Maternal and Child Health
Section Newsletter
Spring 2011

MESSAGE FROM THE CHAIR: BUDGETS, DEFICITS, POLITICS, AND MCH

These past few months have seen a buzz and conflicts over both the federal budget and the ongoing implementation of the Affordable Care Act, which marked its one year anniversary in March. Many of our sister organizations have worked to review, summarize and get information out on both the budget and ACA implementation. Two organizations that stay on top of these issues and provide a wealth of information for our members as well as assist us to advocate on behalf of Women, Children, and Families are the Association of Maternal and Child Health Programs [ http://www.amchp.org ]   and Families USA [ http://familiesusa.org/issues/childrens-health .]

 

AMCHP has created a National Center for Health Reform Implementation that serves as a central point of contact on all things health reform. The purpose of this center is to “provide state maternal and child health leaders and their partners with the information, tools and resources to optimize the opportunities presented by the ACA for improving services, systems, and health outcomes for MCH populations.”

 

In addition AMCHP, through its regular legislative updates, provides summaries of the budget passed in March, the HRSA spending plan, and what to watch for regarding the 2012 budget:

 

On March 7, the U.S. House of Representatives and Senate passed a final Continuing Resolution (HR 1473) to provide funding for federal government operations for the remainder of this fiscal year. The bill cut $38 billion from a range of federal programs, including significant cuts to the budget for HRSA and CDC. However, the bill includes funding levels that restore most of the MCH-related funding cuts from earlier proposals. The bill assumes $662 million for the Maternal Child Health block grant, the same as the FY10 level.

 

In March 2011, HRSA reported that the Title V Maternal and Child Health Services Block Grant has been restored to relatively flat funding of $656 million – a major victory in comparison to the Feb. 9 House of Representatives original proposal to cut $210 million. The final Title V allocation apparently reflects a small cut, less than 1 percent across the board applied to most programs. The HRSA plan also confirms funding of $299 million for Title X Family Planning Grants (a $17.4 million cut), $21.8 million and for Poison Control Centers (a $7.3 million cut) – also positive since both programs were zeroed out in earlier House proposals.  It makes no change to the mandatory $250 million FY 2011 allocation for the Maternal, Infant, and Early Childhood Home Visiting Program or other mandatory Affordable Care Act appropriations.  While this was relatively good news for MCH, there were disturbing cuts to critical HRSA programs:  $660 million cut to the base allocation for Community Health Centers (offset by the $1 billion increase in mandatory Affordable Care Act funds); $65 million cut to health professions; $47 million for rural health programs; $48 million for the Children’s Hospital Graduate Medical Education program; and a range of small cuts to many other programs.

 

Watching out for 2012 – ACT NOW - the U.S. House of Representatives is expected to next consider their FY 2012 Budget Resolution. This will provide a blueprint that sets in motion a process to once again propose perhaps even deeper cuts to discretionary health programs for FY 2012. Work on FY 2012 appropriations bills is expected to commence shortly, so in the coming days and weeks help to make the case for sustained and adequate MCH funding in next year’s budget. 

 

Medicaid and CHIP make up approximately 8 percent of federal spending, so we know these will be key budget lines which will come under scrutiny. As part of the 2012 budget ‘battle,’ Families USA reminds us of key messages in the debates around continuing funding for Medicaid and CHIP.

 

From Families USA - Messages for Decision Makers

Right now, all members of Congress are thinking about the budget and the debt ceiling vote. Even if you don’t have a particular proposal to talk about, it is important that you let your members know your position.

  • Let them know that you realize that it is important to reduce the federal deficit over the long-term, and that includes controlling health care spending.
  • The approach to deficit reduction should be sustainable, should balance spending reductions with revenue raising measures, and should not decimate programs that seniors and their families, people with disabilities, children and our most vulnerable citizens depend on.
  • Medicaid and other low-income entitlement programs should be exempted from any mechanisms for automatic cuts, such as caps or triggers that set cuts in motion if targets are not met.
  • Medicaid is an efficient program, with little fat to spare. It should be spared from cuts.
  • Controlling health care spending should be part of a thoughtful deficit reduction process that focuses on better care delivery, not just making massive federal spending cuts and passing costs on to states and consumers. The Affordable Care Act established a framework for making lasting improvements in health care delivery by reining in spending and increasing coordination of care.

WHAT ARE WE DOING IN THE MCH SECTION?  Our goal is to assist our members to stay abreast of developments and provide tools for influencing policy members.  Timely communications mechanisms include our Facebook Page (APHA Maternal & Child Health Section Community) and our listserv through SLHINet. Make sure you sign into both of these (check our website for information on how to register) to get Section information as well as advocacy information.  You should also sign up for the APHA advocacy alerts which provide information on a wide range of public health issues as they need urgent attention during budget negotiations!  Go to http://www.apha.org/membergroups/sections/aphasections/mch/  for Section information or http://www.apha.org/advocacy/activities/  for APHA Advocacy activities.

 

Also don’t forget to register for the APHA Annual Meeting so we can see you all in November!!

 

Keep up all the good work for Women, Children, and Families!

Debra Jackson

Chair, MCH Section

SECTION AND ASSOCIATION NEWS

 

·         Improving Pregnancy Outcomes:  The Improving Pregnancy Outcomes Committee is looking forward to the Annual Meeting in November in Washington, D.C.  We are in the process of finalizing our sessions, which are organized around the theme of the Annual Meeting: Healthy Communities Promote Healthy Minds and Bodies. The IPO Committee is proud to be the organizer of two podium sessions and one poster session.  We will update you in the fall MCH newsletter on the times and titles of our sessions and provide information about our committee meeting, which is open to all members of the MCH Section.  All are welcome to attend -- we are always looking for new members.  If you would like to get more involved, please contact one of us by email.

 

Your IPO Chairs are:

 

o    Kee Chan -- keechan@bu.edu

o    Judith Katzburg -- jkatzbur@ucla.edu

o    Janine Lewis -- jlewis6@gmail.com

o    Tyan Parker-Dominguez -- tyanpark@usc.edu  

 

 

·         Need-based scholarships available for students to attend Annual Meeting:  APHA is proud to announce the availability of need-based scholarships, sponsored by External Medical Affairs, Pfizer Inc., for student members to attend the 139th Annual Meeting and Exposition in Washington, D.C., from Oct. 29-Nov. 2, 2011.  Twelve students will be granted registration and up to a $500 stipend to use toward food, lodging and transportation.  An additional four students will be given Annual Meeting registration only.  Recipients of the scholarships will be chosen based on financial need and an essay.  As part of the award, students will be strongly encouraged to attend at least one Section business meeting.  Please inform student members of the MCH Section about this unique opportunity!  Visit www.apha.org/meetings/registration/scholarship for complete details and application form.  Please contact Pooja Bhandari at pooja.bhandari@apha.org with any questions. 

 

·         APHA Co-sponsors Text4Baby Contest:  APHA is now a co-sponsor of the Text4Baby initiative, which is a program of the National Healthy Mothers, Healthy Babies Coalition.  Text4Baby is a free text program for pregnant women and new mothers to engage in prenatal and infant health. Text4Babyhas recently launched a nationwide contest for states to compete to enroll women in the new, mobile health program.  The top three states to enroll the most users by October 2011 will be announced at the 139th APHA Annual Meeting in Washington, D.C.  For more information, contact Pamela Rich, Outreach Coordinator, at (703) 838-7504 or prich@hmhb.org 

 

  • New baby for Anna BauerCongratulations to Student Fellow Anna Bauer, who gave birth to a 6lb, 12oz baby girl on May 28, 2011.  Emma Claire Paul was born at 7:55 p.m. and is 18-3/4 inches long.  Emma was born at UNC in Chapel Hill, which her mother says, “represents MCH at its finest -- birth attendants supportive of all of our choices, inclusive of my husband Chris, lots of skin-to-skin contact, and all in a hospital that's clearly working hard to improve policies that are beneficial for mothers and babies.”

 

 

  • Barbara Starfield, noted researcher and teacher, dies:  On a sadder note, word has just reached us of the sudden passing of Barbara Starfield, who apparently died of a coronary event while swimming at her home in California on Friday, June 10.  A pediatrician by training, health services researcher by trade, and natural teacher by talent, Barbara was a tireless advocate for family medicine and primary care.  Her passing is an irreplaceable loss for those of us who care deeply about health care and equity.
 

·         New edition of Caring for our Children: Caring for our Children: National Health and Safety Performance Standards – Guidelines for Early Care and Early Education Programs is now available. A publication of the American Academy of Pediatrics; APHA; and the National Resource Center for Health and Safety in Child Care and Early Education, the new third edition contains updated guidelines on the development and evaluation of the health and safety of children in all types of early care and education settings, including centers and family child care homes.  For more information, see https://secure.apha.org/scriptcontent/beweb/orders/ProductDetail.cfm?pc=978-158110483-7.

 

·         D.C. holds MCH Community Forums: In preparation for their Title V MCH Block Grant application, D.C. held two well received Maternal and Child Health Forums in May to get community input about existing D.C. programs that address the new Title V priorities. Last year, states developed new priorities after completing a five year Needs Assessment. Special attention was paid to having one community meeting in the evening with day care available and light refreshments. Parents of special needs children and other community members were in attendance.  For more information, contact Mary Kornak, Title V Program Coordinator, at mary.kornak@dc.gov.

 

·         Order Our Updated “A Lifetime of Good Health: Your Guide to Staying Healthy!”:  The Office on Women’s Health of the U.S. Department of Health and Human Services is happy to announce that our very popular booklet, “A Lifetime of Good Health,” has been updated and is now available for you to order. With information important to women at every stage of life, we have also added topics such as how much sodium you should eat, heart attack and stroke warning signs, how to deal with an abusive partner, mental health and suicide prevention, and more! Available in English and Spanish. Call to place your order today at (800) 994-9662.  For more information, contact editor Claudia Ruland at claudia_ruland@federal.dell.com.

 

·         Resources on transportation and health available:  These are exciting times when considering the many ways our transportation systems affect health and equity in our communities. Congress extended the current federal surface transportation bill until Sept. 30, 2011, and Congressional committees are aiming to draft a new transportation bill before this latest extension ends. Want to learn more about the connections between transportation, equity and health? View our archived webinar series, subscribe to the monthly transportation and health eNewsletter that offers an array of new events and updates, and download the newly released online public health and transportation toolkit and accompanying resources today. We also invite you to send a message to your members of Congress urging that they ensure that strong public health provisions are included in the federal surface transportation reauthorization. For more information, visit http://apha.org/transportation.

 

·         Register now for best rates at the Annual Meeting:  Registration is now open for the APHA 139th Annual Meeting and Exposition in Washington, D.C., Oct. 29 - Nov. 2, 2011.  More than 1,000 cutting edge scientific sessions will be presented by public health researchers, academicians, policymakers and practitioners on the most current public health issues facing the nation today. For registration and more information about the Annual Meeting visit www.apha.org/meetings. The MCH Section will have a strong presence at the meeting. View the sessions sponsored by the MCH Section in the interactive Online Program accessible at http://apha.confex.com/apha/139am/webprogram/start.html.  Search the program using keyword, author name, or date.  Don’t forget to visit the Section and SPIG pavilion in the Public Health Expo next to Everything APHA to speak to a Section representative.

NEW GOALS FOR APHA 2011: LESS TRASH! LESS PLASTIC!

The 2011 APHA Annual Meeting theme "Healthy Communities Promote Healthy Minds and Bodies" gives APHA members an opportunity to build on the 2009 and 2010 themes of Water and Social Justice as public health priorities.

 

Green Goals.  The APHA Food and Environment Working Group, the Environment Section's 100th Anniversary Committee, and APHA are setting goals to reduce waste and promote a sustainable, just, and healthy food and water system. 

 

Got Trash?  We encourage everyone at APHA 2011 to increase efforts to reduce trash, especially paper and plastic.

 

The Diversion Rate (recycling/trash ratio) in D.C. at APHA 2007 was 34 percent.

The Diversion Rate in Denver at APHA 2010 was 52.75 percent

Can we achieve a Diversion rate of 75 percent at APHA 2011?

 

·         The D.C. Convention Center’s water fountains and food service sinks provide filtered water! Bring your own refillable bottle to the conference to cut down on plastic waste.

 

·         Plan events using local resources and services that encourage wise use of water and other resources. If you need advice or suggestions, contact us: apha.fewg@gmail.com

 

·         Buy food sourced from sustainable producers and distributors. 

 

·         If using disposables, use compostable products and use the facility compost program.  Label containers so compostables do not go into the waste stream.

 

·         Take advantage of the D.C. Convention Center's Green Initiatives.  Learn about it at   http://www.dcconvention.com/Planners/Large/GreenInitiatives.aspx

 

·         Learn more about APHA 2011 Environmental Initiatives at http://www.apha.org/meetings/highlights/environment.htm

 

Be an Ambassador of public health and social justice in your own community.   Share information about the social justice, public health and environmental problems caused by bottled water and water privatization, especially disposable plastic water bottles.  Use the "Resources and References" below and on the Food and Environment Working Group’s Facebook page,  https://www.facebook.com/topic.phpuid=134564799935654&topic=6959

 

Share ideas for waste reduction at APHA 2011 programs, scientific sessions, events and exhibits.  Send your questions and suggestions to Ellie Goldberg at ellie.goldberg@gmail.com, and join the conversation on the Food and Environment Working Group’s Facebook page at https://www.facebook.com/APHA.food.and.environment. 

 

The APHA Food and Environment Working Group is a multi-disciplinary collaboration across APHA Sections, housed in the Food & Nutrition and Environment Sections. Colleagues work together to protect public health by promoting and cultivating a safe, healthy, just and sustainable food system.

 

If you would like to work with us toward these goals, contact Rebecca Klein at rklein@jhsph.edu. Working Group membership is open to all APHA members.

 

Resources and References

 

·         Water Myths:  http://www.storyofstuff.com/pdfs/storyofbottledwater_myth-v-reality.pdf

 

·         Bottled Water: Get the Facts:  http://www.foodandwaterwatch.org/water/bottled/ 

 

·         Blue Gold, Maude Barlow

o    Book: http://www.amazon.com/Blue-Gold-Fight-Corporate-Worlds/dp/1565848136/ref=sr_1_2?ie=UTF8&qid=1302634088&sr=8-2

o    Film: http://www.bluegold-worldwaterwars.com/

 

MCH SECTION REVIEWS PROPOSED POLICIES

The MCH Section is very grateful to members who participated in preparing comments on newly proposed APHA policies. These include the following:

 

·         Katie Baker

·         Adiane Casalotti

·         Ann Dozier

·         Clare Feinson

·         Judith Katzburg

·         Ghada Khan

·         Marian MacDorman

·         Carol Nelson

·         Ellen Pliska

·         Marjory Ruderman.

·         Barbara Singer

·         Phoebe Souza

·         Paulette Spencer

 

Also greatly appreciated is the fine work of the MCH Student Fellows who did an excellent job reviewing the set of APHA policies under consideration for archiving.  These include the following:

 

·         Leslie Golden

·         Skye Peebles

·         Elizabeth Radcliff

·         Phoebe Souza

 

MCH Section members should be on the lookout for information forthcoming in June/July about APHA’s PHACT Campaign, to educate our members of Congress on important public health policies that build and maintain healthy communities. During the August Congressional recess, Aug. 9 - Sept. 10, we are asking APHA members and affiliates to reach out to their Congressional representatives in their home districts to express support for public health funding, healthy transportation policies, and improving child nutrition and wellness policies that build healthy communities.

 

View the APHA 2010 PHACT Campaign Webinar Presentation to find out more about our campaign issues and strategies.

SMOKING RATES LOWER, BUT STILL LEADING CAUSE OF LOW BIRTH WEIGHT IN COLORADO

Smoking while pregnant and not gaining enough weight during pregnancy are two of the leading preventable causes of low birth weight for women in Colorado delivering babies. Women’s health experts at the Colorado Department of Public Health and Environment released the findings after a recent analysis of single births in Colorado from 2007-2009.

 

The good news is that smoking among pregnant women has declined.  One in 14 low-weight births was attributed to smoking in the 2007-2009 findings,  compared to nearly one in eight low-weight births attributed to smoking in the 1995-1997 findings.

 

“Although Colorado has made remarkable improvements in reducing smoking during pregnancy, dropping from 11.6 percent to 8.7 percent, no improvements were made in women gaining enough weight during pregnancy,” said Jillian Jacobellis, Prevention Services Division director at the Colorado Department of Public Health and Environment.

 

Jacobellis said women who smoke during pregnancy or who do not gain enough weight significantly increase their risk for having a baby weighing 5 pounds, 8 ounces or less at delivery.

 

 “These low birth-weight babies are at risk for disabilities, complications requiring longer hospital stays, treatment in intensive care units, and even death. Public health interventions that address these issues are necessary to reduce these numbers,” Jacobellis said.

 

Pregnant women at a normal weight for their height should gain 25 to 35 pounds; underweight women, 28 to 40 pounds; overweight women, 15 to 25 pounds; and obese women, 11 to 20 pounds.

 

Since the release of the 1995-1997 findings in 2000, the Colorado Department of Public Health and Environment has developed public health campaigns targeted at pregnant women to encourage them to quit smoking and gain adequate weight. Prevention efforts to reduce smoking received the added benefit of statewide policies enacted to decrease tobacco consumption and second hand smoke exposure.

 

In January 2005, a tax increase raised the price of cigarettes and tobacco products. In July 2006, Colorado implemented the Clean Indoor Air Act, which prohibits smoking in most indoor public places.  These two changes, which apply to all smokers, together with public health efforts to prevent smoking and help smokers quit, “may have encouraged pregnant women to quit smoking during 2007-2009, compared to a decade ago,” said Jacobellis.

 

For more details about the analysis, visit: http://www.cdphe.state.co.us/pp/womens/pdf/MakingProgressOnTippingTheScales.pdf

 

Pregnant women who want help quitting tobacco can call the Colorado QuitLine at 1-800-QUIT-NOW (1-800-784-8669) for free assistance through the QuitLine’s special pregnancy program. Participants work with the same personal coach throughout the entire quit process, and they earn rewards for participating in the coaching calls.  Services are available in English or Spanish.

REVIEW OF MATERNAL MORTALITY USED TO ADDRESS DISPARITIES IN CALIFORNIA

Maternal mortality has been steadily increasing over the past decade, both in California and in the United States. The rate of maternal deaths in California in 1999 was 8.0 deaths per 100,000 live births, and by 2008 it had increased to 14.0. In 2006, the California Department of Public Health Maternal, Child and Adolescent Health Program initiated the California Pregnancy-Associated Mortality Review, or CA-PAMR, in collaboration with the California Maternal Quality Care Collaborative and the Public Health Institute to investigate the reasons for the rise in maternal mortality. CA-PAMR reviews medical records of maternal deaths, and we are fortunate to have the voluntary service of a statewide, multidisciplinary group of leading clinical experts in maternal health. This committee determines the causes of maternal mortality and identifies quality improvement opportunities in maternity care and public health strategies to prevent maternal deaths. Funding for CA-PAMR is provided by the Federal Title V Maternal and Child Health Block Grant Funds.

 

The following findings were taken from the recently released April, 2011 report, “The California Pregnancy-Associated Mortality Review Report From 2002 and 2003 Maternal Death Reviews,” available at: http://www.phi.org/pdf-library/2011-6-2MaternalDeathReview2002-03.pdf.

 

Women who died were, on average, poorer (based on payer source at labor and delivery) and less educated than the general population of women giving birth in California. There were high rates of obesity among the pregnancy-related deaths, and obesity or excessive gestational weight gain was determined to be a contributing factor in one of four deaths where data on weight was available.  

 

Racial/ethnic disparities continue to persist: African-American women have a four-fold higher risk of maternal death. African-American women were more likely than other groups to have been overweight or obese and were also more likely than other racial/ethnic groups to have died of cardiovascular-related causes. CA-PAMR will continue to explore potential explanations for these disparities and will continue efforts to eliminate this gap in health equity.

 

An important finding of this project was that over a third of pregnancy-related deaths were determined to have had a good or strong chance of being prevented, and several opportunities for improvement have been identified. With funding from the state Maternal, Child and Adolescent Health program, the California Maternal Quality Care Collaborative has been developing resources for health care providers to address the quality of care issues identified by CA-PAMR. One example is the Obstetric Hemorrhage Toolkit, which was developed to improve readiness, recognition, response and reporting of hemorrhage, a common cause of maternal death. The Collaborative also works with several county health departments to implement pilot projects to improve maternity outcomes. For more information on these resources, please visit www.cmqcc.org. 

Medical record review of pregnancy-related deaths has been a valuable tool to increase the accuracy of reporting for this important health indicator. We have identified additional pregnancy-related deaths, provided greater specificity on the underlying causes of death, and have re-evaluated the leading causes of death. For example, after case review, cardiovascular disease was found to be the leading cause of pregnancy-related deaths in 2002-2003; yet this health condition did not appear in the top five causes when only death certificate data were examined. A fuller description of the methodology utilized by CA-PAMR is included in the report (see link above) and may be of use to states that are considering initiating pregnancy-related mortality reviews.

For more information, contact Christy McCain, Research Scientist at the Public Health Institute, www.phi.org or christymccain@cruzio.com.

MORE WOMEN IN LABOR SMILE BECAUSE OF LAUGHING GAS

MedPage Today reports that nitrous oxide, or laughing gas, is being used as an intermediate option for controlling the pain of childbirth.  Obstetric analgesia has a limited range concentrated at the two extremes: nonmedical tools like massage and hot tubs that make women more comfortable, and epidural infusions that block all feeling below the administration site.  Opioid painkillers are also available but typically don't do much for labor pain.  Specialized equipment fixes the oxygen-to-nitrous oxide ratio at 50/50, and the woman holds the mask in her hand, controlling when and how much anesthetic she gets.  Because the body does not metabolize nitrous oxide, it can be a flexible tool in the delivery room, allowing women, for example, to get up and move around, not an option with an epidural.  Since the use of nitrous oxide does not require an anesthesiologist, the technique holds promise for free-standing birthing centers and other facilities without 24/7 access to those services.  Nurse-midwives are especially interested in its use, and an Internet listserv has been created by Judith Rooks of the American College of Nurse Midwives.  Nitrous oxide is widely used in other parts of the world, but not as much in the United States, where the use of nitrous oxide in childbirth is being evaluated at the University of California at San Francisco and at Dartmouth.  Other facilities, such as the Vanderbilt University Medical Center in Nashville, Tenn., are preparing to offer nitrous oxide due to consumer interest in this additional option for safe patient care.  For the full story, go to http://www.medpagetoday.com/Anesthesiology/PainManagement/26153?utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&userid=324535 .

 

MedPage today is a free, online source of medical news and continuing medical education, putting breaking medical news into practice.  It is available at www.medpagetoday.com.  

CAN A STRESSFUL CHILDHOOD MAKE YOU A SICK ADULT?

In March 2011, The New Yorker magazine reported on the work of Dr. Nadine Burke, who studies the physical effects of anxiety.  The rapidly evolving sciences of stress physiology and neuroendocrinology suggest that the anxiety of a difficult life may cause significant and long-lasting chemical changes in both the brains and bodies of young people, making them sick now and increasing their chances of serious medical problems in adulthood.


Burke believes that regarding childhood trauma as a medical issue helps her treat her patients more effectively.  In the view of Burke and the researchers she has been following, many of the problems that we think of as social issues might be better addressed on the molecular level. If these researchers are right, it could be time to reassess the relationship between poverty, child development and health.

 

The Adverse Childhood Experience study showed stunning correlations between adverse childhood experiences and negative adult outcomes.  In many cases, what looks like a social situation was actually a neurochemical situation, and Dr. Burke’s goal is a treatment protocol similar to the one doctors use when they are dealing with cancer or diabetes.  For the full article, see http://www.newyorker.com/reporting/2011/03/21/110321fa_fact_tough#ixzz1Hvaxl7Bs

NOW AN E-BOOK! A DOCTOR IN LITTLE LHASA: ONE YEAR IN DHARAMSALA WITH THE TIBETANS IN EXILE

After completing his adult medicine residency, Dr. Timothy Holtz left Boston to spend a full year practicing medicine in Dharamsala, a small town in the northern Indian foothills of the Himalayan Mountains. A Doctor in Little Lhasa recounts Holtz’s experiences working in the modest hospital that serves the Tibetan refugee and local populations, as well as curious Western tourists who fall ill during their pilgrimages to the region.

 

Since 1962, Dharamsala has been the official site of the Tibetan Government-in-Exile and home to the Dalai Lama. The Tibetan-run, donor-supported facility where Holtz worked has only the most basic equipment and resources, yet it serves a community in excess of 15,000 people. Far removed from the state-of-the-art diagnostic tools and cutting edge medications typical of Western hospitals, Holtz had to go back to the basics of clinical diagnosis and treatment, relying on his skills of observation as well as the medical histories gleaned from his patients. As Holtz matures as a young physician, the excitement of practicing medicine in a remote location is fraught with difficult and challenging moments. At one point, he must try to stop a dangerous outbreak of diphtheria from spreading, with no vaccines on hand. Sometimes he could only watch in frustration as patients died of diseases, such as drug-resistant tuberculosis, that could have been treated in an economically developed country. It was the resilience of the Tibetan people that confirmed the importance of Holtz’s drive to care for an underserved population.

 

A Doctor in Little Lhasa also touches on the contemporary history of Tibet, as well as its people and culture. Tibetans have suffered persecution from the Chinese Government, forcing thousands into exile across the Himalayan Mountains with little more than the clothes on their back. Holtz witnessed the depression, anxiety, and posttraumatic stress disorder borne of torture and mistreatment endured before fleeing Tibet. His investigation into the mental health scars from trauma under occupation and exile led to a meeting with the Dalai Lama and a discussion about how to better serve the survivors. In several cases, Holtz’s medical intervention and treatment of psychological distress saved his patients’ lives.

 

A Doctor in Little Lhasa is a fascinating book that draws readers in from the beginning.  Holtz’s one-year experience in Dharamsala serving Tibetans in exile changed his life forever.  Moreover, his story highlights the inseparable connection between health and human rights.

 

A Doctor in Little Lhasa: One Year in Dharamsala with the Tibetans in Exile, by Timothy H. Holtz, MD, is available from all major booksellers, as well as www.timothyholtzbooks.com. The book is also available for Kindle, Nook, and I-Book.

HEALTH CARE COST AND UTILIZATION PROJECT PROVIDES TRAINING, STATISTICAL REPORTS

The Health Care Cost and Utilization Project is the office within the Agency for Healthcare Research and Quality that provides training materials and webinars, as well as statistical reports that you can use in your daily work. All of these publications are available at www.hcup-us.ahrq.gov .  Recent offerings include the following:

 

·         C-Section rates up, episiotomy and forceps rates down: Use of episiotomy, a surgical incision to widen the vaginal area during childbirth, fell by 60 percent between 1997 and 2008, but the proportion of hospital stays of women who delivered via cesarean section (C-section) increased by 72 percent during the same period. Statistical Brief #110, Hospitalizations Related to Childbirth, 2008 also shows that 40 percent of all childbirth stays were billed to Medicaid, 53 percent to private insurers, 4 percent were uninsured, and the rest were charged to other payers.

 

·         Increases in uninsured hospital stays go from 4 percent in 2003 to 21 percent in 2008:  In Statistical Brief #108, Hospital Stays, 2008, AHRQ found that there were 2.1 million uninsured admissions in 2008, compared to 1.8 million in both 2003 and 1998, and the average cost of a 2008 uninsured hospital stay was $7,300.

 

·         Almost 2 million hospital patients suffer from medication injuries: The number of people treated in US hospitals for illnesses and injuries from taking medicines jumped 52 percent between 2004 and 2008, from 1.2 million to 1.9 million Statistical Brief # 109, Medication-related Adverse Outcomes in US Hospitals and Emergency Departments, 2008 explains that, while about 60 percent of these injuries were from specific medications, including antibiotics, hormones, painkillers, and antidepressants, about 40 percent were from unspecified medications.

 

·         The importance of older patients:  In 2008, more than one in five patients in US hospitals were born before 1933, and treating patients age 75 and older cost hospitals more than $92 billion, compared with $65 billion for patients ages 65 to 74.  These findings are based on data described in Statistical Brief #103, Hospital Utilization among Oldest Adults, 2008.  The report uses data from the 2008 Nationwide Inpatient Sample, a database of hospital inpatient stays in all short-term, nonfederal hospitals.  The data are drawn from hospitals that comprise 95 percent of all discharges in the United States and include patients, regardless of insurance type, as well as the uninsured.

 

·         Growth in Medicaid patient hospital admissions outpace those for privately insured patients:  Hospital admissions of patients covered by Medicaid jumped by 30 percent between 1997 and 2008, compared to a 5 percent growth in those of patients with private health insurance. Statistical Brief #104, Medicaid Hospitalizations, 2008 also describes how, over the time period, average cost for a Medicaid patient stay rose 11 percent, far less than the 34 percent cost increase for privately insured stays and the 26 percent increase for uninsured patients (adjusted for inflation).

 

·         Over 3.4 million emergency room visits due to back pain:  An average of 9,400 emergency room visits a day in the US were related to back-problems in 2008, according to Statistical Brief #105, Emergency Department Visits and Inpatient Stays Related to Back Problems, 2008.  In the same year, there were over 663,000 inpatient stays (a daily average of nearly 1,820 hospitalizations) principally for back surgery or other back disorder treatments.

 

·         Hospitalization for chronic lung disease depends on patient income, place of residence:  Statistical Brief # 106, Overview of Hospitalizations among Patients with COPD, 2008. Chronic obstructive pulmonary disease is an incurable and often fatal disease that includes bronchitis, emphysema or both. Nearly one out of every five patients aged 40 years and older hospitalized in the US has a diagnosis of COPD, either as the main reason for the hospital stay or as a contributing illness. Low-income Americans with COPD and those who lived in rural areas or in the South or Midwest in 2008 had the highest rates of hospitalization for symptoms of the disease.

 

·         Online tutorial series:  HCUP has developed a series of free, interactive courses to provide data users with information about HCUP data and tools, and training on technical methods for conducting research with HCUP data. The online courses are modular, so you can either move through an entire course, or access sections that interest you the most.  Two new modules include the following: 

 

o    The all-new Calculating Standard Errors tutorial is designed to help users determine the precision of the estimates they produce from the HCUP nationwide databases. Users will learn two methods for calculating standard errors for estimates produced from the HCUP nationwide databases.

 

o     The newly-revised HCUP Overview Course is a helpful introduction to HCUP for new users. The original course has been updated to include the latest additions to the HCUP family of databases and tools, including the Nationwide Emergency Department Sample.

GRASS ROOTS

I was standing on a mountainside in rural Makwanpur Province, the grass and earth of Nepal pressing into my bare feet, when the words from the poem The Hollow Men crossed my mind:  "Between the idea and the reality falls the shadow.”  In T.S. Eliot's poem, the idea and the reality are disconnected and lost to one another, but there I was in the brilliant sunshine, the idea and the reality perfectly connected, so what had fallen between the two?  

 

I thought back to my Public Health Program Planning class at New York Medical College during the winter of 2009, when my colleague, Sumitra Gurung, MBBS, from Pokhara, Nepal, and I received our assignment:  analyze an article in Lancet about the MIRA Project.  Sumitra and I laughed at our good fortune to have drawn by sheer luck a project located in her home country, which also embodied my heart's desire for a trip around the world, even though the assignment only required us to read the article, do some library research, and present a Power Point right where we were sitting in Valhalla, N.Y.  But there the idea was planted. 

 

MIRA stands for Mother Infant Research Activities, but Mira was also a Hindu poet (1499-1546) who devoted herself to the God Krishna and was considered the incarnation of his wife Radha (more about Radha later!)  MIRA was founded in 1992 by Dr. Anthony Costello of the Centre for International Health and Development in London and Dr. Dharma Manandhar, working with a group of leading perinatologists in Nepal to conduct research studies to reduce maternal and infant mortality. The Lancet article, "The MIRA Cluster-Randomized Controlled Trial:  A Scientific Approach to Program Planning to Reduce Infant Mortality in Developing Countries," specifically focused on women's empowerment groups using game cards to teach about safe birthing practices.  The research question was, "Can a community-based participatory intervention significantly reduce neonatal mortality?"  The research design was a rigorous randomized controlled trial utilizing Village Development Committees in 12 pairs, matching intervention groups with non-intervention groups.  It included a cohort of almost 30,000 women of reproductive age.  While both pairs received programs that strengthened health care delivery systems, the intervention groups had a local woman facilitator (not a health worker) who organized the participatory groups.  After two years, the research outcomes showed a 30 percent reduction in infant mortality, with the maternal mortality rate at 341/100,000 in the control groups and 69/100,000 in the intervention groups.  Rather than building hospitals or placing a doctor in every community, the intervention was all about community women empowering other women, all advocating for each other and changing health behaviors, instilling a sense of ownership in the process.  Sumitra and I got an A on our project, and I fell in love with MIRA. 

 

My interest in maternal mortality reduction and women's empowerment projects became more and more focused on home births in communities where there was little or no access to health care facilities for deliveries.  I delved into women's empowerment, social design and micro-financing, interviewed leadership from the White Ribbon Alliance, Averting Maternal Death and Disability, and the Birthing Kits Foundation, and poured over my literature searches.  But always the names of MIRA and its leadership and founders kept coming up, making my heart beat faster.  They became the rock stars of the cloistered little world that centered around my computer as I researched and wrote, sometimes from 7:00 a.m. to late at night, weekdays, Saturdays, Sundays and holidays.  In April, The Lancet published the Hogan study that documented the progress that women's education, poverty reduction, and assistance of birthing attendants had made in the reduction of maternal mortality in the past 20 years.  By Memorial Day I had submitted my thesis and graduated. 

 

Along the way, I bought a map of Nepal, in order to locate Makwanpur Province, Kathmandu, the Himalayas, Sumitra's home in Pokhara at the foot of the Annapurnas on the beautiful clear lake, and the winding mountain road that led to Hetauda, the location of MIRA's office.   

 

There was so much that fell between the idea and the reality:  the research, the map, Sumitra's invitation to visit her sister-in-law Radha, who became my Nepali sister, cruising Expedia for the best airfares, the vaccinations and medications, packing, not only clothes but cookies, baby pajamas, T-shirts, brochures about my child advocacy center, notebooks, flashdrives.  And on November 21, 2010, I stepped onto a plane pointed toward Delhi, India and then another that flew past the Himalayas and landed in Kathmandu.  After six days of warm sunshine, temples, monkeys, cows, hiking, wandering the streets of Thamel, observing and grieving over cremations by the river, my friend Keith's wonderful driver, Mehendra, drove me over the mountains to Hetauda, on that winding road I had traced so often with my finger. 

 

So there I was on the mountainside in rural Makwanpur, after having met with the MIRA staff, and driving deep into the Nepali countryside.  There were women, dressed in colorful saris and kurtas, and their beautiful children walking along a dirt road to a meeting place where we would all sit together on the grass to discuss the needs of their community, the stretcher program, the access to the local health center, the safe birthing methods they shared with their neighbors.  We were far away from my home in Piermont, from Valhalla, N.Y., from London, from the pages in the Lancet that documented the success of MIRA and the numbers of lives saved.  There in the grass among those women, animatedly talking to each other in the bright sunshine, was the reality, and not a shadow in sight.

 

Thanks once again to Karel R. Amaranth, MPH, MA, for her insightful stories of a life in public health.