Wednesday, December 31, 2008

My Nomination as a Top 100 Health Blogger

Dear Readers,

Some of you may be aware that Digital Doorway feeds to several other virtual versions of itself. On, Digital Doorway has been nominated for a Top 100 Health Blogger Award. Therefore, I am humbly requesting your vote if you care to click on the image below in order to give me the benefit of your gracious largesse.

For your information, Wellsphere is an excellent online community comprised of health care professionals, health care consumers, and links to useful health-related resources. Many Wellsphere members use the site to plan and share their personal wellness goals. For myself, Wellsphere serves as yet another platform for Digital Doorway to reach even more readers. I also serve as a Wellsphere "Health Maven", answering questions that are posted on the question-and-answer section of the site. Please do pay a visit to Wellsphere when you have a chance. You may actually be moved to use its resources to plan your own wellness goals for the New Year!

Again, thank you for visiting Digital Doorway, and my gratitude is yours whether you choose to vote or not!

Wishing you a healthy and prosperous New Year!

Announcing the Publication of "Final Moments"

It is with great pleasure that I announce the publication of the third book in a series of non-fiction books by nurses, released under the auspices of Kaplan Publishing. "Final Moments: Nurses' Stories About Death and Dying" is a moving collection of stories by nurses, all focused on issues of mortality. It is an honor to have my chapter, "A Nurse's Recovery From Grief", included in this stellar collection.

Earlier this year, the first book in the series, "Reflections on Doctors: Nurses' Stories About Physicians and Surgeons", was released to great fanfare, and I was honored to provide a chapter for that collection, as well as to appear on a number of radio broadcasts promoting its publication. And although I was not a contributor to the second book in the series, I also heartily recommend "Meditations on Hope: Nurses' Stories About Motivation and Inspiration", released this past November.

I am humbled by my inclusion in this new series ("Kaplan Voices: Nurses") by Kaplan Publishing, and would like to express my heartfelt gratitude for this very satisfying opportunity.

Tuesday, December 30, 2008

The Census and Americans With Disabilities

The U.S. Census Bureau has released a report which recounts important and thought-provoking information regarding the millions of Americans who are currently living with disabilities. (The report can be downloaded as a pdf file here).

The report, based on the most recent census data available, reveals that 54.4 million Americans (18.7 % of the population) are currently classified as disabled, and 35 million (12%) of Americans qualify as severely disabled. Both percentages have risen since the last census, and the numbers are most likely expected to rise again in subsequent studies of a significantly aging American population.

In terms of needing assistance with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs), 11 million people (4.1 % of the population) over the age of 6 need assistance with such activities. When examining sensory impairments, 7.8 million people are not able to hear a normal conversation, 1 million are unable to hear at all, 7.8 million people cannot read normal newspaper print, and 1.8 million report not being able to see whatsoever.

When assessing mental, cognitive or emotional function, 16 million Americans are apparently affected, with approximately 8.4 million of those individuals reporting that their condition can prohibit or limit their ability to perform any number of ADLs or IADLs.

Economically speaking, 27% of disabled Americans between the ages of 25 and 64 reportedly live in poverty, compared to 9% who are not disabled in any way. For people with a severe disability, median monthly income was $1,458, whereas it was $2,250 for those with a non-severe disability and $2,539 for those with no disability at all.

In children, 13% (4.7 million) aged 6 to 14 are disabled, the most common difficulty being the completion of schoolwork.

As an individual living with Multiple Chemical Sensitivity, a condition recognized and protected by The Americans with Disabilities Act, I am---as usual---disappointed that environmental illnesses (including MCS and Gulf War Syndrome) have once again been left out of the data. While it is true that individuals with environmentally- or chemically-induced illnesses do indeed experience cognitive, emotional and physical disabilities as effects of their condition, it would be monumentally helpful for studies as relatively exhaustive as the U.S. Census to allow for some extrapolation of data vis-a-vis this constellation of woefully overlooked conditions. And while individuals with MCS and related conditions do not necessarily use wheelchairs, canes, and walkers, we do use oxygen, protective masks and other devices in order to function in the face of our condition. Perhaps, some day, these illnesses will receive their due, and be formally included in such reviews of the disabled and chronically ill.

That said, I am still impressed with the breadth and scope of the census data. The economic disparities reveal what most of us already know: that Americans with disabilities are astronomically more likely to live in poverty than their non-disabled counterparts. It is also extremely helpful and revealing to glean such minute detail about the day to day struggles of the disabled in this country. Regardless of my disappointment about the irksome ignorance of so many about environmental and chemical disabilities (a wrong I am determined to somehow right), this census data is a quantum leap forward and should provide grist for many in the disability rights arena.

The disabled are a large portion of the American voting public, and a vocal percentage of the American disabled are socially progressive and politically active. I hope that the data collected, collated, extrapolated and published by the Census Bureau will be used in ways that greatly benefit the subjects of this study, and that the voices of those who work for disability rights are heard loud and clear by the hopeful new administration assuming power in just under a month. The lives of poverty-stricken disabled Americans deserve to be brought out into the open, and the census data make clear that we still have a long way to go. Be that as it may, our government is indeed paying attention to the disabled members of the population, and for that I am excessively grateful.

Sunday, December 28, 2008

Personal Suffering and the Experience of Compassion

Compassion for those who are suffering is a very human emotion which, when filtered through the lens of one's own suffering, can be honed and developed into a powerful tool of perception and empathy. I have found that my work as a nurse has been directly informed by my ability to empathize with the suffering of others, and my own personal challenges do indeed increase my level of compassion for those with whom I come into contact.

Grief, for example, is a universal human emotional experience common to anyone who has suffered a significant loss, and the nature of that loss is not necessarily a determining factor vis-a-vis the severity, breadth and depth of the suffering that thereby ensues. The loss of a job, a career, a pet, a loved one, a way of life, one's independence, a home, a long cherished but unattainable goal---these are all losses which can trigger grief, and the experience of grief can be equally acute despite the source of the actual loss. In fact, some individuals who lose a job and are thrown into unemployment can sometimes experience more prolonged and significant grief than an individual who has lost a cherished family member. Grief is universal, and every person's experience of grief is unique and potentially life-altering.

Physical pain is yet another area in which suffering can be prolonged and debilitating. Living with chronic pain myself, I experience mild to severe physical discomfort every day, and my ability to concentrate, sleep, socialize and perform my daily activities is often impacted by my level of pain. In fact, I am writing this blog post at three o'clock in the morning, specifically because I was too uncomfortable to sleep. Ask me about pain and its negative consequences, and I can enumerate them for you without a second thought.

Emotional pain is a form of suffering which inflicts itself on almost every human being at some point in their lives. Studies have demonstrated that there are certain individuals who have a natural emotional resilience that enables them to recover from emotional set-backs and negative experiences relatively quickly. These individuals apparently experience few---if any---long-term effects of suffering or trauma, and there is evidence that an actual "resilience gene" bestows such recuperative powers on a percentage of humans. For those who live with chronic mental illness or Post-Traumatic Stress Disorder, these ultra-resilient individuals must seem somewhat unreal and perhaps untouchable by the woes of existence, but they are simply living in a certain place on the continuum of suffering. We all must indeed embrace our own place on that continuum, forever striving for our own unique brand of wholeness and recovery.

I have lived with major depression throughout my life, perhaps since early childhood. I also experienced Post-Traumatic Stress Disorder in late 2001 following the murder of a close friend, and a series of losses subsequent to that very significant loss have been a major challenge for me on a spiritual and emotional level. Coupling these acute losses---and the accompanying grieving process---with chronic pain and several other irksome illnesses, life has indeed challenged me in mid-life (I turned 44 this past summer).

As a nurse, my personal experience of suffering is intrinsic to, and inseparable from, my ability to relate to others' distress. As a hospice nurse, when I enter the home of a family facing the death of a beloved family member, I bring my own experiences of loss with me. Visiting with a patient suffering from chronic major depression, I see myself in that individual, and I am filled with compassion.

At times, my own life experiences negatively color my perception of another's suffering, and I work with my mind and heart to not allow my biases or judgments to diminish my ability to be present for that individual. We are all human, and we can use our own life experience in such a way as to enhance our powers of empathy and compassion, but we can also judge others if their reaction or perceived ability to recover from a similar experience is different from ours. It is natural to form judgments about other human beings and how they live their lives, but when we are faced with the suffering of another, it is important to consistently remind ourselves that each being faces their own set of life challenges filtered through their own experience, memories, relationships, and unique genetic make-up. One person's ultimate trauma can be another person's very manageable life experience, and we must remember that uniqueness when we are face to face with a suffering being.

The Dalai Lama frequently reminds us that suffering and compassion are intrinsic parts of the human condition. I believe that when we can use our own suffering as a vehicle for enhancing our personal ability to be compassionate, we are truly practicing an enlightened form of love.

Even as I write, there are Palestinians and Israelis mourning the loss of innocent lives amidst political conflict and armed struggle. Mothers in Baghdad grieve their murdered children, families await news of a dying patriarch, a home burns to the ground, a beloved dog is diagnosed with cancer, or the sole provider for a family of six receives an unexpected pink slip from her employer of thirty years. Suffering and loss are everywhere, every day. How do we confront our own losses? How do we assuage the suffering of others?

It is often said that there are two sure things in life: death and taxes. This may be a pithy and popular statement, but I feel more strongly that, beyond death, there are three more things of which we can be absolutely certain, and they are suffering, compassion, and love. We mostly all pay taxes, and while some see that as an imposition, many of us will agree that it is simply a necessary rent that we pay for living in human society. However, we are all capable of love, we all suffer at some point in our lives, and we all can manifest compassion. Luckily, opportunities present themselves daily for developing and futhering our powers of compassion and love, and using our own experiences of suffering to amplify our abilities to show compassion for others who are suffering is a laudable and infinitely worthwhile pursuit.

We each owe society---and all sentient beings---our compassionate attention, and when we can magnify our compassion for others through our own experience of suffering, we are truly giving back in a way that is beyond measure. As Robert Fripp once said:

"May my living honor my parents;
May my living repay the debt of my existence."

Saturday, December 27, 2008

Chronic Disease and Optimism for the Future

A recent press conference sponsored by the Partnership to Fight Chronic Disease (PFCD) revealed a startling statistic: chronic disease costs the American taxpayer more than two Wall Street bailouts per year. (To listen to the press conference or download a transcript, click here.)

According to PFCD, 45% of Americans live with a chronic illness; poorly controlled asthma sends 5,000 people to the ER every day; and obesity rates of American teenagers has tripled in the last 20 years.

Perusing the PFCD website, it's obvious that there is a great deal of optimism being verbalized vis-a-vis the opportunity that Barack Obama and his administration have in terms of addressing chronic illness and health care reform. Improvement in the management of chronic illness is seen as a clearly bipartisan issue by many in the know, and a number of members of Congress are apparently already preparing policies vis-a-vis these issues in advance of Mr. Obama's inauguration and first 100 days of governance.

In terms of technological advances, there are many policy-makers and consumers who are calling for a national Electronic Medical Record (EMR) that will streamline information, track prescription drug use and medical visits, as well as allow more continuity of care. This type of system would also allow for easy access to immunization records, would simplify facility-to-facility patient transfers, and facilitate care of patients who have moved or who need health care while traveling. Furthermore, chronic disease care could also be greatly enhanced by such centralized record-keeping, providing crucial financial and medical data about the overall state of American health---and its medical management. While pundits (justifiably) worry that a government-run EMR could raise Orwellian privacy concerns, perhaps some type of third-party oversight could assuage such fears as the project moves ahead.

Obviously, something needs to be done to address the state of disarray in which we find health care in America. We are less healthy, more obese, taking more chronic medications, and experiencing greater levels of stress than ever before. Sadly, 40 million of us are still uninsured (a pathetic statistic which I am apt to belabor ad nauseum here on Digital Doorway), and the percentage of us suffering from chronic conditions such as diabetes and heart disease is currently rising.

As 2009 beckons, the Obama-Biden transition team is revving its engines and preparing for an all-out attack on the American economy, including the economics of health care. In my virtual peregrinations, I am seeing that a great deal of optimism is being expressed vis-a-vis the future of health care and chronic illness management in the United States. As the economy inevitably rises from the ashes and financial stability returns to the markets, many feel that the health care
infrastructure will also revive itself with government-funded resources aimed at curbing chronic illness and improving public health. As a newly-minted Public Health Nurse, I am quietly joining that chorus of optimism, and will do my best (from my lowly municipal position) to support those valuable and forward-thinking efforts.

Thursday, December 25, 2008

Honor Those Who Suffer

Compassion is a far greater and nobler thing than pity. Pity has its roots in fear and carries a sense of arrogance and condescension, sometimes even a smug feeling of “I’m glad it’s not me.” As Stephen Levine says: “When your fear touches someone’s pain it becomes pity; when your love touches someone’s pain, it becomes compassion.” To train in compassion is to know that all beings are the same and suffer in similar ways, to honor all those who suffer, and to know that you are neither separate from nor superior to anyone.

---Sogyal Rinpoche

Wednesday, December 24, 2008

Happy Holidays to All

Whatever you celebrate, whatever you recognize, however you mark this propitious time of year, I offer my best wishes for your happiness, health and prosperity, and that of your loved ones and friends. My best to you, dear Reader, now and always.

Sunday, December 21, 2008

Social Justice, Public Health, and the Pursuit of Happiness

The health department where I am currently employed is the recipient of a three-year social justice grant from a large national foundation. Despite a steep learning curve vis-a-vis emergency preparedness, the coordination of our local Medical Reserve Corps, and developing wellness programs for town employees, the social justice mission of our little health department is one of the most intriguing aspects of my new workplace.

When one generally thinks of public health, one thinks of communicable and infectious diseases, vaccinations, disease surveillance, and epidemiology. But I am learning that access to health care, food insecurity, and access to adequate housing can all be seen under the umbrella of public health, especially when looking at these issues through a social justice lens.

In addition to our social justice grant, our health department also boasts a Cambodian outreach worker who is responsible for outreach to the Cambodian refugee community in our area, a sizeable cohort which has varying levels of need vis-a-vis health care access and other social issues.

For American-born citizens, refugees and immigrants alike, free and equal access to adequate health care is indeed a privilege in this country, but it is a privilege that many of us prefer to view as a basic human right.

Along with housing, employment and education, my progressive heart wants to see every American have free and unfettered access to as much education as his or her heart desires; comfortable and affordable housing; gainful employment; sufficient quality and quantity of food; and high-quality and accessible health care. Call me a bleeding heart, but my personal vision of social justice includes what I see as essential components of "life, liberty, and the pursuit of happiness."

In terms of my work as a Public Health Nurse, I want to remind myself that the "public" aspect of my job entails my responsibility to the public, the people who live within the geographic area of my jurisdiction. The Human Rights Commission in our town is very active, and I see part of my duty as the PHN to reach out to this group (and others) who spend their time assuaging the suffering of our homeless, hungry, and uninsured.

Aside from the nuts and bolts (and syringes) of my work, I want to delve into the area of social justice wholeheartedly. There is nothing more worth fighting for in my book, so why not start right here at home?

Saturday, December 20, 2008

The Economy and Its Discontents

In this historic period of a global economic downturn, my thoughts have been turning towards those whose personal economies have already arrived to a place of significant decline.

Here in the United States, the use of soup kitchens, food pantries, and other emergency assistance has skyrocketed, and applications to Medicaid continue to climb. An astronomical number of individuals are truly wondering how they will put food on the table, gas in their tanks, or heat in their homes, and those individuals are often living in households with members who are children, elderly, or disabled.

Government figures show that unemployment applications are increasing exponentially, and although Congress has passed legislation to extend unemployment benefits, we all know that the end of such assistance does not always coincide with the procurement of new employment opportunities. As the economic slowdown continues, jobs are being slashed daily in a variety of sectors, the consequence being even more people fiercely competing for a dwindling supply of jobs, many of which offer less-than-stellar compensation frequently without health benefits.

With Christmas and Hannukah upon us, bargain hunters scour the shelves for affordable gifts for friends and family, and the ingredients for holiday meals and celebrations are sought through every frugal means necessary. Granted, we all need to celebrate, but this year has brought a level of economic uncertainty not seen in many decades, ostensibly throwing a wet blanket over many families' ability to partake of the holiday season as they might in a more robust financial climate.

But what of those who were already struggling? What about those who have been visiting soup kitchens and food pantries all along? As more and more jobs are slashed and as individuals use up their unemployment benefits, how will we as a society care for those who cannot make ends meet? And as the facilities who support those struggling families see their own operation costs rise amidst an increase in utilization, how will the needy be cared for?

These are uncertain times, and as I have pointed out on Digital Doorway before, food insecurity is real, and the number of families unable to provide for their children has been increasing like never before.

I offer no solutions here, and I have no grand plan or scheme to short-circuit this calculus of need and insecurity. I only know that I awoke at 4am this morning thinking about the millions of people---in this country alone---who cannot honestly say how they will feed their families this week, let alone provide the makings of a holiday celebration.

With the New Year around the corner, there is always desire for a fresh start and an infusion of hope. On January 20th, an historic event of enormous proportions will take place in Washington, D.C., and all eyes will be on the new President and his administration's ability to turn the economy around as soon as possible. And while I understand the need for inaugural celebrations---especially due to the historic nature of this president's unprecedented accomplishment---I cringe when I think of the millions of dollars that will be spent on dinners, formal balls, and lavish parties as millions of Americans wander the streets in search of low-paying jobs and food pantry handouts. Yes, we all need to celebrate, but that astronomically expensive celebration does indeed give me pause as I ponder the plight of those without the means to even feed their families.

My wife and I are both very blessed to have recently found satisfying and relatively well-paying work right in our own town. No longer commuting forty miles per day, we are among the lucky few who have new jobs, short commutes, and robust benefit packages. We realize how very fortunate we are to be in our current position at a time when so many others have experienced the opposite economic reality. We do not take our situation for granted and fully recognize our blessings.

Perhaps my recent luck in finding gainful employment is what has me awake at 4am, thinking about those who have not been so lucky. Admittedly, we will have no problem putting food on the table this holiday season, and while we are indeed being frugal in terms of gifts for family and friends, we are fully cognizant of the fact that buying those gifts is not a significant burden, even as we write checks to our favorite local, national and international charities. Having the economic means to care for ourselves and give to others is not something we take lightly, and we recognize that it is our ethical responsibility to donate to worthy causes at a time when our donations mean so much.

I am saddened by the current plight of millions of deserving individuals and families, and even as I watch the holiday season unfold, my thoughts turn to those who may feel less than celebratory. These are times requiring a great deal of thoughtful reflection, selflessness and compassion, and I hope that the suffering of so many amidst this global crisis will soon be alleviated. In whatever way I can, I choose to be a part of the solution, and I invite you, dear Reader, to do the same.

Wednesday, December 17, 2008

The Challenge of Emergency Preparedness

One of my new professional challenges is learning everything I can about emergency preparedness. I am now, in effect, responsible for emergency preparedness planning for my entire town, thus I am confronting the steep learning curve that that responsibility engenders.

From what I can gather, emergency preparedness operates on several levels, each of which offers its own set of challenges:

For individuals and families, being prepared for emergencies entails family disaster plans, food, water, communication devices such as hand-cranked or battery-operated radios, first aid, flashlights and other equipment, sanitation and hygiene concerns, pets, important family papers, bedding, medications, clothing, as well as the needs of children, the elderly, and the disabled. For a comprehensive list of what a household Basic Emergency Kit should contain, click here.

For neighborhoods, emergency preparedness means identifying vulnerable neighbors, making plans for their care in the event of an emergency, and appointing individuals or groups of individuals to share responsibility for those identified members of the community.

On the municipal level, preparations for disasters, severe weather, terrorism, power outages and public health emergencies obviously encompass the individuals, families and neighborhoods which make up a municipality. However, municipal emergency preparedness also takes into account the need to provide emergency shelter, mass dispensation of medications of vaccinations in the case of epidemics or pandemics, as well as support for potentially overwhelmed first responders.

While the current wave of emergency preparedness was indeed galvanized by the terrorist attacks of 2001, the United States and other countries have seen how varying levels of preparedness on the local, state, and federal level can fail or succeed in the face of natural disasters. Despite the efforts of many, it is painfully clear that the federal response to Hurricane Katrina caused enormous (and altogether preventable) suffering on the part of residents of the American Gulf Coast. The Bush Administration and FEMA failed miserably in their collective response to Katrina, and many people died unnecessarily as a result of systemic problems and governmental hubris.

Although some may still fear terrorist attacks in the form of biological weapons and bombings on American soil, I feel that it is far more likely that our level of preparedness for the unexpected will be tested in the form of natural disasters (hurricanes, tornadoes, floods and earthquakes) and outbreaks of disease (such as pandemic influenza). The recent ice storms in Massachusetts and wild fires in California are two examples of how coordinated efforts on the part of local, state and federal entities are crucial to disaster response, rescue and recovery.

Now, my personal task is to take the helm of my local branch of the Medical Reserve Corps, connect with local, regional and state emergency preparedness officials, and put together a comprehensive preparedness plan for our town of approximately 40,000 residents. Steep learning curve is right, and I will certainly be blogging about my progress as I move forward with this and my other new public health duties, so please stay tuned.

Tuesday, December 16, 2008

Transplants and Ethical Complications

When 80 percent of a woman's face is replaced with the skin, nerves, and deep facial muscles of a cadaver donor, a host of ethical questions are raised in the aftermath of such a ground-breaking medical event.

In Cleveland, Ohio, Dr. Maria Siemionow and a enormous team of specialists have successfully completed just such a surgery, far surpassing the partial face transplants previously performed in France and China.

Performed not to extend life but to enhance quality of life, these types of surgeries carry a very high risk of rejection, a dangerous outcome that many ethicists feel may not warrant such extreme measures.

On the other side of the ethical debate, it is argued that those with major birth defects or other forms of disfigurement deserve a chance to live a normal life with near-normal facial physiognomy and expressive ability, despite the need for life-long immune suppressing medications and the risk of catastrophic rejection.

Meanwhile, some ethicists opine that facial transplant recipients should have the option of assisted suicide in the case of total rejection and transplant failure, an outcome that could lead to complete inability to breathe, eat or otherwise function normally. The removal of a rejected facial graft would leave a post-surgical patient with extreme disfigurement, risk of dangerous secondary infection, and potentially worse quality of life than prior to undergoing the surgery.

Advances in medicine and science often lead to ethical concerns that must be rigorously discussed and debated by interdisciplinary teams of surgeons, ethicists, nurses, laypersons, clergy, and other concerned individuals and groups. Decades ago, heart transplants and liver transplants sent shockwaves throughout the world as the ramifications of such advances became clear. Life support technologies, blood transfusions and advanced pharmacology have all become part and parcel of the medical world, sustaining and prolonging life while often simultaneously increasing quality of life as well.

Now, hand and face transplants once again push the envelope of what some feel is ethically and morally responsible as humans continue to dabble in the more esoteric reaches of medicine and surgery. And as much as brain or total head transplants may still seem like science fiction, I have no doubt that such emotionally charged and ethically challenging surgical events are most likely closer than we think to being reality.

As the 21st century continues to unfold, bioethics and the future of medical intervention are certain to challenge us as the edges of our comfort are once again breached. I am interested to see how the newest facial transplant recipient recovers from her surgery. I am equally interested in observing how the world continues to react and recover from the shock of yet another momentous milestone and its ethical aftermath.

Sunday, December 14, 2008

Public Health and the Economic Downturn: Live Webcast December 15th

A live webcast on Monday, December 15th at 2pm EST, will feature a panel of experts discussing how to keep public health programs afloat during the economic downturn.

Entitled "Public Health Survival: Leadership in a Falling Market," the webcast will be hosted by the Gillings School of Global Public Health at UNC, and will include a number of expert panelists.

The times for all U.S. time zones are thus:

2:00 - 3:00 pm Eastern Time
1:00 - 2:00 pm Central Time
12:00 - 1:00 pm Mountain Time
11:00 am - 12:00 pm Pacific Time

To access live web coverage, please click here for a link to the webcast homepage, where you will also find a downloadable pdf file of the webcast slides, links to articles, and organizations of interest.

Marijke Hosts Change of Shift

The newest edition of Change of Shift, our favorite nurse blog carnival, is ready for reading at Marijke: Nurse Turned Writer.

Saturday, December 13, 2008

If the Flu Fits.....

Well folks, on the eve of Thanksgiving here in New England, I was (figuratively speaking) hit by a truck that most likely was a case of influenza. Vaccinated against the flu more than a month prior, I was hoping---like so many other people around the world---that I would be spared serious illness this winter season, but those hopes were apparently in vain.

That early assault sent me once to the emergency room with the worst chest pain of my life (on the very night that all of the symptoms began), and three times to the nurse practitioner to beg for a bronchodilator and codeine cough syrup. Eighteen days later, I'm struggling with asthmatic bronchitis and am now using inhaled steroids to keep the coughing at bay. As the sun goes down, my lungs seem to naturally fill with congestion, and my level of fatigue is enormous. While I indeed miss exercising and working out, the mere thought of doing twenty laps at the local pool makes me swoon with delirium.

According to the Centers for Disease Control and Prevention website, there have been only 507 positive influenza tests in all of the United States so far this season. This means that only 1.6% of the more than 30,000 specimens submitted for testing so far have actually been positive for influenza. Concurrently, Google's Flu Trends website states quite firmly that, at least in the U.S., influenza activity is quite low, essentially agreeing with the CDC's current data.

No matter the numbers, and no matter how little flu activity is truly being seen out there in the world, those of us who are sure we've already been stricken feel that our Personal Statistic of Significant Suffering (PSSS) is certainly worthy of notice. For myself, I have suffered enough for several winters' worth of illness, and this lingering bronchitis must, on some level, earn me a flu season medal of honor.

For other flu sufferers out there---if you're reading this---one of your own feels your pain, and my wishes to you for a speedy recovery and a subsequently healthy and prosperous winter. And for those of you who have as yet escaped illness, may you continue to be well, and enjoy the holidays and New Year in well-deserved good health.

Stay tuned for more updates on nationwide flu activity as this new Public Health Nurse recovers from his own personal bout of wintry illness and doldrums.

Tuesday, December 09, 2008

Under the Weather

Dear Readers,

I've been a little under the weather and have been remiss about blogging for a few days. Please don't give up on Digital Doorway, and do check back in later this week.

I appreciate your readership and comments, and look forward to getting back in the swing as my health and energy improve.

Thanks so much, and please stay tuned!

All the best,


Saturday, December 06, 2008

The Obama-Biden Health Care Agenda

The Obama-Biden Transition Team is requesting that all interested citizens pay a visit to the transition's website,, and voice ideas and concerns regarding American health care and health care reform. By clicking here, you can go directly to the web page dedicated to the health care agenda and submit your opinions and views.

The Obama-Biden web page discusses health care in this manner:

"On health care reform, the American people are too often offered two extremes -- government-run health care with higher taxes or letting the insurance companies operate without rules. Barack Obama and Joe Biden believe both of these extremes are wrong, and that’s why they’ve proposed a plan that strengthens employer coverage, makes insurance companies accountable and ensures patient choice of doctor and care without government interference.

"The Obama-Biden plan provides affordable, accessible health care for all Americans, builds on the existing health care system, and uses existing providers, doctors, and plans. Under the Obama-Biden plan, patients will be able to make health care decisions with their doctors, instead of being blocked by insurance company bureaucrats.

"Under the plan, if you like your current health insurance, nothing changes, except your costs will go down by as much as $2,500 per year. If you don’t have health insurance, you will have a choice of new, affordable health insurance options."

Allegedly, the plan would:

  • Require insurance companies to cover pre-existing conditions so all Americans regardless of their health status or history can get comprehensive benefits at fair and stable premiums.
  • Create a new Small Business Health Tax Credit to help small businesses provide affordable health insurance to their employees.
  • Lower costs for businesses by covering a portion of the catastrophic health costs they pay in return for lower premiums for employees.
  • Prevent insurers from overcharging doctors for their malpractice insurance and invest in proven strategies to reduce preventable medical errors.
  • Make employer contributions more fair by requiring large employers that do not offer coverage or make a meaningful contribution to the cost of quality health coverage for their employees to contribute a percentage of payroll toward the costs of their employees' health care.
  • Establish a National Health Insurance Exchange with a range of private insurance options as well as a new public plan based on benefits available to members of Congress that will allow individuals and small businesses to buy affordable health coverage.
  • Ensure everyone who needs it will receive a tax credit for their premiums.
  • Lower drug costs by allowing the importation of safe medicines from other developed countries, increasing the use of generic drugs in public programs, and taking on drug companies that block cheaper generic medicines from the market.
  • Require hospitals to collect and report health care cost and quality data.
  • Reduce the costs of catastrophic illnesses for employers and their employees.
  • Reform the insurance market to increase competition by taking on anticompetitive activity that drives up prices without improving quality of care.
I am personally dubious that insurance company practices can be sufficiently reformed to prevent abuses. I am also dubious that such a ponderous system administered by both the federal government and employers will not prove incredibly complex and difficult to manage for employers, government officials, insurers, providers, and consumers alike.

In terms of the plan, I would also like to see the following:

  • details regarding a more robust national plan of preventive health care initiatives
  • sufficient funding for public health initiatives
  • sufficient funding for emergency preparedness and the national Medical Reserve Corps
  • a comprehensive plan to decrease the nursing shortage, including grants and loan forgiveness
  • a plan to assuage the nationwide shortage of primary care physicians
  • a plan to create an Office of the National Nurse

Despite my reservations, doubts, and dubiousness, it is indeed exciting to see a new administration apparently dedicated to transparency, as well as the active participation of all Americans in the process of change that is underway.

Meanwhile, I am willing to suspend my disbelief, listen to the conversation, join in on the conversation when I have something useful to say, and watch as the story unfolds. These are exciting and nerve-wracking times, and I do indeed hope that the change that has been promised will indeed be delivered. Until that time, patience is one virtue we will all need to put into practice.

Friday, December 05, 2008

Young Adults, Healthcare and the Economy

A recent study by Medco Health Solutions reveals that the current economic downturn and increasing healthcare costs are having a severe effect on young adults.

With an increasing number of young adults in their 20s and 30s living with chronic health conditions, health insurance and prescription drug coverage are no longer just issues for middle-aged and older adults. The survey further revealed that young adults are considerably less savvy when it comes to finding ways to save money on healthcare.

Other recent reports show that the prevalance of mental illness among young adults is significantly high, but only a small percentage ever actually seek treatment. With potentially 50% of young college-age adults meeting criteria for substance abuse disorders, personality disorders or other conditions, it is disconcerting that less than 25% are under active medical care.

If the lack of health insurance, the prohibitive costs of prescription medications, or exponentially increasing college tuition is keeping young adults from seeking medical or psychiatric treatment at a very vulnerable time of development and maturation, important outreach and motivational education needs to be set in motion in order to counterbalance such a trend. Whereas older adults might make healthcare expenses more of a personal economic priority in times of fiscal stress, perhaps young adults are less likely to eschew social outings, travel, and other activities in order to save money to cover their healthcare costs. This trend is worrisome since untended health maintenance issues early in adulthood can often come back to haunt the unsuspecting person in middle age.

I am not at all suggesting that young adults are categorically frivolous or laissez-faire about their health, but studies do clearly suggest that they are less likely to understand how to manipulate the economic system to their personal advantage vis-a-vis healthcare expenses. Additionally, having once been a young adult myself, health is generally not as great a priority when one is twenty-something as when one crosses the threshold into middle-age and the first half of one's life comes to a resounding close.

Universal healthcare and free higher education would most likely go a long way towards easing the economic strain on today's young adults, but I would be interested to see a study comparing the healthcare-seeking habits of European young adults (who already have free medical care and higher education) and their American counterparts. It would be revealing to ascertain if it is indeed the cost of healthcare that prevents young adults from seeking care, or if it is more of a developmental issue which is part and parcel of the maturation process.

While considering the underlying causes of the phenomena revealed by the studies mentioned above, it is important to consider what social and economic interventions might increase access to medical care for this important population, as well as what forms of education and outreach might prove to be positively motivational to that desired end. Increased access to affordable healthcare is certainly a very good first step, and while students attending college are required by law to have health insurance, young adults who choose to not go to college---or who simply cannot afford it---are left with few economically viable options once they can no longer be covered under their parents' policies.

Young adults are our future, and it is in our best collective interest to make sure that they receive the necessary preventive healthcare that can detect chronic disease---or even the potential for such disease---long before any lasting damage is done. Healthcare should be affordable, accessible, and understandable for our young adults, and in these hard economic times, too many young people may see healthcare as a luxury that they simply cannot afford. I hope that the new administration in Washington will decrease the costs of both healthcare and higher education, ease the burden on American young adults, and simultaneously educate this population about the crucial importance of detecting chronic illness before it starts to take its toll.

As the father of a young man in his twenties, I have a vested interest in his stellar generation reaching their productive middle-age with good health, economic security, and the means to live a long, happy, healthy and satisfying life.

Thursday, December 04, 2008

Texas Comes Deservedly Under Fire

The appalling care of the mentally disabled in Texas is a story worth disseminating. Whereas the system of state institutions that warehoused and abused the disabled (as late as the 1970s and 1980s) has mostly been dismantled and shuttered around the country, it seems that such treatment is still alive and well in the Lone Star state.

Now, the United States Justice Department has weighed in for the third time in three years to clearly state that the Texan system of care for the institutionalized mentally disabled is decades behind the rest of the country and consistently violates consumers' constitutional rights. Unearthed documents detail beatings, sexual assaults, neglect, and possible allegations of homicide. And according to the Associated Press, more than 800 employees have been fired since 2000 due to reports of abuse, exploitation and neglect.

Called "the institution capital of America", Texas has been accused of warehousing consumers at a rate six times above the national average.

The 62-page downloadable report by the Justice Department details the observed abuses, poor admissions process, lack of knowledge of community services, poor rehabilitation services, and a high rate of injury among residents. Further supporting the evidence that the Texan "state schools" are decades behind the times, the use of straight jackets and other restraints are a common part of residents' behavior management plans, a practice that has been out of fashion (and deemed unconstitutional) for decades.

With its astronomically high rate of (racially skewed) incarceration of the general population and a widely criticized history of aggressive (and racially skewed) capital punishment, Texas obviously needs to do some soul-searching. The Texan system of "state schools" must be immediately dismantled, and a modern and constitutional system of community-based services for the mentally disabled must be put into place as soon as possible. The state government may want to consider creating a trust fund to benefit those who have already been abused and damaged by such egregious and nefarious treatment, and it would not surprise me if a massive class action lawsuit---and criminal proceedings---begin to rise to the surface as the dust settles on this sad moment in American and Texan history.

With every crisis comes opportunity, and Texas now faces a moment wherein it can turn the tables, turn history on its head, and create the most progressive and forward-looking system of care for the mentally disabled in the country. Such a feat will take political will of untold proportions, and it remains to be seen if Governor Perry will step up to the plate. If he has read the report sent to him by the Department of Justice, I hope he did so with tears in his eyes and pain in his heart. The human beings who have been unjustly abused in the Texas state schools are brothers, sisters, sons, daughters, grandparents, mothers and fathers. How we care for our most vulnerable citizens is a true test of our humanity, and on that scorecard, Texas has certainly failed miserably.

Tuesday, December 02, 2008

Gifts That Give More

As many of us gear up for the holiday season, purchasing gifts for everyone on our list can be difficult. This is especially true when we would rather not spend our money at Big Box stores that care little about where products are made, how the workers who made them were treated, and other factors that make being a conscious consumer a morally and ethically painful experience.

With that thought in mind, here are suggestions for ways to give that will delight the recipients while also giving back something meaningful to the world at large. This is not an exhaustive list by any means, but it is a good start for those who wish to shop in a manner that has a ripple effect beyond the cash register.

Global Exchange Fair Trade Store: fair trade gifts from around the world

The Hunger Site Store: gifts from around the world. You can also purchase "gifts that give more" such as a high-efficiency cookstove for refugee families in Darfur. Your family member or friend receives a card detailing how the gift given in their honor will feed a family.

Handcrafting Justice: lovely handmade, fair trade gifts

Uncommon Goods: quality gifts wherein a percentage of the sale goes to progressive causes. This organization also has some brick & mortar locations.

Best Friends Wildlife Sanctuary
: our favorite animal rescue group who saved over 250,000 animals from Hurricane Katrina. You can sponsor an animal in a loved one's name and create an enduring connection that everyone can feel good about. We support this Utah-based group year-round.

Gifts With Humanity: another fair trade website.

Ten Thousand Villages: fair trade merchant with online presence and some brick & mortar locations around the country

World Widlife Fund: adopt an endangered animal and send your gift recipient a stuffed animal and certificate of adoption. Great for kids.

There are many more sites for such types of gift ideas. Simple type "fair trade gifts" or "fair trade shopping" into Google and see for yourself.

Good luck, and remember that gifts do indeed give more when they have been manufactured fairly, when workers have been treated and paid well, when the environment is not degraded during the manufacturing process, and when we know what our money is actually supporting.

Happy holidays to all.

Monday, December 01, 2008

Worlds AIDS Day, 2008

Today is World AIDS Day, and the official website has a great deal to offer in terms of information, opportunities for activism, events, and other ways to get involved.

With 33 million people living with HIV worldwide, World AIDS Day is now in its 21st year and was actually the first international health day commemorating a particular disease. While World AIDS Day in the UK has chosen the theme of "Respect and Protect" for this year, the theme chosen by the global movement appears to be "Leadership", based on their website.

Regardless of thematics, everyone involved seems to agree that there are certain aspects of the fight that necessitate further concerted action on a global scale as governments around the world pledged today to increase funding for treatment, to fight discrimination, and to increase testing.

And in China, where up to 700,000 individuals are said to be infected but only 260,000 are officially recognized as having the disease, the fight against stigma is an uphill battle only newly begun.

The global effort is still in full swing, and it seems to receive a needed boost every year on December 1st. Thank you to all of the individuals and organizations that keep that torch burning year-round.

Temporarily Joining the Ranks

So, dear Readers, as of 12:01 am today, my wife and I are officially uninsured. Caught in that painfully ubiquitous American conundrum, we are both gainfully employed, both starting new jobs (that, admittedly, don't pay exceedingly well), and our new insurance will not kick in until January 1st. With several chronic illnesses between us and a number of medications we take on a regular basis, this could be cause for concern.

Counting our blessings, we indeed realize that, unlike the majority of the other 38 million uninsured Americans waking up this morning, our uninsured status is, in fact, temporary. A month from now, as we ring in the New Year, we will also ring in the renewed security that paying monthly health insurance premiums can bring. Our privilege is not lost on us, but having just been to the emergency room on Thanksgiving Day, I am given pause to remember that life and illness do indeed sometimes happen on their own schedule. But like I've said before, middle class privilege is something we do not take for granted, and our very survival is in no way threatened by this unfortunate but temporary turn of events.

Meanwhile, my incredulous friends in Canada and Europe wonder how such a "powerful" country can leave so many of its citizens in the lurch, many actually going bankrupt when they cannot pay their medical bills. My response is that the United States' free market system coupled with an ingrained Puritan work ethic and "pick-yourself-up-by-your-boot-straps" cowboy mystique leads many mainstream Americans to think of themselves rather than of others, assuming that those who "have not" probably don't deserve it anyway. Ronald Reagan's evisceration of Public Assistance---further decimated by Bill Clinton in the 90's---painted "Welfare Moms" as deadbeats who purportedly birthed children just to get on the dole. We were all expected to make it on our own, and those who didn't were expected to eat our crumbs.

If I sound cynical, it's because there has been a great deal to be cynical about in the last decade of American life. With the economy in shambles, healthcare on the rocks, two never-ending wars, and poverty and hunger on the rise, some healthy cynicism is indeed in order.

So, as the Obama administration revs its engines, I wait patiently along with my fellow citizens, hoping for some change, but admittedly less starry-eyed than many of my brethren. I honestly expect little to change in the next year in terms of the machinations of American healthcare economics, although I do hold out hope that the ranks of the uninsured will somehow be decreased as rapidly as possible. Changing such an entrenched system will not be easy, and some say it is truly impossible with so many economic and political toes to be stepped on. Well, the poor, uninsured and hungry in this country have been repeatedly stepped on throughout the decades, so if the insurance industry cries "foul" as it suffocates, let's simply call it just desserts.

This next month of "insurancelessness" does certainly give me a lot of food for thought. I am grateful that this chapter will be short-lived, but I am all too well aware that, for many others, it is a chapter that seems to never end.

Sunday, November 30, 2008

Casualties of Conspicuous Consumption

As the friends, family and co-workers of Jdimytai Damour mourn his death under a stampede of eager Wal-Mart shoppers on the morning after Thanksgiving, many of us wonder about the state of a country where crazed bargain-hunters can trample a 270-pound man to death and come close to killing a pregnant woman.

For years, my wife and I have made a point of never shopping on Black Friday, a manufactured day of conspicuous consumption that prays on economic fears and people's perceived need for a bargain. Seemingly, the excitement over such potential bargains is enough to foment a mob mentality that can lead to injury, death, and destruction of property, all in the name of commerce.

While some see shopping as a patriotic duty that injects consumer cash back into the economy, I can easily argue the point that not shopping, staying home with family, visiting friends, and volunteering at local soup kitchens and shelters are activities that are exponentially more patriotic and productive than any amount of spending could ever be. Editorials abound about the way that American shoppers have been programmed by Wall Street, coached that abundance is limited, and urged to be the first to lay their hands on goods that are apparently in short supply, available only to the lucky few who are first through the door.

We all know that times are tough. Many Americans are losing jobs in record numbers as the number of uninsured nears 40 million. Putting gifts under the tree is seen as a parental duty and obligation, and no parent wants to see young disappointed faces on Christmas or Hannukah.

In the early years of our marriage, my wife and I received fuel assistance and Medicaid, visited our local food pantry, and often relied on bargain stores for food, clothes, gifts and other items. Despite our political and social beliefs, we also frequently succumbed to our son's wishes, occasionally purchasing mass-produced plastic toys that his young mind believed would make his Christmas complete. We had some lean Christmases in those years, and it was often the gifts mailed by thoughtful grandparents that made the pile under the tree appear more substantial.

Americans are apparently driven by commerce, ownership, and the acquisition of property. The free market has turned us all into miniature fiefdoms wherein we use our purchasing power to outfit our castles with the commodities that we feel will improve our lives, our social standing, or our level of physical or psychological comfort. But at what price?

But please don't get me wrong. I, too, have wants and desires. That new CD? A book hot off the press? Clothes, shoes, furniture, towels, bedding, bicycles and computers? We all want them, and those desires are not necessarily intrinsically wrong. However, when our desires become a wall between ourselves, our families and the humanity of others, then something certainly has gone haywire. When a worker can be trampled to death under the weight of a crowd solely intent on being the first to save a dollar, then the wall between our desires and our humanity has thickened and grown to new heights of Orwellian insanity.

Jdimytai Damour was said to be a gentle and kind man who loved Japanese anime, politics, and movies. He was working at Wal-Mart for the reason that everyone else takes a job: to put food on the table and a roof over his head. Working for low wages and perhaps no appreciable benefits, he was like so many other temporary holiday workers: hard-working and expendable.

At 5 o'clock in the morning on the day after Thanksgiving, Mr. Damour died a painful death under the shoes and boots of shoppers oblivious to the fact that their utterly unnecessary sense of urgency caused a series of events to unfold which would end the life of someone's son, brother, and friend. Nearby the place where Mr. Damour died, a pregnant woman was knocked to the ground, trampled, and came excruciatingly close to losing her baby. It was a tragic scene on many levels.

Perhaps rather than urging Americans to shop, shop, shop, the government and consumer groups should begin to instill the idea that giving comes in many forms. Donations can be made to humanitarian organizations in a family member's name. Endangered species can be sponsored, with a stuffed animal and certificate of adoption mailed to a designated child who will then be educated to see gift-giving in a new light. Homemade gifts and the gift of time can be much more meaningful than most any item purchased at a store. But if an item is indeed purchased, let it be done so thoughtfully, calmly, and with circumspection.

We are not in a race to consume. We are in a race to love, to connect, and to interconnect. In this interdependent world, our choices and actions as consumers have far-reaching effects, and while the hungry mavens of Wall Street want to see us flocking to the cash registers of America like so many automatons, we can make other choices---saner choices---that honor our families and our communities with the embodiment of the holiday spirit we so wish to generate.

Jdimytai Damour was a casualty of the economy and of people's perceived need to consume and his passing is a sad statement about the current state of American culture. In that light, let's take a moment to remember what the holiday season is really all about, and let's remind our friends, families and children (through our words and our actions) that giving has less to do with what is given than with the heart and spirit of the giver.

Rest in peace, Jdimytai Damour.

Saturday, November 29, 2008

Friday, November 28, 2008

A Thanksgiving Ambulance Ride and the Tectonic Plates of Privilege

Yesterday on Thanksgiving, my wife and I were both in so much pain that we could barely do much of anything. We are both living with chronic pain of different kinds, although hers is definitely on the mend and self-limited whereas mine has no explanation and no apparent treatment that's helpful to any great extent. Mary had a steroid injection to her sacroiliac joint on Tuesday and it seems that it may actually be working, and that is something to give thanks for.

However, to add insult to injury, I had a fever of about 100 yesterday, and had several episodes of very intense bilateral chest pain. At about 11:30pm, we were watching a DVD (season 4 of "Six Feet Under", by the way), and I had a bout of chest pain so bad that I was doubled over on the couch, weeping like I was being mercilessly beaten.

Not knowing what else to do, Mary called 911 and the kind dispatcher calmly spoke with her and reassured us both. Minutes later, two paramedics and two police officers were standing in our living room, and I was summarily whisked away to the emergency room. I cannot state more clearly how kind, professional exemplary and efficient everyone was, from the paramedics and police to the ER nurses, attending doctor, radiology techs and phlebotomist. I was very well taken care of, and received a complete cardiac workup from head to toe.

As expected, the bloodwork, EKG, chest x-ray and vital signs were all normal, including my temperature. Meanwhile, the nitroglycerin given to me under my tongue in the ambulance caused a pounding headache, but I was simultaneously hydrated with a full liter of IV fluids as I rested. While it was offered for me to spend the night, I elected to come home and sleep in my own bed, and this morning Mary is caring for me like a saint, as always. My temp is about 99, but there is no chest pain in sight, although my body still feels like it was run over several times. Some holiday weekend.

What is very concerning about the episode described above is that we are about to be completely uninsured for the month of December. Mary and I have both started new jobs recently, and our insurance from her previous employer runs out at midnight on Sunday. Meanwhile, my new insurance doesn't start until January 1st.

So, for the month of December, we will more fully understand---through direct experience---the unfortunate uncertainty of living on that all-American edge of having no health insurance coverage. I think that we have planned well and won't run out of any of our medications, but the experience of last night (and my knowledge of the economic devastation that can be caused by unexpected health crises without insurance) does indeed give me pause.

Here in the United States, where more than 30 million Americans live without health insurance year-round, Mary and I are about to embark on a time-limited taste of that reality (something we did indeed experience back in the early years of our marriage when we were poor). We are determined to remain healthy and avoid any costly emergencies, and I'm certain that all will be well.

As professionals, we are indeed members of a privileged class of Americans who can rest assured that we have the economic wherewithal---even without insurance---to take care of our needs as they arise. With access to home equity, credit cards, and family who would of course help us in a pinch, we truly have nothing to worry about. Calling 911 and going to the ER last night, we knew that the entire affair would cost us precious little monetarily, and I received stellar care.

There are so many Americans who completely lack the the certainty that their healthcare needs will be taken care of. Millions of Americans lack insurance, have no credit at their disposal, and have families who are in no position to offer financial support.

As a nurse and as a human being, it is these people who I worry about. These are the adults, children and elderly Americans who live on the edge and who truly live their lives at daily risk of financial ruin and ill health. Lacking insurance, preventive medical care is eschewed, important screenings are missed, and future health and well-being is compromised.

I never want to lose sight of my relative privilege and how so many other Americans lack even the most basic assurance that their health, well-being and economic stability is important to others. It is crucial for those of us who do indeed have such privilege to speak out on behalf of those who do not, and to pressure the Powers That Be to change the calculus of privilege in this country.

Many privileges taken for granted by so many---healthcare, housing, food, education---are not really privileges at all. These privileges are, in my view, absolute rights. And we must fight for the rights that we feel all Americans deserve. It is my hope that the 21st century will be the momentous era in which American history and society undergo a seismic shift wherein the tectonic plates of privilege give way to a new foundation of national equality.

So how, you might ask, did I make the leap from a Thanksgiving ER visit to the utter lack of economic equality in American society? It is actually an easy leap to make, especially on a holiday that asks us to give thanks for the blessings and abundance in our lives. While I generally enjoy Thanksgiving and the true meaning of the holiday, my experience last night and early this morning only further drives home the point that so many Americans lack so much of what I can easily take for granted. And for me, I simply cannot rest until those disparities are truly a phenomenon of the distant past, a tattered remnant of an America whose bad old years are assuredly only a memory.

Thursday, November 27, 2008

Food Insecurity on Thanksgiving

A fifteen-minute expose on tonight's broadcast of The News Hour with Jim Lehrer on PBS highlighted the challenges faced by food banks and soup kitchens across America. With the current economic downturn, massive layoffs and rising unemployment are pushing more and more families and individuals to seek food assistance from local agencies.

As this wave of need crashes against the American system of emergency food distribution, those very agencies are already overwhelmed as requests for assistance continue to rise. Meanwhile, corporate and individual giving has declined as Americans who might normally donate to their favorite charities are themselves tightening their belts and giving less. Today's news reports demonstrate that some food banks and soup kitchens are sadly in a position wherein needy families are actually being turned away this holiday season.

Currently, 38 million Americans are considered "food insecure". Housing costs and fuel prices are a major factor for many families when it comes to affording basic food needs, although fuel has indeed taken a plunge to record lows in recent weeks (perhaps a temporary economic change). And when such families are eligible to receive food stamps from the government, the average amount allotted is approximately $4.00 per person per day (basically $1.33 per meal). How many of us would be challenged to feed our family a healthy and nutritious meal for $1.33 per person?

While hunger was once seen as a problem of the inner city and rural areas, one-third of poor Americans now live in the suburbs, and hunger in suburban areas is indeed growing while still being largely a hidden phenomenon.

Many of us are painfully aware that a significant number of personal bankruptcies in this country are due to the rising cost of healthcare, and as more and more Americans lose their health insurance after being laid off from work, they will indeed often be faced with a choice between food and healthcare expenses, a particuarly difficult dilemma, especially when children are involved.

Even as millions of Americans sit down to glorious Thanksgiving feasts this afternoon and evening, it is imperative for all of us to realize that there are more than 30 million Americans who face very serious food insecurity on a daily basis. For these individuals and families, even the idea of a Thanksgiving meal might seem like a dream. Perhaps all of us lucky enough to have kitchens filled with nutritious food should consider how we might ourselves contribute to making such dreams more likely to come true.

Wednesday, November 26, 2008

The Mathematics of HIV Infection

A new mathematical model suggests that the HIV virus could be virtually eliminated in 10 years if every person in every country with high infection rates was tested and treated.

Published in "The Lancet", the study is indeed intriguing, and the World Health Organization promises to examine the findings more closely. The model includes voluntary testing of every citizen, with AIDS drugs prescribed for any patient testing positive for the HIV virus, regardless of whether they are symptomatic or not. (Current practices often dictate withholding treatment until a patient has symptoms, or when their T-cells---immune cells that fight opportunistic infection---fall below a certain level.)

At this time, the price tag for such a strategy is estimated at $3.4 billion per year initially, with costs decreasing over time.

With approximately 33 million people infected with HIV worldwide, increased testing and treatment would, of course, cost money. However, an already overwhelmed healthcare infrastructure in places like sub-Saharan Africa (where HIV rates are still rising) would pose significant logistical challenges. (For an interesting map detailing the number of HIV cases and AIDS deaths worldwide, please click here.) How those countries would be financially and logistically supported by the global community in implementing such a strategy remains to be seen.

From a human rights perspective, critics of such an approach feel that universal testing and treatment might infringe on individual rights. And as many patients with HIV and AIDS already know, taking antiretrovirals is not easy, and side effects such as liver toxicity or failure, heart attacks and kidney failure are all relatively common.

Such studies and models for a plausible expansion of the global effort against HIV and AIDS are laudable, and perhaps the AIDS epidemic will indeed be significantly curtailed in the decades to come. Perhaps the greatest gift that we could give to the children of the 22nd century would be to eradicate HIV and AIDS from the face of the earth in the current century, a goal that has generally been seen as virtually impossible until now.

Some nay-sayers may feel that we're getting ahead of ourselves as infection rates steadily rise in Russia and other countries, but there are scientists and researchers around the globe seeing the possibilities of near-complete eradication. One can only hope that plausibility will eventually give way to reality, and someday we will truly look back on the epidemic as a disturbing yet finite piece of post-modern medical and societal history.

Monday, November 24, 2008

So, What Does A Public Health Nurse Do, Anyway?

This is a question that has already been posed to me several times, and coming up with answers helps me to define what it is I'm actually supposed to accomplish in my new job.

Public health nursing has a long and illustrious history which I will not illustrate here, but in terms of my new position, there are a number of things for which I am directly responsible:

-Tuberculosis case management: I closely monitor and follow any cases of active or latent tuberculosis in my community, assuring that patients take their medications as prescribed and follow up with the regional TB clinic as required.

-Emergency preparedness: it is my job to actually make sure that our town has protocols and plans in place for emergency preparedness, whether it be for natural disasters, terrorist attacks, pandemic illness, or other public health emergencies. I will cooperate with other regional agencies and serve as coordinator of our local Medical Reserve Corps.

-Immunization clinics: I will hold monthly immunization clinics for immigrants and other citizens in need of urgent immunizations. Influenza clinics are also an important part of our work in the late Autumn and early Winter.

-Infectious disease surveillance and investigation: I am responsible to track, report, and investigate infectious and communicable diseases in our community.

-Resources and referrals: I will provide the general public with resources, referrals and advice vis-a-vis medical issues, psychosocial issues, and other needs as they arise.

-Employee wellness: on some level, I am supposed to provide employee wellness resources for employees of our town. I'm not sure what this is supposed to look like, and only so much can happen in thirty hours each week. Still, I see this as a potentially interesting aspect of the job if there's any time to actually do it.

There is so much to learn and so much to know. Infectious disease surveillance in general is an enormous area of expertise and I feel ill-prepared to take it on.

The learning curve is indeed quite steep, but in exchange for my own sunny office, a great cafe next door, and excellent health insurance, I think I made the right choice.

Saturday, November 22, 2008

Public Health and Me

So, I have officially accepted a position as the Public Health Nurse for my town, and my hours were approved by the town government just yesterday. While I've been filling in as the Interim Public Health Nurse for ten hours each week over the last several months, I will begin working thirty hours a week beginning on Monday.

After ten months of being a free agent, consultant, and general slacker, having a job to responsibly report to four days a week is indeed a wake-up call. While consulting and working per diem jobs has allowed me a great deal of flexibility and self-determination, the need for high-quality health insurance and a more steady income have also reared their heads. Thus, my decision is propelled by economic need as well as the realization that this will certainly be an interesting and growthful career move on many levels.

As a Public Health Nurse for a town of approximately 40,000 people, I will be responsible for emergency preparedness (including the management of the local Medical Reserve Corps), infectious disease surveillance and reporting, tuberculosis case management, a monthly immunization clinic, influenza clinics each fall and winter, fielding questions and calls from citizens and town employees, and other important responsibilities.

I am honestly slightly overwhelmed as I realize the steep learning curve involved in this undertaking, but I also realize that my desire to work for Partners in Health, Doctors Without Borders, or a similar organization in the future will be even more likely with significant public health experience under my belt. While public health is not necessarily hands-on nursing, it is a crucial part of the healthcare infrastructure of the country, and many of my new skills will certainly be transferable to other countries and societies.

Stay tuned for developments as I dig in to my new position, and I surmise that issues of public health will become an even more intrinsic part of the regular conversation here on Digital Doorway.

Friday, November 21, 2008

Keith's Ephemera

Dear Readers,

If you are so moved, please pay a periodic visit to my newest blog---Fiction, Prose & Ephemera---a collection of fiction and poetry, some of which are works in progress, and others that are more or less complete. It is a project whose time has come.



Thursday, November 20, 2008

The Office of the National Nurse and the Obama Administration

Now that Barack Obama has been elected and some changes in the trajectory of American healthcare are on the way, those of us who support the creation of an Office of the National Nurse are asking that citizens supportive of our cause please communicate that support to the Obama team. For a review of the importance of such an office, please see my previous blog post on the subject. To communicate your opinion to the Obama-Biden team, please click here.

While the current Chief Nurse Officer (CNO) of the United States serves as Assistant Surgeon General, many of us feel strongly that it is time for nurses to be taken seriously as key players in the development of far-reaching preventive measures to improve the health and well-being of the American people. Rather than have the CNO remain in a subservient role to the Surgeon General, giving the National Nurse a prominent, autonomous and equal part in the government's efforts vis-a-vis preventive healthcare would send a clear message that the nursing profession has finally received the recognition it deserves.

Nursing has a great deal to offer to the American healthcare system and to policy discussions vis-a-vis the changes that are needed to improve the health and well-being of all Americans. The establishment of the Office of the National Nurse would be a major step towards recognizing the profession of nursing for its contributions to medicine and health (separate and autonomous from the medical profession), and for moving the United States and its citizens towards improved self-care, improved health outcomes, and renewed standing as a country that views the health of its citizens as a true measure of "national security".

To send the Obama-Biden administration a message regarding this issue---or any issue close to your heart---simply click here to visit a special page for communicating your vision of America to the incoming administration. Your support for the establishment of an Office of the National Nurse would be greatly appreciated.

Wednesday, November 19, 2008

Obama, Daschle and Healthcare

It is now confirmed that Barack Obama has asked former South Dakota Senator Tom Daschle to serve as the administration's Secretary of Health and Human Services. While the nominee has already undergone a rigorous vetting process by the Obama transition team, he will of course face a Senate confirmation hearing after the President-Elect is inaugurated on January 20th. I will venture a guess that Daschle will be handily confirmed by the Senate, and I imagine that he is already setting his sights on a broad plan of action. Whether that plan leads to successful change in the healthcare trenches remains to be seen.

Meanwhile, a powerful bipartisan group of senators met in the offices of Edward Kennedy (D-MA) today, at the behest of Senator Max Baucus (D-MT), to begin shaping potential Democratic legislation vis-a-vis broad healthcare reform.

With 15% of the country's GDP going to healthcare and the number of American uninsured (estimated at 40 to 47 million) expected to rise as layoffs and unemployment increase in response to the economy, the stakes are high for meaningful healthcare reform.

We all know we can do better. In terms of healthcare access, funding and quality of care, the World Health Organization has ranked the United States as 37th in the world. Concurrently, our ranking in terms of infant mortality and life expectancy also continue to plummet when compared with other nations. These statistics bear out the widely accepted notion that the enormous per capita expenditures on healthcare by the United States government have fallen far short of their potential, and many other countries have somehow managed to produce far better results utilizing a percentage of what we spend here.

The battle regarding the potential benefits and pitfalls of universal healthcare is on. Yesterday on Digital Doorway, I pointed readers towards an excellent website where the arguments for and against universal government-sponsored healthcare is being argued quite cogently. This nationwide conversation will only intensify, and it remains to be seen how the Obama administration will rise to this Herculean challenge.

I am personally and professionally invested in the developments vis-a-vis healthcare reform in the United States, and I assume it will be years before we know the true successes or failures of President Obama's efforts, with support from Tom Daschle and other key players (not to mention the input of the American people, if it is heeded amidst the noise).

These next months and years will be an interesting affair, and great grist for writers, bloggers, healthcare policy professionals, pundits, and ordinary citizens alike. Meanwhile, as the conversation and debate rages, the statistics related to the uninsured and underinsured will certainly worsen. We can only hope and pray that a truly remarkable (and successful) solution is indeed within reach.

Tuesday, November 18, 2008

Opposing Views: The U.S. and Universal Healthcare

I would like to bring readers' attention to a website called "Opposing Views" wherein "real experts go head-to-head on issues you care about". From the spanking of children to animal rights, an open forum of debate, discussion and commentary allows experts and readers to chime in on pressing issues of the day.

Apropos of Digital Doorway's predilection for issues related to healthcare, there is currently a lively and very interesting debate on the site which poses the question, "Should the U.S. Have Universal Healthcare"? I highly recommend visiting this particular debate, leaving a comment if you so desire, and perusing the site for other debates, such as "Does Marijuana Have Medical Value?", "Is There a God?", "Do Guns Make You Safer?", and "Should Your Daughter Receive the HPV Vaccine?"

Debate is a healthy way for issues of interest to be discussed under a framework of civil discussion and intellectual sharing. Opposing Views certainly offers a valuable forum for such discussions to take place, and I encourage anyone who enjoys such lively give and take to frequently pay this excellent site a visit.

Sunday, November 16, 2008

Hospitals and Consumers on the Edge

Economically speaking, times are tough all over. People are losing their jobs, the unemployment rate is rising, and retailers and consumers alike seem to be facing a lean holiday season.

On the healthcare front, a number of U.S. hospitals are now in the difficult position wherein they now must buy back debt incurred from "Variable Rate Demand Notes" (VRDNs) and other forms of loans that hospitals use to do many things, including making capital improvements to their facilities. According to some reports, U.S. hospitals may be forced to buy back up to $8 billion dollars of debt, not an easy task in these cash-strapped times.

For hospitals, the economic times are indeed challenging. Patients with outstanding bills are less likely to be able to pay on time, if at all. Many employers are scaling back health insurance coverage for their employees, thus patients are often stuck with hospital bills that they cannot afford. Additionally, the numbers of uninsured and under-insured patients is rising in most states, and charity care is becoming increasingly burdensome for hospitals and health systems that provide such services. As some patients shift to Medicaid, hospitals also understand that reimbursement rates from Medicaid and Medicare often cannot match those from some private plans, thus revenues hemorrhage from numerous economic blood vessels simultaneously.

Equally troubling for hospitals, borrowing is exceedingly difficult, despite dire need for improvements to facilities, upgraded IT equipment and systems, and rising labor costs. With increased costs of utilities, food, supplies, and health insurance premiums for their own workers, hospitals also understand that many patients will continue to cancel or postpone many elective surgeries and procedures that bring much needed revenue to hospitals' bank accounts. With consumers charged co-pays of $200 to $400 for elective procedures such as colonoscopies and vasectomies, hospitals face a serious decrease in such procedures which are much less costly since they generally involve a stay of less than 12 hours from registration to discharge.

From The Wall Street Journal to regional news outlets in the mid-West, the signs all seem to be the same: hospitals are in for a difficult season as the economic belt tightens on the healthcare industry.

As a self-appointed advocate for the uninsured and vulnerable in this country, I am seriously concerned that an enormous cohort of Americans currently face a significant decrease in the availability of affordable preventive healthcare in all regions of the country, not to mention access to many specialists and other providers.

Overall, my fear is that the availability of free and low-cost care will suffer in the current economic climate, and patients in need of care will need to travel further and further afield in search of providers willing to see them, a burden that may keep numerous people from seeking medical attention at all. When access to medical attention is limited, it is frequently the uninsured and under-insured who are left in the healthcare dust, and there are millions of children who will fall into this unfortunate group as their parents simply struggle to make ends meet.

There will be much for the new Obama administration to consider when assessing the current (horrible) state of the American healthcare system. As impatient as we all are for change, it may be many months before any improvements are even suggested for fixing healthcare in this country.

Meanwhile, as hospitals struggle with their bottom line and millions of uninsured Americans struggle to stay healthy, we all must hope that there is still a possibility that the damage, as extensive as it may seem, can still be undone. And as for those millions of uninsured children out there, it should never get any worse than this.

Saturday, November 15, 2008

UNICEF Petition for Child Survival

UNICEF is currently sponsoring an urgent petition to President-Elect Barack Obama requesting that child survival around the world be made a top priority of his administration. With approximately 9.2 million children and babies under five dying unnecessarily around the globe each year (that's 25,000 children per day), this initiative is clearly an investment in our global future and should be taken seriously by governments and NGOs the world over.

On UNICEF's website, they state the case clearly:

"At UNICEF, we believe in children. We believe deeply that every child—regardless of race, gender, religion, nationality or economic status—is equally deserving of a future. We believe that every child, not a percentage of children, should be afforded basic lifesaving vaccines, clean water, nutrition, protection from violence and a chance to survive to adulthood."

And they earnestly continue their message:

"UNICEF believes it is possible to reach zero—zero child lives lost to preventable causes like pneumonia, diarrhea, malnutrition and infection; zero children disabled by unnecessary illness; zero mothers dying as they give birth for lack of health care.

"An impossible dream? No, an achievable goal—with enough will and enough resources. UNICEF has proven that we know how to stop this from happening, with integrated, cost-effective solutions.

"What’s missing? Leadership. Everyone has a part to play: individuals, corporations, civic groups, church organizations—and, yes, government. We need the United States to provide leadership on child survival. That means both Congress and the President."

At this time of global economic meltdown, it is widely recognized that humanitarian aid and related initiatives might be seen as somehow superfluous based on current financial realities. but despite---or perhaps even due to---the economic crisis that is gripping the world, the continued fight to eliminate poverty, hunger and early child mortality is in fact more important than ever.

As developing countries strive to come to grips with the worldwide economic downturn, increased assistance from the world's industrialized nations is paramount. And in terms of global security, keeping the world's citizens fed, housed, safe from violence, and protected from unnecessary illness and death is in fact in our best interest, singularly and collectively.

Appealing to potential donors on a crudely economic basis, I would say that children are especially crucial to the future of the world's economic well-being. As future parents, workers, doctors, lawyers, humanitarians, farmers, etc., they are key to developing a healthy and robust workforce as their generation comes of age. Economically speaking, investing in children's lives is an investment that will pay countless dividends for generations to come.

However, beyond their economic status as future workers and consumers, humanity as a whole has a vested moral and ethical interest in assuring that no child dies unnecessarily from an otherwise preventable cause. This means that children in Iraq, Japan, the United States, Nicaragua, Sierra Leone, Brazil, the Phillipines, Pakistan, or any other country, all deserve the chance to grow, to learn, and to fulfill their potential as human beings and have the opportunity to contribute to the world's development and humanity's evolution. This notion is incontrovertible, and the moral imperative of saving children's lives simply cannot be debated.

I believe that one of the best roads to international security, future global prosperity, and humanity's greatest potential is through realizing the value of children's lives and investing in programs and initiatives to assure that those lives are not cut short by the lack of healthcare, food, shelter, education, and the economic means of survival. 25,000 preventable deaths per day is no laughing matter, and UNICEF's call for a "laser-focused" initiative by the new American president is a good start to what could be a moving and potentially wildly successful undertaking.

Please visit the UNICEF site today and sign the petition calling for a Presidential Initiative to Accelerate Child Survival. 25,000 children will die unnecessarily today. Let's make sure that, within our lifetime, we will bring that morally unacceptable number to zero.