one, particularly for a starlet who is famous for playing buxom femme fatales in movies like Lara Croft: Tomb Raider, Mr. & Mrs. Jones, and Salt. Ms. Jolie admits as much in her Times article. A prophylactic mastectomy doesn’t completely eliminate her risk of breast cancer, only reduces it by about 10-fold.

She is also at increased risk of developing ovarian cancer, but elected not to have her ovaries removed. A prophylactic oophorectomy, as that procedure is known, is an invasive procedure with long-lasting physiological effects, including early menopause, cardiovascular disease, osteoporosis, and loss of sexual function.

With recent advances in reconstructive surgery, there was no need for Ms. Jolie to go public. She wouldn’t have been the only Hollywood star to get breast implants, just one of the few that had a medical reason for doing so. Barring release of her medical records, a serious breech of privacy, no one would have been the wiser.

So why speak out? According to the actress, she wrote about her experience so that other women could benefit. Specifically, so women with a familial history of cancer could get tested for mutations in the BRCA1 and BRCA2 genes and, if necessary, to “take action.”

Having a spokeswoman like Angelina Jolie increase public awareness of breast cancer is good. It is a laudable goal, but it also one that worries me. Women who look to Angelina as a role model might rush to be tested for cancer-causing genes. However, the results of genetic testing have profound consequences — physically, psychologically and for future insurance coverage. In addition, the tests in question are very expensive. A single test costs approximately $3,000, and may not be covered by existing health insurance plans. Many women simply cannot afford to do what Angelina did.

These exorbitant testing costs are due to the fact that a Utah-based company called Myriad Genetics has patented both the BRCA1 and BRCA2 genes. Myriad currently holds a monopoly on testing for breast and ovarian cancer-causing mutations. The legality of this monopoly had been questioned, most notably in a US Supreme Court case challenging a private company’s right to patent human genes. But until the Court’s ruling in October, the company has every legal right to charge what it believes the market will bear.

Given this, only women with a clear familial history breast or ovarian cancer should be tested. But figuring who has such a history is not an easy task. As many as one in eight women in the US will develop breast cancer at some point in their lives, making it likely that most people will have a sister, mother, aunt or grandmother with a diagnosis. People can have as many as two, three or even four female relatives with cancer. But most of these cases will not be associated with mutations in BRCA genes. It takes a trained genetic counselor or skilled physician, using a detailed family tree, to know for sure whether or not a woman is a potential carrier of a mutant gene.

Moreover, for those unlucky few who do carry a mutant copy of BRCA1 or BRCA2, a prophylactic mastectomy or oophorectomy may not be the answer. Ms. Jolie made a carefully considered and informed decision, in consultation with a highly trained team of doctors, to undergo this radical procedure. But there are other less effective but less expensive and less invasive options, including tamoxifen or regular monitoring, that may be the better choice for many woman (particularly those that lack the savvy and resources of Angelina). I’d hate to think that they rushed to have their breasts removed simply because their favorite starlet had done the same.

None of these concerns I voice is meant to take away from what Angelina has done. Speaking publicly about her decision is a courageous thing to do. But the take-home message for women is far more nuanced than get tested and get treated.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on May 14, 2013. It is also available on the WAMC website.]

Fight or Flight

I travel a lot for work. It’s the rare week when I’m not on the road or in the air to attend a conference, give a talk at some symposium, or serve on some panel or commission. In fact, if you’re listening to this commentary as it airs on the radio, I am likely on a plane cruising at 32,000 feet somewhere between Albany and Washington, DC. Given this grueling travel schedule, I was less than thrilled to hear that the federal budget sequester would affect air travel across the US.

Part of the Budget Control Act passed in 2011, the sequester mandated $1.2 trillion in across-the-board cuts over the next decade if Congress could not reach agreement on a budget before March 1^st. Needless to say, our leaders weren’t up to the task. Despite vocal opposition from Republicans and Democrats alike, what was intended to be a measure of “last resort” to cut federal spending became the law of the land.

The sequester includes $85 billion in spending cuts before the federal fiscal year ends in September, or approximately 5% of the budget of federal agencies like the National Institutes of Health, the Internal Revenue Service, and the Social Security Administration.  The Federal Aviation Administration (FAA), the agency that manages and controls the flow of traffic in the nation’s skies, is slated for over $600 million in sequester-related cuts.

Given that nearly three-quarters of that agency’s budget is spent on salaries for air traffic controllers, air safety inspectors and technicians, FAA officials concluded that the only way to achieve $600 million in cuts was to furlough some air traffic controllers and to close some control towers.

Furloughing controllers and closing some towers, however, also requires that the number of flights also be reduced to a level that could be safely managed by the remaining staff. Flight delays of two or three hours in most major cities were predicted, slowing the flow of commerce and inconveniencing large numbers of travelers.

Apparently, the thought of irate businessmen being inconvenienced by flight delays was enough to get Congress to act. Late last week, both the Senate and House voted to end sequester-imposed furloughs of air traffic controllers. But while we jet setters are cheering, this vote illustrates exactly what is wrong with Washington. Cuts to programs that annoy but don’t really harm affluent Americans spur our leaders to action, but cuts that adversely affect the health and well being of poorer Americans are largely ignored.

For example, the sequester requires Head Start – a federally funded educational, health and nutritional program for disadvantaged children – to slash its operating budget. Studies have shown that children enrolled in Head Start are less likely to need special education services, less likely to repeat grades and more likely to graduate from high school. But this year alone, sequester-related budget cuts have forced Head Start programs around the country to ratchet back on day care and transportation services, reduce the number of meals provided to needy preschoolers, and even cut eligible families from its rolls. An estimated 70,000 fewer children will receive services this year as compared with 2012, further swelling the ranks of America’s underclass.

Meals on Wheels – a network of volunteer programs that provides over one million meals daily to elderly or disabled individuals – faces similar cuts. Over a third of all funding for these programs comes from the federal government via money provided under the Older Americans Act. As a result of sequester-related cuts, some Meals on Wheels programs have been forced to cut the number of meals provided and to start waiting lists for seniors who qualify for assistance.

There are dozens of similar examples of how the sequester affects the lives of the less fortunate: cut in benefits for the long-term unemployed, fewer housing vouchers for low-income families or people with disabilities, reduced access to life saving medications for those living with HIV/AIDS. The list goes on and on.

To put it bluntly, the sequester is bad policy. A game of political chicken gone awry, it has had a negative impact on a variety of largely successful federal programs. So why hasn’t Congress acted until now? Why hasn’t Congress ended the sequester, other than addressing the minor inconvenience of airport delays?

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on May 2, 2013. It is also available on the WAMC website.]

We’re All Mad Here

One of my favorite movies of all time is ‘As Good as It Gets,’ which stars Jack Nicholson as a grumpy, obsessive-compulsive writer. In one classic scene, he tells his neighbor’s housekeeper to “sell crazy someplace else, we’re all stocked up here.”

This will soon be true, at least for most Americans. There are plenty of crazy people out there: Aurora shooter James Holmes, Philly abortion doc Kermit Gosnell, and the individual who bombed this week’s Boston Marathon. But the ranks of the mentally ill will soon expand dramatically.

The belief that we’re all a little bit nuts is nothing new. In the 1865 novel ‘Alice in Wonderland,’ the Cheshire Cat tells Alice, “We’re all mad here. I’m mad. You’re mad.” Come the summer of 2013, this will indeed be the case. Over 50% of Americans will, under new diagnostic and treatment guidelines, suffer from some sort of mental disorder in their lifetime.

In May, the American Psychiatric Association is scheduled to release the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Often called the ‘psychiatric bible,’ the DSM provides a set of standard criteria for determining whether or not someone is suffering from a mental illness.

The DSM is widely used in the mental health community. Clinicians use it to diagnose patients. Insurance companies use it to determine whether they will pay for treatment. Pharmaceutical companies use it to set drug prices and plan marketing strategies. Policy makers use it to make decisions about which mental health programs to fund and who is eligible to receive government assistance. Lawyers and judges use it to determine if a criminal can be held responsible for his crimes or whether a mother should be granted custody of her kids.

Obviously, there is a strong incentive on the part of many stakeholders to make the DSM as broad as possible. For example, physicians want to get paid for seeing patients, but often can’t if the patient doesn’t have a recognized illness. Similarly, drug companies want to convince patients that they have a treatable condition so that they will pester their doctors for a prescription.

So, while only 5% of Americans will have a severe mental illness in a particular year, under the DSM-V nearly a quarter of us will have a treatable disorder at any given time.  Half of us will need treatment at some point in our lives. That’s a lot of doctors to see and a lot of pills to take.

Are we really any crazier than we were a generation ago? Perhaps. Some reliable studies suggest that the incidence of conditions like anxiety, neuroticism and narcissism have increased over the past couple of decades. However, much of the increase in disease prevalence can be explained away.

We’ve also gotten a lot better at detecting mental illness, with doctors more aware of the signs and symptoms of common illnesses like depression, attention deficit hyperactivity disorder, or substance abuse. Increased awareness leads to increased diagnosis. In addition, while there is still considerable stigma and shame associated with mental illness, it has decreased in recent years. People suffering from psychiatric disorders are more likely to seek treatment and to be open about their illness. These are good things.

But what worries me is that the DSM-V also classified conditions that are physical not psychological in nature – such as caffeine withdrawal and obstructive sleep apnea – as diagnosable mental illnesses. It also drops Asperger’s as a separate disorder, lumping it in with other autism spectrum conditions. Soon, people living with Asperger’s will have a new diagnosis, which will affect both treatment and their ability to receive services.

Moreover, we will soon be pathologizing behaviors that would, in the past, be seen as quirky but not necessarily unhealthy. For instance, the DSM-V will include paraphilias – atypical sexual interests like bondage or sadomasochism – as diagnosable conditions. What is for some a natural albeit unusual expression of human sexuality could now affect child custody, employment and insurability decisions.

No wonder then that some prominent physicians have described the forthcoming release of the DSM-V as, “a sad day for psychiatry”. Diagnosing and treating mental illness is a challenge, but it’s a challenge that the American Psychiatric Association’s new guidelines fail to meet. The only thing that these guidelines do is to make us all a little bit crazy.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on April 18, 2013. It is also available on the WAMC website.]

Bright Shiny Things

On Tuesday, the US Centers for Disease Control and Prevention (CDC) released startling new data on the incidence of attention deficit hyperactivity disorder (ADHD) in American kids. According to the CDC, over 6 million children between the ages of 4 and 17 have been diagnosed with ADHD. Despite coming on the heels of April Fool’s Day, those numbers are no joke.

Over the past ten years, diagnoses have skyrocketed. Eleven percent of all school age children in the US have received an ADHD diagnosis, nearly twice the number seen in 2001. Rates are even higher among older kids, with nearly 20% of high school age boys having a diagnosis. One in ten adolescent boys are currently taking prescription stimulants like Ritalin or Adderall to treat the condition.

The reasons for the startling increase in rates of ADHD among American children are unknown. One possibility is that physicians are becoming more knowledgeable about the condition, enabling them to recognize it in their patients. Perhaps, but one of the problems that doctors face is the lack of clear diagnostic criteria for ADHD.

Like other attention or hyperactivity disorders, ADHD is characterized by a diffuse set of symptoms. According to the current version of the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), symptoms of ADHD ranging from fidgeting to not listening, to talking excessively, to disliking mentally intensive tasks like schoolwork. But it is rare to find a school age kid in the US who doesn’t have some, if not all, of these symptoms, as so artfully suggested by the satirical cartoon South Park (an episode from season 4 entitled ‘Drug Free Treatment’ for those who are interested). Given the subjective nature of these diagnostic criteria, it is likely that the condition is over-diagnosed.

If I had been born thirty years later, I too would likely have an attention deficit diagnosis. In fifth grade, I was “problem child.” I didn’t pay attention, didn’t complete assignments, didn’t remain in my seat, and didn’t stay quiet in class. The reason was not that I had ADHD. The reason was that I was bored. The material being presented didn’t stimulate me intellectually. Luckily, I had a very astute teacher who recognized this. With my parent’s permission, he started giving me more challenging work to do, and my grades and behavior quickly improved.

Unfortunately, thanks to decades of budget cuts, teachers nowadays do not have the same opportunities to work with struggling students. An educator dealing with a classroom of 40 or more kids, while also being expected to write individualized student learning outcomes (SLOs) and to develop metrics and tools for assessing student achievement, cannot devote the time or effort necessary to figure out why a particular child is failing.

Parents may feel similar pressures. So when a kid is struggling in school or acting out in class or at home, frustrated parents and teachers might automatically label the child as ADHD rather than seek alternative explanations for their behavior.

Given the subjective nature of the symptoms – confirmed primarily by talking with patients, parents and teachers, all of whom have an interest in finding quick and easy answers to complex behavioral problems – it is easy to understand why many doctors feel compelled to prescribe medication. Moreover, some savvy kids may seek diagnosis and treatment on purpose, given that ADHD drugs are now popular as study aids on high school and college campuses.

Therein is one of the biggest problems: over-diagnosis leads to over-medication. This isn’t to say that some kids don’t benefit from treatment with drugs like Adderall or Ritalin. Those with severe attention deficit do benefit from treatment, developing the concentration and impulse control necessary to succeed in school and in the workplace. Untreated ADHD can also lead to problems later in life, including alcohol and drug abuse. But for kids with mild ADHD or who are misdiagnosed, pharmaceutical treatment can come with great cost.

In their advertisements and promotional materials, drug manufacturers tend to overemphasis the benefits of treatment while downplaying the risks. ADHD drugs can improve concentration and impulse control but can also have severe side effects, including anxiety, addiction and psychosis.

The CDC’s shocking statistics should serve as a warning to us all. Not that we are facing an epidemic of attention deficit disorders in the US, but that we are likely facing an epidemic of pathologization. What is normal childhood behavior has become, for harried parents, teachers and physicians, a medical condition to be treated with drugs. Increased public awareness and understanding of attention deficit disorders is a good thing, but we shouldn’t rush to the pharmacy for some Ritalin every time that Johnny fails a test or Sally talks back.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on April 4, 2013. It is also available on the WAMC website.]

Fighting the Invincible Foe

Unbeknownst to most, mankind is at war with an invincible foe. Their numbers are legion and few if any of the weapons we have in our arsenal can stop them. I’m not talking about the rampaging zombie hordes shown on The Walking Dead or in trailers for the upcoming movie World War Z. Rather, I’m talking about antibiotic resistant bacteria.

Earlier this month, officials at the CDC, the US Centers for Disease Control and Prevention, raised concerns about a new family of drug-resistant bacteria that were spreading through hospitals across the country. This particular ‘superbug’ — tongue-twistingly called carbapenem-resistant Enterobacteriaceae but informally named CRE — is largely untreatable.

Without safe and effective antibiotics to treat patients, doctors must resort to alternative methods to cure patients with CRE. This may involve the use of older and more toxic drugs that may cause kidney or liver failure. Alternatively, surgeons may be forced to excise infected tissue or amputate infected limbs. Overall, CRE kills about half of those infected.

Thankfully, infection with this superbug is still rare. Enterobacteriaceae infections occur primarily in very sick patients confined to hospitals and nursing homes, and less than 5% of infections by this class of bacteria are caused by drug-resistant strains. But the number of CRE infections is growing rapidly.

Public health officials estimate that the number of cases has quadrupled in the last decade, but that is likely an underestimate. Smaller hospitals and nursing homes often lack the laboratory expertise to properly test for antibiotic resistant-strains of Enterobacteriaceae, so many CRE infections may go unidentified. Moreover, there is no national requirement that hospitals and nursing homes report cases to the CDC, and only a handful of states have local reporting requirements.

No one is sure how widely these bugs have spread. However, cases have been seen in 42 states and CRE infections are now endemic in many larger communities (including New York).

CRE is also not the only superbug that threatens us, though it is currently the deadliest. Other drug-resistant strains of bacteria are becoming commonplace, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and multidrug-resistant Mycobacterium tuberculosis (MDR-TB). Unlike CRE, these other superbugs are not limited to hospitals and nursing homes. They are found in the community and can infect otherwise healthy individuals. MRSA alone is now estimated to kill around 20,000 people every year in the US.

Sadly, this grave public health threat is one of our making. Overprescribing and misuse of antibiotics are the main reasons that these superbugs have emerged. Antibiotics like methicillin and vancomycin readily kill most bacteria, but an extremely small percentage of these microorganisms are naturally resistant. Whenever an antibiotic is used, the sensitive bacteria die off but the resistant bacteria thrive. Eventually, the resistant bacteria take over. This is why antibiotics should only be used sparingly.

Unfortunately, antibiotics are not used sparingly. Most people expect their doctor to prescribe antibiotics whenever they feel sick, be it strep throat or the flu. In many of these cases, however, an antibiotic is neither needed nor appropriate. For example, antibiotics do not work against viruses. So treating the flu with a ‘Z-pack’ is largely ineffective. But many doctors will prescribe it anyway, if only for the patient’s piece of mind.

Modern agricultural practices are also to blame, particularly factory farming of livestock in order to satisfy Americans’ desire for cheap meat, milk and eggs. Cattle, swine and poultry are often housed and raised in crowded conditions like feedlots, where bacterial infections can spread rapidly and decimate an entire herd. So, it has become routine practice to add antibiotics to the feed and water supply to prevent the spread of disease.

So what needs to be done to combat this threat? There needs to be a concerted effort at the federal, state and local level to track antibiotic resistant infections; reporting of cases to the CDC and State Departments of Health should be mandatory. We can’t fight the enemy unless we can find the enemy.

Moreover, the federal government should provide financial incentives for pharmaceutical companies to develop new antibiotics. Despite the threat that antibiotic-resistant bacteria pose, there are few new drugs in development. It is simply not cost effective for a company to spend billions developing a new antibiotic when the bacteria adapt so quickly. We need more weapons to combat this foe.

Finally, educating the public is important. As patients, we all can stop asking our doctor to prescribe us an antibiotic every time we have the sniffles. As consumers, we can insist on buying free-range and antibiotic-free meat, milk and eggs even if they cost a little bit more. This is a fight that can be won only if we all contribute to the war effort.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on March 21, 2013. It is also available on the WAMC website.]

Sequester This

As many of us expected, our leaders in Washington were unable to overcome their ideological differences long enough to actually do something about the looming and manufactured deadline for federal budget cuts known as the ‘sequester’.

Included as part of the Budget Control Act of 2011 — itself a compromise to deal with the manufactured debt ceiling crisis — the sequester mandates that $1.2 trillion be cut from the federal budget over the next decade, including $85 billion between now and September when the federal fiscal year ends. It would be nice if that $85 billion could be taken from Congressional salaries, seeing as how our Representatives and Senators aren’t doing much. Since it cannot be taken from their paychecks, we have to find other ways to slash this money from the current federal budget.

Now $85 billion doesn’t seem like a lot when you consider that the federal government is expected to spend $3.8 trillion in 2013. This year’s mandated cuts amount to less than three percent of total federal spending. The problem is that much of current government spending is from mandatory programs like Social Security and interest payments on the national debt, which are excluded from the sequester.

The bulk of the spending cuts will fall on discretionary spending programs, both military and domestic, along with an additional $10 billion in cuts to Medicare. The impact of these arbitrary and ill-conceived cuts on public health and safety are likely to be enormous.

For example, the US Food and Drug Administration (FDA) — the federal agency that, among other things, oversees food safety and licensing of new drugs — faces an eight percent cut in its budget this year. Slashing $300 million from the FDA’s budget means that review and approvals of new drugs or medical devices are likely to be delayed, and inspections of drug manufacturing facilities reduced. New brand name and generic drugs will be slower to enter the market, consumer costs will rise, and existing drug shortages will be exacerbated.

Budget cuts also mean that our food will soon be more expensive and less safe to eat. The FDA currently oversees 80 percent of the US food supply, with the US Department of Agriculture (USDA) overseeing the other 20 percent. Reductions to the FDA’s budget mean that it will conduct considerably fewer food safety inspections in the coming year. The Agency will also delay or scrap existing plans to hire and train new inspectors, to work with farms and food distribution companies to create detailed safety plans, and to create a new system for inspecting imported foods.

The USDA’s Food Safety and Inspection Service, in charge of meat and poultry safety, faces similar cuts. Meat and poultry inspectors will likely be furloughed for up to 15 days at a time. As USDA inspectors must be present for a plant to operate, the furloughs mean that some meatpacking plants will have to shut down. While this won’t affect food safety, it will affect consumer prices. The price of filet mignon and chicken fingers is likely to rise at your local ShopRite.

The budget of the US National Institutes of Health (NIH) will be slashed by $1.6 billion this year alone. The NIH is one of the largest public funders of biomedical research in the world, supporting the development of new treatments for the various diseases and conditions that currently drive healthcare spending in the US. In order to achieve the required reductions in spending, the NIH plans to turn down over a thousand new requests for research funding from the nation’s top labs and medical schools.

According to former NIH Director Elias Zerhouni, appointed by President George W. Bush in 2002, these changes in NIH funding priorities will be devastating. Not only will scientific innovation be slowed, but cuts to NIH-funded programs to train and support young investigators may lead many to abandon the field of science altogether. This will lead to a “generational gap” among researchers that will affect science for decades to come.

Finally, the sequester means that Medicare — which provides health coverage for nearly 50 million disabled or elderly Americans — will face a two percent cut in its budget this year. Again, this doesn’t seem like a lot of money until you consider that these cuts come after years of stagnant funding. Medicare payments for services have increased by only four percent since 2001 while the cost of actually caring for patients has increased by nearly 25 percent.

The only way that doctors and hospitals can continue to absorb these costs is by eliminating jobs and slashing services. One study suggests that nearly 300,000 healthcare industry jobs will be lost this year alone, meaning that all patients — those on Medicare and those with private insurance — are likely to face longer wait times for appointments and additional delays in receiving treatment and care.

There are plenty of people around the country, from pundits to politicians, who are in favor of the sequester. These mandatory cuts to the federal budget, they believe, will help rein in out-of-control government spending despite the inability of Congress to make difficult but necessary deficit-reduction decisions. But the capricious and arbitrary nature of these spending cuts endangers the health and safety of us all. If anything, key agencies and federal programs like the FDA, NIH and Medicare should be shielded from further cuts rather than be subject to the bulk of them.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on March 7, 2013. It is also available on the WAMC website.]

Protecting the Victims of Domestic Violence

Last Friday, famed Olympian and Paralympian Oscar Pistorius was arraigned on charges of murder in a South African court of law. Nicknamed the ‘Blade Runner’ after the carbon fiber blades that this double-amputee uses to run, Mr. Pistorius is accused of fatally shooting his 30-year-old girlfriend Reeva Steenkamp.

Ms. Steenkamp’s death may have been the result of a tragic accident. Home invasions are common in South Africa, and Oscar may have mistaken her for an intruder.

Sadly, it is also possible (even likely) that Reeva’s death is the result of a premediated or passionate act of violence. According to preliminary reports, the police in South Africa have been called to Mr. Pistorius’ house on more than one occasion to deal with domestic abuse complaints.

Also known as intimate partner violence, domestic violence is sadly commonplace in the US and around the world. It can take several forms, from physical and sexual assault to emotional and verbal abuse. Victims may also be subject to more passive or covert forms of abuse, such as neglect or economic deprivation.

More often than not, women are the primary victims. A recent survey of 16,000 people by the US Department of Justice found that nearly a quarter of women have been abused by a spouse or partner. The number of American women who are the victims of domestic violence is likely far greater, as the survey asked only about physical or sexual assault. It did not examine some of the more insidious forms of intimate partner violence like verbal, emotion and psychological abuse.

This is not to say that men cannot be victims of domestic violence as well. In the same Justice Department survey, over 7% of men reported a history of abuse. However, women are far more likely to be harmed or killed as a result of domestic violence. Data are spotty, but domestic violence appears to the leading cause of injury among women aged 15 to 45. It is estimated that 1,000 to 1,600 American women die each year from injuries sustained at the hands of an abuser. Many suicides may also be the result of domestic abuse; in one study of women who attempted suicide, researchers found that nearly a third reported a history of intimate partner violence.

Rates of domestic violence also differ by race and ethnicity. In the African-American community, for example, intimate partner violence occurs at a rate that is 35% higher overall. The statistics for Native American women are even more disturbing. Sixty percent of American Indian and Alaska Native women will be physically assaulted in their lifetime. Thirty-five percent will be raped.

The consequences of domestic violence are far reaching. In addition to the lives lost to domestic violence, it costs the American health care system nearly $5 billion a year to treat injuries sustained as a result of abuse. Economic productivity also suffers, with over two million workdays lost when abuse victims must take sick leave to recuperate. Many abuse victims lose their jobs and some even lose their homes as a result; research suggests that domestic violence is the primary cause of homelessness for half of the homeless women in the United States.

Combating domestic violence has proven to be difficult, in part because victims are often reluctant to press charges or to seek medical care. Even when they do, law enforcement agencies and health care providers may be loathe to interfere. For too long, domestic abuse has been viewed as a private matter to be handled within the family.

That is changing, albeit slowly. While police have been reluctant to intervene in domestic disputes in the past, for example, nearly half of US states now have policies that mandate arrest of the perpetrators of domestic abuse, regardless of whether or not a police officer witnessed the crime; the remaining 26 states that lack such laws will hopefully pass them soon. More and more medical schools are also training doctors and nurses recognize and address domestic abuse in their patients.

But while progress is being made at the state level, a coordinated federal response to the domestic violence epidemic is somewhat lacking. One key piece of federal legislation is the Violence Against Women Act, signed into law by then President Bill Clinton in 1994. The Act provides for federal investigation and prosecution of violent crimes against women. It also provides for a coordinated community response to domestic abuse via grant funding and support offered by the federal Office on Violence Against Women, including money to help the states implement mandatory arrest policies.

In recent years, however, some in Congress have tried to gut the law or have refused to reauthorize it. Some legislators object to provisions that would extend the Act’s protections to same-sex couples or undocumented workers. Others reject the inclusion of American Indians living in reservations, which would give tribal authorities jurisdiction over crimes involving non-native Americans on tribal lands. These objections come despite the fact that intimate partner violence is common among these three groups.

Whatever the root cause for these objections — legal concerns about the adequacy of tribal courts or ideological opposition to protecting the health and well being of lesbians and illegal immigrants — these politicians are doing themselves and the American public a grave disservice. It’s time to renew the Violence Against Women Act and extend its protections to all. Domestic violence is a problem that affects us all. All victims, be they gay or straight, white or Native American, a US born citizen or an undocumented worker, deserve the full protection and support of the government.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on February 21, 2013. It is also available on the WAMC website.]

The Bully Pulpit

Last Sunday was one of the biggest American holidays. It was Super Bowl Sunday, the calorie-laden and alcohol-fueled celebration of two of America’s most hallowed traditions: armchair quarterbacking and watching television commercials.

This year’s game, between my hometown San Francisco 49ers and the Baltimore Ravens, was probably the weirdest Super Bowl ever. It was the first brother versus brother coaching matchup in Super Bowl history, with the Raven’s coach John Harbaugh eking out a win over his younger sibling Jim. It was also characterized by the longest kickoff return, Jacoby Jones’ 108-yard touchdown run at the start of the second half, and the first intentional safety, with the Ravens sacrificing two points in order to run down the final clock and secure the win. Finally, I doubt any of us will forget the 35-minute delay after the power failed in half of the stadium.

But I don’t want to talk about the game itself. Rather, I want start by focusing on the curious things said by three players in the week before the game.

Many San Franciscans were shocked when Niners’ Cornerback Chris Culliver went on an anti-gay tirade during an interview with radio shock jock Artie Lange. The team owners and coaching staff quickly distanced themselves from his comments. Culliver himself gave a half-hearted apology the next day, stating that “The derogatory comments I made yesterday were a reflection of thoughts in my head, but they are not how I feel.” I don’t necessarily buy that, but I respect his First Amendment right to be an ignorant homophobe.

Things got really weird the next day when two of Culliver’s teammates, linebacker Ahmad Brooks and nose tackle Isaac Sopoaga, denied appearing in the team’s anti-gay bullying ad despite clear video proof that they had. The San Francisco 49ers were the first NFL team to join the “It Gets Better” campaign, a project designed to combat the bullying experienced by lesbian, gay, bisexual and transgender (LGBT) youth. Apparently, these two football players were okay appearing in an anti-bullying ad but not an anti-bullying ad that is aimed at gay youth. In response, founder of the “It Gets Better” project Dan Savage has deleted the 49ers video from the campaign’s website. This is the first time that an anti-bullying “It Gets Better” video has been removed.

Bullying is a serious and widespread problem in American schools, regardless of sexual orientation. One survey conducted by the American Psychological Association (APA) found more than half of all children experience some degree of bullying or harassment in their school careers. Nearly one-in-eight is bullied on a regular basis, usually because of some perceived difference from social norms. These kids may be perceived as being too smart or they may be seen as not smart enough. They may be considered homely. They may be overweight, a fact that has been getting a lot of attention on popular television shows like The Biggest Loser. However, being gay or being perceived as gay is particularly problematic. As reported in the Gay, Lesbian and Straight Education Network’s 2011 National School Climate Survey, over 80% of LGBT youth have been verbally or physically assaulted by their classmates and (surprisingly) their teachers because of their sexual orientation.

Bullying has serious consequences. Bullied kids often feel unsafe at school, and thus are more likely to drop out. Alternatively, they may resort to extreme measures to regain a sense of security, such as packing a defensive weapon. According to the APA’s bullying survey, a quarter of bullied kids have carried a knife or gun to school. Bullied kids are also more likely to suffer from depression or to have suicidal ideation. Last October, for example, a Staten Island teen killed herself by jumping in front of a moving train while her classmates watched in horror; she was the victim of intense harassment by several of her peers after being the victim of a sexual assault. In late January, a bullied gay Oregon teen attempted suicide by hanging himself from a piece of playground equipment; he died just before the Super Bowl kickoff after being taken off life support when neurological tests showed no brain activity.

Combatting this problem is hard. Cyber-bullying in particular is becoming increasingly common, and the anonymity and ubiquity of the Internet can make it can make it nearly impossible to stop harassment once it starts or to identify and punish a bully. Moreover, recent studies suggest that being a bully can actually boost a kid’s popularity. In one survey of middle school students in California, the children who were considered the coolest were the ones who “start fights or push other kids around” or who “spread nasty rumors about other kids.” Changing this Lord-of-the-Flies-like culture of the schoolyard may prove to be impossible, but it doesn’t mean that we shouldn’t try.

Sociological questions aside, however, one of the biggest problems is right-wing opposition. Conservative politicians like Michele Bachman and organizations like Focus on the Family have opposed many anti-bullying programs for the sole reason that such programs also attempt to combat the widespread bullying of LGBT youth. According to the Family Research Council, bullying prevention initiatives are nothing more than thinly veiled attempts by gay rights activists to “recruit” students, a classic example of the ‘blame the victim’ mentality. Apparently it is okay to bully and harass gay kids because of their immoral and sinful lifestyle, an argument that at least two professional football players seem to publicly support.

The fact of the matter is that bullying, for whatever reason, is wrong. All kids, gay and straight, deserve the chance to feel safe at home, at school, and in the larger community and school officials and other policymakers should reject any attempt to block anti-bullying programs.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on February 7, 2013. It is also available on the WAMC website.]

Stonewalling on Health Care

While being sworn in for a second term earlier this week, Barack Obama made history by being the first president to refer to the LGBT (lesbian, gay, bisexual and transgender) community in an inaugural speech. In what that some pundits are calling ‘Lincoln’s third inaugural address,’ the President laid out a civil rights agenda that placed the fight over gay rights on equal footing as battles against racial, ethnic, religious and gender discrimination.

Gay rights groups were obviously pleased, and now expect the Obama Administration to be more active in their support for marriage equality. Conservative groups were clearly displeased, and anti-gay organizations like the National Organization for Marriage and the Family Research Council quickly released public statements condemning the President’s remarks. The head of the National Organization for Marriage, Brian Brown, went so far as to claim that “gay and lesbian people are already treated equally under the law. They have the same civil rights as anyone else.” That claim is, of course, laughable.

What is sorely overlooked in the gay rights debate, however, is the issue of equal access to health care. The HIV/AIDS epidemic, for example, has had a disproportionate impact on gay and bisexual men in the US. Gay and bisexual men, particularly men of color, still account for nearly two-thirds of all new HIV infections. The impact of HIV/AIDS has been even greater in the transgender community, with almost a third of all transgender women (someone who was born male but whose gender identity is female) testing positive for the virus.

But the problem that the LGBT community faces goes deeper than HIV/AIDS. Recent studies show that the community as a whole is underserved medically. In a companion document to the 2010 Healthy People report – a statement of national health objectives produced every ten years by the US Centers for Disease Control and Prevention – the Gay and Lesbian Medical Association cataloged a long list of health disparities.

Lesbian women, for instance, are more likely to be overweight or obese than straight women. They are also less likely to get preventive services for cancer, such as routine mammograms to detect breast cancer or regular Pap smears to look for cervical cancer.

As already mentioned, gay men and transgendered individuals are at higher risk for HIV and other sexually transmitted diseases. In addition, they are more likely to smoke and to abuse alcohol or other substances. They also have higher rates of untreated mental illness, and are more likely to commit suicide.

These problems are particularly acute among LGBT youth, who are far more likely to be homeless or to be the victims of domestic violence and bullying than their straight counterparts.

These health disparities exist primarily because of social stigma and legal discrimination. Current laws and policies can make it more difficult for LGBT individuals to get insurance. Despite recent gains, for example, many private companies and public institutions still do not offer health insurance to same-sex spouses or domestic partners. Even if they do, the cost is often prohibitive. While federal and state governments do not tax health benefits for spouses, they usually tax benefits for domestic partners because they do not legally recognize same-sex relationships. These benefits may even be subject to double taxation; employees must not only pay their partner’s insurance premium with after-tax dollars, they must pay taxes on the values of the benefit because it counts as income.

Even if they have health insurance, LGBT individuals are less likely to seek medical care. This is due in part to the fact that many doctors and nurses lack any formal training in LGBT health. In a recent review of the curriculum offered by 132 medical schools, nearly half provided no training on LGBT issues. Of those schools that did offer training, on average they spent a meager five hours on LGBT health issues over the course of four years.

This lack of training perpetuates stereotyping and discrimination in the clinic; a 2007 survey of nearly 1,000 physicians in California found that nearly 20% were uncomfortable or unwilling to provide care to gay and lesbian patients. It also exacerbates existing health disparities. Doctors unfamiliar with the special needs of LGBT patients simply cannot provide an adequate level of care and treatment. Moreover, gay and lesbian patients are unlikely to seek or follow medical advice if they feel that the doctor is ignorant or judgmental.

In his inauguration speech, Obama claimed that the promise of equality laid out in the Declaration of Independence would never be fulfilled unless “our gay brothers and sisters are treated like anyone else under the law.” He’s correct. But it’s also important to remember that the Declaration of Independence holds that all men have certain rights, and among these are “Life, Liberty and the pursuit of Happiness.” In order to have both Life and Happiness, however, one must have good health.

Issues of marriage equality aside, the gay rights agenda must address the legal and social barriers that prevent the LGBT community from living a healthy life. We need to change current laws that prohibit or discourage the provision of domestic partner benefits like health insurance, and we need to ensure that all health care professionals are properly trained to recognize LGBT-specific health needs and to provide for them in an appropriate non-discriminatory manner.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on January 24, 2013. It is also available on the WAMC website.]

The Importance of Being Fat

For many Americans, the New Year is often a time to look back on both the successes and failures of the past. More importantly, it is also a time to look forward and to think about the changes we want or need to make in order to live happier and healthier lives.

Given that two-thirds of Americans are now classified as overweight or obese, is it any wonder that the top resolution for 2013 (and for 2012, and 2011, and 2010) is to lose weight. For most of us, this means eating less and exercising more. For some, this is a much more radical undertaking that can involve rather invasive procedures like gastric bypass surgery or (in the near future) the use of an AspireAssist: a mechanical pump that actually drains the stomach contents through a hole inserted through the abdominal wall.

We are a nation of fat people, and every year we resolve to do something about it. I’m no different. Despite the best of intentions last January, I left 2012 about five (well, maybe ten) pounds heavier than when I entered. I’ve again resolved to do something about it, and am two weeks into a dietary program that involves a rather brutal but effective herbal cleanse.

Our desire to lose weight is driven in part by media images of what healthy men and women are supposed to look like, namely the muscle-bound hunks and reed-thin waifs that appear in magazine and television ads. The multi-billion dollar weight-loss industry pushes a similar message of thinness. Finally, we are told time and time again by the medical establishment that it is dangerous to be fat.

For decades now, doctors and public health experts have been warning that those of us who carry a few extra pounds are likely to die at a younger age than our fit and trim counterparts. But is that actually the case? A new study published in a recent issue of the Journal of the American Medical Association suggests otherwise.

That widely publicized study, released just in time for our annual migration to the gym, reviewed data from nearly a hundred previously published epidemiological studies looking at the relationship between weight and mortality risk. Surprisingly, these data — collected from almost three million study participants in twelve different countries — suggest the exact opposite of what we’ve always been told.

It turns out that people who would be classified as overweight by current standards actually had a 6% lower risk of death than those who would be considered to be a normal healthy weight. For the average 5’10″ American male, it is better to tip the scales at a weighty 220 pounds than at a slender 160 pounds, at least as far as the Grim Reaper is concerned.

This is good news for all us chunky monkeys, right? Well, we probably shouldn’t count (and deep fry) our chickens before they are hatched. These study results shouldn’t be seen as giving us license to spend our Sunday evening eating a pint of Häagen-Dazs while watching The Biggest Loser.

First and foremost, these data, like all epidemiological data, apply to populations not individuals. Overweight men and women were slightly less likely than normal weight men and women to die as a whole, but these data cannot be used to predict when you or I as individuals might die. Nor can they predict whether or not our deaths will be caused by obesity-related illness or by stepping in front of a bus.

There are also a number of scientific explanations for why these data fly in the face of conventional wisdom, as outlined in the editorial that accompanied the published study. Overweight and obese people might receive more medical attention and intervention; a number of studies have shown that physicians are more likely to screen and treat overweight patients for a variety of diseases.

The data may also be biased. When researchers looked at rates of death within the normal weight category only, for example, they found that those in the ‘thinner’ half of this category had higher rates of mortality than those in the ‘fatter’ half. The reasons why these thinner people had higher rates of death are unclear. Some may have been that thin because they were suffering from other underlying illnesses, like cancer or diabetes. Some may have suffering from eating disorders. The study did not control for these possibilities, and so the data may have been skewed.

A more plausible explanation for these findings, however, is that the medical and research community still have poor ways of measuring whether or not a person is overweight. The most commonly used measure of obesity is the body-mass index (BMI), which is the ratio of a person’s height to weight. Men with a BMI of 19-24 are consider to be normal, while those with a BMI of 25 or higher are overweight and those with a BMI of 30 of greater are considered obese. For the average 5’10″ American male, this means you are overweight if you weight 175 pounds or more. But this crude measure doesn’t distinguish between fat and muscle, so relatively fit individuals who hit the gym regularly would be considered overweight by this measure even if they had six-pack abs. Inclusion of these individuals in the study might have skewed the data as well.

What this study tells us is not that it is okay to be fat but, rather, that we still have a poor understanding of what it means to be healthy. We need to move beyond the knee jerk ‘fat is bad’ mentality and focus on a ‘fitness is good’ approach. Current categories like thin, fat and obese make no sense. Fitness means different things for different people, and a somewhat overweight individual (at least as determined by our current crude methods) might be extremely fit and healthy while a relatively thin individual might be extremely ill and unhealthy. We need to focus not on what the scale tells us, but rather on having a healthy lifestyle that includes regular activity and eating right.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on January 10, 2013. It is also available on the WAMC website.]