The National Institutes of Health’s Centers for Disease Control and Prevention is charged with the mission of reducing disease not only in the United States, but also across the globe. This includes prevention and education on every aspect of public health. Thomas Frieden, who heads up the CDC, recently laid out several areas he thinks require special attention in 2014:
1. Increasing human papilloma virus (HPV) vaccinations — This vaccine prevents the transmission of viral strains that cause cancer, especially of the cervix.
2. Fighting the problem of antibiotic resistance — Germs keep adapting to the antibiotics used to treat them. The problem is accelerated by their indiscriminate use. If we are unable to stay one step ahead, there will be more infections that cannot be treated by existing medicines.
3. Ending polio once and for all — This disease is on the run, but until it is eradicated, it can always come roaring back.
4. Defending against health threats that originate elsewhere on the globe — We can’t wait until new health threats come to our shores. Global collaboration is essential. Examples include the SARS, H1N1 and H7N9 viruses.
5. Reducing deaths attributable to prescription painkiller abuse and overdose — There is widespread agreement that the management of chronic pain and use of prescription painkillers is suboptimal. Several years ago a medical director from one of the local insurance companies requested that Manakai o Malama conduct a pilot study and provide a comprehensive integrative pain program for the highest users. He complained that there were two types of providers in the state when it came to pain management: those who never met an opiate they didn’t want to prescribe and those who simply did not want to go there. As a result, many patients are undertreated while others are overmedicated and not appropriately worked up.
Pain is one of the areas that is difficult to treat by one provider alone and is more conducive to a multidisciplinary, integrative process. It is unlike a broken bone that can be mended with hardware, or an infection that can be treated by an antibiotic once the sensitivity is known. Skillful treatment of chronic pain requires a comprehensive work-up with appropriate diagnostic testing. It also requires an understanding of psychosocial issues, including family and work and an assessment of activities of daily living. Effective outcomes should be measured by quality of life, function and use of resources. Drugs with the potential for addiction should be used only after evaluating and giving priority to other means of treatment.
The Center for Disease Control should also consider these:
1. Direct assessment of heart disease — Patients are routinely evaluated for high blood pressure, high cholesterol, diabetes, smoking habits, weight and physical activity, but these are only risk factors for disease and do not provide evidence of disease itself. The only way of directly imaging the coronary arteries is with an angiogram that is both expensive and carries some risk. Ultra-Fast CTs have been used to measure calcium levels inside the coronaries, but they cannot definitively measure plaque burden and the radiation risk is in question. A new, safe and inexpensive means of directly imaging plaque burden could save many lives and dollars.
2. Improved treatment and outreach for mental health diseases including dementia — The anguish of those with undertreated mental health disorders is pervasive. It affects not only the patients, but also their families and draws untold hours of caretaker time. Society also pays when the mentally ill are homeless or locked in prison for lack of treatment.
3. Identify social solutions to inappropriate emergency department use — One of the biggest cost sinks in health care today is inappropriate emergency visits and hospital readmissions. Obamacare, Accountable Care Organizations and Patient Centered Medical Homes will make an impact, but it is beyond the scope of health care to fully solve the problem. Hawaii’s emergency physicians are outstanding specialists, but they did not sign up for what they are being asked to do. More political will and multidimensional resources outside of health care must be brought to bear to solve this systemic problem.
4. Leverage predictive medicine to prevent and detect disease — One of the benefits of mapping the human genome is that we can now evaluate genetic material and gain insights into which individuals may be at increased risk for certain diseases. If used skillfully, it can be possible for certain individuals to reduce health risks and identify treatable disease early.
5. Refine health care’s relationship to death and dying — While hospice and palliative care services are highly developed and accessible, as a society we are still learning to have a conversation about death and dying. Advance directives and end-of-life services still need to come to the fore. More can be done to facilitate a graceful death consistent with each person’s wishes.
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Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
