The Role of Medical Technology in the Rising Costs of Insurance Premiums and Healthcare in America

Technological discovery, innovation, and advancement continue to profoundly impact theinnovation-scorecard-landing-page American patient and the economics of American healthcare.  History teaches us that the overall cost of healthcare increases proportionally with the climbing costs of medical technology and the increased training, marketing, and regulatory processes it routinely postulates.  According to The Henry J. Kaiser Family Foundation (2007), “medical technology can be used to refer to the procedures, equipment, and processes by which medical care is delivered.”  This broad spectrum yields an inevitable linkage to virtually every form of medical diagnostic, testing, and procedure.  It can therefore be reasonably inferred that medical technology plays a critical role in the overall cost of healthcare and, consequently, the price of insurance premiums.

Recent data depicts a magnanimous increase in per capita health care spending which rose from $356 in 1970 to $6,697 in 2005, with an expected projection of $12,320 in 2015 (Kaiser, 2007).  With changes of this magnitude, some contend that new medical technological discoveries may be attributed to “about one-half or more of real long-term spending growth” (Kaiser, 2007).  Consequently, the Medicare program “is projected to go bankrupt in nine years”, and overall health care cost is expected to increase from its present $2.1 trillion annually to $4 trillion in 10 years” (Callahan, 2008).  As the reigning pioneer of medical innovation and products development, it is it is imperative that the United States deliver the best technology to its patients without compromising quality or access to care.  Only then can the benefits in public health, the economy, and job productivity be realized.

CT-ScanThe prodigious impact of medical technology necessitates an examination of three major catalysts: CT imaging, drugs for heart disease, and hip replacements for their contributions to healthcare spending and its impact on the overall quality of life for American patients.  The overutilization of diagnostic technologies is highly contributory to excessive healthcare spending.  A versatile component of comprehensive medical treatment, they fulfill screening and assessment needs for a multitude of traumatic injuries and diseases across large populations.  The long term cost benefits of screening for asymptomatic, low-risk individuals comes at an initial high cost.  While early detection is an integral part of preventative medicine, overly aggressive screening practices by clinicians can overburden the patient and the healthcare system.  These financial implications are compounded by the increased sensitivity and decreased specificity of new diagnostic technologies that lead to further diagnostic testing (Mohr et. al., 2001).

According to Mohr et. al, spending can be reduced in the short term when the use of diagnostic technologies are “restricted to an appropriately selected population” (2001).  Their use amongst moderate to high risk individuals would be conducive to responsible screening and healthcare spending.

Beta-BlockersRecent advances in heart disease have played major roles in the treatment and prevention of America’s deadliest disease and for heart attack, the leading cause of death (Kaiser 2007).  This certainly did not come without a monumental growth in cost.  According to Cutler and McClellan, “the average Medicare spending per heart attack patient increased by $9,600, from $12,100 in 1984 to $21,700 in 1998” (Federal Reserve Bank of San Francisco FRBSF, 2002).  The 1990s were a historically significant period due to the advent of clot-inhibiting pharmaceuticals, angioplasty for revascularization, and stents to open blood vessels (Kaiser 2007).  The 2000s introduced diagnostic advances to further prevent the prevalence of myocardial infarction as well as new pharmaceutical treatments for its management.

ACE inhibitors, beta-blockers, and statins were employed for the long-term treatment of heart attack victims and for high-risk patients (Kaiser, 2007).  Rehabilitative cardiac programs also became more preventative in nature while defibrillators became increasingly accessible in public places and more utilized in patients with abnormal heart rhythms (Kaiser, 2007).

These advances proved to be effective as “the overall mortality rate from heart attacks felluntitled by almost half, from 345.2 to 186.0 per 100,000 persons from 1980-2000” (Kaiser, 2007).  While the US has higher rates of bypass and angioplasty procedures when compared to other countries, the difference in mortality rates amongst heart attack patients is considerably less (FRBSF, 2002).  This can be attributed to possible incentives awarded to hospitals and physicians by traditional private insurance companies to provide open bypass units (FRBSF, 2002).  This practice would not be possible in the managed health care systems offered in other countries.  An increase in considerably less expensive, non-invasive, preventative approaches is therefore necessary to improve the overall quality, productivity, and expectancy of life of heart attack patients.  Attempts to counteract the detrimental effects of excessive healthcare spending in America can commence by reducing the delivery of unnecessary treatments, surgical procedures, and care.

The growing demand for hip replacement procedures is an additional economic burden toWMT_BFH both Medicare and the American healthcare system.  According to the American Academy of Orthopaedic Surgeons, there are nearly 200,000 hip replacements completed in the U.S. each year with a total surgery cost ranging between $8,474 to $20,874 with a mean of $14,510 (Dolan & Robinson, 2010).  It is projected that this demand will more than double by 2030 which can be attributed to the epidemic of obesity, an aging population, and patients who desire to increase the quality and productivity of their lives (Dolan & Robinson, 2010).  A new market equilibrium will then be achieved with increases in both the market price of implants and the demand.  The hospital would ultimately need to increase its supply to satisfy market demands impacted by a growth in population and an increase in the number of the elderly.        

The high cost of hip implantation devices is due in part to individual clinician preferences and lack of regard for economic savvy and excessive healthcare spending.  A limited use of multiple manufacturers dictates a market characterized by hiHip-articleLargegh demands with low competitiveness.  According to Dolan & Robinson, the cost of one hip implantation at 45 surveyed California hospitals ranged from $3,645 to $11,308, with an average of $6,531 (2010).  This is a prime example of the occurrence of market monopolization and the lack of competitiveness amongst vendors securing hospital contracts.  In the event the surgical staff is forced to switch to an alternate manufacturer, additional labor and administrative costs will apply (Dolan & Robinson, 2010).  Also, the fixed amounts (DRGs) paid to hospitals by Medicare simply cannot keep up with the rising costs of implantation devices as they comprise a large portion of insurance reimbursement.  A reduction in hospital reimbursements will cause significant implications on the hospital including potential detrimental revenue loss.  The hospital will need to charge more for services rendered and aggressively negotiate commercial payments with health insurance plans.  The overall reduction in hip implantation devices and procedures therefore necessitates a coordinated effort between institutions, surgical staff, and vendors so as to increase the numbers of manufacturers, market competitiveness and ultimately decrease the cost of implantation devices.

imagesCATT76ITA key consideration in the overall cost of medical devices is the federal government’s regulatory standards and complex approval process.  Industry executives and investors are now concerned that increased FDA involvement is compromising the American economy and the potential for developing new innovation (Pollack, 2011).  According to a report by PricewaterhouseCoopers, the US reigns as the world leader in medical device innovation and is home to “some 32 of the 46 medical technology companies with annual sales exceeding $1 billion” (Pollack, 2011).  This lead is expected to decline due to the increased preference for the European market which offers a more rapid approval process.  The process by which products can enter the market in the U.S. has become increasingly time-consuming, exorbitantly expensive, and risky.  “Some estimates put the total cost of developing a novel drug at more than $800 million” (McClellan, 2003).  In Europe, a device must be declared safe before distribution.  Approval in the US is more stringent; however, as a device must be proven to be both safe and effective for the treatment of a disease or condition through multiple clinical trials.  The approval process is handled by a third party in Europe while the US requires the involvement of a central agency such as the FDA.

Although the FDA has recently agreed to employ a more “consistent” and predictable review process,” safety will not be compromised (Pollack 2011).  Dr. Jeffrey Shuren, the director of the FDA’s medical device division affirms the responsibility to exert caution by stating, “We don’t use our people as guinea pigs in the US” (Pollack, 2011).  As devices become more advanced, the FDA must maintain its duty to safeguard the American people without depriving the best technology available.  It must also prevent the outsourcing of jobs to European countries and the decline of the economy.  According to the Lewin Group, “the medical industry employed 422,778 workers nationwide, paid $24.6 billion in earnings, and shipped $135.9 billion worth of products” (Pollack, 2011).  Accordingly, the medical device industry plays a critical role in supporting the infrastructure of the American economy and those employed within it.  It is imperative that the FDA find an appropriate balance between ensuring safety and job security to achieve the most favorable health and economical outcomes.

Improvement in healthcare spending is perhaps best exemplified by the utilization of ehrelectronic health records.  This medical technology contributes to practice organization and efficiency made possible with the storage and electronic delivery of health information.  It also facilitates doctor-patient communication by increasing patient awareness and maintaining comprehensive, organized medical histories.  The Geisinger Model for Healthcare for Medicare and Medicaid beneficiaries advocates the cost-effectiveness and versatility of this assistive technology.  Its use allows non-Geisinger physicians and their staff to have the ability to access their electronic health records through a portal that allows electronic communication between Geisinger specialists and sub-specialists.  This integrated system is an effective prophylaxis for unnecessary hospital visits and the prevention of illness and disease (Davis, 2010).  Electronic records will promote coordinated care amongst multiple providers, drive down administrative costs, and ultimately reduce mortality across broad populations.  Additionally, the minimization of paper usage will prevent the loss or damage of the record, reduce administrative costs, and conserve the Earth’s natural resources.  As in the use of any technology, the short term expenses will initially be elevated for the practice or large institution; however, the long term benefits in conservation and efficiency will far exceed the initial investment.

health-care-costs-300x199The impact of medical technology on the recent exuberance of healthcare spending cannot be evaluated as a whole, but rather must be examined on case by case basis.  Excessive spending is generally dependent on several factors.  Technologies used in conjunction with subsequent forms of treatment are a major cause, especially when it requires the use of additional health care services such as extended hospital stays and/or physician office visits (Kaiser, 2007). A second factor is the particular technology’s frequency of use and the size of the population it covers.  If the diagnostic does not facilitate methods of treatment, the burden of unnecessary testing and spending emerges.  New innovations in diagnostics can prevent overutilization by promoting more targeted treatments (Kaiser, 2007).  This can foster a more rapid rate of healing and prevent clinical complications.  The capacity for preventative care to extend life expectancy, and improve the quality of life is difficult to place a price tag on.  The true value of medical technology is best perceived by the individual impacted by it.

imagesCABU8Q6FThe fragmentation of private and public healthcare in America poses the continuing challenge of controlling costs and averting inordinate expenditures that result from the increased emphasis on highly specialized procedures and care.  The economical impact is exacerbated by the uninsured that accumulate devastating medical debts through the repetitive utilization of hospitals and diagnostics when receiving emergent care.  Any limit placed on the delivery of medical technology would be unprecedented as medical technology plays such a definitive role in American medicine.  Still, there is much debate and uncertainty over determining a possible solution.  According to Callahan (2008), “40% of Americans believe that medical technology can always save their lives.” A similar reverence for technology is less prevalent in Europe where managed care is more effective in controlling excessive healthcare expenditures.

A possible, promising solution is the introduction of Accountable Care Organizations.   The untitledphysician-led system would places a strict emphasis on evidence-based care and the application of comparative effectiveness research to determine the efficacy of drugs, technology, and procedures.  This would result in a reduction in premiums, increasing affordability and the accountability of care.  Incentives for ACO providers aimed towards avoiding unnecessary tests and procedures require collaborated efforts for achieving illness prevention and medical cost reduction.  A potential downside to ACOs; however, is the potential for monopolistic activity amongst insurers due to potential hospital mergers and provider consolidation.  While the downsides of ACOs are worthy of ample consideration by both the consumer and economist, the potential positive implications of ACOs are monumental steps in the right direction.

medtechMonolithic advancements in the areas of cancer and heart disease, proteomics, nanotechnology, and information technology have been made in America.  In the dawn of healthcare reform; however, attempts must now be made to increase the efficient use of medical technology by both doctors and patients, reduce the outrageous costs and ambivalence of developing new technology, and eliminate device and procedure cost disparities across geographical regions.  By trimming unnecessary, unproductive treatments, championing preventative medicine and the acquisition of more primary care physicians, the affordability of healthcare can be more attainable for all Americans.

References

Callahan, Daniel. (2008). Health care costs and medical technology. In M. Crowley (Ed.), From birth to death and bench to clinic: The Hastings Center bioethics briefing book for journalists, policymakers, and campaigns (pp. 79-82). Garrison, NY:  The Hastings   Center. Retrieved April 21, 2011, from http://www.thehastingscenter.org/Publications/BriefingBook/Detail.aspx?id=2178

Davis, K. (2010). A New Era in American Health Care: Realizing the Potential of Reform. The Commonwealth Fund, 1419. Retrieved March 15, 2011, from http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2010/Jun/A-New-Era-in-American-Health-Care.aspx

E.L. Dolan & J.C. Robinson. (2010). Implantable medical devices for hip replacement surgery: Economic implications for California hospitals. Berkeley Center for Health Technology. Retrieved April 21. 2011, from http://www.berkeleyhealthtech.org/wp- \content/uploads/2010/05/issue-brief_May2010.pdf

Federal Reserve Bank of San Francisco. (2002). Productivity in heart attack treatments. Retrieved April 21, 2011, from http://www.frbsf.org/publications/economics/letter/2002/el2002-20.html

The Henry J. Kaiser Family Foundation. How Changes in Medical Technology Affect Health Care Costs. (2007). Retrieved April 21, 2011, from http://www.kff.org/insurance/snapshot/chcm030807oth.cfm://energycommerce.house.gov/news/PRArticle.aspx?NewsID=8244

McClellan, M.B. Technology and Innovation: Their Effects on Cost Growth of Healthcare. Statement before the Joint Economic Committee, July 9, 2003. Retrieved April 21, 2011, from http://www.fda.gov/NewsEvents/Testimony/ucm161029.htm

Mohr, P., Mueller, C., Neumann, P., Franco, S., Milet, M., & Wilensky G. (2001, February 28). The Impact of Medical Technology on Future Health Care Costs. Project Hope: Center for Health Affairs. Retrieved April 21, 2011, from http://cpd.ogi.edu/Seminars05/MoseleyCostsFutureHCTech.pdf

Pollack, A. (2011, February 9). Medical treatment, out of reach. The New York Times. Retrieved April 20, 2011, from http://www.nytimes.com/2011/0210/business/10device.htm

 

 

 

Aquarion Water Company: A Look into the Challenges Facing Connecticut’s Largest Water Utility

The Aquarion Water Company (AWC) is Connecticut’s largest water utility (AWC, 2011).  Headquartered in Bridgeport, the company serves more than 580,000 people in 39 cities/towns throughout Connecticut as well as five in Massachusetts and three in New Hampshire (AWC, 2011).  Aquarion’s presence in the public water supply business is impressive.  Established in 1857, it remains “the largest investor-owned water utility in New England and among the seven largest in the U.S” (AWC, 2011).  Despite exhaustive research efforts, Aquarion Water Company’s “Capital Improvement Plan” could not be located.  This may be attributed to the company’s broad scope of operations which involves an abundance of communities across several states.  Detailed information regarding local infrastructure and improvement projects; however, is readily available.  This includes upgrades in various parts of Connecticut including Greenwich, Stoningham/Groton, and Brookfield.  These provide adequate insight into the company’s broad scope of impact in addition to investment and planning challenges posed by infrastructure improvements of the past, present, and future.

While Aquarion’s undergoing capital improvements are colossal and costly, they are absolutely necessary.  Given the scope of service and the amount of infrastructure and equipment involved, the company must satisfy its responsibility to provide a magnitude of customers with an ample supply of clean, potable water.  In consideration of the company’s aging infrastructure, the urgency for capital improvements is a matter of both public health and safety. As such, the replacement of aging infrastructure continues to be an integral part of the company’s capital project work.   Infrastructure improvements and expenditures are extensive, due in part by Aquarion’s recent growth via the acquisition of smaller water utility companies.

Acquisition expenditures resulting from the rehabilitation of a former company’s infrastructure assets are magnanimous.  Since 2008, Aquarion has invested $25 million to upgrade the Putnam Filter Plant in Greenwich, CT.  Following its purchase of Connecticut American Water Company in 2002, Aquarion immediately began prioritizing capital improvements to address critical infrastructure deficiencies.  The urgency was justified as the plant had not undergone any major improvements since the 1950s (AWC, 2011).   From 2002 to 2008, Aquarion invested $6 million to the Putnam facility, the town’s largest source of water, in order to rehabilitate filters, install stand-by power, and upgrade electrical service to ensure a supply of 20 million gallons of water a day for consumption and fire safety (AWC, 2008).  Improvements also included the replacement of a failing 1920s-era treatment clearwell to meet supply demands and comply with health department standards (AWC, 2008).

Aquarion’s responsibilities recently extended to Brookfield’s Greenridge water system.  On November 2, 2011, Connecticut’s Public Utility Regulatory Authority and the Department of Public Health approved Aquarion’s proposal to deliver uncontaminated water to the Greenridge district, whose previous supplier had filed to cease operations.  According to decision drafted by the Connecticut’s Department of Environmental Energy and Protection (DEEP), Aquarion’s estimated total cost for the proposed water main and associated improvements totaled $3.25 million including $564,000 in improvements made by United Water, the previous supplier (DEEP, 2011).  Aquarion also continues to upgrade its infrastructure in the Stonington/Groton, CT area where it began relining the 21 year old, 8-inch water mains at Lords Point this past August (AWC, 2011).  Aquarion’s capital improvements reflect its self-proclaimed commitment to ensuring the quality of its water systems and delivering uninterrupted service.

All across America, drinking water infrastructure is nearing or exceeding its life expectancy and systems are failing.  Connecticut is certainly no exception.  According to a 2008 survey conducted by the American Society of Civil Engineers (ASCE), “Connecticut’s drinking water infrastructure needs an investment of $653 million over the next 20 years” (2010).  Accordingly, Aquarion’s capital improvement spending is expected to considerably increase over the next few years to achieve the timely replacement of problematic water mains, flow-management valves, fire hydrants, meters and leak-detection equipment (AWC, 2011).  Aquarion’s spending has been recently amplified and accelerated due to the acquisition of smaller, less capable utilities starved of the funding necessary to manage, maintain, and replace their aging water infrastructure.  This poses new challenges as Aquarion must familiarize itself with the water main condition so as to facilitate leak detection and prevent breakage.

Buried infrastructure is especially vulnerable as maintenance and repairs are substantially expensive and disruptive.  The closure of a major intersection and a street lane in Bridgeport caused by a water main break on November 17, 2011 is one such example.  According to the Connecticut Post, “the intersection of State Street and Broad Street has experienced three water leaks in the past six weeks,” a clear indication of the challenges posed by the city’s aging infrastructure, comprised of pipes that are 90 years old (2011).  Bruce Silverstone, a company spokesman for Aquarion Water Company, commented:”It’s difficult, a very difficult area because of all the infrastructure that’s underground, there.  It is an unusual situation. When these breaks take place, we must replace them on kind of a piece-meal basis” (Craig, 2011). Since budget restrictions prevent total replacement, the company is combating problems as they arise. Experts argue; however, that “the ‘fix-on failure’ approach is no longer working” (Kinge, 2009).

Aquarion also faces water supply challenges posed by stream flow regulations required to be developed by Section 26-141b of the General Statutes.  Passed in 2005 by the Connecticut General Assembly, the act requires the DEEP to collaborate with the Department of Public Health and stakeholders to “update standards for maintaining minimum flows in rivers and streams” so as to achieve a balance in water usage that respects river and stream ecology, wildlife, and recreation while providing for public health and safety, industry, agriculture, water supply, and other lawful water uses (DEEP, 2011).  While Aquarion recognizes its responsibility for “conservation and natural resource management,” George Logan, its Director of Capital Planning, testified that the proposed regulations “did not adequately provide for public water supply” (Testimony, n.d.).  According to Logan, “more than nine million gallons per day would have been lost, approximately 10% of our total water supply” (Testimony, n.d.).  Company costs would have also been markedly affected, requiring approximately $100 million to modify its facilities, an investment equivalent to 3 years of total capital spending (Testimony, n.d.).  This would divert monetary allocations from necessary infrastructure improvement.  Logan warns that that the investment “would result in an incremental rate increase of approximately 10%, at a time when personal and municipal budgets can least afford to pay it” (Testimony, n.d.).  Added to a lack of infrastructure funding is the elevated price of electricity as Connecticut has the second highest electric rates in the country (McCarthy, 2008).

To finance its capital investments, Aquarion initiated a customer surcharge in April of 2009 which has steadily increased since its inception (AWC, 2011).  The surcharge bill, referred to as Water Infrastructure and Conservation Adjustment (WICA), was approved in 2007 by the Connecticut Legislature to help fund the timely replacement of water distribution pipes and related infrastructure that have either reached the end of their useful life or threaten water quality or service (AWC, 2011).  As of July, 2011, the current WICA surcharge is 0.32% (AWC, 2011).  The company recently applied for a surcharge increase to 0.35% which will take effect on April 1, 2011, if approved (AWC, 2011).  The WICA is subject to change throughout the year pending infrastructure improvements and approval by Connecticut’s Public Utilities Regulatory Authority (AWC, 2011).

In an interview conducted by Global Water Intelligence (GWI), Frank Firlotte, Aquarion’s CEO, justifies the rate increases, attributing them to the company’s rising opex.  According to Firlotte, an excess of $100 million has been invested in Connecticut alone with 40% of the hike related to capital investment, another 40% to escalating operating expenditures, and the remainder to falling volumetric sales (GWI, 2010).  Since Aquarion currently operates on the basis of a 45/55 debt to equity ratio and a Return on Equity (ROE) of approximately 10%, the utility is able to handle additional debt to fund investment in the rate base (GWI, 2010).  Although Firlotte is hopeful that the Connecticut Department of Utility Control will award Aquarion an ROE above 9.75% in favor of his company’s “efficiency,” “service delivery,” and “operational metrics,” he acknowledges that the system of regulation is not based on performance as it is in other countries (GWI, 2010).

The former director of Yorkshire Water in England, Firlotte is frustrated by the reluctance of local government to relinquish water provisions (GWI, 2010).  As the company sets its sites on continued expansion, it must gain appropriate regulatory approval and acquire adequate infrastructure improvement capital.  In the era of failing water infrastructure, Aquarion is destined to encounter an increasingly challenging process.  As a nation that dedicates only 2.4% of its GDP to infrastructure, a continued lack of financial commitment will further compromise capital improvements, the economy, the water supply, and the public health of a bustling American population (ASCE, 2011).  Comprehensive assessment, planning, and funding over time are the most prudent solutions to this pressing issue.

 References

American Society of Civil Engineers (ASCE). (2010). Report Card for America’s Infrastructure. (2010). Retrieved from http://www.infrastructurereportcard.org/state-page/connecticut

Aquarian Water Company (AWC). (2008). Aquarion Water Co. to invest $25 million in Greenwich filter plant to improve aging structures, water quality, public health, and safety. (2008). [Press release]. Retrieved from http://www.aquarion.com/pdfs/Release%20-%20Putnam%20Press%20Release%20REVISED.pdf

Aquarion Water Company (AWC) (2011). Website. Retrieved from http://www.aquarion.com

Craig, Anne. (2011, November 17). Bridgeport water main breaks for third time. Connecticut Post. Retrieved from http://www.ctpost.com/news/article/Bridgeport-water-main-breaks-for-third-time-2274303.php

Kinge, Hamida. (2009). What’s on tap: America’s failing water infrastructure. Next American City Magazine, 24:32-35. Retrieved from http://www.metcalfinstitute.org/dl/whats_on_tap.pdf

McCarthy, K.E. (2008, August 5). Office of Legislative Research Report: Factors behind Connecticut’s high electric rates.  Retrieved from http://www.cga.ct.gov/2008/rpt/2008-R-0452.htm

Logan, G.S. (n.d.) Testimony regarding SB-1020, an act concerning water resources and economic development. Retrieved November 25 from http://www.cga.ct.gov/2011/CEdata/Tmy/2011SB-01020-R000224-Aquarion%20Water%20Company-TMY.PDF

n.a. (2010, August). Aquarion looks for double digit growth. Global Water Intelligence, 11(8). Retrieved from http://www.globalwaterintel.com/archive/11/8/general/aquarion-looks-for-double-digit-growth.html

State of Connecticut:  Department of Energy and Environmental Protection (DEEP). (2007). Proposed stream flow regulations. Retrieved from http://newtown.patch.com/articles/draft-greenridge-decision-favors-aquarion

State of Connecticut: Department of Energy and Environmental Protection (DEEP): Public Utilities Regulatory Authority (PURA). (2011, October 14). Joint investigation of

PURA and DPH regarding Greenridge tax district’s request to cease operations as a public water supply company – Improvement cost review (Docket No. 07-04-11RE01). New Britain, CT. Retrieved from http://www.brookfieldct.gov/docs-forms/announcements/Greenridge%20Draft%20Decision%20101411.htm

 

 

Should We Regulate the Usage of Mobile Sources of Air Pollution?

While the idea of regulating the amount of usage of mobile sources of air pollution seems promising, it is very unrealistic.  Americans take great pride in their cars and restricting their usage would not be well received.  Also, regulations would also be extremely difficult to enforce.  How are we to enforce the usage of leaf blowers?  Do we start placing usage meters on mobile equipment?  Do we establish a municipal police force solely dedicated to mobile source pollution?  What would this do to our taxes?  What rights would this type of “force” have to enter the property of one’s home without the appropriate warrant?  This would be an overly-bureaucratic government!

We are a mobile populace who relies heavily on our cars and other forms of mobile transportation to get us to a wide variety of environments from the workplace to vacation destinations.  Limiting their use would inflict further wound to a suffering American economy. Now let me be clear, I am not advocating a public free-for-all.  Instead, I propose that we regulate the vehicles and equipment themselves.

Some of you may be thinking, “What about heavily polluted areas?!”  To this I must ask, “How many leaf blowers have you seen being operated in New York City?”  Also, many people do not own cars because there isn’t a compelling need for one.  My brother is one of them.  He sold his car when he moved to Manhattan.  Of course, he always takes mine when he comes home but that is an entirely different topic!  You would also be hard-pressed to find any lawn mowers operating in the City as well.

I am sure many of you have been squeezed into a subway at one point or another.  I cannot help but wonder how much air pollution is actually prevented through use of public transportation in NYC.  My efforts to find research quantifying this has unfortunately failed.  Understandably, this is very difficult to estimate.  However, I did find that gasoline consumption in NYC is at the same rate the national average was in the 1920s (Jervey, 2006).  In fact, NYC’s dense population and low automobile dependence help make New York among the most energy efficient in all of the United States (Owens, 2004).

My point is there must be a balance achieved between usage and toxic emissions of mobile sources of air pollution which can be most efficiently achieved through pragmatic, enforceable regulations.  Examples include improving fuel economy and minimizing emissions through idling policies.  Most states have adopted the latter.  It is also up to the consumer to minimize emissions.  Driving fewer miles and purchasing more fuel efficient cars can indeed save Americans a lot of money.  With the prices of gas expected to soar this summer, these options can be advocated for their advantages to both the consumer and the environment.

Fortunately, the government is doing something to regulate mobile sources of air pollution.  The EPA finalized a rule in February 2007 to reduce hazardous air pollutants from mobile sources by limiting the content of benzene in gasoline and reducing toxic emissions from passenger vehicles and gas cans (EPA, 2012).  Since mobile sources are responsible for the majority of benzene emissions, this is a step in the right direction.  According to EPA estimations, this rule would “reduce total emissions of mobile source air toxics by 330,000 tons and VOC emissions (precursors to ozone and PM2.5) by over 1 million tons” by 2030 (EPA, 2012).  This is a considerable improvement.  The EPA also regulates emissions from highway vehicles and nonroad equipment and controls emissions of hydrocarbons, particulate matter, and nitrogen oxides to significantly reduce toxic emissions (EPA, 2012).  In addition, the EPA is currently developing programs to provide further control of emissions from nonroad gasoline engines and diesel locomotive and marine engines (EPA, 2012).  To reduce the overall risks to communities, the EPA has developed several programs including Clean School Bus USA, the Voluntary Diesel Retrofit Program, and National Clean Diesel Campaign (EPA, 2012).

We have indeed come a long way in controlling mobile sources of air pollution.  As a more informed and environmentally conscious American population continues to emerge, I predict that it will become progressively easier to address the problems of air pollution in the future.  Continued regulation of the automobile manufacturing industry will also continue to modify and adapt its cars to be more fuel efficient and less toxic to the environment.  While I think that the use of electric cars by everyone is a long way off, it is an inevitable possibility we must all are prepare for.

References

Jervey, B. (2006). The Big Green Apple: Your guide to eco-friendly living in New York City. Globe Pequot Press. ISBN 0762738359.

Owen, D. (2004, October 18). Green Manhattan: Everywhere should be more like New York. The New Yorker. http://www.newyorker.com/archive/2004/10/18/041018fa_fact_owen

U.S. Environmental Protection Agency. (2012). Mobile Source Air Toxics. Retrieved from http://www.epa.gov/oms/toxics.htm#epamsat

CONSUMERS BEWARE: The Dangers of Endocrine Disruptors (EDCs) & Pharmaceuticals in Personal Care Products

Just when you thought it was safe to drink the water, look no further than your medicine cabinet.  Concerns continue to  build over the public health impact of our water supply.

What are common chemicals/classes of EDCs?

According to the National Institute of Environmental Health Sciences (NIEHS), chemicals/classes of endocrine disruptors include “pharmaceuticals, dioxin and dioxin-like compounds, polychlorinated biphenyls, DDT and other pesticides, and plasticizers such as bisphenols (2011).”  Disturbingly, endocrine disrupting chemicals (EDCs) can be found in literally thousands of common products including plastic bottles, metal food cans, detergents, flame retardants, food, toys, cosmetics, and pesticides (NIEHS, 2011).  The broad presence of EDCs in everyday products increases the likelihood for interference with the body’s endocrine system to produce a number of adverse developmental, reproductive, neurological, and immune effects (NIEHS, 2011).  While the field of endocrine disruption is fairly new, studies are being conducted to confirm whether endocrine disruptor exposure may reduce fertility and increase the incidence of endometriosis and some cancers (NIEHS, 2011).  The future of this field will undoubtedly yield some extraordinary findings to ultimately increase the public’s awareness and impact future manufacturing processes.

How do EDCs get into receiving water bodies?

Endocrine disruptors infiltrate receiving waterways via personal, pharmaceutical, and agricultural applications.  Human activity, residues from pharmaceutical manufacturing and hospitals, illicit drugs, and veterinary drugs contribute a variety of pharmaceuticals and personal care products (PPCPS) to receiving waters in the form of prescription and OTC therapeutic drugs, veterinary medicines, fragrances, cosmetics, sun-screen products, diagnostic agents, and vitamins (EPA, 2010).  Agricultural applications also supply receiving waters with a plethora of chemicals suspected of acting as endocrine disruptors including insecticides, herbicides, fumigants and fungicides (NRDC, 1998).  Individuals supply wastewater treatment plants with PPCPs through excretion, bathing, and disposal of medications into the sewer system and trash (EPA, 2010).  Discarding unused medications and personal care products into the toilet is an irresponsible yet common practice that exacerbates the problem.  Since PPCPs do not easily dissolve or evaporate at typical temperatures and pressures, they can infiltrate soils and aquatic environments with ease (EPA, 2010).  PPCPs that are not broken down and processed by the body or degraded by the environment enter domestic sewers and remain untreated.  PPCPs also have the capacity to penetrate soil and aquatics via sewage, biosolid applications, and irrigation with reclaimed water (EPA, 2010).

Endocrine disruptors are also introduced through spray-drifts, runoff from livestock and pesticides, and leachate from municipal landfills and septic systems (Center for Biological Diversity, n.d.).  The widespread use of steroid hormones in confined animal feeding operations (CAFOs) is of particular concern for the introduction of  endogenous steroids, exogenous compounds,  pharmaceuticals, and anabolic growth promoters like trenbolone and melengestrol  into receiving waters (Kolodziej, n.d).  The potential for CAFOs to elevate the concentration of steroids in watersheds is considerably higher with the occurrence of extreme precipitation.  The presence of synthetic steroid hormones such as trenbolone, melengestrol, and zeranol, used to promote rapid livestock growth, increases when the accumulation of animal wastes is not controlled and a direct pathway for wastes to reach surface waters exists (Kolodziej, n.d.).

Why are EDCs of particular concern to regulators?

Since municipal sewage treatment plants are not equipped for the removal of PPCPs and other unregulated contaminants, the presence of endocrine disrupting chemicals (EDCs) in the watershed poses a number of public health concerns.  While the measure of health risks has yet to be quantified, growing evidence suggests that EDCs can produce adverse health effects in humans, wildlife, fish, or birds including developmental, reproductive, neural, and immune problems (EPA, 2010).  This can adversely affect fish ecology and threaten the survivability of species.  A panel of experts convened by the NIEHS and the National Toxicology Program (NTP) found ‘credible evidence’ for the effect of hormone-like chemicals on test animals’ bodily functions at levels below the ‘no effect levels’ established by traditional testing (EPA, 2010).  There is also substantial research in experimental animals and wildlife associating EDCs with reduced male fertility and number of males born, male organ defects, female reproductive diseases, and increases in mammary, ovarian, and prostate cancers (EPA, 2010).  The storage of endocrine disruptors in fat cells can also have long-term negative health consequences.  Exposures to Bisphenol A and other EDCs with estrogenic activities increase the detrimental health effects of cancer and obesity (EPA, 2010).  The transgenerational effects of EDCs is also a focus of study as NIEHS research has found that fertility defects have been passed to subsequent generations (EPA, 2010).    

With the omnipresence of Bisphenol A (BPA), Di (2-ethylhexyl) phthalate, and phytoestrogens in many common, everyday products, the simultaneous exposure to multiple EDCs elevates concerns (EPA, 2010).  As of 2007, over 100 individual PPCPs have been identified in addition to antibiotics and steroids that have been found in both environmental samples and drinking water.  Simultaneous exposure occurs through one’s diet and the medications and cosmetics used.  Studies are now focusing on the association between EDCs and resistance to antibiotic drugs as well as special scenarios involving fetal exposures (EPA, 2010).  Further studies are warranted to investigate the acute and long term effects of EDCs as it remains a pressing and highly controversial public health issue.

Considerations for regulating EDCs in wastewater and/or receiving water bodies

Prior to designing regulations, policy-makers must consider scientific uncertainties associated with EDCs and their potential health effects in animals and humans.  Stringent regulations must rely on a definitive classification system for endocrine disrupting chemicals so as to implement appropriate restrictive measures.  The regulation process necessitates further research to identify conclusive evidence to considerably minimize the controversy that surrounds this issue.  This will require the expertise of a broad variety of experienced medical scientists and environmental health specialists along with substantial research investment capital and time for further research completion.  The implementation of appropriate regulations should reflect a close collaboration between policy makers, field experts, and the public at large.

Policy makers must also consider the level of vulnerability of the population exposed to EDCs and their potential impacts when implementing regulations.  This can be based on a variety of factors including the average age, diet, occupation, and prevalence of obesity, cancers, and metabolic diseases.  Other factors include the presence of major industries within a relevant geographical area.  Infants, young children, and the elderly are special populations who exhibit increased susceptibility to EDCs due to inferior immune systems.  Special considerations must also be considered for pregnant women and individuals with immune disorders/diseases such as AIDS.  Obese individuals and people suffering from cancer are of particular concern as increased EDCs exposure can manifest or exacerbate symptoms associated with endocrine system abnormalities.  One’s occupation is also a critical factor as manual laborers face increased frequencies and durations of EDC exposure.  The presence of industries and the type of manufacturing processes and chemicals used are especially pertinent when initiating regulatory legislation to decrease the overall prevalence of EDC exposures among workers and citizens in the environment in which they live.  Regulations should therefore reflect all of these factors to minimize the overall risk to any given population.

The potential impacts on businesses should also be considered.  In a fragile American economy, the development of new restrictions would pose increased financial and administrative burdens, threatening the survivability of businesses.  The alteration of manufacturing and agricultural processes to incorporate new raw materials to eliminate or reduce the release of EDCs could pose considerable financial losses.  Similarly, provisions that necessitate wastewater treatment to improve levels of EDCs in effluent discharges or measures to decrease employee exposure could prove to be exceedingly costly.  Also, company management plans for the monitoring of EDCs would necessitate comprehensive recordkeeping and reporting, requiring additional manpower and staff.

References

Kolodziej, Edward. (n.d.) University of Nevada, Reno. Occurrence, fate, and transport of steroid hormones. Retrieved from http://www.unr.edu/cee/homepages/kolodziej/research.html

Miller, Jeff. Center for Biological Diversity. (n.d.). Endocrine disruptors. Retrieved from http://www.biologicaldiversity.org/campaigns/pesticides_reduction/endocrine_disruptors/index.html

National Institute of Environmental Health Sciences (NIEHS) (n.d.). Endocrine disruptors. Retrieved from http://nymc.mrooms.org/file.php/264/Session_15_Readings/Endocrine_Disruptors_-_intro.pdf

National Institute of Environmental Health Sciences (NIEHS) – National Institutes of Health.(2011). Endocrine disruptors. Retrieved from http://www.niehs.nih.gov/health/topics/agents/endocrine/index.cfm

National Resources Defense Council (NRDC). (1998). Endocrine disruptors. Retrieved from http://www.nrdc.org/health/effects/qendoc.asp

Developing Community Coalitions to Combat Childhood Obesity: Key Stakeholders Identified

As a professional chef, trainer, and Health Coach, combating the epidemic of childhood obesity is very near and dear to my heart.  The statistics regarding trends in childhood obesity speak volumes.  According to data from the National Health and Examination Survey (NHANES), “approximately 17% (or 12.5 million) of children and adolescents aged 2—19 years are obese” (CDC, 2011).  Shockingly, the prevalence of obesity among children and adolescents has nearly tripled since 1980 (CDC, 2011).  The American Heart Association (AHA) warns that although atherosclerotic disease does not clinically manifest until adulthood, epidemiological studies and autopsy data have indicated that “ the atherosclerotic process, as evidenced by functional and morphological changes in the heart and blood vessels, begins early in childhood” (AHA, 2011).  Since obese children are more susceptible to a myriad of diseases, including cardiovascular disease and Type 2 diabetes, this will undoubtedly increase the burden on public health in America.  This necessitates immediate interventions in communities all throughout America in both home and school environments.

A solution to the problem is certainly not easy.  As noted in the study provided, socioeconomic play a definitive role.  Nutritious foods, fitness and sports programs, exercise clothing, and equipment all require sufficient finances.  A lack of supermarkets in the community can significantly reduce adequate intakes of fresh fruits and vegetables.  Families surviving on low incomes, especially those in low, socio-economic communities may have little funding to support the continued purchase of a wide variety of healthy and organic foods.  Similarly, participation in active forms of recreational activities can intensify financial hardship amongst struggling families.  The absence of ample sidewalks as well as the presence of city pollution can deter or even prohibit exercise throughout the community.  Neighborhoods in which public parks and recreational facilities are unsafe and/or overcrowded may further limit opportunities for physical activity.  The rising prevalence of childhood obesity is also threatened by a troubled economy.  Recent budget cuts in school districts compromise funding for extracurricular activities.  Inadequacies in nutrition and physical education in provided at school place an even greater responsibility on the parent(s)/guardian(s) to imbue the foundations for healthy eating and regular physical activity in children.

Coalitions for resolving childhood obesity should implement an evidence-based approach that initiates with a review of pertinent literature on trends and statistics.  The U.S. Department of Health and Human Services and the United States Department of Agriculture are two organizations that have produced an ample amount of reliable information.  The Bogalusa Heart Study and a USDA Economic Research Service study have both attempted to link obesity to children’s diet.  Specifically, the Bogalusa Heart Study analyzed the eating patterns of children over twenty years from 1973-1994 using cross-sectional surveys given to ten year old children.  The USDA Economic Research Service Study focused on the link between fruit consumption and BMI using a cohort of children between five and eighteen years of age from 1994 to1996.  Although both failed to find a direct link between children’s diets and the premature onset of obesity, the sources provide a basis for intervention initiatives and the task at hand.

PARENTS

The identification of key stakeholders is a necessary preliminary step when developing an intervention.  Since children are the target of the intervention, it is imperative that parents be considered the most significant stakeholders.  The foundation for dietary and physical habits is framed at a young age and is developed through the learned behaviors and role modeling of parents and siblings.  Food availability and selection is almost entirely determined by the child’s parent(s)/guardian(s).  Unhealthy dietary patterns during childhood such as increased frequency and duration of meals, enormous portion sizing, and food associations with punishment and/or reward can germinate.  An emphasis on sugar-sweetened, processed, and/or high fatty foods in the home can resonate far into adulthood.  The Bogalusa Heart Study analyzed the eating patterns of children over twenty years from 1973-1994 using cross-sectional surveys given to ten year old children.  The study found that “offspring who had a parental history of diabetes were significantly more obese, irrespective of age” (Bao, Wattigney, and Berenson, 1995).

HEALTH PRACTITIONERS

Pediatricians, physician assistants, and nurses play a major role in the identification of high risk populations and the dissemination of pertinent health information to parent(s)/guardian(s).  Practitioners in the public and private sectors engaged in prevention and wellness programs and activities are also essential.  These individuals can perform the necessary screening for obesity at regular checkups in a clinical or school setting.  The school nurse is especially important as they can identify potential health risks in the school environment.  A school nurse is more accessible to a child who reports to school on a daily basis.  He or she comes in contact with school children more frequently than pediatricians at regular “check-ups.”  They can conduct invaluable medical surveillance to identify children at risk and to oversee school programs for improving physical activity and nutrition.  They can also serve as a liaison between a child’s pediatrician and his or her parents, alerting parents to risk factors including high BMIs and Waste-to-hip ratios.  As coalition members, health practitioners play critical roles in explaining, advising, and supporting parents in improving their child(ren)’s health and wellbeing.

GOVERNMENT OFFICIALS

Government officials serve as the leading agents for convening coalitions and securing the necessary funding, resources, and contacts to support the coalition.  As the Mayor of New York City, Michael Bloomberg can obtain pooled members and external resources in the form of government funding and grants.  Government officials play an integral role in obtaining State and Federal funding/assistance for making large-scale community interventions possible.  In a nation that is suffering economically, our leadership is tasked with prioritizing the needs of the community.  This is a daunting endeavor and the topic of much debate among constituents and needy populations.  Coalition members representing diverse interest groups and organizations committed to combating childhood obesity can come together to lobby important leaders of government to help resolve this pertinent issue.  They can also implement effective policies such as banning hydrogenated foods and including nutrition facts on menus.  These are powerful initiatives to promote positive change.

SCHOOL OFFICIALS

Efficacious interventions that support healthy behavior change need to focus on educating children.   Without an acceptable knowledge base, unhealthy behaviors go uncorrected and the child remains ignorant to the negative health consequences throughout development and life.   Local school and public officials and directors of community-based organizations are integral to providing an age-appropriate knowledge base and opportunities for sufficient physical activity.  School principals, teachers, and physical education instructors can collaborate to provide programs that support the identification of healthy foods, portion sizing, and obesity-related diseases.

DIRECTORS  OF COMMUNITY-BASED ORGANIZATIONS

After school programs that allow for ample amounts of exercise and recreational activities provide opportunities for fitness and social interaction as opposed to sedentary behaviors practiced in the home environment.  Fitness and youth directors at the local YMCA support various programs that motivate and inspire children to engage in healthy physical activities.  These facilities offer programs that are more accessible to children when compared to private health clubs and corporate gyms.  In a nation of “latch-key” children and busy parents, after school programs can fill the void in physical activity that is sickening our children.

VOLUNTEERS

In lower socioeconomic areas, volunteers may be necessary to bridge the gap between these programs and a lack of funding.  Volunteer leaders and paid staff can facilitate the collaborative process and coalition functioning (Glanz, et. al, 2008).  Tax incentives to these individuals can elicit further involvement.

HEALTH EDUCATORS

Health educators can provide an additional means for educating parents and guardians on the dangers of obesity in children.  They can build on the information and support provided by health practitioners and school educators to parents.  They can also advise school officials on the proper planning and implementation of appropriate educational programs by identifying the issues that are most important to guide interventions.  Health educators are equipped at identifying ways to implement behavior change with minimal resources.  They can help remove barriers attributed to a lack of finances and adequate food markets by helping parents identify healthy, affordable options.  They can also advise parents on fitness activities to involve children in the home.  Whether advising school officials or parents on the preparation of healthy foods and cooking techniques or identifying kid-friendly forms of exercise, health educators are key contributors of valuable information and resources.

Proper planning would be centered on the evaluation of needs assessment data concerning children in a particular community.   A historical understanding of the community is imperative as a successful intervention strategies build on community strengths.  This can identify community context, the characteristics that catalyze or inhibit coalition function and influence how the coalition develops such as geography, demographics, politics, social capital, and community readiness (Glanz, et.al, 2008).  The procurement of data pertaining to social indicators such as home and built environments as well as epidemiologic indicators including nutrition-related disease prevalence would facilitate assessment and planning strategies.  Behavioral risk factors involving overnourishment and lack of physical activity should be investigated along with the knowledge, attitudes, and skills necessary for improving dietary and fitness habits should also be considered.  Additionally, community needs and access to health care are important for a thorough analysis. This would improve community capacity to improve its ability to identify, mobilize, and address childhood obesity.

Structures such as formalized organizational agreements and coalition rules, roles, objectives are essential.  Objectives and goals should be clear and measurable so as to determine short and long-term health outcomes which are vital for determining program success.  Objectives should be prepared by experts with substantial experience in the area of childhood obesity.  Objectives should be specific, measurable, attainable, realistic and timely.  Each should have a reliable data source, baseline measure, and targets for improvements to be achieved over a predetermined time period.  They should focus on the reduction in prevalence of overweight/obese children, especially those younger than five years of age.  Objectives should also address the social determinants of health to eliminate health disparities. Coalition operations and processes should facilitate communication between coalition members and staff for decision making, conflict management, organization, and member engagement (Glanz, et, al 2008).  This maximizes member engagement, the extent of participation, commitment, and satisfaction of the members of the coalition to ultimately strengthen the coalition (Glanz, et. al, 2008).

An evaluation of the intervention should also be planned.  The evaluation should determine the number of children served, the time period of service, and the consistency of the intervention’s implementation.  It should also include an assessment of performance of various members of the staff.  Interventions at the community level can potentially require an evaluation of multiple individuals in various sites.  Ideally, all outcomes should be measured at all level of the causal continuum to determine the overall efficiency and effectiveness of the intervention.  Community participation including work conducted by existing community organizations as well as volunteer contributions should not be excluded.  This will provide valuable information for initiating future interventions.

References

Bao, W., Srinivasan, S.R.,Wattigney, W.A., & Berenson, G.S. (1995). The Relation of ParentalCardiovascular Disease to Risk Factors in Children and Young Adults: The Bogalusa Heart Study.  Journal of the American Heart Association, 91, 365-371. doi: 10.1161/01.CIR.91.2.365 Retrieved from http://circ.ahajournals.org/content/91/2/365.full

The Centers for Disease Control and Prevention. (2011). US obesity trends. Retrieved from http://www.cdc.gov/obesity/data/trends.html

Glanz, K., Rimer, B., & Viswanath, K. (Eds.).  (2008). Mobilizing organizations for health promotion. In, Health behavior and health education, pp. 335-361. San Francisco: Jossey-Bass.

Prabhakaran, B., de Ferranti, S.D., Cook, S., Daniels, S.R., Gidding, S.S., Hayman, L.L.,McCrindle, B.W., Mietus-Snyder, M.L., & Steinberger, J. (2011). Nontraditional risk factors and biomarkers for cardiovascular disease: Mechanistic, research, and clinical considerations for youth : A scientific statement from the American Heart Association. Journal of the American Heart Association. Retrieved from http://circ.ahajournals.org/content/123/23/2749.full.pdf+html