August 31, 2014

The Spreading Threat of Ebola – Part I

Mary MahoneyBY Mary Mahoney

J. Robinson Group Blog

This is the first of a three-part series about the reappearance of the Ebola virus in Africa. Part II will look at the struggle in Ebola-stricken regions to access even the most basic hospital supplies and how the Centers for Disease Control plans to address the alarming rate of infectious disease outbreaks in our own hospitals. Part III will address why we should be worried about antibiotic resistance and the pervasive presence of antibiotics in food, cleaning products and the environment.

By now, most of us have heard about Ebola, the deadly and highly infectious viral illness that is spreading across West Africa. With ever-increasing globalization, the possibility of Ebola moving further across the African continent and beyond is a real concern. Without a doubt, the World Health Organization and the Centers for Disease Control and Prevention should be taking every precaution.

Still, it’s important to note that Ebola has come and gone before. According to the World Health Organization, there have been about two dozen reported disease clusters since it was first discovered in simultaneous episodes in Sudan and the Congo in 1976. The previous epidemics were all contained.

As of Aug. 28, the WHO counted 3,069 reported illnesses and 1,552 deaths. While that number is shocking in itself, it pales in comparison with the lives claimed by many other diseases in poor and rich countries across the globe.

Ebola is not as easily transmitted as widespread airborne pathogens like tuberculosis and influenza. According to the WHO, there must be direct contact between broken skin or mucous membranes and blood or other bodily fluids from infected people, or items contaminated with an infected person’s fluids.

Is this the beginning of a larger epidemic? Or is it just a minor blip in the global health picture?

No one can say for sure, but the CDC and the WHO are always keeping their collective eyes peeled for threats. These agencies maintain mountains of data on the world’s largest and deadliest diseases. So what is really on the radar screen of these guardians of global health?

In this and the next two blogs we will look more closely at the numbers behind Ebola and discuss what will much more likely be fatal to both our distant neighbors in this global community as well as the family next door.

The pandemic potential of Ebola should not be minimized. But it  is far from the most dangerous threat to public health.  In fact, this current — albeit the largest — outbreak has had a fatality rate of 55 percent. (Ebola overall has a mean fatality rate of 61 percent.)

Rabies, which can be found, literally, in our back yard, has a fatality rate of virtually 100 percent if untreated. Rabies can be contracted from the bite of infected domestic or wild animals — dogs, bats, skunks, raccoons and so on. Every year, 55,000 people worldwide die from rabies, although the cure rate is high if treated immediately.

Compared with rabies and other dangerous bacterial and viral illnesses including HIV, malaria, influenza, encephalitis and many more, Ebola is nearly statistically insignificant.

So what is the most likely cause of death for the average American?

The most recent WHO census found that 56 million people died worldwide in 2012. About two-thirds of those died from non-communicable diseases. The top four causes were cardiovascular disease, cancer, diabetes and chronic lung disease. The remaining 30 percent of fatalities were attributed to communicable diseases, such as respiratory infections, malaria, HIV/AIDS and diarrheal diseases, as well as nutritional deficits and injuries. Injuries  accounted for 9 percent of all global fatalities, many from car accidents.

Looking at the United States alone, one might be surprised to find that the flu, suicide and nephritis, an inflammation of the kidneys, were among the top 10 causes of death.

Perhaps less surprising are, in order, heart disease, chronic respiratory disease and diabetes. These top three killers are more often than not caused by smoking and/or obesity. According to a blog in the Columbia University Mailman School of Public Health, one in five Americans die from obesity. Worldwide, the  WHO says that obesity has nearly doubled since 1980. In 2008 there were 1.4 billion at-risk obese and overweight adults and children.

CDC posts a list each year, looking back and looking ahead. CDC accomplishments in 2013 included a tobacco education campaign and improvements in its Advanced Molecular Detection program, described as “the use of supercomputers and forensic DNA in the identification of infectious agents for better prevention and control.” The CDC also launched an initiative to prevent heart attacks and contributed to the United States President’s Plan for Emergency AIDS Relief, or PEPFAR.

What does the CDC anticipate being hot-topic issues for 2014 and the rest of the decade? Antibiotic resistance — which is also very much on the radar of the WHO — HPV-caused cervical cancer, prescription opiates addiction and what the report calls a “perfect storm of infectious disease threats.”

Back to infectious disease threats: In an Aug. 7, statement on Ebola, CDC Director Tom Frieden said, “We do not view Ebola as a significant danger to the United States because it is not transmitted easily, does not spread from people who are not ill, and because cultural norms that contribute to the spread of the disease in Africa – such as burial customs – are not a factor in the United States.”

Frieden cannot make any promises, of course. But he does note that while the United States receives 362 million travelers a year, airlines and airports are taking precautions.

However, that perfect storm of globalization and antibiotic resistance may be a cause for an explosion of many other infectious diseases. Besides fighting microbes, we have other battles to wage: obesity and smoking and a toxic-laced environment. These last three are the most relevant to the United States, and something we could, perhaps, make greater strides in controlling.

August 9, 2014

Autism at a Crossroads – Part III

Mary MahoneyBY Mary Mahoney

J. Robinson Group Blog

This is the third installment of a three-part series entitled Autism at a Crossroads.


In parts I and II of our Autism at a Crossroads series, we began to explore new issues and advancements in the world of autism spectrum disorder, a complex developmental disability. Its numbers have nearly doubled in the last decade. According to the Centers for Disease Control and Prevention, autism now affects 1 in 68 children (as well as a significant number of adults.)

Here in part III, we will discuss new research initiatives and therapies and the role of the education system.

Autism spectrum disorder, or ASD, is a complicated subject, in part, because there is wide disagreement on causes, therapies and funding. Even the diagnosis itself recently underwent a change. The only thing most people agree on is that there is no consensus on treatment and that it is very expensive and complicated to raise a child with the disorder.

The CDC figures it costs “at least $17,000 more per year to care for a child with ASD.” Medical expenditures for an ASD child average five times higher than that of the average child, and “intensive behavioral interventions cost $40,000-$60,000 per child per year.” Despite varying degrees of progress, many children are autistic for life. According to a 2014 article in JAMA Pediatrics (The Journal of the American Medical Association), “The cost of supporting an individual with ASD and an intellectual disability during his or her lifespan was $2.4 million in the United States.”

There is plenty of research on ASD, but few solid answers. Among the many theories regarding cause, some point to childhood vaccines, others to the age of the parents at the child’s birth and still others to environmental factors.

Because autism spectrum disorder encompasses, as the name suggests, a range of symptoms and severity, research studies are difficult to conduct.

Some doctors are looking at ASD from a different angle. Dr. David G. Amaral, director of research at the MIND Institute at the University of California, Davis, is doing a study based on subtypes. “One of the major stumbling blocks of understanding autism is that it’s incredibly heterogeneous,” he said in a New York Times article. “Some kids with autism have severe developmental delays, but others have normal or even enhanced IQ’s (intelligence quotient). Some have epilepsy, mental retardation and gastrointestinal problems. Some types are identified genetically, others by the pattern of brain development, and still others by the presence of immune abnormalities.”

Studies at UC Davis, the Marcus Autism Center, Children’s Healthcare of Atlanta and Emory University School of Medicine in 2014 are part of a meta-analysis on GI problems and autism. The results confirm what parents of children with autism have always known: “Children with ASD are more than four times as likely to experience general gastrointestinal complaints compared with peers, are more than three times as prone to experience constipation and diarrhea than peers, and complain twice as much about abdominal pain compared to peers.”

For patients with autistic children who are young or who cannot communicate, this can be especially frustrating. Some resort to restrictive and hard-to-follow diets that are gluten-free, dairy-free and casein-free. Others think pollutants, dyes and other chemicals play a part in acute symptoms.

With this complicated diagnostic picture, a universal treatment for ASD has remained elusive, but therapies abound. The “gold standard” therapy for decades has been ABA – applied behavioral analysis.

But as with everything about autism, the results can be random. In an extensive article in the Los Angeles Times, ABA is described as a very time- and cost-intensive therapy (sometimes taking 40 hours a week.) It usually consists of “breaking down the basic skills of life into thousands of drills,” according to the article’s author, Allen Zarembo. When ABA began about 50 years ago, the drills were accompanied by a system of punishments and rewards.

A reward-based system is still used, and ABA has since also branched off into a more loosely structured programs for improving social skills. Some people say ABA has transformed their child’s life, others say that after years and hundreds of thousands of dollars, ABA has done nothing.

Other programs compete with ABA including TEACCH, developed at the UNC School of Medicine, and Relationship Development Intervention  and Pivotal Response Treatment, described by researchers at the Yale Child Study Center as “designed to improve social communication skills by teaching these skills within the context of natural environments.”

There are controversial programs including Son-Rise and even more controversial chelation therapy and hyperbaric oxygen therapy.

Autism Speaks, the nation’s largest organization for autism advocacy, recently posted its “Top Ten Advances in Autism Therapy 2013” stating that “many of the year’s most important advances used new technologies” including taking note of early signs, new tools to track activity of autism-linked genes and environmental effects in identical twins. But really, none of this is game-changing.

Typically, living with autism is more of a difficult, day-by-day journey. For children with ASD – as with all children – school plays a great part. So how does a child who may not be verbal or otherwise communicative, who cannot connect socially, who has a low IQ and painful gastrointestinal issues do in school?

Well, U.S. law guarantees every child a “Free and Appropriate Public Education” that provision of the law, according to the National Centers for Learning Disabilities, “is one of the most misunderstood concepts of the Individuals with Disabilities in Education Act, and it often causes the greatest conflict between parents and school.”

Evidence shows many ASD children cannot learn and obtain an education simply by sitting in a classroom with children who do not suffer from the disorder. So school districts across the nation have hired thousands of occupational therapists, speech therapists, ABA specialists and physical therapists and created programs so that millions of disabled children receive an education. It has put school districts in the peculiar position of having to pay for what essentially falls under medical care. Yet there seems to be no other way around it.

The 2012 fiscal year budget for the U.S. Department of Education shows a $12.9 billion request for Special Education programs. Yet, according to an article posted by NPR in 2014, “the Obama administration said that the vast majority of the 6.5 million students with disabilities in U.S. schools today are not receiving a quality education and that it will hold states accountable for demonstrating that those students are making progress.”

So, while the economic burden of autism is great on schools, results are mixed. More-severely affected children sometimes are placed in private special education schools with tuitions ranging from a staggering $30,000 to $150,000 per year. Schools do not always want and sometimes are not able to provide services or outplacement, prompting parents to hire their own therapists, advocates, evaluators and psychologists. Many parents also hire lawyers to protect their child’s rights and sometimes go to court.

Raising a child with ASD is complicated. Never mind “it takes a village;” it takes a veritable army to raise such a child to young adulthood and beyond.

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