Tuesday, 26 February 2019

Climate change and Health living

Of the 358 children who died from influenza between 2010 and 2014, only 26% had been vaccinated against it, according to a study just released in the journal Pediatrics.

That means 74%, or three out of four of them, had not. And maybe if they had been vaccinated, they’d be alive right now.

Of all the vaccines I give as a pediatrician, the flu shot is the one that families refuse most. Parents don’t think they need it. They don’t think it works. They think it is dangerous. This frustrates me, because none of these reasons for refusing the flu shot are true.

Influenza can be a dangerous disease. Every year, it kills thousands of people. The 358 above is the number of children who died of what was proven to be influenza by testing; but testing isn’t always done, so the number is likely much higher. And many people die of complications of influenza, such as bacterial pneumonia — or, for people who have chronic conditions, the stress on their body of influenza leads to fatal problems from their condition. For this reason, it’s extremely difficult to know how many people influenza kills each year. But millions of people catch it, and hundreds of thousands end up hospitalized. While many people are just miserable with fever and cough for a few days, for some people it is far more serious.

Of those 358 children in the study, 153 had conditions that put them at higher risk of getting sicker from the flu. That means that more than 200 were healthy children. That’s the thing: being healthy doesn’t mean you will be fine if you get the flu. Again and again, parents tell me that their children don’t need it because they are healthy. Again and again, I try to explain that being healthy isn’t enough to keep you safe.

It’s certainly true that the flu shot doesn’t always work. As the study pointed out, 26% of those children who died had been vaccinated. On average, the flu vaccine is about 50-60% effective. Parents say to me sometimes: why bother, if it might not work? My answer is: why not get it, if it might work?

The only reason not to would be if it were risky, but the scientific truth is that the influenza vaccine is quite safe. It’s certainly possible that your arm can be sore, or that you could get a fever; according to data from the World Health Organization, “local reactions” such as redness or soreness can happen up to 50% of the time. Fevers happen in 12% of children under five who get the vaccine, and in 5% of older children. While uncomfortable, these are brief and manageable side effects.

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But serious reactions, such as severe allergic reactions, Guillain-Barre syndrome, or oculorespiratory syndrome, are extremely rare — only a few people in every million who get the vaccine will experience them. Of these, a severe allergic reaction is the only one that has a significant chance of being deadly — and those reactions happen less than once in every million doses.

While we are still seeing cases of flu, the season is winding down; soon we will stop giving the flu shot again until the end of summer or early fall. I hope that parents who have refused the flu shot in the past will take the time to learn more and talk to their doctor; I hope that when fall comes they won’t miss a chance to help keep their child healthy — and alive. Low back pain, the scourge of mankind: it is the second leading cause of disability here in the United States, and the fourth worldwide. It’s also one of the top five medical problems for which people see doctors. Almost every day that I see patients, I see someone with back pain. It’s one of the top reasons for lost wages due to missed work, as well as for healthcare dollars spent, hence, a very expensive problem.
Looking at two kinds of back pain

Let’s talk about the most common forms of back pain: acute (which lasts less than four weeks) and subacute (which lasts four to 12 weeks). Most of these cases (approximately 85%) are due to harmless causes. We lump them into the “mechanical back pain” diagnosis, which includes muscle spasm, ligament strain, and arthritis. A handful (3% to 4%) will be due to potentially more serious causes such as herniated discs (“bulging” discs), spondylolisthesis (“slipped” discs), a compression fracture of the vertebra due to osteoporosis (collapsed bone due to bone thinning), or spinal stenosis (squeezing of the spinal cord due to arthritis). Rarely, less than 1% of the time, we will see pain due to inflammation (such as ankylosing spondylitis), cancer (usually metastases), or infection.

When someone with acute low back pain comes into the office, my main job is to rule out one of these potentially more serious conditions through my interview and exam. It is only when we suspect a cause other than “mechanical” that we will then order imaging or labs, and then things can go in a different direction.

But most of the time, we’re dealing with a relatively benign and yet really painful, disabling, and expensive condition. How do we treat this? The sheer number of treatments is dizzying, but truly effective treatment options are few.
Analyzing a range of treatments for low back pain

The American College of Physicians (ACP), the second-largest physician group in the U.S., recently updated guidelines for the management of low back pain. Its physician researchers combed through hundreds of published studies of non-interventional treatments of back pain, and analyzed the data. Treatments included medicines such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen), opioids (such as oxycodone), muscle relaxants, benzodiazepines (such as lorazepam and diazepam), antidepressants (like fluoxetine or nortriptyline), anti-seizure medications (like Neurontin), and systemic corticosteroids (like prednisone). The analysis also included studies on non-drug treatments including acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise (working the muscles that support and control the spine), progressive relaxation, biofeedback, low-level laser therapy, behavior based therapies, or spinal manipulation for low back pain.

That’s a lot of therapies!

Researchers were interested in studies that measured the effectiveness (usually measured as pain relief and physical functioning) as well as the harms of all these therapies.
Drugs are not part of the latest recommendations for treating “mechanical” back pain

What the researchers found was surprising: for acute and subacute low back pain, the best and safest treatments are not medicines. The ACP made the following strong recommendation:

Most patients with acute or subacute low back pain improve over time regardless of treatment and can avoid potentially harmful and costly treatments and tests. First-line therapy should include nondrug therapy, such as superficial heat, massage, acupuncture, or spinal manipulation. When nondrug therapy fails, consider NSAIDs or skeletal muscle relaxants.

Because most mechanical back pain improves no matter what, we don’t want to prescribe treatment that can cause harm. Because some medications carry significant risks, we really shouldn’t be recommending these right off the bat. Rather, we should be providing guidance on heating pad or hot water bottle use, and recommendations or referrals to acupuncturists, massage therapists, and chiropractors. These therapies were somewhat effective, and are very unlikely to cause harm.
Even the nonprescription pain relievers are not risk free

Medicines like ibuprofen and naproxen can be helpful, but they can cause stomach inflammation and ulcers, as well as possible bleeding, and even kidney damage, especially in the elderly. Muscle relaxants can be sedating, and can interact with other common medications. Benzodiazepines and opiates not only can cause sedation, making it hard to think clearly and function normally, they are also addictive. Basically, for acute and subacute low back pain, the risks of these medications outweigh the benefits. Other medications, like acetaminophen, steroids, antidepressants, and anti-seizure medications, were not significantly helpful for acute and subacute low back pain at all.
Here’s what the study couldn’t tell us

The study was missing a few potentially helpful low-risk medicines. Topicals such as the lidocaine patch or capsaicin ointment were not included, which is a shame, as these can provide relief for some people, and carry little risk. I would also be interested to know if over-the-counter topical therapies containing menthol and camphor are better than placebo for low back pain. Suggestions for the future research, and the next update! My husband Jay and I turn into super nerds on our brisk morning walk. We sport decidedly uncool but comfy clothes and sneakers, clock the times when we leave and return, count our steps, sometimes break into a run for interval training, and alternate routes in the neighborhood — all while flailing our arms (okay, that’s just me), gabbing away (me again), laughing, and analyzing the issues of the day. It’s fun — like a mini date — and it’s always interesting. The routine suits us. And that comfortable fit is key to sustaining an exercise program. “Finding an activity you enjoy is an incentive to keep doing it,” explains Madhuri Kale, a physical therapist at Harvard-affiliated Brigham and Women’s Hospital.  At first glance, climate change and personal health may not seem related. One is a global political and environmental concern, while the other deals ultimately with an individual’s well-being. However, climate change is already directly affecting human health in many parts of our world, including many areas of the United States. We are just beginning to understand, and to witness, the health effects of climate change.
The problem with a warmer planet

As human-made carbon dioxide levels in our atmosphere increase, we create a “greenhouse effect,” and our world warms. The three hottest years ever recorded in the United States were 2012, 2015, and 2016. As the temperatures rise, arctic ice sheets start to melt, and ocean levels rise. We’ve already seen coastal flooding in many parts of the world. Flooding leads to homelessness, dislocation, the spread of infectious diseases, poverty, and psychological trauma. Just think about the catastrophic flooding after Hurricane Katrina. Local healthcare resources were compromised and quickly overtaxed. Many of the neighborhoods in New Orleans are still trying to recover more than a decade later.

As our earth warms, weather patterns become unstable, and violent storms become more frequent, as do droughts, heat waves, and forest fires. Super Storm Sandy, in 2012, killed hundreds of people and cost tens of billions of dollars in property damage. Scientists warn that with climate change, such unusual storms are certain to become more frequent and more severe. Less affluent people and impoverished nations are affected disproportionately.

Droughts can cripple farming and food production, which leads to poverty, malnutrition, and starvation. As a result, we are seeing more environmental refugees. This, in turn, increases armed conflict and political instability, both of which are disastrous for human health. Areas that are expected to see worsening droughts are southern Africa, southern Asia, the Middle East, and the American Southwest. More carbon dioxide in the atmosphere increases acidity in ocean waters, which is damaging to marine life and affects fresh water fisheries as well.
Climate change and infectious diseases

As our climate changes, the patterns and territories of infectious diseases can be dramatically altered, straining the ability of healthcare systems and governments to contain them. Diseases affected by climate change include those carried by animals and insects — for example, tularemia, plague, Rocky Mountain spotted fever, West Nile virus, and Lyme disease. Others include Zika and dengue. Waterborne infections (for example cholera and other gastrointestinal infections) may become more common. Truly clean water may be harder to come by.
What to do?

Fortunately, almost all scientists agree that we need to aggressively counter climate change, and most governments of the world are dedicated to doing their part. Last year, 196 countries signed the Paris Agreement, which commits signatories to work toward keeping temperatures from rising more than two degrees Celsius (3.6 degrees Fahrenheit). This would at least prevent many of the worst-case scenarios of a “runaway greenhouse effect,” which would threaten human life on earth, and allow us more time to adapt to these changes.

Taking action to reduce your carbon footprint directly benefits your health as well as that of the planet. For example, walking or biking instead of driving avoids burning fossil fuels, provides exercise, and helps maintain a healthy weight. Eating less red meat is linked with a lower risk of heart disease and certain cancers. Growing and consuming produce locally can produce a great sense of community and lead to eating lots of healthy and delicious vegetables. Using renewable energy, and thus creating less air pollution, will result in fewer cases of asthma and lung cancer.

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