HealthyCal.org

By Matt Perry
California Health Report

There was only one possible topic I could address for this maiden entry of “The Age of Innocence,” a new, twice-monthly column devoted to Aging.

The death of my mother.

The photo you see to your right is one I took of my mom last June, only a month before she died.

At age 90 and suffering from the debilitating effects of Alzheimer’s, she was housed in an upscale assisted living facility in East Lansing, Michigan, just miles away from where I grew up.

The facility purportedly offered “memory care” for her failing body and brain, but my siblings and I knew this was largely a joke.

In truth, she received virtually no mental or physical stimulation other than endless blaring reruns of The Carol Burnett Show, punctuated by weekly visits from a volunteer pianist and a handful of other obligatory social activities.

Physical activity? Non-existent. Mental engagement? A marketing sham. Instead, she spent days on end being wheeled from her bedroom to the dining room and into the living room.

When I first arrived from California and stepped inside the facility, my mother’s eyes were glazed orbs, unfocused and dull, staring listlessly downwards.

Since older adults in long-term care facilities rarely experience the joy of human touch, the first thing I did was rub her arms, massage her shoulders, and kiss her cheeks.

While the facility had a back porch, there was no ramp to allow residents access to the grass or trees below. Instead, a locked gate prevented them from descending into the natural world.

With the help of a staffer, we opened the gate and bumped her wheelchair down the five steps onto the grass. As I wheeled my mother forward, the wind hit her face and she recoiled, then did something simple but marvelous: She looked up, her eyes suddenly alert.

Her feet grazing the grass, hands grasping pine tree needles, nose warmed by the sun, face bracing from the wind – she looked to the horizon and became, for the first time since my arrival, alive.

I knelt down beside her and asked “Would you like me to sing to you?”

“Oh, that would be wonderful,” she replied, uttering her first words of the day, in a voice so clear and distinct it shocked me.

I sang “O Holy Night!” which for years she had performed at Christmas services with my father, then segued into Del Shannon’s “Runaway” and the Turtles’ “Happy Together” – two songs I knew by heart.

Finally, my mom was there with me.

Then she commanded me very clearly “Over there. I want to go over there.”

I wheeled her over the grass to the spot in the photo. This sick, frail, elderly woman then reached up to the iron fence, pulled herself out of her wheelchair and began rattling it.

At 90 years old. All by herself. One month before her death.

And that is when I took this photo.

What rang in my head at this moment were the words of Peter Reed, executive director of the Pioneer Network, an organization devoted to changing the culture of aging: “The way we treat older adults in this society borrows more from the prison system than it does the healthcare system.”

Is it any wonder that my mother was rattling her cage, warehoused in a system that rarely meets the physical needs of residents while almost entirely neglecting their emotional and spiritual desires – not to mention their sensual ones?

What has become obvious during the past year that I’ve covered aging issues is that growing old is much like global warming. We are on the precipice of disaster and can either follow the visionaries who seek to redefine aging, or continue to treat and imprison our parents and grandparents – in their bodies and our facilities.

Do I despair? Yes, I despair for older adults like my mom who have had their humanity stripped from them.

Do I have hope? Yes. Because over the past year covering older adults I’ve been blessed to meet many amazing people who are committed to transforming the aging experience. .

In Sacramento alone – my home – there are several national leaders in the field: Reed, who lives here although the Pioneer Network is headquartered in Chicago. And David Troxel, who has established The Best Friends Approach to Alzheimer’s (with his business partner Virginia Bell who is in her 90’s) which trains long-term care workers to treat dementia patients as if they were their own best friend.

In Silicon Valley, the brilliant physician and longevity expert Walter Bortz has outlined a roadmap for successful aging in “We Live Too Short and Die Too Long.”

AgeSong Senior Communities treats residents at their six Bay Area facilities as “wise elders.”

In California and nationally there are hundreds of cutting-edge programs to keep older adults vibrant and engaged, with more and more springing up every month: The Eden Alternative is changing the physical environment for older adults with sunlight, pets and plants; and the Music & Memory initiative seeks to give every single resident in long-term care an iPod so they can listen to the music they love, as emotionally rendered in the film “Alive Inside.”

While in this column I will occasionally spotlight the terrors of aging, I will typically focus on these powerful reformers who are providing solutions and changing the way we live and age.

Because freedom in our Golden Years is worth fighting for.

Photo: Flickr/DoNotLick

By Leah Bartos
California Health Report

Young people may be less likely to suffer from severe health problems, but Tamika Butler wants them — and the lawmakers who draft policies affecting them — to remember they are not immune to illness and disease.

Butler is just one of many advocates worried about how youth of all incomes levels and ethnicities are going to fare once the Affordable Care Act is implemented. She directs the California branch of the Young Invincibles, an organization dedicated to informing and advancing healthcare options for young adults aged 18 to 34.

In California, 3.1 million people in that age group do not have insurance — a pool that accounts for 42 percent of the entire uninsured population in the state.

“We know it’s going to take a shift in culture and a shift in understanding the value of insurance to change the way that people think about it,” Butler said. That shift will need to happen not only in the minds of young people, she said, but also in the policies made in the state Capitol.

Amid the turmoil of the nationwide financial woes, health-care advocates in California are urging lawmakers not to lose sight of what they see as a rare opportunity to help close the gap in the state’s health disparities.

With the Affordable Care Act and the billions of federal dollars coming into the state to back it, the health care prospects for many Californians will improve dramatically. But some worry that if it’s not done correctly, a portion of the state’s population may be left out — specifically, boys and young men of color.

“We’re hoping that they don’t miss this opportunity to expand health care to a really vulnerable population,” said Jamila Edwards, the Northern California Director of the Children’s Defense Fund. “If things don’t go the way we hope, it’s just going to exacerbate conditions for populations that are already super vulnerable and already experiencing inequalities and health challenges.”

In an effort to address some of these inequalities, Speaker of the Assembly John Pérez established the Assembly Select Committee on the Status of Boys and Men of Color in California. The committee sought advice from community leaders in California, including Edwards and her organization, to inform a report it drafted last year, outlining wide-ranging policy recommendations to help alleviate the disparities.

As noted in the committee’s report, young people of color in California — who make up more than 70 percent of the population under the age of 25 — are more likely to face social conditions adversely affecting their health, ranging from inadequate schools and exposure to violence.

Young people of color in California are far more likely to killed in firearm homicides, and in a past survey, Latinos were three times more likely to be murdered than whites.

Some chronic diseases were also found at much higher rates among youth of color than their white counterparts. Asthma, for instance, affects Latino and African American youth at five times the rate as it does non-Hispanic whites.

Ellen Wu, executive director of the California Pan-Ethnic Health Network, has been working on advancing some of the select committee’s recommendations.

“In particular, men and boys of color have specific not only needs but life experiences that need to be addressed and taken into consideration,” Wu said. “You can’t do this one-size-fits-all approach to getting them healthy.”

The report identified health challenges facing even more specific subgroups including young people in immigrant families, foster care, and the juvenile justice system.

In an effort to address the barrier facing young people in immigrant households, the committee recommended that the state’s existing safety net network — such as community health centers and public-based providers — continue to be funded and made available to people of uncertain legal status. Under the Affordable Care Act, undocumented people will not be able to buy insurance through the state’s health benefit exchange. Outreach to these communities, as the report pointed out, also remains a challenge.

“Explaining that to an immigrant family is very complicated,” said Sonal Ambegaokar, a health policy attorney for the National Immigration Law Center. “Most immigrants are not well-versed in how our health care system works and the need for insurance until likely there’s an emergency.”

Ambegaokar added that by law, Medi-Cal and other such programs cannot share application information with immigration authorities. Still, many people remain reluctant to enter their information in the system. She and others worry that this reluctance is not only preventing parents, but also children — who may have full citizenship — from getting the care they need.

“Fear of immigration in general — whether you’re legal or not — keeps a lot of immigrant families as well as their citizen children out of the health care system,” Ambegaokar said, adding that 80 percent of California’s children live in mixed status families.

On the opposite end of the spectrum, the report had additional recommendations to provide coverage for youth very much in the system.

Just as the Affordable Care Act has allowed young people to stay on their parent’s health insurance plans until the age of 26, the report endorsed similar legislation that would continue coverage for former foster youth in California.

Governor Jerry Brown has already approved a bill to expand Medi-Cal coverage up to the age of 26 for young people who have aged out of the state’s foster care program, and advocates are hoping it is taken up again in this month’s special legislative session. Edwards of the Children’s Defense Fund, noted that the state also has the opportunity to develop easy ways to ensure this continuing coverage for former foster youth — such as an automatic enrollment process to prevent lapses in coverage and avoid a burdensome application process.

The committee also recommended that Medi-Cal be available to youth detained in juvenile justice facilities, specifically through two bills also already approved by the governor that would provide federal funding to do so. One of the provisions would provide for acute inpatient hospital services and inpatient psychiatric services; the other would guarantee Medi-Cal coverage to detained youth awaiting adjudication.

Many public health advocates are celebrating Gov. Brown’s announcement last week of his intention to expand Medi-Cal. But others point out, there is still plenty of work to be done, especially on the federal side.

“The big hanging threat for us all — and I hate to say it — is the whole fiscal cliff thing,” said Edwards. With the Affordable Care Act approved by the Supreme Court and many related laws already on the books, she hopes all the hard work stays intact. “This is something that can be easily handled because we’ve already done the heavy lifting.”

Wu of the California Pan-Ethnic Health Network has also been warily watching the federal financial problems unfold.

“So much of the implementation of the Affordable Care Act is tied to the feds. What happens on the national level — or let’s say what continues to not happen on the national level — creates uncertainty,” Wu said. “The uncertainty makes it challenging to move forward. That said, I think California has an obligation to continue to move forward.”

Why Prevention Efforts Won’t Close the Health Gap

Photo: Flickr/Kudaker

By Heather Tirado Gilligan
California Health Report

Fatimah Wilson is part of a social experiment under way in Richmond, Calif., an economically depressed corner of the San Francisco Bay Area.

Wilson is pregnant and is spending the day with other soon-to-be moms learning habits— from better eating to relaxation—to help them improve their health and the health of their babies. The goal: to erase the health disparity that results in African American infants in Contra Costa County dying at twice the rate of white babies before they reach their first birthday.

Wilson, 34, attended the West County African American Community Baby Shower, where she ate healthful food, received gifts for her baby and mingled with other local women. The women attended workshops where they learned, among other things, to use yoga-based relaxation techniques to reduce stress during pregnancy.

“We can change the statistics, because they are gross and grave throughout the United States for African American women and babies,” says Lynor Jackson- Marks, one of the organizers of the shower. Nationally, African American babies are more than twice as likely as white babies to die before their first birthday.

Reducing disparities and educating mothers-to-be were the event’s laudable goals. But years of research suggest that teaching mothers-to-be such as Wilson tips for a healthy pregnancy will only go so far. The gap in the rates of infant mortality can’t be explained by unhealthful behaviors. Instead, it is part of a pattern that goes back generations and persists despite an individual’s changes in income, environment, behavior and living conditions. It is a puzzle with no easy solution—and one that is almost certainly beyond what typical prevention efforts can achieve.

The Rise of Prevention

Preventive programs became popular over the past few decades, as public health officials focused on the difference in health status among racial and ethnic groups, economic classes and geographic locations. That focus reflected researchers’ new understanding of the close connection between health and social factors such as income and race, and is part of a larger movement to address preventable deaths.

“The idea that these are health disparities really emerged about 30 years ago,” explains Nancy Adler, professor of psychiatry at the UCSF School of Medicine and chair of the MacArthur Research Network on Socioeconomic Status and Health. The fact that they are avoidable and hit poor people and people of color harder is what distinguishes a disparity in health from a difference in health. “These differences,” Adler explains, “are avoidable and unjust.”

About 40 percent of deaths in the United States are attributable to avoidable illnesses such as heart disease, analysis by the Institute of Medicine has shown. Among the avoidable deaths, as Adler notes, are all of those caused by disparities.

Public health departments, traditionally focused on preventing communicable diseases, have begun shifting more of their resources to prevention. Contra Costa County, where Richmond is located, has targeted disparities for a decade. The federal Affordable Care Act also reflects the sea change in moving toward improving the health of people by reducing preventable disease, earmarking a huge sum—$10 billion—for prevention initiatives. Healthy People 2020, on ongoing federal initiative to reduce chronic illness and preventable death, names reducing disparities in health as one of their primary goals. They intend to achieve that goal by “Integrating prevention into the continuum of education—from the earliest ages on,” according to the program’s guiding framework.

Changes in behavior, researchers have come to think, can save lives, an understanding that has reshaped public health policy.

The puzzle of infant mortality

The focus on individual behavior as a way to address health disparities seems to suggest that differences in health behavior cause disparities. In the case of infant mortality, for instance, events such as the community shower might imply that African American mothers have bad habits that white mothers do not share. But that’s not actually true, researchers have found. Pregnant African American women, for instance, do not smoke more than other pregnant women or engage in other behaviors linked to higher infant mortality rates in numbers sufficient to explain the higher death rates of their babies.

The problem is much harder to untangle: It is the result of a lifelong diminishment of health that starts before birth and is passed on through generations. On close examination, what has been treated as a problem of an individual’s life choices emerges instead as a deeply rooted social problem.

“What we are seeing in differences between blacks and whites is not just a result of what is happening during the nine months of pregnancy, but actually has also to do with what happens prior to pregnancy,” says Dr. Neal Halfon. Halfon is a professor in the departments of pediatrics, health sciences and policy studies at UCLA, the director of the Center for Healthier Children, Families and Communities, and a former policy advisor to former Vice President Al Gore.

His groundbreaking 2003 article on disparities in infant mortality (co-authored with UCLA colleague Michael Lu) featured an illustration imagining the effects of circumstances on health as a series of upward and downward pressures over the course of a lifetime. Positive events boost health, and stressful, negative events hurt health. Because of poverty and discrimination, African American women often experience more stressful life events and fewer positive ones compared to white women, and as a result their health suffers. So does the health of their children, starting with their development in the womb.

During different periods of development, we are more or less sensitive to our environment. A baby’s initial development in the womb is a critical time. Other important moments occur in childhood. Trauma and stress during these periods affect health permanently. Chronic stress outside these critical periods of development hurts health too. The cumulative effect of stress and disadvantage over the mother’s lifetime, Halfon explains, affects the health of their child.

Some of the stress African American women feel comes from living in disadvantaged neighborhoods where violence and uncertainty in housing and employment are facts of life. And African Americans are poor at sharply disproportional rates. More than 27 percent of African Americans were poor in 2010, compared to about 10 percent of whites.

Health is closely related to income. As income levels for African Americans rose between 1968 and 1978 following the civil rights movement, for instance, mortality rates for African Americans declined. When African American income started to fall again in comparison to white income in the 1980s, the gap between the mortality rates of the two groups grew once again.

The relationship between race, income and health is seen specifically in infant mortality too. Researchers at the National Bureau of Economic Research, for instance, found a relationship between income and low birth weight. Raising the incomes of single, high school educated mothers by as little as $1,000 reduces rates of low birth weight, a predictor of infant mortality, by about 7 to 11 percent. The biggest improvements, they found, are among African American mothers.

Researchers have been trying to unearth the causes of these relationships for years. They do know that the feeling of being a part of an isolated group—one that other social groups view as distinct and below them on the social hierarchy—is a part of the experience of poverty that’s harmful to health. That connection was revealed by a ground- breaking study of British civil servants in the late 1960s, called the Whitehall Study, which showed a social gradient in health. People at the top of the social hierarchy have the best health, and people at the bottom have the worst. People in the middle of the hierarchy, who do not lack access to care and have sufficient incomes, also have worse health than those at the top of the hierarchy. The social gradient affects everyone’s health—and that may be the primary culprit in the poor health of low-income people.

Amani Nuru-Jeter, a professor of public health at the University of California, Berkeley, says that people understand when their place on the social ladder is on the lowest rung. “People know when they are living in those kinds of neighborhoods,” she explains. “And knowing that can be stressful.”

But the puzzle is even more complicated than that. African American babies who are not born to poor mothers are also more likely to die within their first of life than white babies, suggesting that the effects of poverty linger past the day when a woman is no longer poor. That fact also suggests that race affects health whether or not you are poor. African American mothers with a college education—an indicator of higher socioeconomic status—have infant mortality rates of 10 per 100,000 births. That’s three times higher than rates for babies born to white mothers with a college education.

For African American mothers, stress is “ever present in your life, because of how you are treated as a member of a racial minority in this country,” Halfon says. Kids are often aware of their status as a minority from a young age. “Children who experience the kind of racism that has to do with their status in society feel that status,” he says. “That can just wear against them over long periods of time.”

A telling fact that supports the relationship between discrimination and health is the lower death rates of babies born to African immigrants. African immigrants who are new to the United States have similar birth outcomes to those of white women. The children of African immigrants, however, have birth outcomes similar to those of African American women—a pattern not seen in white immigrants. The data suggest that something particular to living as a black woman in the United States is hurting the health of their children.

The experience of poverty and the stress of occupying a lower rung of the social ladder may be the cause of the disproportionate share of health problems borne by African Americans. But thinking about health in that way—as a social problem rather than an individual problem, and a systemic problem rather than a health behavior problem—requires a conceptual shift in thinking. And it means that a solution to health disparities will require much more than the current emphasis on prevention programs.

Global Approaches

People live longer on average in Sweden and Norway than they do in the United States, as do people in 49 other countries. The United States ranks 50th in life expectancy from birth, a number that is attributable at least in part to sharp health disparities, including the infant mortality rate.

Halfon points to the example of the protective social programs in Scandinavian countries, where education is equalized and unemployment benefits are generous enough to keep citizens from feeling that they will fall into an abyss if they lose their jobs. Social programs don’t kick in only after an individual is in acute distress, as they do here.

“We pay when people fail,” Halfon says. “Other countries invest for success—and invest for equity.” They have figured out that early investments produce social dividends for everyone. Our approach, he adds, lacks that kind of consideration. “If NASA used the same kind of philosophy that we used in social programs,” he says, “they would launch satellites into any old trajectory and spend all of their money to make sure they didn’t fall to the ground.” In light of the scale of disparities in problems like infant mortality, solutions that rely on individuals making different choices are unlikely to work.

Laurette Dubé, the founding chair and scientific director of the McGill World Platform for Health and Economic Convergence, is one expert pushing for a change of thinking about global health. Dubé’s work on the interconnection between systems such as the agriculture industry and worldwide problems such as hunger and obesity appeared in a recent special issue of Proceedings of the National Academy of Science.

Behavior is linked to health, as current approaches to reducing preventable illness suggest. But so are social and economic systems. “Right now public health experts are saying we should behave differently than we do,” Dubé says, “and they are right.” But, she adds, “if the whole machine is going 300 miles per hour in a direction that runs counter to the change we need to be making, we will never make any significant dent in the changes that need to be made.”

Improving health requires changes to entire systems, Dubé says. Public health plays an integral role in improving population health, but prevention efforts must be more closely tied to widespread re form to truly improve health. “It is clear that we need a whole social change.”

Change, Dubé stresses, is “critical.” She points to escalating health-care costs and their ever-increasing share of national budgets. Health-care expenditures in the United States, for instance, doubled between 2000 and 2010, according to analysis by the Centers for Medicare and Medicaid Services. “In industrialized countries,” Dubé says, “we are reaching the limits of what financially society can afford in terms of health care.”

Despite the urgency, sweeping changes do not seem to be on the horizon. “I’ve been seeing more that’s distressing,” Adler says. “It seems like we are going in the wrong direction on this issue.”

“We may not have the political will to do it,” she adds. “But disparities are preventable over time if we would make that a priority. We could drastically reduce them.”

Nuru-Jeter of UC Berkeley agrees that larger policy changes would help reduce health disparities. But since that is unlikely, smaller interventions remain important. “I definitely think we need broader scale society reformation,” she says. “In the meantime, we don’t just sit still and wait for that to happen.”

At the baby shower in Richmond, no one was simply waiting for better health to happen. Instead, the women carefully followed directions from an instructor to breathe in and out at a late-morning stress management class, doing what they could to improve their own health and the health of their children.

Prevention programs have been successful in the past. For example, they have been shown to sharply reduce smoking and the illnesses associated with tobacco, and disparities in infectious diseases like the flu were reduced decades ago. In short, prevention has made huge improvements in the health of the U.S. population. These programs, however, have dealt with problems that are simpler to solve, with a clearer cause and effect. But disparities such as those that affect infant health and mortality today are far more complex. They are a profound public health problem, but they may also be a problem that public health can’t solve.

Photo: Flickr/Bies

By Robert Fulton
California Health Report

Yolanda Serrano eagerly anticipates the arrival of her first child. The 22-year-old is due to give birth to her baby boy this month, and has regular checkups with her obstetrician at the Institute for Maternal Fetal Health, a collaboration between Children’s Hospital and the University of Southern California at Hollywood Presbyterian Medical Center in Los Angeles.

Doctors diagnosed Serrano with hyperthyroidism at the age of 12, and she treats the condition through a combination of diet and medication. Serrano’s thyroid levels are under control, and though they may increase after giving birth, there should be no complications to her or her child because of the condition.

“Now it’s just a matter of me continuing that diet, not trying to eat fast food as much,” said Serrano, a South Los Angeles resident studying criminal justice at East Los Angeles College.

Serrano is proactively maintaining her health during her pregnancy, a strategy experts think may be key to improving maternal mortality rates.

A recent report from the California Health Care Foundation shows that the maternal mortality rate in California has increased significantly since the late 1990s. Furthermore, the same report shows a wide disparity in maternal mortality between African American women and the rest of the population.

“A Mixed Bag: Clinical Quality in California,” authored by health care consultant Jennifer Joynt, is part of the CHCF’s California Health Care Almanac. Joynt is also the project manager Almanac.

According to the report, the maternal mortality rate in California more than doubled from 1999 to 2006 before declining in recent years. The rate was 7.7 deaths per 100,000 live births in 1999 and 11.6 in 2009. The national rate rose from 9.9 deaths per 100,000 live births in 1999 to 12.7 in 2007. African American women in California were nearly four times as likely to die from childbirth, suffering 41.1 deaths per 100,000 live births over a three year moving average from 2007 to 2009.

“The number of mothers dying during birth is still pretty small, but it is concerning that it’s been going up,” Joynt said.

“A Mixed Bag” doesn’t give specific reasons for the increase in maternal mortality, nor does it offer solutions. But the report, health care providers and officials offer insight as to possible causes for the increase. These include changes in the way maternal mortality has been reported; access to quality pre-natal care; an increase in the number of women having children later in life; an increase in the number of women with chronic diseases such as obesity, hypertension and diabetes; and an increase in artificial reproduction methods and Cesarean sections.

The California Pregnancy-Associated Mortality Review, published in April 2011, states that improved data reporting may account for approximately a third of the increase in the maternal mortality rate. However, this does not explain the entire increase, nor the ethnic disparities in the maternal mortality rate.

Sara Twogood and Alyssa Wittenberg, obstetricians/gynecologists with the Institute for Maternal Fetal Health and assistant professors of clinical obstetrics and gynecology at the USC Keck School of Medicine, point to the impact of chronic diseases and poor health on expectant and postpartum mothers.

Expectant mothers with chronic diseases such as diabetes, hypertension and obesity are at greater risks for complications relating to childbirth; and expectant mothers who are obese are at risk for gestational diabetes, gestational hypertension and preeclampsia. Obesity can lead to a hypercoagulable state, which can lead to blood clots, pulmonary embolism, stroke and heart attack. “A Mixed Bag” shows that one in five California mothers with a recent live birth was obese prior to pregnancy, 12 percent had diabetes and 10 percent had hypertension.

“If you’re dealing with a patient who has multiple chronic diseases, they’re a lot likely to have issues during their labor course or post-partum complications, things like that,” Wittenberg said.

Twogood added that an increase in artificial reproductive technology such as invitro fertilization could lead to increases in morbidity and possibly mortality; and that women are getting pregnant later in life. According to “A Mixed Bag,” women age 40 and older suffered maternal mortality at a rate of 41.8 deaths per 100,000 live births from 2007 to 2009.

“With increased age you’re at an increased risk for multiple health problems before and during pregnancy, like high blood pressure, diabetes,” Twogood said.

Another factor in increased maternal mortality may be an increase in Cesarean sections. Live births by Caesarean rose 40 percent in California from 2000 to 2010, according to the California Health Care Foundation report.

“If you think about the main reasons that would lead to mortality in a pregnant woman, pulmonary embolism is huge, and so is hemorrhage,” Wittenberg said. “And both of those things you’re at higher risk of after caesarean delivery.”

The disparities between African American women and the rest of population in relation to maternal mortality are difficult to explain, but professionals believe that the population is more susceptible to the potential causes of maternal mortality, such as lack of access to quality prenatal care and chronic disease.

“In general we don’t really know, but there’s a lot of theorized reasons as to why,” said Dr. Diana Ramos, Director of Reproductive Health of Maternal, Child, and Adolescent Health Programs for the Los Angeles County Department of Health, and an associate professor at the USC Keck School of Medicine.

While the increase in the maternal mortality in California since 1999 is alarming, successful steps have been taken to lower the rate in recent years.

According to the California Department of Public health, the maternal mortality rate for all women in California dropped to 9.2 deaths per 100,000 live births in 2010, and to 33.8 for African American women during a three year moving average from 2008 to 2010. While the numbers are still higher than they were in the late ‘90s, and the disparity remains, the declining numbers are a positive sign.

Dr. Shabbir Ahmad is the Director of the California Department of Public Health Center of Family Health’s Maternal, Child and Adolescent Health Program. He credits various programs implemented in recent years for the continuing decrease in maternal mortality, such as a partnership with the California Maternal Quality Care Collaborative. Toolkits created include looking at how to reduce non-medically necessary inductions and how to respond to hemorrhaging.

“I am hopeful as we move forward we’ll be seeing a better result,” Ahmad said. “My main concern is how we can reduce the gap between African Americans and other ethnic groups.”

The Los Angeles County Maternal Care Quality Improvement Project Implementation Guide was designed to provide public health departments with a guide to decrease obstetric hemorrhage.

“We took advantage of the electronic platform in which to disseminate all of the information and subsequent data has shown that there’s decrease in blood product transfusion in those hospitals that actually implemented it,” Ramos said.

The Institute for Maternal Fetal Health treats expectant mothers with a fetal anomaly. Patients receive top obstetrician care through USC and then Children’s Hospital steps in with care for the baby.

Wittenberg and Twogood see the key to the maternal mortality rate continuing to decline laying in better overall health.

“If patients are healthier before pregnancy, then the likelihood of having complications is a lot less,” Wittenberg said.

The areas highlighted have higher than average rates of breast cancer. Map courtesy of the California Breast Cancer Mapping Project.

By Leah Bartos
California Health Report

Though the exact causes of breast cancer remain a mystery, a new mapping study in California has brought researchers another step closer to unlocking answers.

By charting data on a hyper-local level, the California Breast Cancer Mapping Project of the Public Health Institute discovered significantly heightened rates of invasive breast cancer in four areas that had previously gone undetected. In the newly discovered areas of concern — the report stops short of calling them “cancer clusters” — researchers found the invasive breast cancer incidence to be 10 to 20 percent higher than the state average.

The four areas include swaths of the north and south San Francisco Bay Area, neighboring sections of east Ventura and west Los Angeles counties, and the southern portion of Orange County, spilling into a small part of Riverside County. The project used data reported to the California Cancer Registry from 2000 to 2008.

In the past, breast cancer rates had been calculated only on the county level. Eric Roberts, the lead author of the study, explained that the old method missed some significant pockets, as county boundaries are somewhat arbitrary when it comes to mapping disease.

“The idea is that we can think about areas of concern for invasive breast cancer in terms of areas that are smaller than counties or that cross county boundaries,” Roberts said.

Marin County — a relatively small, homogenous area — has long been known to have an elevated rate of breast cancer amongst its residents. But elsewhere in the Bay Area, leaders in breast cancer advocacy are not surprised by the new study results.

“It confirms what we know to be true anecdotally from the women we serve,” said Peggy McGuire, executive director of the Women’s Cancer Resource Center of Oakland. “We’ve all been aware for a long time of the higher incidence in Marin County, but this study points out that it’s really a Bay Area concern.”

In California, breast cancer is the most common type of cancer diagnosed in women — an average 26,300 new cases are diagnosed each year and account for 4,175 deaths annually.

While studying who is affected by breast cancer has great potential to help researchers understand the underlying causes, Roberts cautions that we should not jump to conclusions.

“The science is pretty clear that breast cancer comes from a mix of genetic and environmental and behavioral exposures, and that’s about all that it’s clear on,” he said. “We have no knowledge really of what that mix is.”

Roberts sees the mapping project as a starting point for further research — the geographical approach could be particularly useful in the search for possible environmental factors contributing to breast cancer development.

“There’s a really, really big caveat though,” Roberts said. “And that is that most scientists when they’re looking at environmental causes of breast cancer, they’re mostly interested in exposures that happened during puberty or in the child-bearing age.”

Still, Bay Area researchers will be taking a closer look at the environments where the high rates have been reported. Among them is Neena Murgai, an epidemiologist at the Alameda County Department of Public Health.

“It points toward looking at more factors in the social environment and in the health care system in the prevention efforts, as opposed to looking strictly at genetic factors,” Murgai said. “It clearly needs further investigation on the local level.”

Others, like Janice Barlow, say the new study calls for political action. Barlow, who is the executive director of Zero Breast Cancer in Marin County, has been at the forefront of the fight since 1994. She sees the potential for the new data to help mobilize people to demand answers.

“Just putting the information out I hope will activate people living in those communities to take that map and go to their supervisors or their public health department and say, ‘We want you to look into this. Why do we have a high incidence?’”

And whatever clues may be uncovered in other areas, she continued, will be in everyone’s best interest.

“I think this is a great opportunity. What you learn in Richmond and what you learn in Berkeley and elsewhere advances all our understanding of breast cancer.”