Health Education Found Lacking

The relationship between school health programs and public health in the United States dates back to the early 1800s. The work of Chadwick in Europe, and the subsequent work of Shattuck in the United States, focused attention on the importance of child and adolescent health in improving public health. Chadwick noted that one-half of all children born to working class parents in England died before age five. Likewise, Shattuck’s insightful report offered several futuristic recommendations to promote public health in the United States. Many of the recommendations had implications for child and adolescent health, particularly for school-age children. In one important area of public health concern — control of communicable diseases — school health programs played a significant role through health inspections, immunization campaigns, and related activities.

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As advances in science and medicine during the late 1800s and early 1900s eliminated or controlled many communicable diseases, attention increasingly was focused on the impact of chronic disease in American society. Participation by the United States in four major wars during this century provided evidence that American youth lacked adequate levels of health. The first such conflict — World War I — provided the first comprehensive assessment of the health status of the American people. Though standards for induction into the United States armed forces were lowered at the beginning of the war, 34% of American males examined for military service still were rejected due to physical and mental health problems. Had these defects been detected previously, many could have been prevented or corrected.

Consequently, public health professionals realized that, while progress had been made in controlling communicable disease, chronic diseases posed a new and growing threat to public health.

Findings from recent research confirm a continuing need to improve child and adolescent health. One such study, the National Adolescent Student Health Survey (NASHS), examined the health knowledge, attitudes, and behavior of American teenagers, and constructed a national health profile for that age group. During fall 1987, a national sample of about 11,000 eighth and 10th grade students was drawn from more than 200 public and private schools in 20 states.

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Interestingly, the NASHS results were similar to findings from the national School Health Education Study (SHES) conducted during the early 1960s. While the subject matter addressed by the SHES and NASHS differed in some respects, both studies confirmed a continuing need to promote comprehensive school health programs that increase knowledge, favorably influence attitudes, and promote positive behavior and effective decision-making among American youth.

The problems noted in the NASHS and related studies pose negative implications for the nation not only in terms of child and adolescent health status, but broader negative implications for public health and welfare in areas such as national defense, economic competitiveness, and the long-term social and fiscal impact of chronic diseases on society. An analysis of causes of death in the United States underscore the necessity for dealing with the problem of chronic diseases.

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More HIV Patients Suing Doctors

Physicians face a rising number of suits filed by HIV-infected patients, and the lack of clear cut laws and legal precedents is mud-dying the course that doctors should follow to limit their liability.

Though no statistics exist yet to document the trend, “all the physician-owned insurance companies are handling suits” brought by patients seropositive for the human immunodeficiency virus, said Douglass Phillips, president of the Physician Insurers Association of America located here.

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“It’s a phenomenon that’s occurred in the last 12 to 18 months and is too new for us to have specific numbers,” added Phillips, who is also chief executive officer of the Medical Mutual Insurance Company of North Carolina, in Raleigh.

He and other experts cite three allegations made in many of the claims awaiting resolution:

* disclosure of a patient’s HIV seropositive status to a known sexual partner of the patient or to health care providers treating the patient,
* failure to properly diagnose HIV seropositivity or related disorders, and
* discrimination against the seropositive patient by a refusal to provide medical care.

A physician’s freedom to inform others of a patient’s HIV status is complicated in states such as California, which last year passed a law that bars doctors from revealing a patient’s HIV status to anyone other than a spouse. But “if what’s correct medically, morally, and reasonably outweighs what a state legislature has ruled, then the doctor has to break the law,” said Duncan Barr, an attorney with the San Francisco firm of O’Connor, Cohn, Dillon, and Barr.

“Without question, doctors have the option to breach confidentiality to protect the public,” said lawyer George Annas, chief of health law at Boston University. “Suits against doctors who’ve revealed a patient’s HIV status to sexual partners or health care providers are losers,” he told MWN.

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State laws may soon come into accord with these opinions. A “new trend” in laws under consideration by many states is that health care providers won’t be held liable for a “good cause” breach of patient confidentiality that involves another provider or a patient’s sexual partner, said Connie Thomas, a research associate with the Washington-based Intergovernmental Health Policy Project, which tracks health legislation at the state level.

Growing liability. But the failure-to-diagnose issue has become more pressing in the wake of a Massachusetts court’s decision earlier this year that a physician was liable for failing to diagnose the Pneumocystis carinii pneumonia of an HIV seropositive patient (MWN, March 28, p. 24). This ruling “provides the common sense message to doctors that if a patient has symptoms of an HIV-related disease, they better … determine if the patient is HIV seropositive and has a related disease,” said Barr, who specializes in defending sued physicians.

Phillips maintains that failure to diagnose an HIV infection won’t be an issue until a therapy is proven reliably effective against the virus, but Annas said it’s already a liability against which physicians must take precautions.

The absence of a good therapy “doesn’t mean you don’t have to diagnose it,” Annas said, and the reported efficacy of zidovudine (Retrovir, Burroughs Wellcome; formerly known as AZT) in early-diagnosed cases makes the damages of failure to diagnose a “jury question.” He sees this issue pushing physicians toward wider use of HIV antibody testing and thinks that testing will become much more common when an easy antigen test becomes available.

A third major area of liability is discrimination, which hinges on a patient’s proving that a doctor refused to provide treatment solely because the patient is HIV seropositive. Annas said particular targets of such discrimination suits are dentists, who find it hard to justify not treating certain patients. He said a New York appeals court’s upholding the city human rights commission’s ruling against a dentist “showed that both commissions and courts are serious about enforcing the antidiscrimination laws.”

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Health Education Survey Part II

The health survey taken by teenagers addressed eight components: AIDS, injury prevention, violence, suicide, substance abuse, sexually transmitted disease, consumer health, and nutrition. Survey results suggest American youth lack sufficient health knowledge and decision-making skills. Key findings from the survey include:

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AIDS. Some 93% of students knew the disease is transmitted by sexual intercourse, and 91% knew it is transmitted by drug needles. They reported knowing that condoms provide an effective way to avoid AIDS, and they believed condoms should be used. However, several significant misconceptions about the disease existed within the group; many mistakenly believe the risk of AIDS increases when donating blood, and more than half believed that washing after sexual intercourse reduces the probability of being infected with the AIDS virus. Many students believe that having sexual intercourse is acceptable with a steady partner for people their age. In addition, 82% reported knowing the risk of acquiring AIDS increases by having more than one sexual partner.

Sexually Transmitted Diseases. Many adolescents do not know how to avoid contracting sexually transmitted diseases, nor can they identify common early signs of a sexually transmitted disease. In addition, 38% of adolescents would not know where to go for medical care should they contract a sexually transmitted disease.

Unintentional Injuries. Accidents constitute the leading cause of death for young people ages 15-25. The survey found that most adolescents put themselves at risk for injury in automobiles by not wearing seatbelts (56%), and by riding in automobiles when the driver has been drinking (39%). In addition, most of those surveyed who ride a bicycle or motorcycle do not wear protective gear.

Suicide. As the second leading cause of death for American youth ages 15-24, suicide represents a serious public health problem. Many adolescents reported having attempted suicide. In addition, almost two-thirds reported that it would be difficult for them to obtain help for a friend who was considering suicide.

Substance Abuse. Though other surveys indicate the prevalence of alcohol, drugs, and tobacco use among American teens has declined in recent years, the NASHS revealed that substance use remains a serious problem. The survey revealed 51% of eighth grade students and 63% of 10th grade students reported having tried alcoholic beverages. About one-third reported having five or more drinks on one occasion during the past two weeks.

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Violence. Adolescents ages 12-19, particularly males, have the highest victimization rates for crimes of violence. The NASHS revealed that 39% of teens surveyed indicated they had been in a fight in the past year. More than one-third (34%) reported that someone had threatened or hurt them, 14% reported having been robbed, and 13% reported having been attacked while at school or on a school bus during the past year. One-third reported that someone had threatened to hurt them, 15% reported having been robbed, and 16% reported having been attacked while outside of school during the past year. In addition, both boys and girls said that weapons were accessible to them, with nearly one-fourth of boys reporting carrying a knife to school at least once in the past year.

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Breakfast with the Surgeon General

He cites his work on AIDS, abortion, and smoking as his greatest accomplishments during his tenure as the country’s surgeon general and `health conscience.’ The first 10 months of pre-confirmation machinations were “hellish,” but the nine-year period he spent as the nation’s chief health officer was the “most exciting time of my life,” Dr. C. Everett Koop said.

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At a breakfast gathering held here one month before his “terminal leave” was scheduled to begin, the outgoing U.S. surgeon general said, yes, he would have stayed in government if someone had taken him up on his desire to be HHS secretary. “I think I would have done a credible job,” he told about two dozen reporters.

But he had decided to foreshorten his appointed tenure regardless of how the suggested role change was received and had informed the president of his decision several weeks after the inauguration. “I’d done all I could do in that job and I didn’t want to continue,” Dr. Koop said.

What’s next? “I’m 73 and I’ve had eight good years [as surgeon general],” he said, looking and sounding like a person at the peak of productivity. “In the three to five years left,” he continued, looking and sounding like someone with at least several decades to go, “I’d like to take a crack at the private sector and see what I can do there.”

Reviewing his impact in the public sector, he said he’s proudest of moving the country toward a “smoke-free” society. “During my tenure, the percentage of the smoking population has declined from 34% to 26%, per capita [tobacco] consumption has steadily dropped, the tobacco industry has had to diversify, and there are more than 400 antismoking laws on the books.”

And he’s pleased with how he handled his AIDS report of 1986. “Within a week of its release, certain conservative people in the White House asked me to `update’ the report and take out the word `condom.’ They left my office in a huff.

“It’s a pleasure to me that report is just as accurate today as it was then. I faced the issue squarely, using such words as `penis,’ `vagina,’ `condom,’ pushing people into a position more in touch with reality. That had a salutory affect on the way the public thinks, and it provided the needed pressure from Congress to get out the household AIDS mailer, the largest of any such government effort save the tax forms,” Dr. Koop recalled.

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He views his refusal to issue a report on the emotional consequences of abortion in the same vein. “The president was misled into believing that what I’d find would serve as a basis to reverse Roe vs. Wade. And the worst thing I could have done would have been to put out an unscientific report, which would have been attacked by scientists and ethicists to the point where the pro-life movement would have been destroyed.”

Sex education. Overturning Roe vs. Wade could “merely lead to 50 little Roe vs. Wades,” Dr. Koop said. “If you want to get rid of abortions, you have to get rid of the reasons for them: unwanted pregnancies. We have to use a public health model, educate our children like we’ve never done.

“Now, some people are as opposed to contraception as they are to abortion. Let’s get this out in the open.

“We start teaching too late. My suggestion that we begin sex education in third grade raised a furor. But a coalition of educators and parents and church groups could do it, and we could raise a generation of preteens and teens who are less sexually active, and that would affect unwanted pregnancies, sexually transmitted diseases, and low birth-weight babies,” Dr. Koop asserted.

He skirted questions about whether his accomplishments had been aided by the government he served or achieved in spite of it. And he said he wasn’t leaving Washington with any bitterness. “In fact, I’m not leaving Washington.” As a “private entrepreneur” after Oct. 1, when he will officially cease being surgeon general, he’ll write his memoirs–and then, he said, he’d like to “really accomplish something big. I’d like to continue to be the country’s health conscience.”

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New Methods of Contraception

Three new barrier methods of contraception remain in regulatory or entrepreneurial limbo, thwarting predictions that a male “microcondom” and a “female condom” would hit the market early this year.

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Two of the three devices received FDA clearance last year, without undergoing standard safety and efficacy trials, under a regulation permitting approval of products “substantially equivalent” to those already on the market. But the Washington-based National Women’s Health Network petitioned the FDA last December to rescind approval, pending proof of pregnancy prevention and protection against sexually transmitted diseases.

At a March hearing, an FDA advisory committee agreed with the NWHN that the products could not fall under the “510 K” or “substantially equivalent” rubric, but that they were actually class 3 devices requiring the full premarket application. The decision also applied to another female device submitted in January under the 510 K provision but held for consideration pending the hearing. The term “female condom” was changed to “vaginal pouch” to reflect the new status of the devices.

At MWN press time, the FDA hadn’t formally agreed with its advisory committee, but insiders said a ruling to that effect was in the wings.

“We want more barrier methods out there,” said Victoria Leonard, NWHN executive director, “but in the age of AIDS, it’s especially crucial to have user tests and hearings where data can be examined.”

Although the FDA had cleared the microcondom–made by Anthl Laboratories of Chicago–as a contraceptive only, Leonard said she felt the term itself was misleading. “A condom has been shown to prevent pregnancy and STDs. The microcondom fits over the head of the penis, and is kept in place by adhesive strips. What about herpes, syphilis, and AIDS?”

The NWHN is more enthusiastic about the contraceptive and disease-protective potential of the vaginal pouches, not only because women control their use but also because they line the entire vaginal canal. The approved version covers the entire genital and rectal area with a latex panty that has a pouch that fits into the vagina.

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According to FDA spokesman Dave Duarte, manufacturers could legally market the two products that received prior clearance, but then would have to submit clinical data within 30 months.

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