Not On the Universal Health Insurance Bandwagon

Paul Krugman’s column in the New York Times (which you can also find here, if you don’t want to pay to get past the Times Select firewall) has spurred a new flurry of concern about spiraling health insurance costs impacting American businesses.

Revere over at Effect Measure mentioned a post over at My DD by Scott Shields titled “GM Layoffs and The High Cost of Healthcare”, in which the case is made that healthcare costs for employees and retirees are a major part of GM’s financial problems, and that universal health insurance is a matter of economic competitiveness. Revere’s comment was this issue should be a no-brainer for Democrats.

What drew my attention to Mr. Shields’s post, the associated comments, nor the other blogs he cited (summarized here), was not seeing health promotion featured in the discussion. Universal health insurance may be a great bandwagon for Democratic politics, but I’m not ready to jump on if it isn’t going to address wellness, including instituting some standards of individual responsibility on the part of beneficiaries to maintain their health. Maybe there’s a trade that can be made here – workers will eat their fruits and vegetables, and get more exercise, if investors cough up some of their dividends.

For example,

Taking a cigarette break outside a General Motors (GM) assembly plant in Lansing, Mich., last week, Mike O'Driscoll admits he has problems: diabetes, high blood pressure, high cholesterol.

But his arteries are cleaned out, thanks to a $160,000 heart-bypass surgery a few years back.

"I ate too many steaks and not enough veggies," says O'Driscoll with a laugh.

For as long as O'Driscoll has worked at GM, he hasn't had to worry about health care costs. . . .

The intent here is not to endorse a moral hazard argument (Malcolm Gladwell makes a good case here that moral hazard is a really bad idea), but there’s a balance to be struck somewhere – at least the debate over universal health insurance could also encompass the role of health promotion in controlling medical expenses.

Is Mr. Shield’s post a representative cross-section of the discussion in the liberal blogosphere? If it is, then a vital public health component to addressing the health insurance crisis is absent. Phillip Longman published an interesting article in Washington Monthly a couple of years ago, suggesting that the money being used to prop up benefits in a healthcare system that is already financially unsustainable, instead be used to bribe people into acting preventively and taking better care of themselves. While possibly an unconventional approach, at least it has health promotion at its core. A political no-brainer it may be for the Democratic Party, but will universal health care really accomplish anything of value if it does nothing to address the avoidable causes of disease?

Postscript: minor editing for grammar on November 27, 2005.

Medicare Prescription Drug Coverage as Wellness Promotion

Watching the spectacle of millions of seniors across the country wrestle with enrolling for prescription drug benefits led me to the conclusion that the Bush Administration’s new program potentially has an important role in wellness promotion. Before too long, people will start trying anything, including eating better and exercising, to stave off the need for prescription drugs and to keep out of the clutches of this bureaucratic monster.

Green Bottom Line?

Over in the hated New York Times earlier this week was a story about various companies taking steps to sell greener products (with the catchy title, “Saving the Environment, One Quarterly Earning Statement at a Time”). A lot of the examples invoke the high price of oil as a driver, but there isn’t any discussion about whether corn-based packaging or biodiesel are really promoting sustainability. That’s because the topic of sustainability metrics is probably a little too advanced for the Times. Come to think of it, the definition of “sustainability” is a bit plastic, depending on your political and economic orientation. But at least the market’s dimly growing awareness of the environment is slowly becoming part of the conventional wisdom, if it’s being published in the Times. Strangely enough, there’s scarcely a word on trading credits for greenhouse gas emissions, even with this story nearby.

What to do About PCE in Dry Cleaning?

In 1997, New York State and New York City adopted regulations to control perchloroethylene (PCE) emissions from dry cleaners located in residential and other buildings. From 2001 to 2003, the New York State Department of Health (NYSDOH) measured indoor air concentrations of PCE in apartments located in buildings in New York City where dry cleaners used PCE on site. While PCE exposures are widespread in the U.S. population, previous studies have shown that the most significant non-occupational exposures occurs in residences located over or adjacent to dry cleaners.

Mean indoor air PCE concentrations have decreased by about 10-fold since 1997, when additional dry cleaner regulations were implemented. Despite these accomplishments, PCE concentrations in several of the sampled apartments still exceeded the NYSDOH residential air guideline of 100 ug/m3. PCE concentrations in a few apartments exceeded the 1,000 ug/m3 action level set by NYSDOH. Moreover, the mean indoor air PCE concentrations in minority neighborhoods (75 ug/m3) were four times higher than in nonminority households (19 ug/m3). The mean PCE concentrations were > 10 times higher in low-income neighborhoods (256 ug/m3) than in higher income neighborhoods (23 ug/m3).

The study concluded that "[f]actors that may be contributing to the elevated perc levels detected, especially in minority and low-income neighborhoods, are being explored".

It doesn't take a lot of looking around to come up with a plausible explanation for why low-income neighborhoods (which would substantially overlap with minority neighborhoods) have higher PCE exposures. Dry cleaning is not a high-margin industry. According to the International Fabricare Institute, most commercial drycleaners are single facility, family-owned operations. An average number of five employees work at a plant. Commercial dry cleaning may not generate large profit with median annual revenues below $250,000. Bureau of Census statistics essentially confirm the industry figure. Bureau of Labor Statistics figures show that mean annual incomes of dry cleaning workers is $8.80 per hour ($18,290 per year). EPA’s draft dry cleaning NESHAP from 1993 cited the capital cost of secondary controls (a refrigerated condenser) at $6,300 with annual costs of $1,000 for process vent controls. The California ARB’s recent report on the dry cleaning industry also cites similar costs for installation of secondary controls.

Even before doing the arithmetic, it appears reasonable that many dry cleaning facilities would find installation of emission controls to be an economic burden, worth the risk of non-compliance. If it’s assumed that the dry cleaners in the lower-income neighborhoods have revenues lower than the median, the burden of emissions controls would be proportionately greater, the proportion of non-compliance greater, hence higher PCE exposures in lower income neighborhoods.

Whether we should continue to use PCE to dry clean clothes involves a balancing of the risks versus the benefits, and balancing competing risks. Beyond that, it involves balancing who is reaping the benefits versus who is being subjected to the risks. How significant are those risks? Are the costs for controlling PCE emissions an economic burden to dry cleaners? Are the risks and costs for control significant enough to warrant finding alternatives to PCE for dry cleaning? A further question is what kinds of alternatives are there to dry cleaning with PCE? Are these more “environmentally friendly”? Do they provide suitable quality in fabric care? What kinds of economic impacts are there to the dry cleaning industry with switching from PCE?

PCE use in dry cleaning is a laboratory experiment for implementation of the precautionary principle. In this case, some harm potentially has been done from PCE exposure (more on this topic later), and more harm may be averted through finding alternatives to PCE in dry cleaning. However, other types of harm such as economic dislocation, unemployment and poverty for some, which have their attendant health risks, might be created by forcing the replacement of PCE as a dry cleaning solvent, indicating the need for a more nuanced view of the precautionary principle than “just don’t use it”. Navigating through this maze and solving the problem of replacing PCE in dry cleaning might provide lessons in toxic substance use reduction that could be applied elsewhere.

Political Blogs in a Bubble

After reading this post, I’ve become more convinced that political blogs live in their own little world in which not much exists beyond the front page of the New York Times. Someone who announces, “[t]he New York Times is simply not a good newspaper anymore”, hasn’t encountered this story about the PCB cleanup in the Hudson River, or this story about how the revitalization of public health services in a rural New Mexico community has contributed to economic revitalization.

The Times hasn’t covered itself in glory in past years on the political front, and I stopped reading and moved exclusively to the WaPo after the Judith Miller thing. However, I decided reluctantly that useful news can be found in the Times if you don’t pay attention to the political reporting.

Reading Getting Things Done

I read Getting Things Done: The Art of Stress-Free Productivity by David Allen on the plane this week (at a height of six foot, two inches, it’s tough to use a computer in a coach seat) and now I know what’s meant by “43 folders”. I’m not telling – you’ll have to read about yourself.

Some think that multitasking is the art of productivity, but this picture from the productivity blog 43 folders shows what multitasking really means. . . .

Disparities in Disease Patterns

NIEHS is considering discontinuing sponsorship of Environmental Health Perspectives, which currently is offered as an open source journal. So, I’ve been trolling through the back issues to download interesting papers and catch up on anything I’ve missed.

An interesting constellation of articles is in the September 2005 issue. Illnesses such as cardiovascular disease, diabetes, high blood pressure, and cancers of the breast and prostate have been observed to affect certain population groups disproportionately. Observation of these health disparities (defined as differences in incidence, prevalence, mortality, and burden of disease among specific population groups) led the NIH to fund eight different research centers with a total of $60.5 million over five years to study what factors might mediate the onset or outcomes of these common diseases. This research conducted by the Centers for Population Health and Health Disparities (CPHHDs) has been addressing how the combination of biological, social, cultural, environmental, and economic factors influence disease occurrence in certain populations. These studies are investigating the disparities affecting breast, prostate and cervical cancers, multiple disease burden in a single population, mental stress-related disabilities, and ethnic homogeneity and disease incidence.

The most interesting study conducted by the RAND CPHHD provides an overlay of multiple data types (census, cost of living, census, air quality and land use) that can be used to evaluate how neighborhood variables affect mental and physical health. The results from this study might be used to identify ways these neighborhood variables could be affected by policy. Neighborhood variables investigated include the relationship between built environment factors and obesity (for example, bike paths, sidewalks, parks), physical and social factors affecting quality of life in the elderly, and impacts of outdoor air quality (particulate matter and ozone) on asthma occurrence. The news blurb doesn’t say anything about a GIS component, but it makes sense there would be one for this application.

Another study published in the same issue assessed the effect of diet on arsenic metabolism. Many individuals in the Western U.S. who get their drinking water from private wells are exposed to arsenic concentrations higher than the 10 ug/L primary drinking water standard. Arsenic is naturally occurring in groundwater, with higher levels observed in Western U.S. aquifers. The primary metabolic pathway of ingested is methylation to monomethyl arsenic (MMA) and dimethyl arsenic (DMA). Recent evidence suggests that those who excrete high proportions of ingested arsenic as MMA are more susceptible than others to arsenic-caused cancer. Diet might be one factor that affects arsenic methylation. This study examined dietary intakes and urinary arsenic methylation patterns in volunteers from two high-arsenic regions in the western United States. The results indicated that subjects with lower protein, niacin, iron and zinc intakes excreted a higher proportion of ingested arsenic as MMA and a lower proportion as DMA than did subjects with higher nutrient intakes. These associations were observed even when adjusted for age, sex, smoking, and total urinary arsenic. The investigators concluded these findings are consistent with the theory that people with diets deficient in protein and other nutrients are more susceptible to arsenic-related cancers.

The lesson from these examples is that sustaining environmental health isn’t simply a matter of reducing or preventing hazardous exposures, but making sure that a range of environmental factors are properly balanced. Making sure that you eat properly to reduce your risks from arsenic in drinking water may be a cost-effective alternative, with collateral benefits, to costly drinking water treatment. Having a built environment that promotes exercise may be a better investment that expensive prescriptions for cholesterol-lowering drugs.

Traveling - No Posting Rest of the Week

I'll be traveling the remainder of the week with no computer or internet access. Look for posting to start again this weekend.

It’s Official – Get Off of Your Butt and Move Around

According to the Washington Post today, a daily workout can add years to your life, and increase the quality of your remaining years. While this would seem to be a firm grasp of the obvious, a study, published this month in the Archives of Internal Medicine, is reported to be the first to quantify the benefits:

Moderate and high physical activity levels led to 1.3 and 3.7 years more in total life expectancy and 1.1 and 3.2 more years lived without cardiovascular disease, respectively, for men aged 50 years or older compared with those who maintained a low physical activity level. For women the differences were 1.5 and 3.5 years in total life expectancy and 1.3 and 3.3 more years lived free of cardiovascular disease, respectively.

The authors concluded:

. . .avoiding a sedentary lifestyle during adulthood not only prevents cardiovascular disease independently of other risk factors but also substantially expands the total life expectancy and the cardiovascular disease–free life expectancy for men and women.

If exercise increases the number of years free of cardiovascular disease “independently of other risk factors”, would the interaction between exercise and a healthy diet also be quantifiable? What about other effects, such as joint problems and diabetes, associated with poor diet and a sedentary lifestyle? With so much of the news devoted to crises in health care financing of one form or another, along with the signal that medical expenses can bankrupt you, the message seems to be clear – get off of your butt and move around.

Endocrine Disrupting Chemicals and Gender Issues

October’s issue of Environmental Health Perspectives has a good summary, from varying perspectives, about environmental exposures to endocrine disrupting chemicals, their potential for increasing the frequency of abnormalities in human sexuality (gender development, reproductive capacity and sex ratios), and the implications potentially associated with various outcomes. There have been isolated occurrences of abnormalities, principally in wildlife in high-dose exposure settings, and there is an active debate about whether or not there are risks to human populations from widespread low-dose exposures. Some argue that we need to look harder at other causes for the incidence of sexual abnormalities (advanced parenting age, smoking, diet), but if the ”Our Stolen Future” side of the debate turns out to the correct outcome, the results may be significant public health and social problems in the future, as well as economic disruptions. The economic disruptions would come about from the replacement of numerous widely used products, including plastics, plasticizers, pesticides and pharmaceuticals currently in the commerce stream.

The same issue also has the paper discussing the declining sex ratio in an Aamjiwnaang First Nation community near Sarnia, Ontario, Canada. The sex ratio (proportion of male births) of the Aamjiwnaang First Nation was observed over the period 1984-2003. The trend in the proportion of male live births has been declining continuously from the early 1990s to 2003, from an apparently stable sex ratio prior to that time. While a number of factors may be responsible, the community is located in proximity to a large aggregation of chemical industries, warranting further investigation of potential chemical exposures.

Skin Deep

The Environmental Working Group has created Skin Deep, a

. . . personal care product safety guide with in-depth information on 14,229 products - 988 brands of lotion, lip balm, deodorant, sunscreen and other popular products - and the 6,921 ingredients that form them. With its core of 37 toxicity and regulatory databases, Skin Deep provides safety ratings and brand-by-brand comparisons that can help consumers choose safer products. EWG’s reason for developing Skin Deep is that the government cannot mandate safety studies of cosmetics, and only 11 percent of the 10,500 ingredients FDA has documented in products have been assessed for safety by the cosmetic industry's review panel.

It’s not a bad product. You can search by brand name or product type, and there is a ranking from “highest concern” to “lowest concern” products. Skin Deep’s highest concern product is a relaxer (a hair conditioning product) provides a good example of how the site works. EWG provides a pretty complete, though highly conservative, screening of the potential health hazards associated with the ingredients in each product.

For example, the ingredient cocamide DEA (or coconut diethanolamide), a surfactant used in shampoos, body washes and conditioners, is identified to have “thought to cause cancer in humans basd on limited data”. In checking this out, I found that the National Toxicology Program has completed a lifetime topical application (skin exposure) cancer bioassay for cocamide DEA. NTP concluded cocamide DEA produced “clear evidence of carcinogenicity” in mice, both sexes at doses of 0, 50 mg/kg and 100 mg/kg, and “no evidence of carcinogenicity” in male rats, and “equivocal evidence of carcinogenicity” in female rats at doses of 0, 100 mg/kg and 200 mg/kg. These descriptions are in quotes because they are NTP terms of art. So, this is probably a pretty fair description of the cancer hazard of the product.

EWG also raises some concern about cocamide DEA for being a nitrosating agent that can form carcinogenic nitrosamines if mixed with amines. I can not confirm this one – and nitrosamines form as a result of the reaction of amines with sodium nitrite used as a preservative, which doesn’t look anything like the chemistry of cocamide DEA (I hesitate to say EWG has this one wrong, but I am now curious about what their backup is for that statement). Carcinogenic nitrosamines are a concern in personal care products, because diethanolamine may be present and thus might be a source for nitrosamines.

Chemical in your microenvironment may be meaningful sources of exposures, as indicated by this recent paper on phthalate urinary metabolite concentrations and personal care product use. This site is informative for identifying the chemicals in personal care products, and providing some limited information for identifying potential hazards. You would need to go elsewhere to find more assessment of the relevance of these identified hazards to human health. However, it doesn’t seem that those charged with risk assessment for cosmetic products are moving very fast (at least for surfactants). In response, Skin Deep is very much a precautionary response to the uncertainties in our understanding of the risks associated with ingredients in personal care products. If you’re interested in not taking chances, Skin Deep may be useful for you as a buying guide for personal care products.

A couple of suggestions would make this a more usable web site. First, provide CAS numbers which would make it easier to find information on the various chemicals. Finding an unambiguous description of cocamide DEA (alkanolamide of coconut oil fatty acids and diethanolamine, CASRN 68603-42-9) took a little time. Second, provide some more links to the data used to develop the rankings. The methodology used in ranking the various products can be found here.

Caffeinated Fun

I’m torn between seeing this as modestly inventive and mildly pointless. You can calculate the lethal dose for caffeine in units of your favorite caffeinated beverage. For my usual morning drip coffee and my body weight (100.6 kg, measured yesterday), a lethal dose would be 104.49 cups.

Using the caffeine database (a nice touch, but references for the caffeine contents of different beverages and foods would have been even nicer), I figured out that the 104.49 cups, 145 mg per 8 oz cup, comes out to 15,151 mg of caffeine or about 150 mg/kg. It was a little tough to ground-truth this value – most of the references I found on caffeine hazard assessment when Googling “median lethal dose caffeine humans” were of the more sensible variety, such as this or this (courtesy of “A Small Dose Of. . .”). This MSDS gives the median lethal dose in humans at 192 mg/kg, but they don’t give a source for that value. My workhorse resource, TOXNET notes that the lethal dose of caffeine in adults appears to be about 5 to 10 g, though it doesn’t say anything about how big these adults are, or give a statistical basis for that dose (you can tell a lot about how much someone knows of toxicology based on whether or not they refer to the LD50 as “the dose that kills 50% in a group. . .”).

If this seems a heavy-handed response to essentially a humorous discussion on caffeine, my apologies, but I’m an introvert. Thanks to Majikthise for the link.

Environmental Health Tools – CBC’s Interactive Feature “The Toxic House”

The Canadian Broadcasting Corporation reports on a body burden study conducted by Environmental Defense. Nothing really special here, just the usual themes – a wide range of chemical detected in the test subjects, regulatory agency skepticism over the small test population (a total of 11 subjects were tested), calls for eliminating chemical use and increased regulation. The only surprise was the cost for testing, $1,545 per subject; hey, where can I find that lab – that’s cheap.

Actually, what drew my attention to this story was the link to CBC’s program “The Nature of Things” interactive features – scroll to the bottom to find “The Toxic House”, a neat Macromedia Flash program, that provides a room-by-room tour educating homeowners about chemical exposures in the house. This is well worth checking out. I wonder if PBS has anything as imaginative.

Actually all of the Flash programs on this page look pretty interesting.

I found this story off of Fark; my attention was drawn to it by the caption, “Canadians' bodies are full of environmental toxins. Please try to limit your consumption of wild-caught Canadians to one or two servings per week”.