Dr. Victor Dzau

Considering that the Duke University Health System dominates healthcare in Durham, the community’s health status stands in stark contrast to the hospital’s nationwide ranking. Dr. Victor Dzau, Duke’s chancellor for health affairs and chief executive of Duke University Health System, acknowledged as much during a speech he gave March 9 at the Research Triangle Park Rotary Club’s Luther Hodges Ethics Luncheon.

But then Durham is no exception. Communities surrounding the best health systems in the country often have the worst health status, Dzau said.

The problems these communities face with access to healthcare and healthcare quality and affordability in many ways epitomize national challenges: Healthcare spending has increased faster than the economy and now represents 16 percent to 17 percent of the U.S. gross national product, but the U.S. population isn’t getting healthier. Obesity and diabetes rates are up, the infant mortality rate is higher in the U.S. than in most other developed countries and about 50 million American age 18 to 64 are uninsured, according to the Centers for Disease Control and Prevention.

“Some people say we’re in a crisis,” Dzau said.

As a doctor who promised to hold service above self and as the head of a health system whose costs for services to patients unable to pay reportedly increased from $45 million in fiscal year 2009 to $47.7 million in fiscal year 2010, Dzau said he believes healthcare is a human right and he worries about who’s going to pay for it.

He sees part of the solution in the federal healthcare reform act that passed last year. The law “has lots of elements we should embrace,” Dzau told RTP Rotarians, even though it’s “pretty scary for providers. It changes my entire business model.”

But he also envisions a role for academic health sciences centers like Duke to better pass on their knowledge from the bench to the bedside and to help surrounding communities come up with strategies for prevention and treatment. (More about organizational changes at Duke to embrace Dzau’s vision here.)

Implementing the reform act, which would expand health insurance to more than 30 million uninsured Americans, is projected to cost more than $1 trillion over nine years, according to a Congressional Budget Office report. But it also promises to change an inefficient and expensive fee-for-service system in which healthcare providers are paid whether treatments work or not.

Another CBO report estimated that by 2019 reform act provisions will reduce the national deficit by up to $143 billion.

Healthcare reform aims to, for example, reduce the more than $28 billion spent every year on infections by bacteria that can be traced back to healthcare settings. Provisions in the reform act include programs to increase measuring and reporting of healthcare-associated infections, to restrict reimbursements to hospitals for HAIs and to establish financial penalties for providers with high HAI rates. (More about efforts to reduce HAIs in North Carolina hospitals here.)

Other provisions restrict reimbursements to hospitals that discharge patients too quickly and have to readmit them within 30 days of the discharge.

The reform act would also test whether healthcare costs can be reduced by bundling payments to multiple providers, from the physician who treats, say a patient being admitted for a heart attack, to the home-health nurse who makes sure the patient takes his medicines, adjusts his diet and sticks with an appropriate exercise regimen.

“It’s going to be painful,” Dzau said. But “we’ve got to get the cost down and keep the quality.”

Financially, the status quo of U.S. healthcare is no longer tenable, he said.

Private health insurers have ratcheted up copays and deductibles for years to corral payments. To deal with a drop in tax revenue and a rise in Medicaid enrollments, states have begun slashing Medicaid programs to fill budget deficits. Meanwhile, hospitals have been shifting costs from Medicare and Medicaid patients to privately insured patients to reduce losses, Dzau said.

In addition to charity care for patients who couldn’t pay, Duke reported it absorbed $62 million in losses during fiscal year 2010 because Medicaid reimburses only 60 cents for every $1 spent on patients.

Dr. Laura Jackson of the EPA's National Health and Environmental Effects Research Laboratory (NHEERL), a unit of the EPA’s Office of Research and Development that is housed in Research Triangle Park.

Dr. Jackson and her colleagues in this RTP lab—more than 100 scientists—conduct research on ecosystem services, those benefits provided by the environment over and above the psychological benefits of being out in nature. These services can have tangible and measurable economic value.

For instance, in a normally functioning ecosystem, vegetation would take up nitrogen and phosphorus from animal waste and keep those nutrients from overburdening groundwater and streams. In last week’s example, when hogs were added to an ecosystem, they knocked it out of balance by depositing more nutrients than the vegetation could handle and by removing plants that could take up the nutrients and provide erosion control. The researchers at the Center for Environmental Farming Systems were developing countermeasures to keep the water clean near hog farming operations and restore ecosystem function.

In addition to cleaning water, vegetation can also scrub pollutants from the air, and the EPA’s Dr. Jackson and her colleagues are looking into the capacity of plantings near roads to filter pollutants from vehicles. Given the connection between tailpipe emissions and respiratory illnesses, this promises to be a fruitful area of research: imagine the cost savings on medication and lost work time if nature can help prevent illness.

Another example of an ecosystem service, Dr. Jackson said, is the ability of urban vegetation to mitigate the “heat-island” effect, reducing the risk of heat stress in vulnerable populations. (Think green roofs.) In this example, nature would not only alleviate illness but eliminate some of the need to burn fossil fuels for air conditioning.

It’s already obvious that ecosystem services can be an important public health tool, and we haven’t even gotten to the topic I called Dr. Jackson to discuss: Lyme disease.

Lyme is of growing concern in the Research Triangle region; more on that in a moment. It is also of particular interest to me, because I am a renegade Durhamite living in New York’s Hudson Valley. My new home is not only the hotbed of Lyme disease but one of the hotbeds of Lyme disease research. It’s almost child’s play to get Lyme disease here, and nearly any symptom that brings you to the doctor will result in blood tests for Lyme and other tick-borne illnesses. They are that common.

At the Cary Institute of Ecosystem Studies, where I am loosely affiliated as a science writer, Dr. Richard S. Ostfeld is leading a team studying the impact of biodiversity on Lyme and other tick-borne illnesses. Long-term research conducted by Ostfeld’s lab reveals that more people get Lyme disease when natural landscapes are fragmented by development and other human activities. Large carnivores who need lots of space are driven away, and white-footed mice, which carry the bacteria that causes Lyme, thrive in the absence of these predators.

Given my newfound geographical interest in Lyme, I was incredibly interested to hear that someone in the Triangle—my beat for this blog—is working on this same topic. Dr. Jackson talked to me about her research findings and about how the EPA is using research like hers to affect decision making.

Dr. Jackson initiated the Lyme research as part of her Ph.D. program in Ecology at UNC-Chapel Hill. Her primary research tool: satellite imagery upon which she plotted records of Lyme disease cases gleaned from existing state health department records. Using an off-the-shelf statistical program, she was able to identify the types of landscapes most associated with high rates of Lyme disease: places where the edges of forests intermixed with herbaceous cover such as lawn or pasture.

And these are the kinds of places where new neighborhoods are being developed, says Jackson. “It’s popular to build out towards ‘green fields’ or undeveloped land,” she says. “People want to be near forests.” On these edges, where deer, ticks, white-footed mice, and people all exist, it’s what she calls “a perfect environment” for the transmission of Lyme disease.

Figure from Hilborn E, Jackson L, Orme-Zavaleta J. 2010. Environment and Lyme Disease Risk. Pages 399-414 In: Holmgren, A. and G. Borg (eds.), Handbook of Disease Outbreaks: Prevention, Detection and Control. Nova Science Publishers: New York.

There is no vaccine against Lyme disease in humans; it can be treated with antibiotics, but people can get it many times if infected ticks bite them. Individuals can avoid the disease by dressing appropriately, using bug spray, and checking their skin for ticks. Education in these individual measures is one public health approach to disease prevention.

But to Dr. Jackson, a broader approach to risk is called for. One landowner on a forest edge can clear shrubs to discourage deer, or lay down a strip of wood chips as a buffer between forest and lawn, but unless all of the property owners along an edge do this, she says, the risk factors will remain for the entire nearby population. She believes that whole neighborhoods have to work in concert to reduce risk.

In addition, one goal is to “design out the risk” for Lyme and related diseases by making decisions about land use based on research findings. To that end, she and her EPA colleagues are partnering with Michigan State University’s Digital Watershed to create an online tool that will predict whether developing a particular landscape in a particular way will create a high or low risk for Lyme disease. It will become part of EPA’s online Environmental Decision Toolkit in the future. Using tools like this, it is possible that without spending an extra cent in development costs or public health money, neighborhoods could be designed that work with nature to reduce the risk of Lyme. That is the concept of ecosystem services at work.

Although Dr. Jackson’s original research focused on Maryland, it has implications for the Research Triangle area, where she grew up. “The tick is here,” she says, referring to the black-legged tick that carries the bacterium that causes Lyme. “And the disease is here.” As wildlife habitats are being converted for development, she says, we don’t have the expansive natural habitats that we used to have. Given the style of development happening in the Triangle, she says, “it’s not surprising that Lyme is here.”

Monday

Tuesday

Wednesday

Thursday

Americans who are disabled because of a traumatic brain injury, stroke, diabetes, arthritis or a vision impairment are generally in poorer health. They use health care services more often and have more chronic conditions. But they also encounter bigger obstacles to obtain health care, which lands them in the emergency room more frequently.

The cost? About $398 billion in 2006, according to the study.

Northeastern states had the highest costs per disabled adult, states in the western part of the country the lowest. In North Carolina, the cost per disabled adult was about $12,213, which was above the national average. (Read the whole report here.)

The majority of the cost was shouldered by taxpayers through Medicaid and Medicare.

To reduce the spending, the study suggested to decrease hospitalizations and premature entry into nursing homes, mainly through more preventive care such as smoking cessation and mammograms, by interventions such as nutritional improvement programs by improving access to medical care.

“When looking for ways to improve health and control costs, the role of disability in care management should be addressed,” said Wayne Anderson, senior health policy analyst at RTI, in a prepared statement.

Tuesday

Noon to 12:45 p.m.
SBIR/STTR training series
Webinar: Intellectual Property: Conception and capture (to include war stories of what not to do managing government-funded work)
Presented by Scott Merrell, Hutchison Law Group
More information here.

7 p.m.
Broad Street Cafe, 1116 Broad St., Durham
The Periodic Tables: Science on tap: The chemistry of beer
Presented by Triangle Brewing Co. and Brewmaster Store
More information here.

Wednesday

9 a.m. to 10 a.m.
National Institute of Environmental Health Sciences
111. T. W. Alexander Srive, Research Triangle Park
Keystone Room 1003AB
Seminar: Idenfication of genetic and epigenetic biomarkers of metal exposure and metal-induced disease using environmental toxicogenomics and systems biology
Speaker: Rebecca Fry

11 a.m. to noon
NIEHS
111 T.W. Alexander Drive, Research Triangle Park
Rall Bldg. Rodbell B
Seminar: Unarmed but dangerous
Speaker: Tawana Williams, Wilson

4:15 p.m.
Raleigh Convention Center
BioProcess International Conference and Exhibition
ObamaCare: Stimulus Spending, System Reform and Market Change
Speaker: J.D. Kleinke, medical economist and author, Oxymorons: The Myth of a U.S. Health Care System
More information here and here.

Thursday

7:30 a.m. to 8:30 a.m.
N.C. Biotechnology Center
15 T.W. Alexander Drive, Research Triangle Park
Triangle Global Health Consortium breakfast discussion: Cloud computing for health system strengthening
More information here.

7:30 a.m. to 10:30 a.m.
Embassy Suites, 201 Harrison Oaks Blvd., Cary
Triangle Business Journal symposium: Health care and you – what’s at stake?
Cost: $28
More information here.

10 a.m. to 11 a.m.
NIEHS
111 T.W. Alexander Drive, Research Triangle Park
Rall Bldg. Room D450
Seminar: Environmental exposure to engineered nanomaterials as a potential cause of lung inflammation, fibrosis and cancer
Speaker: James C. Bonner, N.C. State University