Progressive Gaming International Corporation (NASDAQ: PGIC) (“the Company”), a leading provider of diversified products and services used in the gaming industry worldwide, announced today that it plans to effect a one-for-eight reverse split of the authorized, issued and outstanding shares of the Company’s common stock after the close of trading on September 15, 2008. The Company is implementing the reverse stock split to maintain compliance with regulatory agencies, its recent financing transactions and NASDAQ listing requirements. Following the reverse stock split the Company will have approximately 10.8 million shares issued and outstanding, inclusive of 2.1 million shares issuable pursuant to the convertible note debenture with International Game Technology (“IGT”) and approximately 0.8 million shares issuable under option and warrant agreements. The preceding calculation does not include any contingent warrants or shares that may be issuable to Private Equity Management (“PEM”) and IGT. Following the reverse stock split, the number of total authorized shares of the Company’s common stock will be reduced to 12.5 million shares.

Separately, the Company announced that, since August 18, 2008, it has repurchased 139,300 shares of its common stock for total consideration of approximately $100,000 in open market transactions pursuant to the share repurchase plan initially authorized in 2002. Prior to August 18, 2008, the Company had approximately $1.5 million remaining under this share repurchase plan. Additional purchases may be made from time to time, as and when permissible under applicable securities law, in the open market at prevailing market prices, through 10b5-1 programs or in privately negotiated transactions. The timing and actual number of shares to be purchased will depend on market conditions and other factors. Purchases may be discontinued at any time.

About Progressive Gaming International Corporation(R)

Progressive Gaming is a trusted leader of enterprise gaming solutions and supplier of integrated casino and jackpot management systems for the gaming industry worldwide. This technology is widely used to enhance casino operations and drive greater revenues for existing products. Progressive Gaming is unique in the industry in offering casino management and progressive systems in a modular yet integrated solution. Products include multiple forms of regulated wagering solutions in wired, wireless and mobile formats. There are Progressive Gaming products in over 1,000 casinos throughout the world. For further information, visit www.progressivegaming.net.

(C)2008 Progressive Gaming International Corporation(R). All rights reserved.

Safe Harbor Statements under The Private Securities Litigation Reform Act of 1995: This release contains forward-looking statements, including statements regarding Progressive Gaming’s plans to effect a reverse stock split, maintaining compliance with various regulatory bodies and the repurchase of Progressive Gaming’s stock. Such statements are subject to certain risks and uncertainties, and actual circumstances, events or results may differ materially from those projected in such forward-looking statements. Factors that could cause or contribute to differences include, but are not limited to, the risk that the anticipated reverse stock split may not occur when anticipated, or at all, the risk that Progressive Gaming may not maintain compliance with Nasdaq listing requirements, Progressive Gaming’s ability to meet its capital requirements, the denial, suspension or revocation of privileged operating licenses by governmental and regulatory authorities, competitive pressures and general economic conditions as well as Progressive Gaming’s debt service obligations. For a discussion of these and other factors which may cause actual events or results to differ from those projected, please refer to Progressive Gaming’s most recent annual report on Form 10-K and quarterly reports on Form 10-Q, as well as other subsequent filings with the Securities and Exchange Commission. Progressive Gaming cautions readers not to place undue reliance on any forward-looking statements. Progressive Gaming does not undertake, and specifically disclaims any obligation, to update or revise any forward-looking statements to reflect new circumstances or anticipated or unanticipated events or circumstances.

MOUNTAIN VIEW, Calif., Sept. 2 /PRNewswire-FirstCall/ — Alexza Pharmaceuticals, Inc. today announced positive results from its first Phase 3 clinical trial of AZ-004 (Staccato(R) loxapine) in schizophrenic patients with acute agitation. Both the 5 mg and 10 mg doses of AZ-004 met the primary endpoint of the trial, which was a statistically significant reduction in agitation from baseline to the 2-hour post-dose time point, compared to placebo. AZ-004 is an inhalation product candidate being developed for the treatment of acute agitation in patients with schizophrenia or bipolar disorder. AZ-004 is being developed through Symphony Allegro, a product development partnership formed between Alexza and Symphony Capital, LLC.

“Alexza initiated the first Phase 3 clinical trial of our lead program in late February and completed enrollment in less than four months, and today we are reporting positive top-line results for the primary and secondary endpoints,” said James V. Cassella, PhD, Alexza Senior Vice President, Research and Development. “We believe that the ability to provide loxapine via our Staccato technology, thus combining a drug with a well-established mechanism of action with rapid absorption and patient self-administration, makes AZ-004 a potentially important new drug candidate for treating acute agitation.”

“The clinical data we have seen to date, in terms of both efficacy and side-effect profiles, are compelling,” said Michael H. Allen, MD, Director of Research, University of Colorado Depression Center. “There is a significant unmet medical need to treat acute agitation with new therapies that provide rapid onset of predictable effect and are delivered in a patient-friendly, non-invasive manner.”

Phase 3 Clinical Trial Design

The AZ-004 clinical trial enrolled 344 schizophrenic patients with acute agitation at 24 U.S. clinical centers. The trial was designed as an in-clinic, multi-center, randomized, double-blind, placebo-controlled study and tested AZ-004 at two dose levels, 5 mg and 10 mg. Patients were eligible to receive up to 3 doses of study drug in a 24-hour period, depending on their clinical status. Only one dose of study drug was allowed during the first 2 hours of the study period.

The primary endpoint for the study was the change from baseline in the PANSS (Positive and Negative Symptom Scale) Excited Component score (also known as PEC score), measured at 2 hours after the first dose. The key secondary endpoint was the Clinical Global Impression-Improvement (CGI-I) score, measured at 2 hours after the first dose. All results were considered statistically significant at the p

Primary Efficacy Endpoint

Both the 5 mg and the 10 mg dose of AZ-004 met the primary endpoint of the clinical trial, showing a statistically significant improvement in the 2-hour post-dose PEC score, compared to placebo.

                          PEC Scores (Mean Values)                                                        p-Value for Change                                                         from Baseline   Study Arm            Baseline    2-Hour Post-Dose      vs. Placebo   10 mg AZ-004    (n=112)               17.6           9.0               
 A Clinical Global Impression-Severity (CGI-S) scale rating of agitation was completed at baseline for each patient, prior to AZ-004 administration, to ensure comparability across groups.  The CGI-S scale ranges from 1 (normal) to 7 (among the most extremely agitated patients).  Scores were similar across the three dose groups with a range of 3.9 to 4.1. 
 In addition to the PEC score, the Clinical Global Impression-Improvement (CGI-I) is another commonly used scale to measure the reduction of agitation in patients over time, normally following therapeutic treatment.  The CGI-I standard scale ranges from 1 (very much improved) to 7 (very much worse).  At the 2-hour post-dose time point, a CGI-I scale rating was completed for each patient, which was the key secondary endpoint of the study.  Both the 10 mg and the 5 mg doses of AZ-004 showed statistically significant differences versus placebo in the CGI-I scores at the 2-hour post-dose time point. 
                         CGI-I Scores (Mean Values)    Study Arm                 2-Hour Post-Dose             p-Value   10 mg AZ-004 (n=112)           2.1                     
 The 10 mg dose of AZ-004 also exhibited a rapid onset of effect.  At 10 minutes post-dose, the 10 mg dose showed a statistically significant improvement in the PEC score (p 
 A dose response pattern for AZ-004 was also apparent, as measured by the need for a patient to require more than one dose of study drug by the 4-hour post-first dose time point.  Compared to the 44% of the placebo group that required more than one dose of the study drug, only 25% of the 10 mg group (p = 0.0039) and 32% of the 5 mg group (p = 0.085) required more than one dose of study drug. 
 A responder analysis was conducted using the CGI-I scale.  A responder was defined as having a CGI-I score at 2 hours after the first dose of either a 1 (very much improved) or 2 (much improved).  Both the 5 mg (57% responders; p = 0.0015) and 10 mg (67% responders; p 
 Safety Evaluations 
 Side effects were recorded throughout the clinical trial period.  The administration of AZ-004 was generally safe and well tolerated.  The most common side effects reported (> 10% in any treatment group) were taste (dysgeusia), dizziness, sedation and headache.  These side effects were generally mild to moderate in severity, and occurred in both drug and placebo dose groups. 
                      Treatment Emergent Side Effects                       (> 2% in any treatment group)                     Placebo             5 mg AZ-004       10 mg AZ-004   Term             (n=115)             (n=116)           (n=113)   Dysgeusia            3 %                9 %              11 %   Dizziness           10 %                5 %              11 %   Sedation            10 %               13 %              11 %   Oral    Hypoaesthesia       0 %                1 %               4 %   Headache            14 %                3 %               3 %   Somnolence           3 %                3 %               3 %   Nausea               5 %                1 %               2 %   Vomiting             3 %                1 %               1 %   Agitation            3 %                1 %               0 %     
 There were two serious adverse events reported during the trial: exacerbation of schizophrenia (1 patient in the placebo group) and gastroenteritis (1 patient in the 10 mg group).  Both of these events were scored by the investigator as "unrelated" to study drug. 
 The Agitation-Calmness Evaluation Scale (ACES) was recorded at baseline and at 2 hours after dosing, to determine the level of patient sedation. Baseline ACES scores were similar across the three patient groups.  Mean scores at 2-hours post-dose for the 5 mg and 10 mg AZ-004 groups were in the range of "normal" to "mild calmness". 
"These positive Phase 3 results, corroborating our Phase 2 findings, show that AZ-004 is a viable product candidate to treat acute agitation," said Thomas B. King, Alexza President and CEO.  "We are very encouraged with the pace at which we have developed into a Phase 3 company.  In addition to our clinical successes, we are aggressively escalating many commercialization activities, including our manufacturing scale-up, quality systems, regulatory affairs and commercial operations, as we continue to track toward our planned AZ-004 NDA submission in early 2010."
 Conference Call Information 
 Alexza will host a conference call later today, Tuesday, September 2, 2008 at 5:00 p.m. Eastern Time.  A replay of the call will be available for two weeks following the event.  The conference call and replay are open to all interested parties. 
 To access the live conference call via phone, dial 800-299-8538. International callers may access the live call by dialing 617-786-2902.  The reference number to enter the call is 39290605. 
 The replay of the conference call may be accessed via the Internet, at http://www.alexza.com/, or via phone at 888-286-8010 for domestic callers or 617-801-6888 for international callers.  The reference number for the replay of the call is 52049815. 
 About Acute Agitation 
 Acute agitation, characterized by unpleasant arousal, tension, irritability and hostility, is one of the most common and severe symptoms of many major psychiatric disorders, including schizophrenia and bipolar disorder.  According to the National Institute of Mental Health (NIMH), bipolar disorder affects about 5.7 million American adults while schizophrenia afflicts about 2.4 million people in the United States.  Market research among physicians and health-care providers indicates that over 90% of these patients will experience agitation during their lifetime and that about 70% of those who experience agitation will have one to six episodes per year. 
 Agitated patients are often treated in an emergency department, and are also treated as in-patients in psychiatric hospitals or psychiatric units in standard hospitals.  Market research among psychiatrists indicates that these physicians currently treat acute agitation with intramuscular (IM) injections, rapid-dissolve tablets or standard tablets.  IM injections are invasive, can be disconcerting to patients as they often require the use of restraints, and can be dangerous to the medical personnel while they attempt to inject the patient.  IM injections can also take up to 60 minutes to work.  Oral tablets provide convenience of dosing alternatives, but have a slower onset of action. This market research has also identified speed of onset as an important factor that affects the choice of therapy for treating acute agitation.  Alexza believes that many patients with schizophrenia or bipolar disorder can make informed decisions regarding their treatment in an acute agitated state and would prefer a rapid-acting, noninvasive treatment. 
 In summary, Alexza is developing AZ-004 to potentially offer an acute agitation treatment option that provides a fast onset of effect, that is noninvasive and safer to administer than injections, and that allows patients to be active participants in choosing acceptable treatment options. 
 About AZ-004 (Staccato loxapine) 
 AZ-004 is the combination of Alexza's proprietary Staccato system with loxapine, a drug belonging to the class of compounds known generally as antipsychotics.  The Staccato system is a hand-held, chemically-heated, single dose inhaler designed to generate and deliver excipient-free drug aerosol for deep lung delivery that results in IV-like pharmacokinetics.  Alexza has completed four clinical trials with AZ-004  and has announced positive results from all four studies, including a 50 subject Phase 1 study in healthy volunteers, a 129 patient Phase 2 study in agitated schizophrenic patients, a 32 patient multiple-dose tolerability and PK study in non-agitated schizophrenic patients, and a 344 patient Phase 3 study in agitated schizophrenic patients.  In July 2008, Alexza initiated a second Phase 3 clinical trial in bipolar disorder patients with acute agitation. 
 About Symphony Allegro 
 In December 2006, Alexza entered into a collaboration with Symphony Capital LLC, a biotech-focused private equity firm.  Under the terms of the agreement, Alexza and Symphony Capital established Symphony Allegro, Inc., which is providing funding to Alexza to accelerate clinical and other related development activities of Staccato loxapine (AZ-004 and AZ-104) and Staccato alprazolam (AZ-002).  Alexza has granted a license to certain intellectual property rights for the selected product candidates.  Through a purchase option, Alexza retains the exclusive right, but not the obligation, to acquire 100% of the equity of Symphony Allegro at specified prices during the term of the agreement.  If Alexza chooses not to exercise the purchase option, Symphony Allegro retains the rights to the product candidates.  The purchase option expires December 1, 2010. 
 About Alexza Pharmaceuticals, Inc. 
 Alexza Pharmaceuticals is an emerging specialty pharmaceutical company focused on the development and commercialization of novel, proprietary products for the treatment of acute and intermittent conditions.  The Company's technology, the Staccato system, vaporizes unformulated drug to form a condensation aerosol that allows rapid systemic drug delivery through deep lung inhalation.  The drug is quickly absorbed through the lungs into the bloodstream, providing speed of therapeutic onset that is comparable to intravenous administration, but with greater ease, patient comfort and convenience. 
 Alexza has five product candidates in clinical development.  Alexza's lead program, AZ-004 (Staccato loxapine) for the treatment of acute agitation in schizophrenic or bipolar disorder patients, has completed one Phase 3 clinical trial and the second Phase 3 clinical trial ongoing.  For the acute treatment of migraine headaches, AZ-001 (Staccato prochlorperazine) has completed Phase 2 testing and AZ-104 (Staccato loxapine) is in Phase 2 testing.  Product candidates in Phase 1 testing are AZ-003 (Staccato fentanyl) for the treatment of breakthrough pain, which is partnered with Endo Pharmaceuticals in North America, and AZ-007 (Staccato zaleplon) for the treatment of insomnia.  More information, including this and past press releases from Alexza, is available online at http://www.alexza.com/. 
 Safe Harbor Statement 
 This press release includes forward-looking statements regarding the development, therapeutic potential, efficacy and safety of AZ-004.  Any statement describing a product candidate or Alexza's goals, expectations or beliefs is a forward-looking statement, as defined in the Private Securities Litigation Reform Act of 1995, and should be considered an at-risk statement. Such statements are subject to certain risks and uncertainties, particularly those inherent in the process of developing and commercializing drugs.  The Company's forward-looking statements also involve assumptions that, if they prove incorrect, would cause its results to differ materially from those expressed or implied by such forward-looking statements.  These and other risks concerning Alexza's business are described in additional detail in the Company's Annual Report on Form 10-K for the year ended December 31, 2007, and the Company's other Periodic and Current Reports filed with the Securities and Exchange Commission including the risks under the headings: "Failure or delay in commencing or completing clinical trials for our product candidates could harm our business" and "If our product candidates do not meet safety and efficacy endpoints in clinical trials, they will not receive regulatory approval, and we will be unable to market them".  Forward-looking statements contained in this announcement are made as of this date, and the Company undertakes no obligation to publicly update any forward-looking statement, whether as a result of new information, future events or otherwise.  
 Alexza Pharmaceuticals, Inc. 
 CONTACT:  Thomas B. King, President & CEO of Alexza Pharmaceuticals,Inc., +1-650-944-7634, [email protected] 
 Web site:  http://www.alexza.com/

FORT BELVOIR, Va., Sept. 2 /PRNewswire-USNewswire/ — As local, state and federal agencies took steps to support the nearly two million residents fleeing the path of Hurricane Gustav this weekend, Defense Logistics Agency employees were busy getting food, fuel and health kits to staging areas determined by the Federal Emergency Management Agency.

DLA met FEMA’s request for humanitarian support by providing 2.33 million Meals, Ready to Eat and nearly 1,000 health kits. More than 130,000 of the meals went to National Guard members activated to assist local authorities with security efforts. And each health kit provided by DLA was packed with enough supplies to support 10 people for 30 days.

The Defense Energy Support Center also sent 15,000 gallons of ultra-low sulfur diesel and 5,300 gallons of unleaded gasoline to a FEMA staging area in Carville, La.

Interagency coordination with such agencies as FEMA and the U.S. Northern Command began as early as last Wednesday, according to Air Force Maj. Felix Cruz-Montanez, an operations officer for DLA’s Joint Logistics Operations Center at Fort Belvoir, Va.

“We alerted our field activities early on that there would be a potential for extended operations, that we might have to provide support for Gustav,” he said.

Through an interagency agreement with FEMA, DLA provides commodities needed for humanitarian assistance both in the United States and overseas. FEMA requests are first given to DLA’s JLOC, which forwards them to supply centers.

“FEMA tells us what they need, where and on what date. We then send that information to the Defense Supply Center Philadelphia and the Defense Distribution Center at the same time so they can start making preparations,” said Cruz-Montanez.

FEMA preorders MREs from DLA each year, and DLA stores them at distribution centers throughout the country until needed.

“In this instance, we shipped a lot of MREs from our facilities in Kansas City, Mo., and Albany, Ga.,” said Cruz-Montanez. “We sent most of them to logistics staging areas or FEMA warehouses near the action so FEMA could move them out quickly.”

The JLOC sprung into 24/7 operations on Saturday. In addition to providing MREs, fuel and health kits, the JLOC staff answered requests for information on tents, cots, blankets, additional health and comfort packs, and mortuary affairs items.

“A lot of these information requests were just so we’d know what was in stock in case more support was needed,” he said.

Gustav was this season’s strongest hurricane to hit the United States. The next major hurricane — Hanna — is expected to hit the United States by week’s end.

“We’re already watching that one. A lot of what we’ll provide depends on the strength of the hurricane,” said Cruz-Montanez, stressing that DLA’s support goes to victims as well as members of task forces providing emergency and recovery operations.

DLA provides supply support, and technical and logistics services to the U.S. military services and several federal civilian agencies. Headquartered at Fort Belvoir, Va., the agency is the one source for nearly every consumable item, whether for combat readiness, emergency preparedness or day-to-day operations. More information about DLA is available at http://www.dla.mil/.

Defense Logistics Agency

CONTACT: DLA Public Affairs, +1-703-767-6200, [email protected]

Web Site: http://www.dla.mil/

DEAR DR. DONOHUE: Everything I read or hear about macular degeneration is always about dry macular degeneration. I happen to have the wet kind, and would like to know what its treatments are. I’ve heard that vitamins work. Do they? Thank you. – T.R.

ANSWER: In the well-off countries of the world, macular degeneration is the leading cause of blindness in people over 50. There are two varieties, wet and dry. The dry kind is the more common of the two, accounting for 85 percent to 90 percent of all macular degeneration cases. Both involve deterioration of the macula, a small circle on the retina, jam-packed with vision cells necessary for high-resolution sight like reading, watching TV, distinguishing faces and driving. Wet macular degeneration comes from a sudden proliferation of fragile blood vessels blossoming in and around the macula. Those vessels leak fluid and blood, and disrupt that sensitive area of sight.

Wet macular degeneration often comes on quickly and can progress rapidly.

You might have heard of the vitamin-mineral mixture used for slowing the progression of macular degeneration. It consists of vitamins C and E, beta-carotene and the minerals zinc and copper. It is much more useful for dry macular degeneration. For wet macular degeneration, eye doctors can inject the eye with medicines that stop the generation and growth of new, delicate blood vessels. Lucentis and Avastin are two examples. Photodynamic therapy is another method of handling wet degeneration. Here, a drug that is sensitive to light is injected into a blood vessel. The drug localizes in the newly formed, fragile, troublemaking macular vessels. A laser is flashed on those vessels and they dry up.

I don’t know if your doctor has suggested any treatment. It may be that you’re not at a stage when therapy would provide the most benefit.

DEAR DR. DONOHUE: I need your advice. I had a mastectomy in 1981, and it was followed with chemotherapy and radiation. Three years ago, I had ovarian cancer. I also have osteoporosis, and I recently fractured a foot bone that has not yet healed. A nutritionist advised I take vitamin D and vitamin K. I don’t know why I need vitamin K. Do I? – S.F.

ANSWER: For years, vitamin K’s principal action was believed to be only in its involvement with blood clotting. In the past few years, researchers have learned that vitamin K plays an important part in maintaining bone health.

Vitamin K comes in two forms: one called menaquinone-4 and the other, phylloquinone. The menaquinone-4 type is the one that does the most for bones.

With your history, vitamin K would be a great benefit.

DEAR DR. DONOHUE: In my 58 years, I never have had any problem with my scalp. My hair has turned a salt-and-pepper color. Due to vanity, I have been coloring it for the past several years. I have never experienced any problems. Recently I have had a rash of pimples forming on my scalp at the hair shaft. They hurt when the scalp is touched or the hair brushed. I had a good friend look at my scalp with a magnifying glass, and he says they look like small pimples. He removed a hair with tweezers and a small discharge came out of the pimple. I am considering letting my hair grow back to its natural color to see if the dye has anything to do with this. Any suggestions? – N.N.

ANSWER: I like your approach. The dye might be irritating your scalp, and the hair follicles might have become infected secondary to the irritation. If things don’t clear up after going dyeless for a couple of months, have a doctor take a look. You might need an antibiotic prescription.

DEAR DR. DONOHUE: I lost vision in my left eye years ago due to a brain tumor. Now I see flashing colors off to one side in my right eye. The eye doctor said it is caused by an aura. Please explain what an aura is. I can’t find it in any of my books. – P.K.

ANSWER: In medicine, an aura (OR-uh) is a warning sign.

The condition where an aura is most often found is migraine headache. About 15 percent of people who get such headaches experience a warning that the headache is about to occur. They see a C-shaped jagged line off to one side of their vision, and often, it is multicolored and flashing. It lasts anywhere from 20 to 25 minutes, and then the headache strikes.

A few people have the aura without getting the headache. Then the aura is called a migraine equivalent.

Dr. Donohue regrets that he is unable to answer individual letters, but he will incorporate them in his column whenever possible. Readers may write him or request an order form of available health newsletters at P.O. Box 536475, Orlando, FL 32853- 6475.

(c) 2008 Sun-Journal Lewiston, Me.. Provided by ProQuest LLC. All rights Reserved.

U.S. HealthWorks Medical Group today announced the acquisition of five (5) medical and physical therapy centers in the Greater San Diego, California area. The medical centers include American Occupational Medicine (AOM) in Carlsbad and Industrial Family Medical Care centers in Escondido and Murrieta. The physical therapy centers include Palomar Airport Physical Therapy in Carlsbad and Murrieta Valley Physical Therapy and Hand Rehabilitation in Murrieta. U.S. HealthWorks Medical Group is a leading operator of occupational healthcare centers in the nation.

The medical centers in Escondido and Murrieta are full-service, walk-in centers offering both occupational medicine and urgent care services; the Carlsbad center is a dedicated occupational medicine facility. All three centers offer the full spectrum of occupational medicine needs, including injury and illness diagnosis and treatment, preventive services, pre-placement and post-offer exams and testing, physical therapy, return-to-work programs and orthopedic services. Terms of the transaction were not disclosed.

Laurie Pierce, M.D., Medical Director of Carlsbad AOM, said, “Our physician group is excited about this partnership as U.S. HealthWorks has an outstanding reputation in the San Diego market, and we’re pleased to be part of this professional organization.”

Leonard Okun, M.D., National Medical Director for U.S. HealthWorks stated, “We are looking forward to adding three strong operations to our twelve centers in the San Diego area. The physicians at these centers are all staying on board with us, which will ensure a smooth transition of services for our clients and patients.”

“AOM and U.S. HealthWorks clients will both benefit by this alliance, which allows more access by clients and patients to quality medical care in the San Diego community,” said Therese Hernandez, Senior Vice President and General Manager of U.S. HealthWorks in California.

U.S. HealthWorks now operates 62 medical centers in California.

About U.S. HealthWorks Medical Group

Based in Valencia, California, U.S. HealthWorks Medical Group was founded in 1995 and is the largest operator of occupational health care centers in the state of California. With 116 centers in 13 states and 2,400 employees — including approximately 350 affiliated physicians — U.S. HealthWorks centers serve more than 10,000 patients each day throughout the country. U.S. HealthWorks centers help employers control work-related injury costs through quality medical care and effective management of claims and lost work time. They specialize in early return-to-work programs, injury prevention and wellness programs.

For more information, visit www.ushealthworks.com.

The telephone numbers of the U.S. HealthWorks centers are:

Carlsbad East: 760-929-8269, Escondido South: 760-740-0707, Murrieta: 951-600-9070.

Arizona Physicians IPA (APIPA) and Yuma Regional Medical Center (YRMC) in today announced an agreement that will provide beneficiaries of Arizona’s Children’s Rehabilitative Services program (CRS) with access to YRMC’s full range of services and its 250 physicians.

Bill Hagan, CEO of APIPA, which was awarded a contract by the State to manage the CRS program beginning next October 1, said, “We are pleased that CRS beneficiaries and their families in Yuma and southwestern Arizona will continue to have access to the services provided by Yuma Regional Medical Center. APIPA and Yuma Regional Medical Center are committed to high quality health care and comprehensive services to the vulnerable population served by the CRS program.”

Pat Walz, YRMC chief financial officer, said, “Because of our distance from Phoenix and Tucson, it is vital that CRS provide services within our community so that families do not have to travel out of town to get the care they need for their children. We are pleased to partner with APIPA to be able to continue to bring this clinical service to our youngsters in the community.”

Joan Agostinelli, Administrator of the CRS program, said, “We are pleased that CRS members will continue to be able to receive care from the doctors that they have come to know through Yuma Regional Medical Center. ADHS looks forward to working with both APIPA and Yuma Regional Medical Center in continually improving the system of care for children and youth with special health care needs.”

About APIPA

APIPA, a unit of AmeriChoice, a UnitedHealth Group company, has served the needs of medically underserved Arizonans since 1982, including beneficiaries of the State’s AHCCCS program and other government sponsored program such as Medicare Advantage Special Needs Plans, developmentally disabled, premium share and Medicaid in the Public Schools. APIPA currently serves nearly 280,000 AHCCCS members, many with unique or complex health conditions. In addition, it has 14,200 Medicare Special Needs Plans members and more than 9,600 Developmentally Disabled (DD) individuals through its contract with the Arizona Department of Economic Security/Division of Developmentally Disabled.

About Yuma Regional Medical Center

Yuma Regional Medical Center is a not-for-profit, full-service 333-bed acute care hospital. About 2,000 employees and more than 250 physicians join to create a health center unparalleled for a city the size of Yuma. YRMC features a Women and Children Services Center; a Level 2 EQ neonatal ICU. The Cullison Cardiac Care unit for open heart surgery patients is part of our 42-bed Intensive Care Unit. Our Heart Center provides the latest in interventional cardiology procedures, such as heart and peripheral stenting and pacemaker implantation.

About Children’s Rehabilitative Services

The Children’s Rehabilitative Services program (CRS) is administered by the Arizona Department of Health Services, Office for Children with Special Health Care Needs (OCSHCN). The mission of CRS is to improve the quality of life for children and youths up to age 21 with special health care needs by providing family-centered medical treatment, rehabilitation, and related support services.

Research and Markets (http://www.researchandmarkets.com/research/f0d42d/cns_drug_discoveri) has announced the addition of the “CNS Drug Discoveries: Multiple Sclerosis Chapter” report to their offering.

This chapter of CNS Drug Discoveries focuses on the multiple sclerosis market.

With the launch of up to 12 new disease-modifying agents, three vaccines and one novel drug designed to treat the symptoms of multiple sclerosis (MS) and improve quality of life, the MS market is in an exciting phase of evolution.

The MS market is estimated to be worth almost US$8 billion in 2008, with a growth rate of 10.6% year-on-year. It is the fifth largest segment of the CNS markets considered in this report and has attracted considerable R&D investment from the big pharmaceutical companies, biotechnology companies and specialty pharma.

Over the next six years a number of oral agents are expected to be launched that could drastically change the way in which MS patients are treated. These include: Novartis’ fingolimod, Teva’s laquinimod, Merck KGaA’s Mylinax (cladribine), sanofi-aventis’ teriflunomide and Biogen Idec’s BG-12 in Phase III development, and GSK/Mitsubishi Tanabe Pharma’s firategrast, MediciNova’s ibudilast and Biogen/UCB’s CDP323 in Phase II development.

Three companies have taken on the ambitious task of developing vaccines to treat MS and each has adopted a unique approach to addressing the underlying causes of the disease. Orchestra Therapeutic’s NeuroVax targets three proteins expressed on T-cell receptors whilst Opexa Therapeutics’ Tovaxin uses attenuated autologous cells to stimulant an immune response. Bayhill Therapeutics is developing BHT-3009, a tolerising DNA vaccine. All vaccines are in Phase II development and could reach market by 2012.

Key MS questions answered:

— What is the estimated global population for MS in 2014 and what % will be diagnosed and treated?

— Which off-patent MS treatments are resistant to generic competition?

— Will Biogen Idec, Teva and Merck KGaA be able to defend their leading positions in 5 years time?

— There are 7 late-phase pipeline products which target the underlying cause of MS – what are their strengths and weaknesses?

 Key Topics Covered:  - EXECUTIVE SUMMARY - THE FACTS - PATIENT STATISTICS - PATIENT MODEL - DRUG GROWTH DRIVERS - DRUG GROWTH RISKS/DAMPENERS - THE MS MARKET - CURRENT MS TREATMENTS - GLOBAL SALES FORECASTS OF CURRENT TREATMENTS 2007A-2014E - ANALYSIS OF PHASE III DRUGS - GLOBAL SALES FORECASTS OF PHASE III MS DRUGS 2009E-2014E - ANALYSIS OF PHASE II DRUGS - GLOBAL SALES FORECASTS OF PHASE II MS DRUGS 2011E - 2014E - COMPETITOR RATIO ANALYSIS - COMPETITOR RATIO ANALYSIS - PRODUCTS - COMPETITOR RATIO ANALYSIS - COMPANIES - WINNERS & LOSERS - DISCONTINUATION OF DRUGS - MS GLOSSARY - MS REFERENCES - ACRONYMNS  Key Products Analysed and Forecast:  - BG-12 - Biogen Idec - Campath - Bayer - Fingolimod - Novartis - Lacquinimod - Teva - MBP 8298 - BioMS/Lilly - Mylinax - Merck KGaA - Teriflunomide - sanofi-aventis - Neurelan - Elan/Acorda 

For more information visit http://www.researchandmarkets.com/research/f0d42d/cns_drug_discoveri

Source: Espicom Business Intelligence Ltd

CUPERTINO, Calif., Sept. 2 /PRNewswire/ — Novare Surgical Systems announced the successful completion of a series of single port Lap-Band procedures that results in reduced scarring and less postoperative pain for patients. Dr. Julio Teixeira at St. Luke’s-Roosevelt Hospital has pioneered an innovative approach that allows for the entire Lap-Band procedure to be performed exclusively through the patient’s belly button and he is believed to be the first surgeon to successfully do so. Dr. Teixeira uses RealHand HD instruments to enable the procedure and his approach eliminates an upper abdominal trocar placement that is often a site for significant patient discomfort.

“This is a major step toward reducing pain and recovery time for bariatric patients,” said Dr. Teixeira. “By reducing the operative site to one single incision in the belly button we are also able to significantly improve cosmetic results for our patients,” continued Dr. Teixeira. “The dexterity and control afforded by the RealHand HD instruments now opens the door for single port lap band procedures to be done safely and effectively through one single incision.”

“Dr. Teixeira’s impressive accomplishment represents a potential shift in the way gastric banding procedures will be performed,” said Kerry Pope, Novare Surgical’s President and Chief Executive Officer. “Offering patients a path to less pain and scarring is clearly an advancement and the access that RealHand provides is a cornerstone of this innovation.”

The Lap-Band Adjustable Gastric Banding System (manufactured by Allergan Inc.) is a silicone band that is surgically placed to reduce the amount of food a patient can hold in his or her stomach. The band helps patients control food intake and supports long term, sustainable weight loss. Although this procedure is performed laparoscopically, it typically requires at least five abdominal incisions.

Single Port laparoscopy is an advanced minimally invasive approach in which the surgeon operates exclusively through a single entry point, typically the patient’s belly button. All of the instruments necessary for the surgery are used through this single incision. After surgery, the scar is almost completely hidden inside the belly button.

About RealHand(R) High Dexterity (HD) Instruments for Minimally Invasive Surgery

RealHand HD instruments are the very first full range of motion hand-held laparoscopic instruments. RealHand technology is designed to mirror the surgeon’s hand direction with the added benefit of tactile feedback. As such, when the surgeon’s hand moves in one direction, the instrument tip exactly follows.

Unlike standard laparoscopic instrumentation, RealHand offers complete 7 degrees of freedom of movement in a hand-held instrument and with no need for additional hardware. Moreover, RealHand will enable surgeons to perform more difficult maneuvers that otherwise cannot be completed with traditional rigid instruments. RealHand HD instruments make it easy to actively manipulate and complete tasks regardless of whether the instrument is positioned over, under, or around structures.

RealHand HD instruments provide for greater dexterity and control around critical structures and vasculature. The increase in range of motion is leading the way in the development of new surgical approaches and techniques. RealHand instruments have received FDA 510(k) clearance and the CE mark.

About Novare Surgical Systems

Based in Cupertino, Calif., Novare Surgical Systems was originally founded in 1999. RealHand was developed entirely at Novare Surgical and represents a shift in the company’s focus toward devices for minimally invasive surgery. For more information, visit the company’s web site at http://www.novaresurgical.com/.

Novare Surgical Systems Inc.

CONTACT: Kerry Pope, President and CEO of Novare Surgical Systems Inc.,+1-408-873-3161, [email protected]

Web site: http://www.novaresurgical.com/

BIRMINGHAM, Ala., Sept. 2 /PRNewswire-FirstCall/ — HealthSouth Corporation has finalized its previously announced acquisition of a 38-bed inpatient rehabilitation hospital in Midland, Texas. The hospital was owned by RehabCare Group of Midland, L.P. The hospital’s operations will relocate to HealthSouth Rehabilitation Hospital of Midland/Odessa.

“We have provided high-quality services to the Midland/Odessa market since 1993 and, with the closing of this transaction, continue our commitment to expand the reach of HealthSouth’s services,” said Jay Grinney, HealthSouth’s president and chief executive officer. “We look forward to serving more patients in this area.”

HealthSouth operates 14 rehabilitation hospitals throughout Texas. Accredited by The Joint Commission, HealthSouth’s inpatient rehabilitation hospitals provide a higher level of rehabilitative care to patients who are recovering from stroke and other neurological disorders, brain and spinal cord injury, amputations, orthopedic, cardiac and pulmonary conditions.

About HealthSouth

HealthSouth is the nation’s largest provider of inpatient rehabilitation services. Operating in 26 states across the country and in Puerto Rico, HealthSouth serves more than 250,000 patients annually through its network of inpatient rehabilitation hospitals, long-term acute care hospitals, outpatient rehabilitation satellites, and home health agencies. HealthSouth strives to be the health care company of choice for its patients, employees, physicians and shareholders and can be found on the Web at http://www.healthsouth.com/ .

Statements contained in this press release which are not historical facts are forward-looking statements. In addition, HealthSouth, through its senior management, may from time to time make forward-looking public statements concerning the matters described herein. All such estimates, projections, and forward-looking information speak only as of the date hereof, and HealthSouth undertakes no duty to publicly update or revise such forward-looking information, whether as a result of new information, future events, or otherwise. Such forward-looking statements are necessarily estimates based upon current information and involve a number of risks and uncertainties. HealthSouth’s actual results may differ materially from the results anticipated in these forward-looking statements as a result of a variety of factors. While it is impossible to identify all such factors, factors which could cause actual results to differ materially from those estimated by HealthSouth include, but are not limited to, any adverse outcome of various lawsuits, claims, and legal or regulatory proceedings that may be brought against us or any adverse outcome relating to the settlement of the federal securities class action previously disclosed by us; significant changes in HealthSouth’s management team; HealthSouth’s ability to continue to operate in the ordinary course and manage its relationships with its creditors, including its lenders, bondholders, vendors and suppliers, employees, and customers; changes, delays in, or suspension of reimbursement for HealthSouth’s services by governmental or private payors; changes in the regulation of the healthcare industry at either or both of the federal and state levels; competitive pressures in the healthcare industry and HealthSouth’s response thereto; HealthSouth’s ability to obtain and retain favorable arrangements with third-party payors; HealthSouth’s ability to attract and retain nurses, therapists, and other healthcare professionals in a highly competitive environment with often severe staffing shortages; general conditions in the economy and capital markets; and other factors which may be identified from time to time in the Company’s SEC filings and other public announcements, including HealthSouth’s Form 10-K for the year ended December 31, 2007.

Media Contact

Andy Brimmer, 205-410-2777

HealthSouth Corporation

CONTACT: Andy Brimmer for HealthSouth Corporation, +1-205-410-2777

Web site: http://www.healthsouth.com/

Human Arc, a best practices leader in reimbursement and revenue enhancement services for hospitals and health plans, has been named for the seventh time as a NorthCoast 99 Award recipient.

The program began in 1999 and is presented by the Employers’ Resource Council, Northeast Ohio’s leading professional organization dedicated to HR programs and services. The annual recognition honors 99 workplaces for top talent in Northeast Ohio. NorthCoast 99 workplaces excel in attracting, retaining and motivating top performers through a foundation of organizational policies and practices that support the fundamental needs of great talent. The NorthCoast 99 specifically examines policies and practices that address seven workplace characteristics: flexibility, opportunity, recognition, development, security, support, and talent integrity.

“We’re proud to continue to be recognized among the NorthCoast 99,” stated Jeff Markle, Human Arc President and Chief Operating Officer. “Each year, we place major focus on our associates to ensure they have the right environment, proper tools and positive encouragement to be successful in their jobs and personal careers. Our clients and their patients and members deserve nothing less.”

North Coast 99 sponsors include Anthem Blue Cross and Blue Shield, CareerBoard.com, CareerCurve, Cinecraft Productions, the Cleveland Society for Human Resource Management, FirstMerit Bank, Inside Business Magazine, JumpStart, the Northeast Ohio Human Resource Planning Society, The Oswald Companies, Real Living Relocation Management, Staffing Solutions Enterprises, WVIZ/PBS and 90.3 WCPN Ideastream(SM).

Human Arc

Established in 1984, Cleveland, Ohio-based Human Arc employs hundreds of professionals across many states to serve hospitals and healthcare systems with self-pay reimbursement-related services (including the company’s Eligibility Enrollment Service(SM), Disproportionate Share Services(SM), Denial Management Solutions(SM) and Claims Management Service(SM)) as well as the technology to help healthcare providers manage their own in-house self-pay eligibility/enrollment efforts. Human Arc also provides innovative revenue enhancement solutions to managed care health insurers, including specialized PremiumAssist(SM) Dual Eligibility and Part D Solutions(SM) Services to Medicare Advantage, prescription drug and special needs health plans, as well as Best Benefits(SM) Supplemental Security Income enrollment assistance to qualified Medicaid managed plan members and Medicare Conversion Services to commercial small business group plans. Human Arc helps clients optimize their fiscal health in the marketplace while improving access to healthcare and quality-of-life benefits. For more, please visit the company’s web site, www.humanarc.com.

 Contact: Mary Jayne Reedy Vice President, Corporate Marketing Email Contact (216) 431-5200  

SOURCE: Human Arc

MIAMI and PALM BEACH, Fla., Sept. 2 /PRNewswire/ — September is Prostate Cancer Awareness Month, and the CyberKnife Centers of Miami and Palm Beach announce a revolutionary new way to treat prostate cancer without surgery and long treatment courses of radiation. Prostate cancer is the most common form of cancer affecting men in the US.

Morse CyberKnife CEO, James G. Schwade, M.D., says, “for many cases that are diagnosed early on, CyberKnife radiosurgery may be highly effective without invasive, debilitating surgery or long courses of radiation.”

CyberKnife is image guided robotic radiosurgery that precisely targets a lesion or tumor and delivers an intense dose of radiation to a very small area killing the cancer cells within.

   The CyberKnife treats prostate cancer in the following manner:   -- Outpatient status   -- Non-invasive   -- Less pain and side effect than most alternatives   -- Complete treatment in 3-5 visits, each usually no longer than 1.5 hrs   -- Minimum radiation to surrounding normal areas    

It is the mission of the Morse CyberKnife Centers to make the technology an option available to all cancer patients who might benefit. For more information please visit http://www.morsecyberknife.com/ or call 1-800-279-2900.

Morse CyberKnife

CONTACT: Susan Nefzger, Susan Nefzger PR & Web Marketing,+1-561-632-9525, for Morse CyberKnife

Web site: http://www.morsecyberknife.com/

By Madelyn Pennino

Students at Millersville University won’t have access to around- the-clock health care for the fall semester and maybe longer.

Hours at the school health services center have been cut to run the center more efficiently, according to Aminta Breaux, MU’s vice president of student affairs.

Health center hours will be Monday through Friday from 8 a.m. to 9 p.m., and Saturday from 10 a.m. to 6 p.m.

In the spring, a task force made up of students, staff and community organizations reviewed the concept of health services, said Holly Freas-Webster, MU’s nursing supervisor.

Freas-Webster said the task force decided the health center could serve more people if it operated on a limited basis and by appointment only.

“It was mobbed every day. By moving the night nurse to the day, we will be able to serve students better and decrease the waiting time,” Freas-Webster said. “I think it will be more efficient for students.”

Health Services is in Witmer Infirmary on McCollough Street.

The university also is searching for a medical director to replace longtime medical director Dr. James Heffern, who died in April.

Breaux said reducing hours wasn’t an easy decision.

“Our goal is to provide a high standard of care. The loss of our medical director and staffing issues that limit overnight coverage to one nurse made it necessary to make changes.”

The health center employs five registered nurses, one nurse practitioner and a part-time doctor. There will be no layoffs as a result of the new hours.

About 12,000 students visited the health center last year, Freas- Webster said.

On a weekly basis, Freas-Webster said, 70 to 75 students visit the health center on average, except during the height of flu season.

When the clinic was open 24 hours a day, Freas-Webster said, nights would pass when no students visited it.

“I think there are some advantages to having 24-hour care,” Shannon Farrelly, the university’s student senate president, said. “But most of the time when someone needs care late at night, they need to go to the emergency room anyway.”

Freas-Webster said the new hours reflect realities beyond the campus. “It’s how the real world operates,” she said. “We’re an educational institution, so it seems right.”

Freas-Webster also said keeping a nurse overnight created security issues.

“We were concerned for the safety of staff and of the students,” Freas-Webster said. “In the middle of the night a student might have a medical issue a nurse may not be able to treat,” Freas-Webster said. “There also were some other things that were not appropriate.”

For example, Breaux said, students who visited the health center with high blood-alcohol-content levels.

“We just don’t have the necessary equipment to deal with that situation,” Breaux said. Usually these students are transported to Lancaster General Hospital.

The new hours have been in place for a week.

“We’re in a trial phase,” Freas-Webster said. “We’ll see what happens.”

So far, Farrelly said, students have expressed mixed feelings about the hours changing.

“For freshmen, it’s not anything different because they don’t know anything else,” Farrelly said. “Some students haven’t said too much. Others are upset, and with good reason, because they are paying for the services.”

A full-time undergraduate student pays a fee of $94.50 a semester for health services.

Farrelly said student focus groups are being organized to evaluate whether the health center should resume 24-hour-a-day operations.

Breaux said she also hopes to hear from hospital officials and police to see how the new hours are affecting their operations.

“It’s a wait-and-see situation,” Breaux said.

(c) 2008 Intelligencer Journal. Provided by ProQuest LLC. All rights Reserved.

Pregnancy can completely change the shape and tone of a woman’s stomach and breasts, and many women yearn for a sleek and trim silhouette after giving birth. Many women cannot lose the loose skin and fat from the abdominal area after pregnancy; however, tummy tucks and liposuction procedures are helping hundreds of women enjoy a trim and sculpted silhouette after the days of pregnancy are over. Dr. Zarrabi, a leading Santa Monica cosmetic surgeon offers the ‘Mommy Makeover’ at his exclusive Santa Monica plastic surgery center, catering to hundreds of women searching for body contouring procedures.

Mommy makeovers have become increasingly popular in recent years as more women forego traditional methods of losing weight and toning up and turn to plastic surgery instead. Dieting and exercise don’t always help in getting rid of excess pregnancy weight, and body contouring is an attractive solution for many women who want a dramatic change in their appearance. The Mommy Makeover is a set of procedures designed to lift, tighten, tone and firm up any loose skin resulting from pregnancy, and can also help sculpt and contour the body so that it appears more youthful and attractive.

Key procedures that make up the Mommy Makeover include tummy tucks, breast augmentation, breast lifts, liposuction, cellulite removal, stretch mark removal and skin rejuvenation. Dr. Zarrabi offers all of these key procedures at his exclusive plastic surgery center in Santa Monica, and has become a leader in Santa Monica cosmetic surgery procedures, and has a growing track record of success. Dr. Zarrabi ensures all patients receive a customized, personalized approach for any procedure they are interested in, and those pursuing the Mommy Makeover can take advantage of several safe and effective procedures for a complete transformation.

About Dr. Zarrabi

Dr. Michael Zarrabi (www.drzarrabi.com) is a Board Certified Plastic and Reconstructive Surgeon. He has built his career to become a leader in Santa Monica cosmetic surgery services, and specializes in all aspects of facial rejuvenation, body contouring, breast augmentation and skin reduction. As a top Santa Monica cosmetic surgeon, Dr. Zarrabi offers personalized treatments so that teach patient can experience individualized operative care for their specific needs.

 MEDIA CONTACT: Joshua Pourgol Email Contact (310) 858-5557  

SOURCE: Dr. Michael Zarrabi

PALO ALTO, Calif., Sept. 2 /PRNewswire-FirstCall/ — CV Therapeutics, Inc. announced today that the company has enrolled the first patient in a Phase 1 trial of CVT-3619, a novel oral compound for potential treatment of cardiometabolic diseases. The U.S. Food and Drug Administration recently accepted the Company’s investigational new drug application for CVT-3619, a partial A1 adenosine receptor agonist.

This Phase 1 trial will assess the safety and pharmacokinetic profile of CVT-3619 in healthy volunteers. The Phase 1 program will provide early data on the compound’s potential effects on circulating levels of free fatty acids, which are associated with high blood lipid levels, insulin resistance and other cardiometabolic risk factors.

“Despite current therapies, millions of Americans continue to suffer from both heart disease and diabetes. CVT-3619 is a first in class, potent, orally available new chemical entity that targets yet untreatable aspects of dysfunctional metabolism in these patients,” said Louis G. Lange, M.D., Ph.D., chairman and chief executive officer of CV Therapeutics. “CVT-3619 was invented by CV Therapeutics and represents our fourth clinical program to complement our two approved products.”

CVT-3619 binds to the adenosine A1 receptor on fat cells, called adipocytes, potentially leading to a reduction in the breakdown in fats, also known as lipolysis, and a lowering of free fatty acids in preclinical models. Preclinical studies also have shown that CVT-3619 improves insulin sensitivity, reduces elevated triglycerides, and may lower very low density lipoproteins and potentially raise high density lipoproteins.

“CVT-3619 represents a first-in-class agent that appears to inhibit the release of free fatty acids from fat cells and has the potential to meet a tremendous unmet need by potentially treating both dyslipidemia and diabetes. We look forward to the clinical development of this innovative medication,” said Ralph A. DeFronzo, M.D., professor of medicine and chief of the diabetes division at the University of Texas Health Science Center in San Antonio, Texas.

About CV Therapeutics

CV Therapeutics, Inc., headquartered in Palo Alto, California, is a biopharmaceutical company primarily focused on applying molecular cardiology to the discovery, development and commercialization of novel, small molecule drugs for the treatment of cardiovascular diseases. CV Therapeutics Ltd. is the company’s European subsidiary based in the United Kingdom.

CV Therapeutics’ approved products in the United States include Ranexa(R) (ranolazine extended-release tablets), indicated for the treatment of chronic angina in patients who have not achieved an adequate response with other antianginal drugs, and Lexiscan(TM) (regadenoson) injection for use as a pharmacologic stress agent in radionuclide myocardial perfusion imaging in patients unable to undergo adequate exercise stress. Ranexa is also approved for use in the European Union as add-on therapy for the symptomatic treatment of patients with stable angina pectoris who are inadequately controlled or intolerant to first-line antianginal therapies.

Except for the historical information contained herein, the matters set forth in this press release, including statements as to research and development and commercialization of products, are forward-looking statements within the meaning of the “safe harbor” provisions of the Private Securities Litigation Reform Act of 1995. These forward-looking statements are subject to risks and uncertainties that may cause actual results to differ materially, including operating losses and fluctuations in operating results; capital requirements; regulatory review and approval of our products; special protocol assessment agreement; the conduct and timing of clinical trials; commercialization of products; market acceptance of products; product labeling; concentrated customer base; reliance on strategic partnerships and collaborations; uncertainties in drug development; uncertainties regarding intellectual property and other risks detailed from time to time in CV Therapeutics’ SEC reports, including its Quarterly Report on Form 10-Q for the quarter ended June 30, 2008. CV Therapeutics disclaims any intent or obligation to update these forward-looking statements.

CV Therapeutics, Inc.

CONTACT: Investors and Media, John Bluth, Executive Director, CorporateCommunications & Investor Relations of CV Therapeutics, Inc., +1-650-384-8850

Web site: http://www.cvt.com/

Delcath Systems, Inc. (NASDAQ: DCTH) announced today that the National Cancer Institute (NCI) has named Dr. Marybeth S. Hughes, MD as the Principal Investigator for the current Phase III and Phase II clinical trials of the Company’s Percutaneous Hepatic Perfusion (PHP) System. These trials are being conducted under a Cooperative Research and Development Agreement (CRADA) between the NCI and Delcath. This announcement comes as Dr. James F. Pingpank, Jr., who was Principal Investigator of the trials while at NCI, has assumed the position of associate professor in the division of surgical oncology at the University of Pittsburgh School of Medicine. Dr. Pingpank has been named extramural Adjunct Principal Investigator for the ongoing trials at the NCI.

Dr. Marybeth Hughes, who has been Co-Investigator on these studies since 2004, will provide continued experience and leadership to the trials as the Phase III study treating metastatic melanoma in the liver continues to accelerate with the recent announcements that eight additional treatment centers have joined the trial.

The NCI continues to serve as the lead center for the multi-center Phase III trial and Steven A. Rosenberg, MD, PhD, Head, NCI Tumor Immunology Section and Chief, NCI Surgery Branch will continue in his role as Principal Investigator for all aspects of research under the Cooperative Research and Development Agreement (CRADA) between NCI and the Company.

On his recent move to UPMC, Dr. Pingpank stated, “UPMC is a recognized leader in the area of regional cancer therapies. I am delighted to join the team at The University of Pittsburgh Medical Center, and I look forward to continue working closely with Dr. Hughes, Dr. Rosenberg and NCI on these studies.”

On these announcements, Richard L. Taney, President and CEO of Delcath, stated, “We are excited about these recent developments, and the continuation of our close working relationship with NCI and Dr. Hughes in her expanded role as Principal Investigator on the study. The NCI’s commitment to the Delcath technology remains instrumental in identifying clinical and technological improvements to the PHP system and in training new physicians in the administration of PHP. We are also pleased to continue our relationship with Dr. Pingpank and look forward to working with him at UPMC towards completion of the Phase III trial and a variety of projects to expand the reach of Delcath’s technology and establish PHP as a first-line treatment for liver cancers.”

About Delcath Systems, Inc.

Delcath Systems, Inc. is a medical technology company specializing in cancer treatment. The Company has developed a proprietary, patented system which will improve the efficacy of cancer treatment while reducing the considerable, systemic side-effects of chemotherapy. Delcath’s novel drug delivery platform is capable of delivering anti-cancer drugs at very high doses to a specific organ or region of the body while preventing these high doses of drug from entering the patient’s bloodstream. The Company is currently enrolling patients in Phase III and Phase II clinical studies for the treatment of liver cancers using high doses of melphalan. The Company’s intellectual property portfolio consists of twenty-eight patents on a worldwide basis including the U.S., Europe, Asia and Canada. For more information, please visit the Company’s website at www.delcath.com.

The Private Securities Litigation Reform Act of 1995 provides a safe harbor for forward-looking statements made by the Company or on its behalf. This news release contains forward-looking statements, which are subject to certain risks and uncertainties that can cause actual results to differ materially from those described. Factors that may cause such differences include, but are not limited to, uncertainties relating to our ability to successfully complete Phase III clinical trials and secure regulatory approval of our current or future drug-delivery system and uncertainties regarding our ability to obtain financial and other resources for any research, development and commercialization activities. These factors, and others, are discussed from time to time in our filings with the Securities and Exchange Commission. You should not place undue reliance on these forward-looking statements, which speak only as of the date they are made. We undertake no obligation to publicly update or revise these forward-looking statements to reflect events or circumstances after the date they are made.

 Company Contact: Delcath Systems, Inc. Richard Taney (212) 489-2100 Email Contact  Investor Relations Contact: Strategic Growth International, Inc. Richard E. Cooper/Cass Almendral (212) 838-1444 Email ContactEmail Contact  Public Relations Contact: Rubenstein Associates, Inc. Robin Wagge (212) 843-8006 Email Contact

SOURCE: Delcath Systems, Inc.

Fibrex Medical, a biopharmaceutical company focusing on cardiovascular and inflammatory diseases, today announced positive Phase II results for FX06, a peptide for the treatment of reperfusion injury – the damage to heart muscle that results from remedial treatment following a heart attack. The results will be presented at the ESC Congress today in Munich, Germany.

The Phase II clinical trial of FX06 (F.I.R.E. study) in 234 patients with acute myocardial infarcts was completed in March 2008, with data indicating a statistically significant reduction in myocardial necrosis compared to placebo following intravenous application of FX06 during reperfusion treatment . FX06 is a peptide that binds to vascular endothelial (VE) cadherin, thereby inhibiting tissue inflammation and injury as well as preserving endothelial barrier function. These effects are deemed to be important for the prevention of the paradoxical additional damage to the heart muscle known as reperfusion injury.

“We are delighted that FX06 has demonstrated efficacy in this Phase II trial” stated Dr. Rainer Henning, President and CEO of Fibrex Medical. “FX06 is a first in class product and we have demonstrated that it can provide clinical benefit by preventing reperfusion injury for the huge number of patients who survive heart attacks each year. FX06 can clearly be expected to become an important addition to the armamentarium of the cardiologist in the catheter lab.”

“Re-establishment of blood flow either by catheter-based balloon-intervention (PCI) or by thrombolysis, is necessary and life-saving in the treatment of acute myocardial infarctions, however such interventions can lead to tissue damage due to resulting free radicals and an acute inflammatory response,” said Dan Atar, Professor of Cardiology at the Aker University Hospital, University of Oslo, Norway, who is the Coordinating Investigator for the F.I.R.E. Study. “Based on the F.I.R.E. results, we believe that FX06 can inhibit this inflammatory response and thus prevent reperfusion injury in patients. We predict that FX06 may become a novel treatment for STEMI patients undergoing PCI representing a major advance in acute cardiac care.”

Fibrex is now planning an ambitious development program to bring this promising new product to registration and expect to carry this program out together with a licensing partner. This program will be discussed with regulatory agencies in US and Europe later this year.

About Fibrex Medical Inc.

Fibrex Medical Inc. is a privately held company headquartered in Cambridge, MA, USA with operations in Vienna, Austria. The Company is developing innovative therapeutics for acute and intensive care in cardiovascular and inflammatory conditions based on novel mechanisms of action. Fibrex Medical started operations in 2001, and has raised a EUR 13 M in investments from top tier venture capital investors including Atlas Venture, Global Life Science Ventures, EMBL Ventures and Mulligan Biocapital.

Notes to editors:

Acute Myocardial Infarction (AMI) and reperfusion injury

Acute Myocardial Infarction (AMI) remains to be the number one cause of death in the developed world with approximately 2.1 million new cases per year in the USA, Western Europe and Japan. Percutaneous coronary intervention to re-establish blood flow has become the standard of care for AMI patients. While rapid reperfusion is essential to preserve myocardium, the sudden exposure of the ischemic area to blood leads to an acute inflammatory reaction causing additional damage. It is now well accepted that this process termed reperfusion injury limits clinical success of the intervention.

About the Phase II (F.I.R.E.) study (FX06 in Ischemia / REperfusion):

The Phase II clinical trial of FX06 (F.I.R.E. study) randomized 234 patients with acute myocardial infarcts, to FX06 or placebo, with data indicating a statistically significant reduction in myocardial necrosis following intravenous application of 400mg FX06 at the time of reperfusion. Detailed results will be presented at the ESC Congress on 2nd September in Munich, Germany.

Magnetic resonance imaging data showed that at 5 days after the treatment the necrotic zone of the infarct was significantly reduced by 58% with FX06 and the total zone of the left ventricle affected by the ischemia was reduced by 21% (not statistically significant). This was accompanied by a reduction of markers of muscle damage (troponin I and CK-MB). After 4 months the resulting scar was also reduced to some extent, suggesting that a reduction of reperfusion injury leads to decrease in scar formation. There were signs of clinical efficacy as well, since cardiac related serious events were also lower in FX06 treated patients (21 vc. 29 events).

BOOTHWYN, Pa., Sept. 2 /PRNewswire/ — The number of Chronic Kidney Disease (CKD) patients requiring hemodialysis, considered Stage 5 CKD, is growing every year in spite of medical advances. This growth is fueled by the aging baby boomer population and the diabetes epidemic in the United States. There were nearly 100,000 new cases of Stage 5 CKD in 2005 alone, according to the United States Renal Data System, and approximately 600,000 in total today. That number is expected to climb 76% by 2020 and cost Medicare nearly $54 billion. (1, 2)

It is estimated that up to 70% of dialysis patients suffer from varying degrees of malnutrition that can result in unwanted weight loss and low blood protein levels, specifically, albumin.(3) Low body mass index coupled with low serum albumin have been strongly linked to mortality and close to 60% of new dialysis patients begin therapy with albumin levels below the lower limit of normal.(4, 5, 6) For dialysis patients who do not respond adequately to a standard approach, like liberalized diet and oral supplements, protein malnutrition and/or calorie malnutrition remain significant problems.

To address the specific nutritional needs of this patient group, Pentec Health developed a new line of patent-pending Intradialytic Parenteral Nutrition (IDPN) solutions called PROPLETE(TM). IDPN is a type of IV nutrition administered through the dialysis machine directly into the bloodstream while patients receive dialysis. PROPLETE(TM) is formulated to address the protein malnourished dialysis population and has specific advantages for diabetes patients, as well as those with fluid management challenges.

Eileen Moore, CNSD, R.D, L.D., a nationally recognized expert on IDPN, believes the new formulation may be of additional benefit to malnourished hemodialysis patients with diabetes. “Traditional formulations for IDPN have been particularly troublesome for malnourished patients with diabetes. They often require close supervision of blood glucose and may require insulin administration. The unique formulation of PROPLETE(TM) provides an option for these patients and may make managing their glucose and fluids easier.”

“The introduction of PROPLETE(TM) reaffirms our commitment to patients, innovation and the renal nutrition market. Pentec Health has a 25 year history of offering traditional IDPN therapy and the introduction of PROPLETE(TM) allows us to extend the benefits to a broader range of patients,” said Joe Cosgrove, President and CEO of Pentec Health. “Given the current magnitude of diabetes, we are confident that PROPLETE(TM) will play a significant role in addressing unmet renal nutritional needs.”

PROPLETE(TM) is available exclusively from Pentec Health and can be ordered immediately to begin addressing the malnutrition needs of the hemodialysis population.

About Pentec Health, Inc.

For 25 years, Pentec Health has been an industry leader in providing Specialty Infusion Services nationwide to patients who require access to complex pharmaceutical products and services outside of the hospital setting.

Pentec Health provides Intraperitoneal Parenteral Nutrition (IPN) and Intradialytic Parenteral Nutrition (IDPN) products and services to dialysis centers for their malnourished dialysis patients; and, as a JCAHO accredited home care provider, offers specialty in-home infusion services for highly complex conditions that are underserved by traditional home care providers. Pentec Health offers preparation and clinical management of drug therapies, skilled nursing support, reimbursement services and unparalleled care coordination to patients with acute and chronic conditions.

For more information about Pentec Health, Inc. visit, http://www.pentechealth.com/.

Joe Cosgrove, President and CEO, Pentec Health, Inc., +1-610-494-8700, [email protected] or contact Michael Abens +1-610-494-8700, [email protected]

About Chronic Kidney Disease

Chronic kidney disease (CKD) is a worldwide public health problem. In the US alone, 20 million adults (1 in 9) have CKD and another 20 million are at increased risk for developing it, and most people are unaware. The term CKD refers to the five stages of kidney disease — the early stages (stages 1 and 2) as well as kidney failure (stage 5). Diabetes is the leading risk factor for CKD followed by high blood pressure.

   REFERENCES   1. United States Renal Data System. (2007). Incidence and Prevalence.      Retrieved Aug. 14, 2008 from      http://www.usrds.org/2007/pdf/02_incid_prev_07.pdf.   2. Gilbertson DT, Liu J, Xue JL, Louis TA, Solid CA, Ebben JP, Collins A.      Projecting the number of patients with end-stage renal disease in the      United States to the year 2015. J Am Soc Nephrol. 2005 Dec;16(12):      3736-41.   3. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for      Nutrition in Chronic Renal Failure. Am. J Kidney Dis 2000; 35      (suppl 2):S1 -S140.   4. Kalantar-Zadeh K, Kilpatrick R, Kuwae N, et al. Revisiting mortality      predictability of serum albumin in the dialysis population: time      dependency, longitudinal changes and population-attributable fraction.      Nephrol Dial Transplant. 2005;20:1880-1888.   5. Beddhu S, Cheung A, Larive B, et al. Inflammation and Inverse      Associations of Body Mass Index and Serum Creatinine With Mortality ion      Hemodialysis Patients. J Ren Nutr 2007;17 (6): 372-380.   6. United States Renal Data System. (2007). Patient Characteristics.      Retrieved Aug. 14, 2008 from      http://www.usrds.org/2007/pdf/03_pt_char_07.pdf.  

Pentec Health, Inc.

CONTACT: Joe Cosgrove, President and CEO, [email protected], orMichael Abens, [email protected], both of Pentec Health, Inc.,+1-610-494-8700

Web site: http://www.pentechealth.com/

MONROVIA – Free mammograms and flu/pneumonia shots for low- income seniors will be offered from 9 a.m. to 3 p.m. Saturday at SET for LIFE’s 4th Annual Healthy Living 50+ program at Second Baptist Church, Inc. 925 S. Shamrock Ave.

The program is sponsored by The Elizabeth Center for Cancer Detection and Flintridge Pharmacy.

Workshops on “Preventing Identity Theft” and “Living a Healthier Lifestyle” will also be held between noon and 3 p.m.

To schedule an appointment for a free mammogram or flu shot, call SET for LIFE at (626) 358-1944 or visit www.setforlifenews.org. Space is limited and income restrictions apply.

SET for LIFE 50+ (Senior Education and Training for Living Informed Futures Everyday) provides seniors with practical skills, education, and training.

(c) 2008 San Gabriel Valley Tribune. Provided by ProQuest LLC. All rights Reserved.

By Thomas, James C Torrone, Elizabeth

Objectives. We estimated the effects of high incarceration rates on rates of sexually transmitted infections and teenage pregnancies. Methods. We calculated correlations between rates of incarceration in state prisons and county jails and rates of sexually transmitted infections and teenage pregnancies for each of the 100 counties in North Carolina during 1995 to 2002. We also estimated increases in negative health outcomes associated with increases in incarceration rates using negative binomial regression analyses.

Results. Rates of sexually transmitted infections and teenage pregnancies, adjusted for age, race, and poverty distributions by county, consistently increased with increasing incarceration rates. In the most extreme case, teenage pregnancies exhibited an increase of 71.61 per 100000 population (95% confidence interval [CI]=41.88, 101.35) in 1996 after an increase in the prison population rate from 223.31 to 468.58 per 100 000 population in 1995.

Conclusions. High rates of incarceration can have the unintended consequence of destabilizing communities and contributing to adverse health outcomes. (Am J Public Health. 2006;96:1762-1765. doi:10.2105/ AJPH.2005.081760)

Community health pioneer Sidney Kark attributed high rates of syphilis in South Africa in the late 1930s to the socially destabilizing effects of migration related to the seeking of mining jobs.1 Extreme gender ratio imbalances in the areas surrounding the mines led to sexual behaviors that facilitated the transmission of such diseases. Social epidemiologist Mark Lurie has documented similar effects associated with HIV/AIDS in presentday South Africa.2

Because incarceration leads to a select portion of a community’s residents being removed from their families and neighborhoods, it is tantamount to “forced migration,” contributing to imbalances in neighborhood gender ratios and resulting in the potential for community health effects similar to those just described for South Africa. Moreover, such disruptions of families and social networks can degrade social cohesion and the norms that might otherwise prevent sexually transmitted diseases and teenage pregnancies. Since the early 1980s, rates of incarceration in the United States have tripled and are now the highest of any country in the world. Men are 10 times more likely than women to be incarcerated. In addition, African Americans are 6 times more likely than Whites to face incarceration.3

Moreover, rates of several sexually transmitted infections (STIs), including HIV, are higher among African Americans than Whites, and this is especially the case among male African Americans. For example, in 2000 the gonorrhea rate among male non- Hispanic Blacks in the United States was 40 times greater than that among male non-Hispanic Whites.4 Also, teenage pregnancies were 2.8 times more common among Blacks than among non-Hispanic Whites in 2000.5 Finally, in a 1999 study of counties in North Carolina, Thomas and Sampson found bivariate correlations between rates of incarceration and rates of STIs.6

North Carolina has 76 state prisons and 97 jails, and its rate of incarceration ranks 31st among the 50 states.7 We analyzed countylevel data from the state in an attempt to determine (1) the incarceration variables that would have the strongest correlations with community health effects, (2) whether these correlations would remain stable over time, and (3) whether there would be a lag in time between incarceration and observable community health effects.

METHODS

Data Sources

We obtained 1995 through 2002 data on entries, releases, and state prison system populations from the North Carolina Department of Corrections. We did not analyze federal incarcerations (which represent approximately one tenth of the state’s incarcerations) or juvenile incarcerations (which constitute less than 1% of incarcerations).8,9 Data on numbers of individuals incarcerated were classified by year, county (of which there are 100 in North Carolina), race, and gender. Data for a given year were reported as number of individuals entering prison, number of individuals being released, or mean number of individuals incarcerated during the year. We also gathered information on county of conviction and county of residence at the time of arrest.

We obtained data on county jail entries, releases, and populations for the years 1995 through 2000 from the North Carolina County Court System. Information on numbers of individuals incarcerated was categorized by year and county of conviction.

The North Carolina Department of Health and Human Services provided data on STI counts according to type of infection (gonorrhea, chlamydia, HIV [new cases reported as either HIV or AIDS], and syphilis [primary or secondary]), race/ethnicity, gender, age, year, and county of residence for the years 1995 through 2002. We obtained data on numbers of pregnancies among young women aged 15 to 19 years by county and year (1995-2001) from the North Carolina Office of Vital Statistics.

Finally, population data, grouped according to county, age group, gender, and race/ ethnicity, were derived from the US census Web site (http://www.cenus.gov). We used intercensal estimates for the years 1995 through 1999.

Data Analysis

We calculated a county-level Pearson correlation coefficient between each incarceration variable (rate of entry, rate of release, and population size by county of conviction and county of residence) and each health outcome (rates of gonorrhea, chlamydia, primary or secondary syphilis, HIV, and teenage pregnancies) for each year from 1995 to 2000. We calculated these same correlations for the incarceration rate in a given year and health outcomes 1 year and 2 years later to approximate a temporal causal sequence and to determine when effects were most evident. Because data on health outcomes beyond 2002 were not available, we were unable to conduct time-lagged incarceration analyses for 2001 and 2002.

Multivariate analyses were limited to state prison incarcerations grouped by county of residence, because we hypothesized that the county where one lives is affected by one’s imprisonment more than the county in which one was arrested (if these counties are not the same). We did not conduct multivariate analyses of county jail incarcerations because bivariate correlations were less strong and stable than the corresponding prison correlations.

Variables included as potential confounders were the percentage of a county’s population that was African American, the percentage of residents living below the poverty line, and age (categorized as younger than 24 years, 24-44 years, and 44 years or older). Negative binomial regression models were used to calculate health outcome rate differences and their corresponding confidence intervals (CIs). These rate differences referred to increases in the number of individuals with a reported health outcome per 100000 population in a given year, derived from comparisons between the 75th percentile and 25th percentile of the distribution of North Carolina county incarceration rates (either rates for the year in question or time- lagged rates). All analyses were conducted with Stata version 9 (Stata Corp, College Station, Tex).

RESULTS

The state’s mean yearly prison population increased slightly during the study period, from 29495 in 1995 to 31534 in 2000. However, as a result of the increase in the state population over the period, overall there was a slight decrease in the prison population rate (from 401.58 prisoners per 100000 population in 1995 to 391.76 per 100000 in 2000). The average daily jail population increased from 142.78 per 100000 in 1995 to 163.45 per 100000 in 2000.

During the same years, respective rates of reported STIs (per 100 000 population) for the state were as follows: 326.24 and 223.60 for gonorrhea, 214.85 and 275.58 for chlamydia, 15.41 and 6.01 for primary or secondary syphilis, and 30.61 and 18.04 for HIV. In 1995 and 2000, teenage pregnancy rates were 292.95 and 234.57 per 100 000, respectively.

Bivariate correlations calculated with a 1-year lag were consistently larger than correlations calculated with no lag. For example, correlations between prison populations grouped by county of residence in 1995 and gonorrhea rates in 1995 and 1996 were 0.71 and 0.74, respectively. A 2-year lag yielded stronger correlations than the 1-year lag in the case of some of the incarceration and health outcome variables and weaker correlations for other variables. In the following, we report results for 1-year lags only.

With a single exception (the correlation of jail entry with HIV), all of the correlations between the various incarceration variables and health outcomes were statistically significant (Table 1). The correlations between health outcomes and prison incarceration variables were greater (nearly double) than the corresponding correlations between health outcomes and jail incarceration variables except for the case of syphilis. The incarceration variable most strongly correlated with each of the health outcomes was prison population by county of residence. In all but a few instances, correlations were stronger by county of residence than by county of conviction. Correlations by entry and release were similar. The correlations between particular incarceration variables and health outcomes varied little over the study period. For example, correlations between prison population sizes in 1995, 1997, and 1999 and gonorrhea rates a year later were 0.74, 0.67, and 0.68, respectively.

Adjustment for county age, race, and poverty distributions attenuated the strength of the relationships between incarceration variables and health outcomes, although many of the associations nonetheless remained large and statistically significant (Table 2). For example, after adjustment, a county with a prison population rate at the 25th percentile of the distribution in 1996 would have had a teenage pregnancy rate of 221.09 per 100 000 population in the same year, whereas a county at the 75th percentile would have had a teenage pregnancy rate of 293.56 per 100000. Increasing the prison population rate from the 25th to the 75th percentile would thus result in an additional 71.61 (95% CI=41.88, 101.35) teenage pregnancies per 100000 population, or a 32% increase.

The 1996 health outcome rate differences associated with changes in prison population rates were nearly twice as high as the rate differences associated with changes in prison entry and exit rates. Rate differences for health outcomes decreased in 1998 and 2000, as did the contrast between rate differences for given health outcomes according to the 3 incarceration variables. In 2002, rate differences increased again, as did the contrast in rate differences for given health outcomes between the incarceration variables.

DISCUSSION

Associations between incarceration rates and health outcomes were strong and consistent. Results were strongest for teenage pregnancies and the most common STIs. For the less frequent STIs (syphilis and HIV), several counties reported no cases. In such instances and instances in which there were low frequencies of reported STIs, counties were at increased susceptibility of extreme variation in rates with the addition or subtraction of a single reported case, resulting in wider confidence intervals. Associations of incarceration with teenage pregnancy were more consistent than associations with STIs. This finding may reflect, in part, more thorough reporting of teenage pregnancies than STIs and, thus, less statistical vulnerability to variations in underreporting between counties.

The stronger correlations between health outcomes and incarceration in prisons as opposed to jails probably reflect meaningful differences in the effects of these types of incarceration on the lives of a community’s residents. Jail terms are briefer, on average, than prison terms. Individuals in jail are awaiting trial or serving time for a minor offense, whereas those in prison are serving time, often in years, for more serious offenses. They are absent from their families and communities for longer periods of time than are jail detainees.

The fact that stronger correlations were obtained with a 1-year lag than with no lag suggests that high incarceration rates lead to negative community health effects, strengthening the argument for a causal relationship. The incarceration variable most strongly related to health outcomes was number of prisoners per 100 000 population, the measure representing the closest proxy for absence of individuals from a community. The effects on health outcomes of prison entry and exit rates, which might be considered to represent community transitions, were not remarkably different from each other.

In contrast to rate ratios, rate differences indicate the number of new cases that can be expected with a change in the independent variable (in this case, incarceration), thus providing an indication of the public health importance of the issue in question.10 For example, the number of excess gonorrhea cases generated by increases in incarceration rates was sizable, ranging from 22.65 (in 2000) to 62.46 (in 1996) per 100000 population; similarly, the number of excess teenage pregnancies generated ranged from 50.26 (2000) to 71.61 (1996) per 100000 population.

This study, conducted at the ecological level, was based on county rates of incarceration and sexually related health outcomes. The classic ecological fallacy would be to infer from our results that incarceration leads to higher STI and teenage pregnancy rates.11, 12 Although we are unaware of any data on rates of infection among ex-offenders, fewer than one half of 1% of reported gonorrhea and chlamydial infections in North Carolina in 2000 were reported from correctional facilities (either jails or prisons; L. Sampson, North Carolina Division of Public Health, written communication, February 2004). This small percentage suggests that incarceration’s effects on STI incidence may be greatest outside prison walls.

Given that 10 times more men than women are imprisoned, incarceration lowers the community ratio of men to women; this is particularly the case for African Americans, among whom the incarceration rate is several times higher than that among individuals from other racial groups. Lower gender ratios have been shown to affect rates of teenage pregnancy, syphilis, and gonorrhea.13-15 Small numbers of men relative to women can result in the men remaining in the community having more power in their relationships with women. For instance, if a woman insists that her male sexual partner be faithful, he can leave her for another partner who will be less demanding or who will turn a blind eye to his other sexual relationships.

At any given time, more than 12% of male African Americans aged 25 to 29 years are incarcerated.16 The corresponding high rates of removals from and releases to communities disrupt relationships and contribute to the inability of communities to maintain social norms, in that maintenance of these norms is based on long-term relationships. In communities where neighbors know one another, these individuals can be involved in each other’s lives and in the lives of their children; they can observe each other’s actions and offer encouragement or advice. Even people guilty of committing crimes can and do play such positive social roles, and their absence from a community may have intergenerational effects. More than half (56%) of state and federal prisoners in the United States in 1997 had children.17 To the degree that parenting affects the sexual behaviors of adolescents, adolescents with a parent who is absent as a result of incarceration may be more at risk of behaviors that result in an STI or pregnancy.

The ex-offender population represents another means through which incarceration can affect community STI rates. One study showed that men with HIV who were released from prison had sexual intercourse within an average of 6 days of their release, and 31% of these men believed that it was likely they would infect their primary sexual partner.18 Similarly, Kark noted that migrants themselves were principally responsible for the high rates of syphilis in South Africa in the 1940s.1 As a result of laws prohibiting gold and diamond miners from migrating with their families, the gender ratios in the mining communities reached extreme levels, as high as 12:1. The men at the mines would have sexual intercourse with prostitutes and possibly carry an infection back to their wives.

As mentioned earlier, Lurie has described a similar phenomenon driving HIV transmission in South Africa in recent years.2 Whereas the present-day high rates of HIV in South Africa (with rates of adult diagnoses ranging from 21% to 39%) might be explained in part by selective migration to cities, the relatively low infection rate in the Congo (approximately 4% of adults), where some of the first identified cases originated, might be attributable in part to the country’s lack of an infrastructure that would facilitate migration.16

People generally prefer to stay in their home communities. Typically, only a complex mixture of market forces, politics, and cultural factors (e.g., racial attitudes) results in individuals leaving their communities en masse. The earlier-mentioned 3-time increase in incarceration rates in the United States since 1980 has been attributed principally to the “war on drugs.”3 Thus, present- day incarceration-based “migration” has been linked to factors such as poverty and the maelstrom of economic and political forces surrounding illicit drugs. However, because this form of “migration” does entail force, the American public can decide whether to exert more or less force, that is, whether to raise or lower incarceration rates and, thus, community turnover rates.

It is unlikely that the negative community health effects associated with incarceration will prove to be a sufficient motivation for determining alternative means of responding to the social ills addressed today via incarceration. It is more likely that economic factors, such as the expense of incarcerating large numbers of people and a political climate that allows elected officials the opportunity to develop creative alternatives to incarceration, will determine the rate at which people are moved into and out of prison and, thus, into and out of their communities. In any event, until changes in policy take place, high rates of incarceration will have the unintended consequences of destabilizing communities and generating worse social ills.

Originally published as: James C. Thomas, PhD, MPH, and Elizabeth Torrone, MSPH. Incarceration as Forced Migration: Effects on Selected Community Health Outcomes. Am J Public Health. 2006;96:1762- 1765. doi:10.2105/AJPH.2005.081760.

References

1. Kark SL. The social pathology of syphilis in Africans. S Afr Med J. 1949;23:77-84.

2. Lurie M, Harrison A, Wilkinson D, Abdool Karim SS. Circular migration and sexual networking in rural KwaZulu/Natal: implications for the spread of HIV and other sexually transmitted disease. Health Transition Rev. 1997;7(suppl 3):S15-S24. 3. Austin J, Irwin J. It’s About Time: America’s Imprisonment Binge. 3rd ed. Belmont, Calif: Wadsworth/ Thompson Learning; 2001.

4. Sexually Transmitted Disease Surveillance, 2000. Atlanta, Ga: Centers for Disease Control and Prevention; 2001.

5. Alan Guttmacher Institute. US teenage pregnancy statistics: overall trends, trends by race and ethnicity, and state-by-state information, New York, 2004. Available at: http:// www.guttmacher.org/pubs/state_pregnancy_trends.pdf. Accessed July 5, 2006.

6. Thomas JC, Sampson L. Incarceration as a social force affecting STD rates. Rev Infect Dis. 2005;191: S55-S60.

7. National Institute of Corrections. Corrections statistics for North Carolina. Available at: http://nicic.org/ StateCorrectionsStatistics. Accessed July 5, 2006.

8. US Department of Justice. Correctional populations in the United States, 1995. Available at: http://www.ojp.usdoj.gov/bjs/pub/ pdf/cpius95.pdf. Accessed July 27, 2006.

9. US Department of Justice. Profile of state prisoners under age 18, 1985-1997. Available at: http://www.ojp.usdoj.gov/bjs/pub/pdf/ pspa1897.pdf. Accessed July 5, 2006.

10. Dombrowski J, Thomas JC, Kaufman J. A study in contrasts: measures of racial disparity in the occurrence of gonorrhea. Sex Transm Dis. 2004;31:149-153.

11. Hammett TM, Harmon MP, Rhodes W. The burden of infectious disease among inmates of and releasees from US correctional facilities, 1997. Am J Public Health. 2002;92:1789-1794.

12. Maruschak LM. HIV in Prisons and Jails, 1999. Washington, DC: US Dept of Justice; 2001.

13. Sampson RJ. Unemployment and imbalanced sex ratios: race- specific consequences for family structure and crime. In: Tucker MB, Mitchell-Kernan C, eds. The Decline in Marriage Among African Americans: Causes, Consequences and Policy Implications. New York, NY: Russell Sage Foundation; 1995:229-254.

14. Kilmarx PH, Zaidi AA, Thomas JC, et al. Ecologic analysis of socio-demographic factors and the variation in syphilis rates among counties in the United States, 1984-93. Am J Public Health. 1997; 87:1937-1943.

15. Thomas JC, Gaffield ME. Social structure, race, and gonorrhea rates in the southeastern United States. Ethn Dis. 2003;13:362-368.

16. The 2004 Report on the Global AIDS Epidemic. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2004.

17. Mumola CJ. Incarcerated parents and their children. Available at: http://www.ojp.usdoj.gov/bjs/pub/ascii/iptc.txt. Accessed July 27, 2006.

18. Stephenson BL, Wohl DA, McKaig R, et al. Sexual behaviours of HIV-seropositive men and women following release from prison. Int J STD AIDS. 2006; 17:103-108.

About the Authors

The authors are with the Department of Epidemiology, University of North Carolina, Chapel Hill.

Requests for reprints should be sent to James C. Thomas, PhD, MPH, Department of Epidemiology, CB# 7435, University of North Carolina, Chapel Hill, NC 27599-7435 (e-mail: [email protected]).

This article was accepted March 25, 2006.

Contributors

J. C. Thomas originated the study, acquired the data, directed the analysis, interpreted the findings, and was the principal author of the article. E. Torrone conducted the data analysis and contributed to the interpretation of the findings and the writing of the article.

Acknowledgments

This study was supported by funds from the University of North Carolina Center for AIDS Research (National Institutes of Health grant P3 AI50410) and the Open Society Institute (grant 74411-00 01).

Human Participant Protection

This study was approved by the institutional review board of the University of North Carolina.

Copyright American Public Health Association Sep 2008

(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.

BARCELONA, Spain, Sept. 2 /PRNewswire-FirstCall/ — Patients with serious mental illness, such as schizophrenia, schizoaffective disorder and bipolar disorder can live productive and fulfilling lives. Yet an international survey of psychiatrists illuminates that there are major barriers to long-term wellness, which include stigma, limited resources and the fear and consequences of relapse.

Gathering perspectives of 697 psychiatrists from Australia, Canada, France, Germany, Italy, Portugal, Spain, the United Kingdom and the United States, the survey tapped into their insights on how family caregivers, stigma, treatment non-adherence and relapse affect the lives of people living with these debilitating illnesses. Findings show that psychiatrists have frequently seen how relapse can be a devastating blow to both individuals and their families, and how this has resulted in hospitalization, employment loss, incarceration or even suicide.

This survey of psychiatrists, the second of a Keeping Care Complete series of surveys, builds upon findings from a 2006 assessment of 1,082 caregivers that shed light on experiences of family caregivers of individuals with bipolar disorder, schizophrenia and schizoaffective disorder.

“More than 50 million people suffer from serious mental illnesses around the world,” said Preston Garrison, Secretary-General and Chief Executive Officer, World Federation for Mental Health (WFMH). “An indirect consequence of serious mental illness is that it can have a negative impact on family caregivers’ own physical and emotional health. That is why it’s so important that family members get the support they need so that they can take better care of their loved ones. Keeping Care Complete is a vital research initiative that is helping us understand the real life challenges faced by those who treat, care for and live with serious mental illness.”

Keeping Care Complete was developed in partnership with the World Federation for Mental Health and Eli Lilly and Company.

Consequences of relapse

Relapse is a major concern for caregivers and psychiatrists as patients can suffer multiple relapses over the course of their lives. Thirty-seven percent of caregivers said that their family member relapsed five or more times since becoming diagnosed, leaving a majority of caregivers to often or always worry about their loved one relapsing.

The consequences of relapse are devastating to patients and their caregivers.

— Fifty-two percent of psychiatrists said they had a patient attempt suicide as a result of relapse

— For caregivers, the relapse of a family member can result in the deterioration of their own mental and physical health and financial situation, lead to employment loss and cause substantial disruptions to their lives.

Considerations for selecting medication and non-adherence

Eighty-four percent of psychiatrists surveyed said that a lack of adherence to medication is the number one cause of relapse in patients with schizophrenia, and 98 percent said that complete or partial non-adherence is a significant barrier to effective treatment for most patients with bipolar disorder. In addition, psychiatrists and caregivers both agree that medication discontinuation poses as an obstacle for successful treatment and very often leads to relapse.

“This study shows that psychiatrists continue to see that medication adherence is a huge challenge for patients,” said Prof. Dr. Dieter Naber, chairman, Department of Psychiatry and Psychotherapy, University of Hamburg, Germany. “All patients are different, which is why psychiatrists need to know their patients, their attitudes toward treatment and their social conditions to help patients find and stay on the treatment plan that works for them. But, as this survey shows, patients benefit from more than just medication alone – family support, talk therapy, diet, exercise and stable schedules also help patients stay well.”

Consequences of Stigma

Stigma against people with serious mental illness is painful and can have harmful consequences.

— 92 percent of psychiatrists said that inaccurate portrayals of serious mental illness in the mainstream media can further add to the stigma and negatively affect their wellness and hinder their treatment.

— 87 percent of psychiatrists and 82 percent of caregivers have seen the effects of stigma and discrimination make it harder for individuals with serious mental illnesses to get and stay well.

Road to Wellness: Finding the Right Treatment, Caregivers and Wellness Programs

Finding and staying on the right treatment can result in marked improvements in a patient’s everyday life. Results from both surveys showed that performing daily tasks independently, staying out of the hospital, holding a steady job, living on their own and forming romantic relationships are some of the positive outcomes patients may experience as a result of being treated successfully.

Ninety-six percent of psychiatrists and 74 percent of caregivers said that in addition to medication, family support is a key factor that helps keep patients well. Caregivers and psychiatrists both reported that programs designed to help patients with their overall wellness are valuable in helping them manage their symptoms. However, findings indicate there is a need for more services for mental health.

Although a majority of psychiatrists encourage caregivers to participate in support and education programs, 57 percent reported that less than 10 percent of caregivers they interact with actually participate in these programs. When asked about rehabilitation resources, only 19 percent of psychiatrists believed there were enough resources available in the community for their patients.

International survey data and fact sheets on schizophrenia, schizoaffective disorder and bipolar disorder and the caregiver perspective are available at http://www.wfmh.org/.

About bipolar disorder, schizophrenia, and schizoaffective disorder

Bipolar disorder, schizophrenia and schizoaffective disorder are complex mental illnesses that know no racial, cultural or economic boundaries.(1) Bipolar disorder, formerly known as manic-depression, is characterized by debilitating mood swings with symptoms of mania and depression.(2) Schizophrenia is characterized by acute psychotic episodes including delusions (false beliefs that cannot be corrected by reason), hallucinations (usually in the form of non-existent voices or visions) and long-term impairments such as diminished emotion, lack of interest and depressive symptoms, such as hopelessness and suicidal thoughts.(3) Schizoaffective disorder is characterized by a combination of symptoms of schizophrenia and an affective (mood) disorder. Twenty-seven million people suffer from bipolar disorder and 25 million people suffer from schizophrenia worldwide.(4,5) Although the exact prevalence of schizoaffective disorder is not clear, it is estimated to range from two to five in a thousand people. Schizoaffective disorder may also account for one-fourth or even one-third of all persons with schizophrenia.(6)

About WFMH

WFMH is an international interdisciplinary membership organization committed to promoting, among all people and nations, the highest possible level of mental health in its broadest biological, medical, educational, and social aspect. Consultative status at the United Nations provides WFMH a variety of opportunities to engage in mental health advocacy at the global level, working closely with the World Health Organization, UNESCO, the UN High Commissioner for Refugees, the UN Commission on Human Rights, the International Labor Organization and others. Additional information about WFMH is available at http://www.wfmh.org/.

About Eli Lilly and Company

Lilly, a leading innovation-driven corporation, is developing a growing portfolio of first-in-class and best-in-class pharmaceutical products by applying the latest research from its own worldwide laboratories and from collaborations with eminent scientific organizations. Headquartered in Indianapolis, Ind., Lilly provides answers – through medicines and information – for some of the world’s most urgent medical needs. Additional information about Lilly is available at http://www.lilly.com/.

(1) Schizophrenia: What You Need to Know. National Mental Health Association. Available at: http://www.nmha.org/infoctr/factsheets/51.cfm, accessed June 7, 2006.

(2) Bipolar Disorder National Institute of Mental Health. NIH Publication No. 02-3679; Printed 2001, Reprinted September 2002. Available at: http://www.nimh.nih.gov/publicat/bipolar.cfm, accessed June 7, 2006.

(3) Weiden P, Scheifler P, Diamond R, et al. Breakthroughs in Antipsychotic Medications. New York: W.W. Norton & Company, 1999.

(4) The World Health Report 2001: Mental Health – New Understanding, New Hope. World Health Organization. Available at: http://www.who.int/whr/2001/chapter3/en/index1.html, accessed January 6, 2006.

(5) The World Health Report 2003: Shaping the Future. World Health Organization, 2003. Available at http://www.who.int/whr/2003/en/whr03_en.pdf

(6) Schizoaffective Disorder. National Alliance on Mental Illness. Available at: http://www.nami.org/Template.cfm?Section=By_Illness&template=/ContentManagemen t/ContentDisplay.cfm&ContentID=11837, accessed on June 7, 2006.

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Photo: http://www.newscom.com/cgi-bin/prnh/20080902/CLTU002LOGOPRN Photo Desk, [email protected]

Eli Lilly and Company

CONTACT: Charles McAtee of Eli Lilly and Company, +1-317-277-1566,or +1-317-997-1627

By Allukian, Myron

The first US surgeon general’s report on oral health will be released soon. Oral diseases have been called a “neglected epidemic,” 1-4 because, although they affect virtually the entire population, they have not been made a priority in our country. The surgeon general’s report can help educate and sensitize policymakers and health leaders about the importance of oral health and the need to make oral health an integral component of all health programs. In the words of former Surgeon General C. Everett Koop, “You’re not healthy without good oral health.” We must seize this unprecedented opportunity to ensure that the mouth becomes reconnected to the rest of the body in health policies and programs. It makes no sense that children, diabetic persons, or senior citizens with an abscess on their leg can receive care through their health insurance or a health program, but if the abscess is in their mouth, they may not be covered. For vulnerable populations and the “have-nots,” the barriers to dental care are even greater.

Although we have made much progress in improving oral health since the 1970s as a result of fluoridation, fluorides, new technology, changing attitudes, and increased use of services, oral diseases are still a neglected epidemic. The facts speak for themselves. Seventy-eight percent of 17-year-olds have had tooth decay, with an average of 7 affected tooth surfaces (C. M. Vargas, unpublished estimates, Third National Health and Nutrition Examination Survey, 2000), and 98% of 40- to 44-year-olds have had tooth decay, with an average of 45 affected tooth surfaces (C. M. Vargas, unpublished estimates, Third National Health and Nutrition Examination Survey, 2000). Thirty percent of Americans older than 65 years have no teeth at all.5 Twenty-two percent of 35- to 44-year- olds have destructive periodontal disease.5 Finally, more Americans die from oral and pharyngeal cancer than cervical cancer or melanoma each year.6

Although tooth decay in children has decreased considerably, 7 it still affects most children and adults, especially as people live longer and retain more of their teeth. Populations at higher socioeconomic levels are able to pay for dental care; however, dental care is often a luxury for vulnerable and high-risk populations. Jonathan Kozol writes, “Bleeding gums, impacted teeth and rotting teeth are routine matters for the children I have interviewed in the South Bronx. Children get used to feeling constant pain. They go to sleep with it. They go to school with it. . . . Children live for months with pain that grown-ups would find unendurable.”8(p20,21)

VULNERABLE POPULATIONS

The oral health disparities of the underserved are unacceptable and must be addressed among vulnerable and high-risk populations- children, the elderly, individuals with low incomes, the developmentally disabled, the medically compromised, people who are homebound or homeless, persons with HIV, uninsured and institutionalized individuals, and racial, cultural, and linguistic minorities. For example:

* The rate of untreated dental disease among low-income children aged 2 to 5 years is almost 5 times that of highincome children.9

* Among 14-year-old White children, the use of dental sealants, a preventive service, is almost 4 times that among African American children.5

* The rate of untreated dental disease among American Indian and Alaska Native children aged 2 to 4 years is 6 times that among White children.5

* Oral cancer mortality is 2 times higher for male African Americans than for male Whites.10

* People without health insurance have 4 times the rate of unmet dental needs as those with private insurance.11

Why should so many Americans, especially children and vulnerable populations, be neglected and experience so much unnecessary pain and suffering when we have the knowledge and resources to prevent it? Oral diseases should not be lifelong conditions that compromise quality of life. Poor oral health affects mortality, general health, nutrition, digestion, speech, social mobility, employability, self- image and esteem, school absences, quality of life, and well- being.2,5 In addition, recent studies have shown associations between periodontal disease and the incidence of premature, low- birthweight babies12-14 and between oral infections and heart disease and stroke.15-17

Dental care costs should not be a barrier, given other health expenditures. The cost of providing dental care is not driving increases in health care costs. About $60.2 billion will be spent in the United States for oral health services in the year 2000; however, as a percentage of total health expenditures, dental service expenditures have decreased 28%, from 6.4% in 1970 to about 4.6% today.18

PREVENTION

We are fortunate that cost-effective preventive measures for many of these oral diseases and conditions are available. However, they are not being fully used, thus compounding unmet dental needs and disparities. For example, more than 100 million Americans do not live in fluoridated communities19; 85% of 14-year-old children have not had dental sealants, a simple preventive measure5; and 93% of US adults 40 years and older have not had an oral cancer examination in the past year.20 For the underserved who are not able to obtain care, the lack of preventive services creates an even greater burden of disease.

DENTAL PUBLIC HEALTH INFRASTRUCTURE

In addition, our public health system responsible for oral health is in disarray, and its infrastructure is lacking. Eighty percent of local health departments do not have a dental program.5 Thirty-nine percent of state health departments do not have a full-time dental director, and 8 (40%) of these departments do not have a dental director at all (H. Goodman, State Program Evaluation Committee, Association of State and Territorial Dental Directors, written communication, December 28, 1999). Further, most school-based health centers do not have a dental component,5 and 44% of community health centers do not have a dental program.6 Only 136 dentists are board certified in dental public health (S. Lotzkar, American Board of Dental Public Health, written communication, January 21, 2000).

ACCESS

In addition to the lack of preventive services and programs, access to dental care for many individuals and communities is a problem. For example, about 125 million Americans do not have any dental insurance.5 Furthermore, 81% of nursing home residents have not had a dental visit in the past year,5 and 80% of children on Medicaid have not had a preventive dental visit in the same period.21 Finally, 38% of rural counties have no dentist, and 62% do not have a dental hygienist.22

Access to dental care is even more difficult for vulnerable and underserved populations. Access may also be limited by the availability of providers, especially culturally competent providers. However, financial and social constraints affect practice location and the diversity of our oral health workforce, factors that exacerbate oral health disparities among the underserved. The cost of a dental education continues to increase. Approximately 42% of all dental school graduates are more than $100 000 in debt, and about 42% of those who graduate from private dental schools are more than $150 000 in debt.23 Although African Americans constitute 12% of the general US population, they represent only 2.2% of professionally active dentists.24 There is also a need for more Hispanic and Native American dentists.

Inequities in access to dental care and preventive services and the lack of a dental public health workforce to respond to these needs have been clearly spelled out in the Healthy People 2000 Progress Review for Oral Health10 and in Healthy People 2010: Oral Health.5 The surgeon general’s report on oral health gives us a unique opportunity to sensitize the nation to this neglected epidemic and to stimulate the political will to integrate oral health as part of all health programs and policies.

RECOMMENDATIONS

1. Oral health must become a much higher priority at the local, state, and national levels, so that oral health disparities can be improved and resolved. Oral health services should be an integral component of all health programs and all health insurance programs, including Medicare. Government must become more responsive to the oral health needs of the public, especially the underserved. Local, state, and federal health officials, leaders, agencies, and organizations, including organized dentistry, must ensure that health programs and initiatives have a meaningful oral health component and respond to the Healthy People 2010 oral health objectives. More foundations should make oral health a priority. Oral health partnerships, coalitions, constituencies, and legislative action are needed. The public and private sectors, including business, labor, insurers, academia, and the faith communities, must work together.

An effective dental public health infrastructure also needs to be developed and funded at the local, state, and national levels to provide guidance in responding to these needs. Every state and every major local and county health department should have a full-time dental director trained in public health, along with sufficient support. 2. The federal government must be a role model and set the example that oral health is an integral and important component of all health programs. The federal government must make oral health a much higher priority in all of its agencies that affect health. It must rebuild its dental public health infrastructure centrally and regionally with leadership and funds to promote costeffective, population-based prevention programs and improved access to dental services for all, with a special focus on vulnerable populations and the underserved. Creative leadership, incentives, oral health literacy, health promotion, and sufficient resources will be needed from all programs in the federal government to help us eliminate disparities and reach the Healthy People 2010 national oral health objectives.

Although the Oral Health Initiative of the US Department of Health and Human Services is a good beginning, it is limited in scope and impact. The oral health needs of the underserved must be more effectively met by community and migrant health centers, the National Health Service Corps, Head Start, maternal and child health agencies, Healthy Start, the Special Supplemental Nutrition Program for Women, Infants, and Children, area health education centers, school-based health centers, and other such programs. More practical and applied research is also needed to increase the use of, and improve access to, effective prevention programs.

3. Promotion and use of effective individual and populationbased prevention services and programs must become a much higher priority at the local, state, and national levels, especially for children and high-risk populations. All kindergarten through 12th-grade students should be provided with meaningful oral health education, and children in high-risk communities should have effective school- based dental prevention programs. Federal and state incentives must be provided for such programs. All private insurance programs, dental Medicaid, and the Child Health Insurance Program must include and encourage the use of preventive dental services.

Tobacco settlement funds must also be used to develop and institutionalize effective prevention programs because of the relationship between tobacco use and oral diseases. These services and programs can include school, community, or institutional prevention initiatives that provide fluorides, dental sealants, early childhood caries prevention, and oral and pharyngeal cancer examinations.

4. The oral health component of Medicaid and the Child Health Insurance Program must be upgraded and improved. The accountability of state officials involved in dental Medicaid and the Child Health Insurance Program must be increased. Some progress has been made in a few states toward improving dental Medicaid, often as a result of legal challenges. Local, state, and federal agencies, organizations, and constituencies must work together to improve these programs. Adult Medicaid beneficiaries who are at high risk (e.g., pregnant women, the developmentally disabled, and the medically compromised) must be included in dental Medicaid programs, an optional service in many states. An effective statewide distribution of safety-net providers must be available in every state. Disparities in access to dental services for the underserved cannot be corrected until the effectiveness of dental Medicaid programs is improved.

5. All communities with a central water supply must have fluoridation. Fluoridation is the most cost-effective preventive measure for better oral health; however, 38% of US communities with public water supplies do not have fluoridation. Other than the recent advances in California, little progress has been made nationally since 1980.

Fluoridation has been called one of the 10 great public health achievements of the 20th century. 25 It should be the foundation for better oral health for all Americans. The US Department of Health and Human Services must play a much stronger leadership role, working with local and state agencies and organizations to promote and support community water fluoridation.

6. The oral health workforce needs to be modified and augmented. More dentists, including those of minority backgrounds, should be trained in dental public health. Given the magnitude of debt of recent graduates, this will not occur without changes. Minorities are more likely to receive services in areas where there are racial/ ethnic minority providers26; thus, minority, innercity, rural, and low-income students must be recruited, mentored, and funded to attend schools of dentistry, dental hygiene, and public health. This is especially true for African Americans, Hispanics, and Native Americans. In addition to expanding and improving scholarship and loan repayment programs, more creative programs are needed to attract the best and the brightest of these students to careers in populationbased dental programs.

State practice acts must also be less restrictive and more responsive to the needs of the public in such areas as national reciprocity for licensees and delegation of duties for dental hygienists and assistants. Other health professional schools, such as medicine, nursing, and public health, should include oral health in their curriculum so that their graduates can contribute to the resolution of this epidemic.

CONCLUSIONS

The oral disease epidemic has been neglected for too long. The richest country in the world, one with a booming economy in the last decade, can do much better. As we begin the new millennium, oral health disparities among the underserved must be addressed. We know how to prevent or control most oral diseases. The surgeon general’s report on oral health will grasp the attention of our country. We are once again at the crossroads.27 Now is the time to integrate oral health into all health policies and programs. We must focus the country’s political will to make oral diseases a public health dinosaur of the past. We can and must ensure a legacy of better oral health for all Americans in the future.

Originally published as: Myron Allukian, Jr, DDS, MPH. The Neglected Epidemic and the Surgeon General’s Report: A Call to Action for Better Oral Health. Am J Public Health. 2000;90:843-845.

References

1. Allukian M. The neglected American epidemic. The Nation’s Health. May-June 1990:2.

2. Allukian M. Oral diseases: the neglected epidemic. In: Scutchfield FD, Keck CW, eds. Principles of Public Health Practice. Albany, NY: Delmar Publishers Inc; 1996:261-279.

3. The Oral Health of California’s Children: A Neglected Epidemic. San Rafael, Calif: Dental Health Foundation; 1997.

4. Gotsch AR. The neglected epidemic. The Nation’s Health. September 1999:2.

5. Healthy People 2010: Oral Health. Washington, DC: US Dept of Health and Human Services; 2000.

6. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin. 2000;50:7-33.

7. Brown LJ, Wall TP, Lazar V. Trends in total caries experience: permanent and primary teeth. J Am Dent Assoc. 2000;131:223-231.

8. Kozol J. Savage Inequalities: Children in America’s Schools. New York, NY: Crown Publishers Inc; 1991.

9. Vargas CM, Crall J, Schneider D. Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J Am Dent Assoc. 1998; 129:1229-1238.

10. Healthy People 2000 Progress Review for Oral Health. Washington, DC: National Institute of Dental and Craniofacial Research, US Dept of Health and Human Services; 1999.

11. Mueller CD, Schur CL, Paramore C. Access to dental care in the United States. J Am Dent Assoc. 1998;129:429-437.

12. Dasanayake AP. Poor periodontal health of the pregnant woman as a risk factor for low birth weight. Ann Periodontol. 1998;70:206- 211.

13. Offenbacher S, Katz V, Fertik G, et al. Periodontal infection as a possible factor for preterm low birth weight. Ann Periodontol. 1995;67(suppl 10): 1103-1113.

14. Davenport ES, Willias CE, Sterne JA, et al. The East London study of maternal chronic periodontal disease and preterm low birth weight infants: study design and prevalence data. Ann Periodontol. 1998;70:213-221.

15. Beck JD, Offenbacher S, Williams R, Gibbs P, Garcia R. Periodontitis: a risk factor for coronary heart disease? Ann Periodontol. 1998;70:127-141.

16. Genco RJ. Periodontal disease and risk for myocardial infarction and cardiovascular disease. Cardiovasc Rev Rep. 1998;19:34-40.

17. Slavkin HC. Does the mouth put the heart at risk? J Am Dent Assoc. 1999;130:109-113.

18. Health Care Financing Administration. National health care expenditures. Available at: http:// www.hcfa.gov/stats/stats.htm. Accessed February 3, 2000.

19. Hinman AR, Steritt GR, Reeves TR. The US experience with fluoridation. Community Dent Health. 1996;13(suppl 2):5-9.

20. Horowitz AM, Nourjah PA. Patterns of screening oral cancer among US adults. J Public Health Dent. 1996;56:331-335.

21. Children’s Dental Services Under Medicaid: Access and Utilization. San Francisco, Calif: Office of the Inspector General; 1996. DHHS publication OEI-09-93-00240.

22. Milgrom PM, Tishendorf D. Dental care. In: Geyman JP, Norris TE, Hart LG, eds. Textbook of Rural Health Care. New York, NY: McGraw-Hill International Book Co. In press.

23. Survey of Dental School Seniors, 1998, Graduating Class. Washington, DC: American Association of Dental Schools; 1999.

24. Brown LJ, Lazar V. Closing the Gap. Minority Dentists: Why Do We Need Them? Washington, DC: Office of Minority Health, US Dept of Health and Human Services; 1999.

25. Ten great public health achievements-United States, 1900- 1999. MMWR Morb Mortal Wkly Rep. 1999;48:241-243.

26. Health Care Rx: Access for All. The President’s Initiative on Race. Rockville, Md: Health Resources and Services Administration, US Dept of Health and Human Services; 1998. 27. Allukian M. Dentistry at the crossroads: the future is uncertain; the challenges are many. Am J Public Health. 1982;72:653-654.

Myron Allukian, Jr, DDS, MPH

About the Author

Requests for reprints should be sent to Myron Allukian, Jr, DDS, MPH, Community Dental Programs, Boston Public Health Commission, 1010 Massachusetts Ave, Boston, MA 02118 (e-mail: [email protected]).

Copyright American Public Health Association Sep 2008

(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.

By Lalla, Evanthia Park, David B; Papapanou, Panos N; Lamster, Ira B

Objectives. We explored the association between diabetes mellitus and oral disease in a low-socioeconomic-status urban population. Methods. Dental records of 150 adults with diabetes and 150 nondiabetic controls from the dental clinic at Columbia University in Northern Manhattan matched by age and gender were studied.

Results. There was a 50% increase in alveolar bone loss in diabetic patients compared with nondiabetic controls. Diabetes, increasing age, male gender, and use of tobacco products had a statistically significant effect on bone loss.

Conclusions. Our findings provide evidence that diabetes is an added risk for oral disease in this low-income, underserved population of Northern Manhattan. Oral disease prevention and treatment programs may need to be part of the standards of continuing care for patients with diabetes (Am J Public Health. 2004;94: 755-758)

Periodontal diseases are bacterially induced chronic inflammatory diseases affecting the tissues surrounding and supporting the teeth. The lesion begins as gingivitis, an inflammation of the gingival tissues only, and may progress to periodontitis, where destruction of connective tissue attachment and alveolar bone can eventually lead to tooth loss. In 1993, periodontitis was referred to as the sixth complication of diabetes mellitus1; in the 1997 report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, it was cited as one of the pathological conditions often found in patients with diabetes. 2 Indeed, multiple studies have provided conclusive evidence that the prevalence, severity, and progression of periodontal disease are significantly increased in patients with diabetes.3 Other oral complications have been reported in patients with diabetes, such as caries, xerostomia, and mucosal lesions. However these associations are weaker, and conflicting data have been reported.4-8

If left untreated, periodontitis can lead to tooth loss, thereby compromising a patient’s ability to maintain a proper diet and affecting the quality of life. Furthermore, longitudinal studies have reported that severe periodontal disease in diabetic patients at baseline is associated with poor metabolic control and other diabetic complications at follow-up.9,10 There also has been a suggestion in the literature that mechanical periodontal therapy in conjunction with systemic antibiotics may result in improved metabolic control in some patients with diabetes, especially those with poor metabolic control and severe periodontitis at baseline.11

As previous studies have reported an overall high degree of agreement between radiographic and clinical assessments of destructive periodontal disease,12 we explored the association between oral/periodontal disease and diabetes using dental and radiographic records of patients seen at the Comprehensive Care Clinic at Columbia University School of Dental and Oral Surgery. Most individuals served by this clinic, and included in this retrospective case-control study, reside in Northern Manhattan. The Northern Manhattan communities of Washington Heights/Inwood and Harlem had a population of 500000 in 2000; residents’ incomes were among the lowest in New York City.13 An estimated 34% of this population was living at or below the federal poverty level as of 1990, and Northern Manhattan is identified as a Medical and Dental Health Manpower Shortage Area by the Health Resources Services Administration of the Department of Health and Human Services. Forty- nine percent of the residents are Hispanic (mostly of Dominican origin), 44% are African American, and the balance represents other ethnic/ racial groups.14

METHODS

Study Population

Data on 300 dentate adults were included in this study. Dental records for 150 people aged older than 18 with diabetes mellitus seen at the Comprehensive Care Clinic at Columbia University School of Dental and Oral Surgery in Northern Manhattan were selected at random. Dental records with a full-mouth series of intraoral radiographs taken during a 3-year period (1999-2001) were used. The selection process involved reviewing the recorded medical history to identify a positive history for diabetes. The age range of the diabetic patients was 20 to 88 years. The records of a control group of 150 nondiabetic patients were then chosen. Control subjects were matched by gender and age (+-5 years) to the case group. The age range of the nondiabetic subjects was 18 to 90 years.

The following general patient information was identified from the chart and recorded: age at the time of the radiographic examination, gender, and ethnicity (Hispanic or non- Hispanic). No information on race was available in the dental records. The subjects’ tobacco use habits and pregnancy status also were recorded. In addition, for the diabetic group, type of diabetes (type 1, type 2, or unknown) and mode of therapy (insulin, oral hypoglycemic agent, both, or unknown) were noted.

Radiographic Examination and Assessments

Full-mouth periapical and posterior bitewing radiographs for all patients were evaluated by a single examiner (D. B.P.). All linear measurements, performed with a ruler, were rounded to the nearest whole millimeter. Sites where excessive radiographic distortion existed or where either the cementoenamel junction (the junction of the crown and root of the tooth) or alveolar bone crest were unidentifiable were recorded as “nonreadable” and excluded from the analysis. The following parameters were determined:

* Missing teeth: the number of missing teeth based on a complete dentition of 32 teeth.

* Alveolar bone level: the distance in millimeters from the cementoenamel junction to the most coronal level along the distal and mesial root surface at which the periodontal ligament space was considered to have a normal width.15 Thus, an increased value translates into increased alveolar bone loss.

* Root length: the distance from the cementoenamel junction to the radiographic apex of the tooth along the distal and mesial root surface of the tooth.

* Proportional bone loss: the ratio of the alveolar bone level minus 2 to the root length minus 2 was calculated for the distal and mesial surface of each tooth (in healthy periodontal tissues, the alveolar bone crest is approximately 2 mm apical to the cementoenamel junction).

* Furcation involvement: the number of multirooted teeth with radiolucency between the roots, suggesting interradicular bone destruction.

* Carious lesions: the number of teeth with radiolucencies extending into the dentin.

* Periapical radiolucencies: the number of teeth with radiolucencies around the apex, indicative of necrosis of pulpal tissue and an inflammatory response at the root tip.

* Endodontic treatment: the number of teeth with radiographic evidence of endodontic treatment (obturation of the root canal with radio-opaque material).

* Restorations and fixed prostheses: the number of teeth with radiographic evidence of amalgam restorations and crowns, respectively.

Error of the Method

The error inherent in the linear measurements was evaluated by repeated measurements. Specifically, in a subsample of 100 individuals, 50 with diabetes and 50 nondiabetic, measurements of alveolar bone level were repeated on a second occasion by the same examiner. The mean difference between the first and second measurement for alveolar bone level was 0.6 mm (SD=0.7). At 44.4% of the sites, the double measurements were identical. Reproducibility within 1 mm was 88.4%; within 2 mm it was 98.1%, and within 3 mm it was 99.3%.

The error inherent in the method by which the radiographs were obtained and evaluated also was assessed through the root length measurements as follows: for all teeth, except molars, the 2 root length measurements were averaged and used in the calculation of the mean root length per tooth type. These values were compared with published root length data obtained from measurements on extracted teeth. The radiographically assessed root length was similar to the data reported by Wheeler16 on extracted teeth: for 14 of the 18 measurements, the difference was less than 1 mm. The biggest differences were noted in maxillary second molar and mandibular premolar measurements, similar to what has been reported previously17; they seem to be mostly related to the technique used to obtain dental radiographs.

Statistical Analysis

The Statistical Analysis System package (SAS Institute Inc, Cary, NC) was used for calculating mean values, standard deviations, and frequencies, as well as for performing Student t tests and multiple regression analyses. P values of less than .05 were considered statistically significant.

RESULTS

The case and control group each consisted of 93 females (62%) and 57 males (38%). None of the females in either group was pregnant. In the diabetic group, 103 subjects (69%) were Hispanic and 47 (31%) were non-Hispanic. In the control group, 90 subjects (60%) were Hispanic and 60 (40%) were non-Hispanic. The mean age in the diabetic group was 56.1 +-13.1 years versus 55 +-14.2 years in the control group. Twentythree (15%) of the cases, versus 25 (17%) of the controls, had reported that they were cigarette smokers, were using some other tobacco product, or both. Of the 150 patients with diabetes, 23 (15%) were type 1, 103 (69%) were type 2, and 24 (16%) did not know their type and we were unable to retrieve this information from other chart entries. Forty-two (28%) of the diabetic patients were on insulin, 94 were (63%) on 1 or more oral hypoglycemic agents, 10 (7%) were on both, and 5 (3%) were on a diet/ exercise regimen only. There was no relevant information for 10 (7%) of the diabetic individuals in the group.

Table 1 shows the radiographic findings in our study population. The mean number of missing teeth per patient was 10 +-6.6 in the control group and 11.5 +-6.8 in the diabetic group. This difference approached, but did not reach, statistical significance (P=.06). However, alveolar bone loss was significantly greater in the diabetic group than in the control group (mean alveolar bone level=4.0 +-1.9 mm and 3.1 +-1.4 mm, respectively; P= .0001). Proportional bone loss was 50% higher in the diabetic group (0.09 +- 0.07) than in the control group (0.06 +-0.05; P= .0001). The mean number of teeth with radiographic evidence of furcation involvement per subject in both the control and the diabetic group was 0.5 (+- 1.3 and +-1.1, respectively; P=.9999).

Interestingly, although the mean number of teeth with carious lesions was similar in controls and cases (2.2 +-2.2 and 2.4 +-2.4, respectively; P=.4), the control group had significantly more teeth with restorations and fixed prostheses than the diabetic group (8.5 +-5.4 and 6.7 +-5.4, respectively; P=.005). Similarly, although the mean number of teeth with periapical radiolucencies per patient in the control group (0.4 +-1.0) was comparable to that in the diabetic group (0.4 +-0.7; P=.6), the control group had significantly more endodontically treated teeth than the diabetic group (1.0 +-1.8 and 0.6 +-1.2, respectively; P=.02).

To identify some of the determinants of alveolar bone destruction in our study population (both cases and controls), a multiple regression model using diagnosis of diabetes, age, gender, and cigarette smoking/tobacco product use as the independent variables was constructed. Of particular significance, the model revealed that, in this population, diabetes, increasing age, male gender, and smoking/ use of tobacco products had a statistically significant effect on bone loss, with age and diabetes being the most important determinants (Table 2). Multiple regression for alveolar bone destruction in the cases included (in addition to the variables above) only type of diabetes and type of diabetes regimen (insulin vs oral agent) as independent variables. This model also revealed increasing age, male gender, and smoking as statistically significant determinants of bone loss.

DISCUSSION

Our findings in this Northern Manhattan population confirm previous evidence that diabetes mellitus is associated with increased severity of periodontal destruction. Our study cohort represents a low-income, underserved, mostly Hispanic population. Recent studies in children and seniors from this population have reported that, compared with national standards, the oral disease burden in Northern Manhattan is high.18-20 In such communities, inability to afford care and limited access to dental services are likely to lead to high levels of oral disease. Diabetes then becomes an added risk in a population already at risk for oral disease. Indeed, although evidence of periodontal destruction and tooth loss was present in the control group of nondiabetic individuals, diabetes clearly conferred an increased risk.

In our multiple regression model for the whole study population, diabetes, age, male gender, and use of tobacco products were identified as significant determinants of bone destruction. For the diabetic group only, the same 3 variables also had a statistically significant effect on bone loss, which is in agreement with what is well established for periodontal destruction in the general population. 21 Furthermore, there was a trend for an increased number of missing teeth in the individuals with diabetes, but the difference only approached statistical significance (P= .06). It is important to remember that tooth loss reflects not only a history of severe periodontal destruction but also the accumulated effects of advanced caries and endodontic infections. In patients with limited resources living in underserved areas, teeth with even moderately advanced dental problems are often extracted rather than restored or endodontically treated.

Of importance is the finding that although the caries rate and presence of periapical pathology were similar in the case and control groups, diabetic patients had fewer teeth previously treated for these conditions. In a recent report,22 patients with diabetes were less likely than those without diabetes to have seen a dentist within the past year; this difference was statistically significant even after age, race/ethnicity, education, income, and dental insurance coverage were adjusted for. Interestingly, the primary reason for not seeing a dentist given in that study was lack of a perceived need.

The etiopathogenesis of periodontitis is complex, and evidence is accumulating that a wide range of factors are probably responsible for the increased risk of periodontal disease observed in diabetes. Impaired recruitment and function of neutrophils, upregulated pro- inflammatory monocyte response to pathogenic bacteria, impaired collagen synthesis, exaggerated collagenolytic activity, and genetic predisposition are all factors that have been implicated.23-25 Work from our group has suggested a role for RAGE (receptor of advanced glycation end products) activation in this setting. Blockade of RAGE resulted in suppression of alveolar bone loss and of markers of inflammation/tissue destruction in diabetic mice infected with a periodontal pathogen, providing novel insights into the mechanisms underlying the association between diabetes and oral disease.26

Importantly, evidence of an effect of oral/ periodontal infections on systemic health has accumulated in recent years. This includes an effect on the level of metabolic control in diabetic individuals11 and an increased risk for cardiovascular and cerebrovascular events.27,28 In combination with the increased risk of vascular disease associated with diabetes mellitus, this highlights another reason for referral of patients with diabetes for dental evaluation and treatment.

Currently, treatment guidelines of the Centers for Disease Control and Prevention recommend that people with diabetes see a dentist at least every 6 months, and more frequently if they are diagnosed with periodontal disease. However, in the American Diabetes Association position statement on standards of care for diabetic patients, an oral examination is suggested as part of the initial evaluation but not as a standard of continuing care.29

Taken together, our findings provide additional evidence that diabetes is associated with an added risk for periodontal destruction, even in a population already at increased risk for oral disease. Further, our findings corroborate the importance of including oral health information in educational materials and promoting oral prevention/treatment programs for patients with diabetes.

Originally published as: Evanthia Lalla, DDS, MS, David B. Park, DDS, Panos N. Papapanou, DDS, PhD, and Ira B. Lamster, DDS, MMSc. Oral Disease Burden in Northern Manhattan Patients With Diabetes Mellitus. Am J Public Health. 2004;94:755-758.

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20. Ahluwalia KP, Sadowsky D. Oral disease burden and dental services utilization by Latino and African- American seniors in Northern Manhattan. J Community Health. 2003;28:267-280.

21. Papapanou PN. Periodontal diseases: epidemiology. Ann Periodontol. 1996;1:1-36.

22. Tomar SL, Lester A. Dental and other health care visits among US adults with diabetes. Diabetes Care. 2000;23:1505-1510.

23. Manouchehr-Pour M, Spagnuolo PJ, Rodman HM, Bissada NF. Comparison of neutrophil chemotactic response in diabetic patients with mild and severe periodontal disease. J Periodontol. 1981;52:410- 415.

24. Yalda B, Offenbacher S, Collins JG. Diabetes as a modifier of periodontal disease expression. Periodontology 2000. 1994;6:37-49.

25. Sasaki T, Ramamurthy NS, Golub LM. Tetracycline administration increases collagen synthesis in osteoblasts of streptozotocin-induced diabetic rats: a quantitative autoradiographic study. Calcif Tissue Int. 1992;50:411-419.

26. Lalla E, Lamster IB, Feit M, et al. Blockade of RAGE suppresses periodontitis-associated bone loss in diabetic mice. J Clin Invest. 2000;105:1117-1124.

27. Beck J, Garcia R, Heiss G, Vokonas P, Offenbacher S. Periodontal disease and cardiovascular disease. J Periodontol. 1996;67(suppl 10):1123-1137.

28. Grau AJ, Buggle F, Ziegler C, et al. Association between acute cerebrovascular ischemia and chronic and recurrent infection. Stroke. 1997;28:1724-1729.

29. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1): S33-S50.

About the Authors

The authors are with the Division of Periodontics, Section of Oral and Diagnostic Sciences, Columbia University School of Dental and Oral Surgery, New York, NY.

Requests for reprints should be sent to Evanthia Lalla, DDS, MS, Division of Periodontics, Section of Oral and Diagnostic Sciences, Columbia University School of Dental and Oral Surgery, 630 W 168th St, PH7E-110, New York, NY 10032 (e-mail: [email protected]).

This article was accepted January 7, 2004.

Contributors

E. Lalla synthesized the analyses and led the writing of the article. D. B. Park collected the data and performed all radiographic measurements. P. N. Papapanou assisted with the study and conducted the data analyses. I. B. Lamster conceived the study and supervised its implementation. All authors helped to interpret findings and reviewed drafts of the article.

Acknowledgment

This study was supported by US Public Health Service grant DE14898.

Human Participant Protection

No protocol approval was needed for this study at the time it was conducted.

Copyright American Public Health Association Sep 2008

(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.

By Treadwell, Henrie M

I once was lost, but now am found, was blind, but now I see.” – Newton J. Amazing Grace. In: Olney Hymns.

London, England: W. Oliver; 1779.

Community Voices: Healthcare for the Underserved, an initiative funded and initially operated by the W. K. Kellogg Foundation and now run through a program office at the Morehouse School of Medicine, has health justice as its fundamental mission. This initiative has matured over the past decade from a national network of learning laboratories into a program with distinctive and directive practice and policy goals. The program needed to evolve, because far too many people in this nation are “invisible” when solutions for devising humane and accessible health care plans are proposed by public policymakers.

Who do we count among us? We embrace the “working every day” poor men and women of color and the homeless. We stand with exoffenders who are barred from obtaining safe and affordable housing, employment with health benefits, and loans to finance their educational dreams. Who else appears invisible to policymakers? Restaurant workers, domestic workers, and laid-off workers have apparently slipped off the screen, as have the day-care providers who watch over our children, the pastors of small and medium-sized churches serving poor and near-poor communities that dot our landscapes, and countless others. What these millions of people have in common is limited or no access to comprehensive primary health care. Thus, these legions are left to suffer needless pain and premature deaths and to somehow make a way out of no way, as if they were to blame for the failings of our society.

The work of Community Voices across the nation served to affirm particularly serious deficiencies in our systems of care that had already been highlighted in the Journal, namely, the connections between racism and health (section 1), critical appraisals of health care reform proposals (section 2), and the need to reconnect the mouth to the body of public health through provision of oral health care throughout the life course (section 3). Community Voices also faced the reality that other topics and populations were being neglected and desperately needed attention. Thus, we sponsored Journal issues on our broken mental health systems (section 4), men’s health (section 5), and prisons and health (section 6). When we began our work a decade ago, little had been written about the mental health service gaps that affect our communities, the plight of poor men of color, or the thorny issues of reentry and recidivism among incarcerated populations. That has now changed for the better.

This special legacy issue pulls together memorable selections from the Journal on the aforementioned Community Voices priorities and permits collective reflection on the vast chasms in access to humane and comprehensive health care that impede the attainment of health justice in our nation. The array of articles across formats also permits examination from diverse perspectives of the state of health and well-being in this nation, the land of the free, the home of the brave.

In communities across the nation, Community Voices has established permanent beachhead health services that were driven by informed community-based decisionmaking and strategic informing of policy activities (see http:// www.communityvoices.org). We believe our nation is poised on a pathway that may ultimately lead to health justice. Our hope is to ensure that others see the way, and we trust that this legacy issue will serve as a guidepost.

Henrie M. Treadwell, PhD

National Center for Primary Care

Morehouse School of Medicine

Atlanta, GA

doi;10.2105/AJPH.2008.145540

Copyright American Public Health Association Sep 2008

(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.

By Satcher, David Higginbotham, Eve J

Reducing and eliminating disparities in health is a matter of life and death. Each year in the United States, thousands of individuals die unnecessarily from easily preventable diseases and conditions. It is critical that we approach this problem from a broad public health perspective, attacking all of the determinants of health: access to care, behavior, social and physical environments, and overriding policies of universal access to care, physical education in schools, and restricted exposure to toxic substances. We describe the historical background for recognizing and addressing disparities in health, various factors that contribute to disparities, how the public health approach addresses such challenges, and two successful programs that apply the public health approach to reducing disparities in health. Public health leaders must advocate for public health solutions to eliminate disparities in health. (Am J Public Health. 2008;98:400-403. doi:10.2105/ AJPH.2007.123919) THE ISSUE OF DISPARITIES

in health is serious-it is a matter of life and death. Disparities in health among different racial, ethnic, and socioeconomic groups in the United States are real and represent a serious threat to our future as a nation. It is time for leaders and communities to take a public health approach to eliminating disparities in health.

Much of the national discussion, reporting, and research on disparities in health focus primarily on differences in access to quality health care. Although critical to eliminating disparities, access only accounts for 15% to 20% of the variation in morbidity and mortality that we see in different populations in this country.1 Other determinants of health are environment, biology and genetics, and human behavior. We must take a public health approach to target all of these determinants. Not only is it the only approach that is comprehensive and science based enough to succeed in reducing and ultimately eliminating disparities, but it focuses on health promotion and disease prevention, which are not only more cost effective but also more humane. Public health leaders must be ethically bound to promote and advocate for this approach. We propose a public health-oriented (preventive) strategy for eliminating disparities in health that is more comprehensive and more likely than a biomedical (curative) approach to be successful in the long term.

THE RESEARCH, THE PROBLEM, AND THE GOAL

Health disparities among minorities have long accounted for higher infant mortality, premature death rates and disease burden, and lower quality of health care when compared with the national average. Today, an African American baby born in the United States is 2.5 times more likely to die before his or her first birthday than his or her White counterparts. In 2000, 83 500 more African Americans died than would have died if we had eliminated disparities in health in the last century.2 In 1998, the president and surgeon general first announced a national goal of eliminating disparities in health, and that initiative was later incorporated as a goal of Healthy People 2010.3 The goal remained a national concern and the Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care came to be considered a landmark report on disparities in health by describing the nature and magnitude of disparities in health in the United States.4 This report informed many different strategies developed to approach the challenge of eliminating disparities in health. More recent reports from the Agency for Healthcare Research and Quality have documented and thoroughly discussed this problem.5

A PUBLIC HEALTH FRAMEWORK FOR HEALTH DISPARITIES

Public health is defined as “what we, as a society, do collectively to assure the conditions for people to be healthy.”6(p19) These “conditions” relate to the determinants of health and play a critical role in disparities: environment, biology and genetics, human behavior, and access to quality health care. We see access disparities evidenced by minorities being most likely to be uninsured, underinsured, underserved, and underrepresented in our national health care system.

Major disparities exist in different physical and social environments in the United States, and these factors account for 20% to 25% of the variations in outcome in morbidity and mortality.1 For example, African American and Hispanic children are far more likely to grow up in communities near toxic waste sites compared with White children.7 The impact of some environmental toxins has been well documented, and the general removal of lead from the environment was a great public health achievement of the past century.8 Asthma, on the other hand, is a rampant epidemic largely environmental in nature that disproportionately affects minority children in emergency department visits, hospitalizations, and deaths, even though there is little difference in prevalence when compared with Whites.9

Another recent study showed that urban children exposed to severe violence, including murder, were much more likely than children who had not been exposed to such violence to become victims or perpetrators of the same kind of violence later in life, even when controlling for socioeconomic status.10 Furthermore, natural and human-made disasters such as Hurricane Katrina11 or battlefield combat12 increase the risk for posttraumatic stress disorder in both children and adults. To implement aggressive, targeted interventions, much more rigorous research is needed to fully understand the mechanisms by which environmental disparities influence behavior later in life and the impact that they have upon the brain.

The most sensitive of the determinants of health are biology and genetics, and because of histories of eugenics and other approaches that label and blame individuals, many stay away from this area. Genetics is responsible for 20% to 25% of variations in morbidity and mortality.1 With increasing understanding of the human genome and the relationship between genetics and health outcomes, we see greater opportunities to intervene. As we move toward personalized health care, this area will increase in importance on the basis of knowledge of genetics and the ability to target interventions.

Human behavior is the most important determinant of variations in health outcomes. Lifestyle practices such as tobacco use, level of physical activity, nutritional habits, sexual behavior, and stress- coping mechanisms are key factors affecting health and account for more than 40% of variations in health outcomes.1

Smoking is still the leading cause of preventable death in the United States, accounting for more than 430 000 deaths annually. The Surgeon General’s Report on Tobacco Use Among U.S. Racial/Ethnic Minority Groups highlighted variations in smoking behavior and its impact on minority groups.13 African American men have the greatest rate of lung cancer from smoking, and both African American men and African American women suffer disproportionately from cardiovascular disease. American Indian women have the highest rate of smoking during pregnancy, a major contributing factor in the high rate of infant mortality in that population. American Indian infants are twice as likely to die in their first year of life compared with their majority counterparts.2 The impact of physical activity was highlighted in the Surgeon General’s Report on Physical Activity and Health.14 Another comprehensive study examined the impact of programs of physical activity and nutrition on the onset of diabetes among high-risk populations and demonstrated that they could significantly reduce the onset of diabetes, even in high-risk populations.15

Today, the obesity epidemic in the United States disproportionately affects American Indians, African Americans, and Hispanics. For African Americans and American Indians, these effects are major concern, given the disparities that already exist for overweight and obesity: diabetes, cardiovascular disease, and cancer. Access to nutritious food and safe places to be physically active are critical for these groups.

DEPLOYING THE PUBLIC HEALTH APPROACH TO ELIMINATING DISPARITIES

Given these determinants of health and their varying impacts on different groups in the United States, what is the public health approach to the elimination of disparities in health? The public health approach involves defining and measuring the problem, determining the cause or risk factors for the problem, determining how to prevent or ameliorate the problem, and implementing effective strategies on a larger scale and evaluating the impact.16 In order to eliminate disparities in health, the public health approach must take place in the context of a balanced community health system, which includes health promotion, disease prevention, and early detection, moving towards universal access to health care.

Measuring the magnitude and distribution of a problem in different populations, generally through surveillance or screening, not only defines the problem but also helps to define the success or failure of the intervention. Analyzing surveillance data and distributions determine associations or risk factors for the identified problem. Surveillance may include laboratory research to identify a virus or bacteria causing a problem or community-based research to evaluate the role of environment or behavior. We must next determine what works to prevent or ameliorate the problem. If dealing with an infectious disease, the search for a vaccine may be critical. Many examples of success exist-one of the most dramatic was the development of the polio vaccine in the early 1950s. However, other problems such as obesity, hypertension, and diabetes require more complex solutions based on behavioral and environmental interventions. Once we have determined what works to prevent or ameliorate a problem, we then have the burden of implementing solutions on a larger scale and evaluating and replicating their impacts.

How then would we apply a balanced community health system to disparities in health? First, we must more aggressively target programs to groups suffering disproportionately from chronic diseases and their risk factors. Two key examples are the Action for Healthy Kids program and the 100 Black Men Health Challenge.

Former Surgeon General David Satcher and First Lady Laura Bush started the Action for Healthy Kids program in 2002. The goal of the initial conference was to follow through on The Surgeon General’s Call to Action to Prevent and Reduce Overweight and Obesity, released in 2001.17 More than 250 community leaders, legislators, and school system representatives attended a 2-day conference on the potential role of schools in combating obesity by helping children develop healthy lifestyles. The conference ended with a commitment to develop a nationwide program to fight obesity.

Volunteers worked with schools and school boards to implement programs of support for physical education in grades K-12 in an environment that modeled good nutrition. Within 1 year, all 50 states and the District of Columbia had Action for Healthy Kids programs. Schools were appropriate settings for such an effort because 53 million children attend school each day, schools provide opportunities for children to improve their lives and futures regardless of socioeconomic background or ethnicity, and schools may provide the opportunity for children to adopt healthy lifestyles of nutrition and fitness even when family and community cannot.

How could schools struggling with the No Child Left Behind Act and other efforts be expected to take on the added challenge of helping children develop healthy lifestyles? Many schools throughout the country raised this question, and a 2004 publication, The Learning Connection, answered that question.18 Several studies showed that children who ate breakfast and were physically fit generally performed better on standardized exams, attended school more regularly, and concentrated on their work better, whereas children who were overweight and obese had a higher prevalence of depression and school absenteeism.

Many schools and districts throughout the nation are enhancing the content, frequency, and quality of their physical education programs and are developing model nutrition programs, including changing the content of vending machines and altering school meals. This effort received a major boost when Congress passed the Wellness Act of 2004, mandating that all schools or districts receiving federal funds for school meals implement wellness policies within 1 year.19

Schools have begun to reach out to parents and communities with targeted programs supporting healthy lifestyles. According to Action for Healthy Kids reports, more than 70% of school districts have developed adequate policies to comply with the Wellness Act, and most other schools are working diligently to develop such policies.20 Not only are minority and lower-socioeconomic-status children overly represented in public schools, especially those receiving federal support for meals, they also benefit disproportionately through school programs because they may not have adequate family and community support or resources for healthy lifestyles.

In a separate focus on adults, the 100 Black Men Health Challenge program started in 2002 with the Atlanta chapter of 100 Black Men out of concern that many African American men were becoming ill and dying well before the age of 70 (given that the national average life expectancy was over age 77 years), even in higher socioeconomic groups.21 The 100 Black Men of America Inc is an organization of professional men who are of higher socioeconomic status and are committed to mentoring, tutoring, and supporting children and their families in lower socioeconomic communities; encouraging children to succeed academically; and guaranteeing scholarships for college. The success of this program is well documented in Project Success: Doing the Right Thing for the Right Reason and has been widely touted in the media.22

In the pilot center for the study, our concern was first with the members of 100 Black Men themselves. Despite their career success, they suffered highly from health disparities, especially in cardiovascular disease, diabetes, and cancer. The 100 Black Men Health Challenge targeted these men with 3 major personal health goals. First, we wanted each man to get regular physical activity and good nutrition- especially increasing fruit and vegetable intake and reducing unhealthy calories. Second, we offered a smoking cessation program, and third, we wanted each man to regularly visit a primary care provider. We screened the men quarterly for weight, nutrition, physical activity, and prostate health when indicated. This program has been praised as one of the most successful interventions targeting African American men.23 These men are now incorporating healthy lifestyle modeling and education for their mentees and increasingly are able to improve their community environments and support opportunities for healthy lifestyles.

Action for Healthy Kids and the 100 Black Men Health Challenge are quite different in location, style, target, and approach, yet each has the potential to reduce disparities and risk factors while also improving learning among children. The public health approach to eliminating disparities in health is being well modeled in these two programs and in others beginning to take place throughout the country. Given overwhelming evidence for the problems in disparities and the major risk factors involved, we develop programs to prevent or ameliorate the risks. Although Action for Healthy Kids is already being implemented nationally, the 100 Black Men Health Challenge has primarily been modeled and evaluated in Atlanta. We will soon move our monitoring to other cities with chapters of 100 Black Men, and ultimately, to the more than 100 chapters nationwide. Strong support and funding for the national leadership of 100 Black Men has helped us to plan for the broad implementation of this program.

CONCLUSIONS

Given the public health approach to the elimination of disparities in health and the evidence of successful programs that have implemented this approach, clearly this model can be effective in reducing disparities. However, applying this approach on a nationwide scale will require robust support for public health and prevention. Less than 3% of our country’s massive health budget goes toward population-based prevention, and more than 90% is spent on treating diseases and their complications-many of which are easily preventable. It is now critical that more of these programs be made available to all populations affected by disparities in health. We urge our colleagues in public health to advocate for this approach with public officials, policymakers, grant-making organizations, and their constituent communities. To eliminate disparities in health, we need leaders who care enough, know enough, will do enough, and are persistent enough.

Originally published as: David Satcher, MD, PhD, and Eve J. Higginbotham, MD. The Public Health Approach to Eliminating Disparities in Health. Am J Public Health. 2008;98:400-403. doi:10.2105/AJPH.2007.123919.

References

1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270(18):2207-2212.

2. Satcher D, Fryer GE, McCann J, Troutman A, Woolf SH, Rust G. What if we were equal? A comparison of the Black-White mortality gap in 1960 and 2000. Health Aff. 2005;24(2): 459-464.

3. Healthy People 2010: Understanding and Improving Health. Washington, DC: US Dept of Health and Human Services; 2000. Available at: http://web.health. gov/healthypeople/document. Accessed March 31, 2007.

4. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press; 2003.

5. National Healthcare Disparities Report, 2003. Rockville, Md: Agency for Healthcare Research and Quality. Available at: http:// www.ahrq.gov/qual/ nhdr03/nhdr03.htm. Accessed March 31, 2007

6. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1988.

7. United States Government Accountability Office. Hazardous and Non- Hazardous Waste: Demographics of People Living Near Waste Facilities. RCED 95-84. Washington, DC: United States General Accounting Office; 1995.

8. US Environmental Protection Agency. Lead in paint, dust and soil. Available at: http://www.epa.gov/lead. Accessed March 30, 2007.

9. Centers for Disease Control and Prevention. Asthma prevalence, health care use and mortality. Available at: http:// 209.217.72.34/ HDAA/tableviewer/ document.aspx?FileId=54. Accessed March 30, 2007.

10. Bingenheimer JB, Brennan RT, Earls FJ. Firearm violence exposure and serious violent behavior. Science. 2005; 308:1323- 1326.

11. Mollica RF, Cardozo BL, Osofsky HJ, Raphael B, Ager A, Salama P. Mental health in complex emergencies. Lancet. 2004;364:2508- 2567.

12. Hoge CW, Castro CA, Messe SC, McGurk D, Cotting DI, Kauffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351:13-22. 13. The Surgeon General’s Report on Tobacco Use Among U.S. Racial/Ethnic Minority Groups. Washington, DC: US Dept Health Human Services; 1998.

14. Surgeon General’s Report on Physical Activity and Health. Washington, DC: US Dept Health Human Services; 1996.

15. Wing RR, Venditti E, Jakicic JM, Polley BA, Lang W. Lifestyle intervention in overweight individuals with a family history of diabetes. Diabetes Care. 1998;121(3):350-359.

16. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. The public health approach to violence prevention. Available at: http://www.cdc.gov/ncipc/ dvp/ PublicHealthApproachToViolence Prevention.htm. Accessed March 30, 2007.

17. The Surgeon General’s Call to Action to Prevent and Reduce Overweight and Obesity. Washington, DC: US Dept Health Human Services; 2001.

18. Action for Healthy Kids. The Learning Connection. Available at: http:// www.actionforhealthykids.org/pdf/ Learning%20Connection%20- %20Full%20Report%20011006.pdf. Accessed December 23, 2007.

19. Child Nutrition and WIC Reauthorization Act of 2004. Public L No. 108- 265 [section]204. Available at: http://www. fns.usda.gov/ TN/Healthy/108-265.pdf. Accessed December 16, 2007.

20. Action for Healthy Kids. 2005- 2006 Annual Report. Available at: http://www.actionforhealthykids.org/pdf / AFHK_report_FINAL_5_7_07.pdf. Accessed January 14, 2008.

21. Centers for Disease Contro and Prevention, National Center for Health Statistics. Health, United States, 2006. Available at: http://www.cdc.gov/nchs/ data/hus/hus06.pdf#027. Accessed January 14, 2008.

22. Moses S. Project Success: Doing the Right Thing for the Right Reason. Detroit, Mich: Gale Group; 2006.

23. Williams-Brown S, Satcher D, Alexander W, Levine RS, Gailor M. The 100 Black Men Health Challenge: a healthy lifestyle and role model program for educated, upper-middle class, affluent African American men and their youth mentees. Am J Health Ed. 2007;38(1):55- 59.

About the Authors

David Satcher is the director of the Satcher Health Leadership Institute and the Center of Excellence on Health Disparities, Morehouse School of Medicine, Atlanta, Ga, and the 16th Surgeon General of the United States. Eve J. Higginbotham is Dean and Senior Vice President for academic affairs at Morehouse School of Medicine, Atlanta.

Requests for reprints should be sent to David Satcher, MD, PhD, Satcher Health Leadership Institute, Morehouse School of Medicine, National Center for Primary Care, 720 Westview Dr SW, Suite 238, Atlanta, GA 30310 (e-mail: dsatcher@ msm.edu).

This article was accepted October 31, 2007.

Contributors

D. Satcher and E. J. Higginbotham contributed to writing this commentary and share the opinions it discusses.

Acknowledgments

D. Satcher’s contribution to authorship and his work on health disparities was made possible in part by the Center of Excellence on Health Disparities at the Morehouse School of Medicine (grant 5P20MD00272).

Jeannette Duerr, APR, of Duerr Communications, and Sharon Rachel, MA, MPH, of the Satcher Health Leadership Institute at Morehouse School of Medicine contributed to article and submission preparation.

Copyright American Public Health Association Sep 2008

(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.

By Richman, Judith A Cloninger, Lea; Rospenda, Kathleen M

Objectives. We examined the extent to which the stress paradigm linking psychosocial stressors to mental health status has focused disproportionate attention on microlevel social stressors to the detriment of macrolevel stressors. Also, we assessed the effects of the terrorist attacks of September 11, 2001, on subsequent mental health among participants in a Midwestern cohort study. Methods. Respondents in a 6-wave longitudinal mail survey completed questionnaires before September 11, 2001, and again in 2003 and 2005. Regression analyses focused on measures of negative terrorism- related beliefs and fears, as well as psychological distress and deleterious alcohol use outcomes measured both before and after September 11.

Results. Negative terrorism-related beliefs and fears assessed in 2003 predicted distress and drinking outcomes in 2005 after control for sociodemographic characteristics and pre-September 11 distress and drinking.

Conclusions. The events of September 11 continue to negatively affect the mental health of the American population. Our results support the utility of according greater attention to the effects of such macrolevel social stressors in population studies embracing the stress paradigm. (Am J Public Health. 2008;98: 323-329. doi:10.2105/ AJPH.2007.113118)

The stress paradigm guiding research on the effects of psychosocial stressors on mental health outcomes1-4 initially addressed exposure to stressful life experiences involving acute life events, such as the death of significant others, or chronic stressors, such as financial difficulties, as predictors of negative mental health outcomes. An important limitation of stress research has been its narrow focus on micro- or individual-level stressors to the detriment of broader macrolevel social stressors.

Stress researchers3,5,6 reviewing the stressors typically studied in large representative samples have noted the predominant focus on individual-level stressors (e.g., stress caused by life-changing events). Although some studies have also addressed more macrolevel stressors such as economic recessions7 and adverse living conditions,8 Wheaton5 noted that the macro-micro distinction highlights the fact that typical life event or role strain scales have excluded macrolevel traumas such as war stress, nuclear accidents, and natural disasters. For example, Holahan et al.,9 in their longitudinal study of stress, coping, and depression, addressed acute and chronic stressors involving experiences in 8 life domains: spouse, children, extended family, physical health, home, neighborhood, finances, and work. With the exception of neighborhood, all of these constitute microlevel domains.

In Wheaton’s review of the social stress literature, he further emphasized the continuing predominant focus on individual stressors and noted that “we also can and should consider political, military and social events and conditions that act as social stressors.”6(p288) A few researchers have included more macrolevel experiences. For example, the work of Turner et al. has addressed adversities such as “[being] in combat in a war, [living] near a war- zone, [being] present during a political uprising [and being] in a major fire, flood, earthquake or other natural disaster.”10(p232) However, this focus constitutes more the exception than what is typical in the overall literature.

In a different although related perspective on the evolution of the stress paradigm, Link and Phelan argued that the stress literature has gradually shifted from interest in “social conditions as fundamental causes of diseases”11(p85) to intervening mechanisms involving the ways in which individuals cope with these conditions. They concluded that “while the current approach focuses on the individual, it can readily be seen that economic and political forces shape individuals’ exposure to risks.”11(p85) This perspective suggests the importance of historical contexts and changes over time in social conditions, which play etiological roles in detrimental mental health outcomes (e.g., the extent to which social institutions such as the state may be viewed as unable to provide a sense of safety for their citizens).12

The events of September 11, 2001, signaled a major change in the sociopolitical context in the United States, highlighting the salience of political terrorism as a continuing threat to individuals’ sense of safety and well-being. A sizable literature has demonstrated that the September 11 attacks adversely affected the mental health of individuals across the nation13-16 as well as those most directly affected in New York, Washington, DC, and western Pennsylvania.17-19 These empirical studies, conducted in the immediate aftermath of the attacks, demonstrated elevated symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD) and increased alcohol consumption.

Subsequent studies conducted between 2 months20 and 6 months21,22 after September 11 demonstrated lingering feelings of distress and increased use of alcohol and other substances, including cigarettes and marijuana, relative to the period before September 11. It should be noted that research addressing alcohol use outcomes has been much more limited than research addressing manifestations of psychological distress alone. However, one national study, conducted shortly after September 11, showed decreased rather than increased alcohol consumption.12

The extent to which the relatively immediate mental health effects of September 11 revealed in most studies have lingered is just beginning to be addressed. Boscarino et al.23 found that exposure to psychological trauma related to the World Trade Center attack in New York City was associated with increased alcohol consumption 2 years after the attack. Richman et al.24 demonstrated that a substantial percentage of a Midwestern population maintained negative beliefs and fears about their future safety linked to threats of future terrorist attacks in 2003 and that, after they controled for distress and drinking before September 11, these beliefs were significantly associated with distress and problematic drinking. However, a major limitation of that study was that terrorism-related beliefs and fears were measured at the same time point as distress and drinking outcomes, and thus the causal direction of the relationship between terrorism-related fears and mental health was ambiguous.

In this study, we further address the salience of post-September 11 beliefs and fears in terms of mental health outcomes. That is, we examined the extent to which these fears and beliefs, as assessed in 2003, predicted a range of distress and alcohol use outcomes in 2005 after controlling for previous distress and alcohol use. We also examined gender differences given evidence indicating that such post- September 11 effects are more pronounced among women than among men.13,17

METHODS

Sampling and Data Collection

Data were derived from a longitudinal mail survey of employees initially recruited from a Midwestern urban university during the fall of 1996. The sample was stratified into 8 groups according to gender and occupation. Initial wave-1 occupational groups included faculty, graduate student workers or trainees, clerical or secretarial workers, and service or maintenance workers. Employees (2416 men and 2416 women) were sampled from the university payroll database. Dillman’s25 total design method for mail surveys was used in collecting data, along with additional follow-up strategies (i.e supplementary reminder postcards, 2 additional mailings, reminder e- mail messages, and follow-up telephone calls).

The final wave-1 sample comprised 2492 employees (52% response rate). The lower than desired response rate reflected the fact that individuals may have been reluctant to complete questionnaires that were selfadministered and contained identifiers for subsequent tracking and highly sensitive material. 26 A comparison of the characteristics of the sample with the characteristics of the overall employee population indicated no significant differences in terms of race within each occupational stratum. Gender differences between our sample and the overall population were also very small and nonsignificant for 2 of the 4 strata (service workers and student trainees). However, men were overrepresented by 8.3 percentage points within the clerical group, and women were overrepresented by 11.3 percentage points in the faculty group.27

One year later (during the fall of 1997), 2038 wave-1 respondents were resurveyed (an 82% retention rate). Three years later (during the fall of 200l), the sample was again resurveyed, producing a sample of 1730 and a retention rate of 70%. Wave-4 data were collected similarly during the fall of 2002, producing a sample of 1654 (and a 67% retention rate). Wave-5 data were collected during the fall of 2003 (a sample of 1453 and a 59.1% retention rate), and finally, wave-6 data were collected during the fall of 2005 (a sample of 1517 and a 62.1% retention rate).

In comparison with dropouts, respondents who completed wave 6 were more likely to be older (mean age=51 vs 47 years; P

Terrorism-related stressors were measured with a 12-item scale (score range=12-60) assessing terrorism-related negative beliefs and fears about the world, other people, and oneself (response options were not true/a little true, somewhat true, and very true/extremely true). (Because a t test showed no significant difference between men and women on this scale, we present only overall results.) Items were specifically linked to September 11 and fears of future terrorist attacks. The scale was a modified version of an instrument developed by Norris.28 Alpha coefficients were 0.82 for women and 0.83 for men.

Measures of mental health focused on symptomatic distress (depression, anxiety, hostility, somatization, and PTSD symptoms linked to September 11 and threats of future terrorist attacks) and alcohol consumption (quantity of consumption, escapist motives for drinking, binge drinking, and drinking to intoxication). Pre- September 11 baseline measures served as controls for all outcomes other than terrorism-related PTSD symptoms and somatization, which were added to the wave-5 questionnaire. For these 2 variables, wave- 5 measures served as controls.

Past-week depressive symptomatology was measured with 7 items (score range=0-21) from the Center for Epidemiological Studies Depression Scale29 that correlate highly with the overall scale.30 Alpha coefficients were 0.87 for women and 0.84 for men. Anxiety during the past week was measured with the 9-item tension-anxiety scale (score range=0-36) of the Profile of Mood States.31 Alpha coefficients were 0.86 for women and 0.87 for men. The 6-item hostility scale (score range=0-22) of the Symptom Checklist 90 Revised32 was used to assess hostility during the past week. Alpha coefficients were 0.78 for women and 0.76 for men.

Past-week somatization was measured via the 12-item somatization scale (score range=0-48) of the Symptom Checklist 90 Revised.32 The alpha coefficient was 0.81 for both women and men. Terrorism- related PTSD symptoms were assessed with an adapted version of the PTSD Checklist- Terror,33 a 17-item instrument that encompasses the criteria for a PTSD diagnosis; scale items were summed to produce a score with a range of 17 to 85. We broadened the instructions for completing the instrument to capture symptoms associated with terroristrelated experiences and fear of terrorism after September 11, as well as fear of foreign wars or the threat of future wars. Alpha coefficients were 0.87 for women and 0.90 for men.

With respect to quantity of alcohol consumption, respondents were asked “When you drank any alcoholic beverage during the last 30 days, how many drinks did you usually have per day?” Escapist drinking motives were assessed via 5 items (to feel less tense, to escape, to cheer up, to forget things, and to forget worries) from the instrument developed by Temple.34 Alpha coefficients were 0.91 for women and 0.90 for men. Binge drinking was measured with a question used by Wilsnack et al.35:

“During the last 12 months, how often did you have 6 or more drinks of wine, beer, or liquor in a single day? (That would be a bottle or more of wine, more than 2 quarts of beer, or a half pint or more of liquor.)”

Drinking to intoxication was also measured with a question used by Wilsnack et al.35: “About how often in the last 12 months did you drink enough to feel drunk, that is, where drinking noticeably affected your thinking, talking, and behavior?”

Data Analyses

Because missing data in longitudinal research are common and potentially problematic, 36,37 we used the SAS38 MI procedure to impute missing data and produce complete data sets (including observed and missing values). The missing data were replaced 10 times to produce 10 complete data sets, and the regression procedure (PROC REG) was used to analyze the complete data sets. As a means of generating valid statistical inferences about the parameters of interest, we used the SAS MIANALYZE procedure to combine the results. Results of ordinary least squares regression analyses with deleted cases were compared with results from the imputed data set. Because the analyses involving ordinary least squares with deleted cases produced results equivalent to those involving data imputation, we present the ordinary least squares results for ease of interpretation.

Also, given that many of the outcome variables included in this study were skewed, we used the negative binomial distribution to estimate regression models.39,40 These analyses were carried out through the SAS GENMOD procedure. The negative binomial regression model results were compared with the ordinary least squares regression model results, and the overall results were virtually the same. These analyses further supported our decision to present ordinary least squares results.

We conducted hierarchical multiple regression analyses examining the relationships between terrorism-related negative beliefs and fears measured at wave 5 and distress and alcohol- related outcomes measured at wave 6; these analyses controlled for education, race/ ethnicity, age, gender, and baseline distress and drinking (except in the case of PTSD and somatization, for which wave-5 controls were used). Of central interest was the impact of negative beliefs and fears (alone or in interaction with gender) on subsequent distress and drinking after accounting for the variance explained by prior distress and drinking.

RESULTS

Tables 1 and 2 present sociodemographic characteristics of the wave-6 sample and mean scores and standard deviations for each of the relevant variables. Participants’ average age was 51 years, and the sample was 56% female, disproportionately White, and skewed toward higher educational attainment.

Table 3 shows the distribution of negative perceptions of the world and negative selfperceptions resulting from the September 11 attacks, along with fears related to future terrorist attacks. As opposed to items tapping negative interpersonal relationships or feelings of personal failure after September 11, results showed that terrorism’s effects primarily involved perceptions of the world as being a less safe place and as the government being less effective. For example, 30.0% of the participants reported that they felt very or extremely more pessimistic about world peace, and 27.6% reported that they had less faith in the government’s ability to protect them. By contrast, only 1.6% of the participants reported being very or extremely disappointed in themselves during the period following the events of September 11.

Three blocks of variables were entered into the hierarchical multiple regression analyses. The first block consisted of the controls: age, racial/ethnic group, educational level, distress (depression, anxiety, hostility), and alcohol use (drinking quantity, escapist motives for drinking, binge drinking, drinking to intoxication) measures at wave 1 and distress measures (somatization and PTSD) at wave 5. The second block included gender and terrorism- related negative beliefs and fears, and the third block included the interaction term of gender and terrorism-related negative beliefs and fears.

Table 4 presents the significant distress outcomes predicted by terrorism-related negative beliefs and fears and the extent to which, after controlling for sociodemographic variables and previous distress levels, these beliefs and fears predicted distress. Results showed that negative beliefs and fears were predictive of significantly increased levels of depression (P

Table 4 also shows the effects of terrorismrelated negative beliefs and fears at wave 5 on escapist motives for drinking at wave 6. Negative beliefs and fears were predictive of significantly increased escapist motives for drinking (P

Finally, the statistically significant interaction between gender and terrorism-related negative beliefs and fears at wave 5 predicted drinking to intoxication at wave 6 (P

DISCUSSION

We argue that the stress paradigm has paid inadequate attention to macrolevel social stressors. Our results demonstrate the continuing significance-here, with respect to subsequent distress and problematic alcohol use- of the terrorist events of September 11, 2001, 4 years after these events led to political terrorism being defined by the government and other sectors of society as a salient macrolevel social stressor for the American population. We found that in 2003 our participants continued to fear future terrorist attacks and to believe that the government could not protect them. We also found that in 2005 these fears and beliefs had negative effects on symptomatic distress and escapist motives for drinking among both men and women as well as negative effects on drinking to intoxication among men (after we controled for previous distress and drinking). Thus, our data suggest that political terrorism is a macrolevel stressor of major public health significance. Our findings should be interpreted within the context of its methodological strengths and limitations. The central strength entailed our ability to address the mental health consequences of exposure to the terrorist attacks of September 11 within the context of an ongoing longitudinal study that included pre- September 11 assessments of mental health status. This is in contrast to the majority of studies of the effects of exposure to the September 11 attacks, which were initiated after September 11, 2001, and thus could not take into account individuals’ previous mental health status or could do so only within the context of the biases inherent in the use of retrospective measures.

Limitations

The study’s limitations included the less-thanideal initial response rate and the differing rates of attrition typically associated with long-term longitudinal research. In particular, by the wave- 6 time point, the sample was disproportionately White, middle aged, and highly educated. Thus, future research is needed to address similar issues in the context of a sample representative of the larger population in terms of age, social class, and racial/ ethnic composition. However, the sociodemographic biases of our sample were somewhat offset by the fact that those who completed wave 6 did not differ from the original wave-1 sample with respect to most of the outcome variables assessed.

Moreover, additional analyses were conducted to examine whether sociodemographic variables (in addition to gender) interacted with negative terrorism-related beliefs to create differences in prediction of outcomes. Because these analyses produced nonsignificant results, they were not clearly suggestive of strong biases linked to sociodemographically based sample attrition. Nonetheless, future studies of more-diverse population groups may reveal stronger relationships between negative terrorism-related beliefs and mental health outcomes.

Another limitation is that the measure assessing negative terrorism-related beliefs and fears may have tapped other period effects, including the war in Iraq, economic conditions, and the general policies of the Bush administration, that have covaried with terrorism- related issues. Finally, it may be useful in future studies to disaggregate the overall negative terrorism-related beliefs measure as a means of addressing the relative salience of different subcomponents with respect to mental health assessment.

Another interesting issue for future investigation involves the relative salience of terrorismrelated threats experienced by the Midwestern US population assessed here as opposed to the continuous and unpredictable exposure of those in other parts of the world to a variety of real dangers and hardships such as genocide, extended droughts, and massive political displacements. Although a major Midwestern landmark (the Sears Tower in Chicago) was an intended target of the September 11 perpetrators, this clearly did not represent the same level of personal danger or hardship as the types of macrolevel social stressors just described. Future research could also address the salience of terrorismrelated fears and beliefs in conjunction with both protective factors (e.g., social support and religiosity) and vulnerability factors (e.g., genes that interact with deleterious environmental experiences in predicting outcomes associated with alcohol use and psychopathology).41,42

Conclusions

Our findings regarding the salience of gender with respect to the effects of terrorism-related beliefs and fears on distress and drinking outcomes are interesting in that they are discrepant with earlier results from this data set regarding the more immediate aftereffects of the September 11 terrorist attacks on distress and alcohol use. These earlier findings showed that women, but not men, manifested elevated levels of alcohol consumption and anxiety during the 6 months after September 11.13 By contrast, our results showed that 4 years after September 11, terrorism-related fears and beliefs (assessed in 2003) predicted distress similarly in women and men, whereas men but not women exhibited changes in alcohol consumption. Moreover, in contrast to women’s elevated quantity of consumption after September 11, men’s later reactions involved an increase in an indicator of more-clearly pathological levels of drinking, that of drinking to intoxication.

It has been speculated that changes in gender-linked mental health reactions to the September 11 terrorist attacks may reflect gender-differentiated styles of emotional feeling states in which women more quickly react to powerful threats to their security and men initially are more likely to deny or intellectualize fearful states.24 Our findings regarding the links between terrorism- related beliefs and fears and men’s increased levels of drinking to intoxication suggest that men’s reactions to politically threatening experiences may be more pathological over time. Future research is necessary to further explore the meaning of gender-differentiated reactions over time to terrorist events and threats.

Finally, our results indicate the significance of exposure to political terrorism as a macrolevel social stressor. It might be useful in future research to develop an instrument that covers the broad array of potential macrolevel stressors and addresses the salience of different stressors for mental health outcomes in broad population surveys. Such an instrument might focus on exposure to disasters associated with natural causes (e.g., hurricanes, tornadoes, earthquakes, fires) as well as other causes (e.g., governmental inaction related to ensuring the safety of the food supply or lack of response to actual or possible infectious disease outbreaks). Moreover, in line with calls for epidemiological studies to include multilevel analyses,43 future research should encompass both macrolevel stressors across varied social contexts and individual-level characteristics as they relate to mental health and other outcomes.

Originally published as: Judith A. Richman, PhD, Lea Cloninger, PhD, and Kathleen M. Rospenda, PhD. Macrolevel Stressors, Terrorism, and Mental Health Outcomes: Broadening the Stress Paradigm. Am J Public Health. 2008;98:323-329. doi:10.2105/AJPH.2007.113118.

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2. Pearlin LI. The sociological study of stress. J Health Soc Behav. 1989;30:241-256.

3. Thoits P. Stress, coping and social support processes: where are we? What next? J Health Soc Behav. 1995;35(extra issue):53-79.

4. Turner RJ, Wheaton B, Lloyd DA. The epidemiology of social stress. Am Sociol Rev. 1995;60:104-125.

5. Wheaton B. Sampling the stress universe. In: Avison WR, Gotlib IH, eds. Stress and Mental Health: Contemporary Issues and Prospects for the Future. New York, NY: Plenum Press; 1994:77-114.

6. Wheaton B. The nature of stressors. In: Horwitz AV, Scheid TL, eds. A Handbook for the Study of Mental Health: Social Context, Theories, and Systems. New York, NY: Cambridge University Press; 1999:176-197.

7. Brenner MH. Mental Illness and the Economy. Cambridge, Mass: Harvard University Press; 1974.

8. Aneshensel CS, Sucoff C. The neighborhood context of adolescent mental health. J Health Soc Behav. 1996;37:293-310.

9. Holahan CJ, Moos RH, Holahan CK, Brennan PL, Schutte KK. Stress generation, avoidance coping, and depressive symptoms: a 10- year model. J Consult Clin Psychol. 2005;73:658-666.

10. Turner HA, Turner RJ. Understanding variations in exposure to social stress. Health. 2005;9:209-240.

11. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;30:80-94.

12. Knudsen HK, Roman PM, Johnson JA, Ducharme LJ. A changed America? The effects of September 11th on depressive symptoms and alcohol consumption. J Health Soc Behav. 2005;46:260-273.

13. Richman JA, Wisler JS, Flaherty JA, Fendrich M, Rospenda KM. Effects on alcohol use and anxiety of the September 11, 2001, attacks and chronic work stressors: a longitudinal cohort study. Am J Public Health. 2004;94:2010-2015.

14. Schlenger WE, Caddell JM, Ebert L, Jordan BK, Rourke KM. Psychological reactions to terrorist attacks: findings from the national study of Americans’ reactions to September 11th. JAMA. 2002;288:581-588.

15. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl J Med. 2001;345:1507-1512.

16. Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. A nationwide longitudinal study of psychological responses to September 11. JAMA. 2002; 288:1235-1244.

17. Cardenas J, Williams K, Wilson JP, Fanouraki G, Singh A. PTSD, major depressive symptoms, and substance abuse following September 11, 2001, in a midwestern university population. Int J Emerg Ment Health. 2003;5:15-28.

18. Centers for Disease Control and Prevention. Psychological and emotional effects of the September 11 attacks on the World Trade Center-Connecticut, New Jersey, and New York, 2001. JAMA. 2002;288:1467-1468.

19. Simeon D, Greenberg J, Knutelska M. Schmeidler J, Hollander E. Peritraumatic reactions associated with the World Trade Center disaster. Am J Psychiatry. 2003;160:1702-1704.

20. Stein BD, Elliott MN, Jaycox LH, et al. A national longitudinal study of the psychological consequences of the September 11, 2001, terrorist attacks: reaction, impairment, and help-seeking. Psychiatry. 2004;67: 105-117.

21. DeLisi LE, Maurizio A, Yost M, et al. A survey of New Yorkers after the September 11, 2001, terrorist attacks. Am J Psychiatry. 2003;160:780-783.

22. Vlahov D, Galea S, Ahern J, Resnick H, Kilpatrick D. Sustained increased consumption of cigarettes, alcohol, and marijuana among Manhattan residents after September 11, 2001. Am J Public Health. 2004;94:253-254. 23. Boscarino JA, Adams RE, Galea S. Alcohol use in New York after the terrorist attacks: a study of the effects of psychological trauma on drinking behavior. Addict Behav. 2006;31:606-621.

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About the Authors

The authors are with the Department of Psychiatry, University of Illinois at Chicago.

Requests for reprints should be sent to Judith A. Richman, PhD, University of Illinois at Chicago, Department of Psychiatry, Room 469, 1601 W Taylor St (M/C 912), Chicago, IL 60612 (e-mail: [email protected].).

This article was accepted May 10, 2007.

Contributors

J. A. Richman originated the study and assumed primary responsibility for writing the article. L. Cloninger conducted the data analyses and provided methodological expertise. K. M. Rospenda contributed to study conceptualization and interpretation of findings. All of the authors reviewed drafts of the article.

Acknowledgments

This study was funded by the National Institute on Alcohol Abuse and Alcoholism (grant R01AA009989).

We thank the University of Illinois at Chicago Survey Research Laboratory for collection of the data and Sally Freels for her helpful statistical advice.

Human Participant Protection

This research was approved by the institutional review board of the University of Illinois at Chicago. Respondents received a consent information document with each questionnaire, and informed consent was assumed if respondents returned completed questionnaires.

Copyright American Public Health Association Sep 2008

(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.

By Treadwell, Henrie M Ro, Marguerite

Improving access to primary health care by the poor, the underserved, and those living at the economic and social margins of this nation’s social construct has been work that the W. K. Kellogg Foundation has pursued rigorously and with deep commitment. We have worked to lead and serve as we supported health clinics, as well as to define, refine, and implement pathways to improve health for many. But like most, we have neglected a significant part of the population most in need of health care. We were blind to the fact that when we visited clinics and worked with communities to address their health needs, there were few men in the waiting rooms of the clinics where primary health and prevention services were being provided. Virtually no health efforts were directed toward men. Poor men had become invisible and their health needs neglected. WHY A FOCUS ON MEN’S HEALTH

Ultimately, we confronted the brutal reality: Poor men and men of color live with a tremendous amount of pain, are demeaned and devalued in a system that rewards wealth and values some people over others, and die early. When social determinants of health-such as poverty, poor education and educational opportunities, underemployment and unemployment, confrontations with law enforcement, the sequelae of incarceration, and social and racial discrimination-are factored into the health status of men, the scope and depth of the health crisis is even more evident and poignant. Poor men are less likely to have health insurance, less likely to seek needed health services, and less likely to receive adequate care when they do.

Even among the poor, some men are less than equal. The generally abysmal health status of men of African descent best demonstrates the great peril that poor men have to face. Life expectancy for African American men is 7.1 years shorter than that for all men.1 Forty percent of African American men die prematurely from cardiovascular disease, compared with 21% of White men.2 And death rates for HIV/AIDS are nearly 5 times higher for African American men than for White men.3 African American men also have the highest incidence rates of oral cancer.4 Sadly, the health status of African American men may serve as the proverbial canary in the coal mine for other poor men in this nation and in our global village, and it is a clarion call to health care providers and policymakers charged with defending the nation’s health.

This society has no system in place to support the health and health-seeking behaviors of men who work at the lowest wage levels or of those who are unable to work as a result of poor education, absence of jobs, mismatch in skills, or other reasons. Those in the faith-based community and in community-based organizations tell us that men are so concerned about their daily survival, caring for their families, and having a good job, that they do not make their health a priority. Recent articles in major US newspapers have shown how poor men jeopardize their health as they seek to support their families and themselves. 5-9 Working conditions are frequently hazardous, and policies designed to protect these employees are often grossly inadequate. Most often, low-paid and low-skilled workers are not offered health insurance coverage through work. Low- income men who are childless are excluded from publicly funded insurance programs. The only exceptions are for those who qualify for insurance because of disability or who find coverage through very limited state or local programs for the indigent.

Sadly, the penal system is the only place where men have the right to health care, under the US Constitution’s protection from “cruel and unusual punishment.” There are currently more than 1.4 million inmates in federal and state prisons, and more than 600000 inmates are to be released during the year.10 A recent report funded by the US Department of Justice highlights the great need for health care by this population.11 The report demonstrates the high rates of communicable disease, chronic disease, and mental illness of inmates (93% of whom are male and 44% of whom are people of color). The report acknowledges that these men are a largely underserved population. It recommends federal support for the provision of services for these “captive” men, in part to reduce the threat to the public’s health upon their release. Clearly there is a need to treat inmates, but what are we doing for these men before they enter the penal system, and if we are not doing anything, what is the cost to them and to society?

While access to care is theoretically available through prisons, there are no clear data that suggest that the care provided results in improved health status. Studies have clearly indicated that mental health and oral health access in prisons is extremely curtailed despite the high need.11,12 In addition, the health care that is provided is expensive. Wisconsin alone spent $37.2 million to provide health care to approximately 14 900 inmates in fiscal year 1999-2000.13 A rough comparison reveals that federal and state health care expenditures per inmate approximate or exceed expenditures for a Medicaid enrollee. The average cost for health care in prison was $3242 in 1999, while the average cost for health care for a Medicaid enrollee was $3822 in 1998.14,15 However, if we exclude the elderly, blind, and disabled, the average cost for an adult Medicaid enrollee was $1892. We must ask whether the federal and state money being spent on inmate health care could be better spent, both within and outside prison walls.

One of the major challenges we face in addressing the health status of poor men and men of color is a lack of data. Existing research, while important, focuses on issues related to reproductive organs, illnesses resulting from sexual practices or contagious disease (e.g., HIV/AIDS), violence, substance abuse, behavioral health, and other conditions that characterize these men, by inference, as not having the same illnesses and concerns that women and well-to-do men face. Does this lack of research reflect society’s “isms” that perpetuate disparities in health and well- being? Or does it reflect limited interest by a cadre of health policy researchers who may need more diversity in their ranks to broaden the research agenda and fill in the gaps? How else to explain this epidemic of poor health among men of color and poor men and lack of proven intervention and prevention strategies?

In the numerous documents on access to care and quality of care that we examined, little mention was made of poor men. Seminal reports such as those produced by the Institute of Medicine have yet to examine the availability and quality of prison care. Nor is there adequate documentation on the accessibility or quality of preventive and primary health care for the diverse population of poor men. We were not able to identify benchmarks for access to or quality of care that apply universally to all men, women, and children.

Despite our efforts, we did not find the intellectual underpinnings that would guide our actions or affirm our strategies. Ultimately, we were left to decide that our responsibility was to act now, even though the practice and policy pathways were not apparent.

A MEN’S HEALTH INITIATIVE

As part of Kellogg’s Community Voices initiative (http:// www.communityvoices.org), we began the process of teaching ourselves about the issues. We developed 3 publications, designed for a variety of audiences, that highlight the disparity in health outcomes and the barriers to care experienced by men, particularly men of color.16-17 (Additional information available from the authors upon request.) Included in each publication are policy strategies and recommendations for improving the health of men.

The Kellogg Foundation’s trustees authorized $3 million for a men’s health initiative. The use of these funds in specific markets (Atlanta, Ga; Baltimore, Md; Boston, Mass; Clarksdale, Miss; Denver, Colo; Miami, Fla) will provide focused care for men and education for health care providers, as well as inform policy on shaping health services and providing health care coverage for poor men. An equally important goal of this initiative is to engage men in shaping the delivery of care for themselves. Social and educational programs will be included as integral components of comprehensive primary care. Strategies will include extensive use of community outreach, use of focus groups, case management, and identification of service gaps. Proposed coalitions including men, health and human services providers, family members, and concerned community members will work across state lines to build a policy program that informs decisionmakers and promotes inclusion of poor men as beneficiaries of publicly supported coverage programs (e.g., Medicaid and the Children’s Health Insurance Program).

While many in the policy arena tell us that the time may not be right for a discussion of coverage for poor men, we know that it is not acceptable for any human beings to be left out, included incrementally only when convenient. Regardless of whether the nation’s budget is running a surplus or a deficit, our nation’s leaders have never declared it the right time for providing coverage to poor adults, specifically poor men. Yet the financial, physical, and emotional devastation that is experienced by poor men who have no health care is too harsh a price for all of us to pay.18,19 Emphasizing treatment rather than prevention creates a system that is impossible to sustain and perpetuates disparity. We know how to improve the public health of our nation. We simply have yet to do what is best for our nation’s families, and particularly its sons. SUSTAINING CHANGE IN A TIME OF COMPETING PRIORITIES

The opportunity we have with this issue of the Journal is to begin to change the paradigm that treats poor men and men of color as undeserving of routine primary health care. The articles in this issue begin the process of revealing men’s needs, the services that exist, and the changes in services, systems, and policies that are required to improve the situation. We wish we could tell you more about what men want, their priorities, and their aspirations with regard to health and well-being. We wish that more voices could have been raised in this issue. We wanted to gain more understanding about men’s social contexts and be provided clues as to how to support them. And we wanted to discuss how good primary health care providers take into account all contextual variables (educational level, employment, housing, enfranchisement) when they treat the body so that they might also heal the spirit.

We are at the beginning. We are so very proud to be able to help guide comprehensive efforts to include men in the realm of health and health care services so that they and their families can live with more dignity, respect, and freedom. We hope that these efforts will also serve as a platform for health and human rights, reminding us that inclusiveness in the health care setting and good health cannot exist in a world where priorities are based on wealth, social status, race, or creed. We hope that all who read this issue of the Journal will join us in our mission: “Leave no poor father, brother, uncle, nephew, or son behind, as they too have a right to the tree of life.”

We trust that we at the Kellogg Foundation have done no harm as we have stepped forward to claim this public health issue and to initiate this review of what we know, what we do not know, what we must do-and why we cannot wait.

Originally published as: Henrie M. Treadwell, PhD and Marguerite Ro, DrPh. Poverty, Race, and the Invisible Men. Am J Public Health. 2003;93: 705-707.

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11. The Health Status of Soon-To-Be- Released Inmates: A Report to Congress. 2 vols. Chicago, Ill: National Commission on Correctional Health Care; 2002. Also available at: http://www. ncchc.org/pubs/pubs_stbr.html. Accessed March 17, 2003.

12. Salive ME, Carolla JM, Brewer TF. Dental health of male inmates in a state prison system. J Public Health Dent. 49(2):83- 86,1989 Spring.

13. Wisconsin Legislative Audit Bureau. Prison Health Care [press release]. May 2001. Available at: http://www. wispolitics.com/ freeser/pr/pr0105/ May%2015/pr01051510.htm. Accessed March 17, 2003.

14. Bruen B, Holahan J. Medicaid Spending Growth Remained Modest in 1998, But Likely Headed Upward. Washington, DC: The Henry J. Kaiser Family Foundation; February 2001. Publication 2230.

15. Stana RM. Federal Prisons: Containing Health Care Costs for an Increasing Inmate Population. Washington, DC: General Accounting Office; 2000.

16. Rich JA, Ro M. A Poor Man’s Plight: Uncovering the Disparity in Men’s Health. Battle Creek, Mich: The W. K. Kellogg Foundation; February 2002.

17. What About Men? Exploring the Inequities in Minority Men’s Health. Battle Creek, Mich: The W. K. Kellogg Foundation; 2001.

18. Committee on the Consequences of Uninsurance, Board of Health Care Services, Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: National Academy Press; 2001.

19. Hadley J. Sicker and Poorer: The Consequences of Being Uninsured. Washington, DC: The Urban Institute and the Kaiser Commission on Medicaid and the Uninsured; 2002.

Henrie M. Treadwell, PhD

Marguerite Ro, DrPh

About the Author

Requests for reprints should be sent to Henrie M. Treadwell, PhD, W. K. Kellogg foundation, One Michigan Ave E, Battle Creek, MI 49017 (e-mail: [email protected]).

This editorial was accepted February 3, 2003.

Copyright American Public Health Association Sep 2008

(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.

By Wadyka, Sally

Here’s what Shape editors, beauty pros, and almost 5,000 readers say are tops in makeup, skin, and hair care now. by Sally Wadyka 1 Facial Cleansers

St. Ives Protective Cleanser ($7; at drugstores) Morning multitasking has never been easier. When you wash off this extra- creamy cleanser, it leaves behind a protective layer of SPF 10 sunscreen. (The sunscreen is packed into microscopic capsules that cling to skin.) Testers feared it would have a filmy feel but were pleasantly surprised by the lack of residue. “The product rinses well and made my skin feel clean and soft-not at all greasy,” says Mary Bemis, a spa expert and Shape editorial advisory board member.

Origins Organics Foaming Face Wash ($25; origins .com) Among the things you won’t get in this “silky” face wash: parabens (chemical preservatives that can cause irritation) or any animal ingredients. What you will get: a mix of organic oils, including clove, pink grapefruit, lemon, lavender, and patchouli, which testers called “invigorating and effective.””It dissolved my makeup without any need for scrubbing,” said one.

2 Facial Exfoliators

L’Oreal Paris Advanced Revitalift MicroDermabrasion Kit ($25; at drugstores) Skin looking dull? Dead skin cells are most likely to blame. When these cells don’t slough off every 28 days like they’re supposed to, they clump together on the surface of your skin, making your complexion appear less than luminous. To the rescue: this easy- to-use kit, which features an exfoliating scrub and soothing post- treatment moisturizer with SPF 15 and vitamin E (shown below). Testers said the combo left their skin “supersmooth and bright.”

Philosophy the Microdelivery Exfoliating Wash ($25; philosophy.com) “Regular exfoliation is the key to fresh, youthful- looking skin, but you need to do it gently or you risk irritation,” says Darrell S. Rigel, M.D., a dermatologist and Shape editorial advisory board member. And that’s exactly why testers (including Rigel) were drawn to this mild exfoliator you can safely use daily. In addition to crushed sea fossils (to slough off dead cells), it also contains omega-6 fatty acids, which help skin retain moisture. Testers claimed their “skin had never glowed this much” and that, after several weeks of use, their face became so soft, their makeup went on smoother and looked better.

3 Facial Moisturizers

Olay Definity Night Restorative Sleep Cream ($25; at drugstores) “This cream made me look like I was really getting my beauty sleep,” said one tester. In fact, all testers felt they woke up to fresher, brighter, more even skin. The “rich but not greasy” night cream has a potent antiaging mix of the vitamin complex niacin (to lighten dark spots and diminish fine lines), glucosamine (to strengthen skin’s moisture barrier), and glycerin (to hydrate). “In combination, these ingredients are a highly effective way to improve your complexion,” says Rigel. “It’s a very good product at a very reasonable price.”

Shiseido the Skincare Tinted Moisture Protection SPF 20 ($36; sca.shiseido.com for stores) Testers got more than they’d hoped for in this cream: dewy, well-hydrated skin; sun protection; plus a completely natural-looking glow. The yuzu seed extract (which comes from an Asian citrus fruit) helps jump-start the production of hyaluronic acid, the natural humectant that helps bind moisture to skin. Jeanine Downie, M.D., a dermatologist and Shape editorial advisory board member, praises it for “complementing darker skin too.”

4 Body Cleansers

Dove Supreme Cream oil Body Wash in Sleek Satin ($5; walgreens.com} “My skin felt so smooth when I got out of the shower, I didn’t even need lotion!” exclaimed one happy tester. This luxurious wash not only delivers great lather, it’s also super- moisturizing, thanks to high levels of soybean oil.

Sephora Body Wash in Tangerine Grapefruit ($12; sephora.com’) If your morning shower isn’t waking you up enough, try adding this body wash to your daily routine. Testers couldn’t say enough about the uplifting scent. “It smells like a glass of fresh-squeezed grapefruit juice,” said one. “Using it after my morning workout made me feel doubly refreshed.”

5 Body Moisturizers

Aveeno Daily Moisturizing Lotion With Sunscreen ($7; at drugstores) You wouldn’t head out the door in the morning without putting moisturizer and sunscreen on your face, so why shouldn’t you treat your body the same way? This lightweight, hydrating body lotion makes it simple by combining soothing, moisturizing oatmeal with a powerful hit of UVA and UVB protection (it has an SPF of 15). Testers also consistently noted that the formula “absorbed fast and wasn’t at all greasy.”

Kiehl’s Creme de Corps Light-Weight Body Lotion ($27; kiehls.com) “This is simply a great product,” says Ruth Tedaldi, M.D., a dermatologist and Shape editorial advisory board member. “It’s a wonderful daily moisturizer you can slather on all over after your morning shower to seal in hydration and ensure you’re protected from the sun with SPF 30.” Testers took favorably to how soft the comforting jojoba butter, olive fruit oil, and sesame seed oil left their bodies. “My skin didn’t revert back to its usual dry state!” said one.

6 Body Firming

Nivea Good-Bye Cellulite ($13; walgreens.com) This non-sticky gel/ cream contains L-carnitine, an amino acid said to rev up your metabolism. “After spreading it on twice a day for two weeks, my skin was visibly tighter, smoother, and worthy of showing off,” said one Shape editor.

Chanel Body Excellence Firming and Refining Serum ($120; chanel.com) Testers found that their “problem areas turned into no problem at all” with this new smoothing and tightening serum, which relies on glycolic acid and the amino acid L-arginine to make dimpling less pronounced, without causing irritation. “Glycolic acid is a powerful exfoliator that definitely improves the surface of the skin,” says Downie.

7 Eye Care

Burt’s Bees Naturally Ageless Line Smoothing Eye Creme ($25; burtsbees.com’) “I’ve always thought the botanicals in natural products couldn’t be as effective as synthetic ingredients, but this cream changed my mind,” said a tester. Composed of antioxidant-rich pomegranate (to fight free radical damage), magnolia (to reduce dark circles), para cress plant (to diminish lines), horse chestnut (to reduce puffiness), and moisturizing olive and evening primrose oils, this cream leaves under-eye skin soft, plump, and radiant.

Elizabeth Arden Prevage Eye Anti-Aging Moisturizing Treatment ($98; shop.e/izabetharden.com) This supercharged eye cream, which contains idebenone, a potent antioxidant, gave one of our testers “noticeably smoother skin virtually overnight.”

8 Dermatologist Brands

Patricia Wexler M.D. Dermatology Intensive 3-in-1 Eye Cream ($33; bathandbodyworks.com’) A peptide complex is responsible for giving this concentrated cream its firming and fine-line-fighting capabilities. “Peptides help stimulate the production of new collagen, and over time that can make under-eye creases and darkness less obvious,” says Tedaldi.

DDF Mesojection Healthy Cell Serum ($80; ddf.com) This serum has the potent antioxidants acai berry and scavenol to fight free radical damage, a glycol complex to brighten and resurface skin, and humectants to moisturize. “It hydrates for hours,” said a Shape editor.

9 Antiaging Treatments

Olay Regenerist 14 Day Skin Intervention ($26; drugstore.com) Our testers were thrilled with the results of this kit, which promises younger-looking skin in two weeks. “By day 10, my skin was smoother and brighter, and some of my fine lines had definitely vanished,” said one. The system includes 14 vials you break open and apply nightly. The first week’s vials feature a peptide complex designed to regenerate cells and improve skin’s moisture barrier; week two’s vials contain more of the same, plus micro powders to help fill in fine lines. “My friends kept asking me if I’d had something done because my skin was so luminous!” said a Shape editor.

Clinique Zero Gravity Repairwear Lift ($53; dinique.com’) With repeated sun exposure and natural biological aging, collagen, the substance that helps keep your face plump and taut, begins to break down, giving you saggylooking skin (the result of gravity). But this night cream helps restore your skin with a combination of plumping peptides, exfoliating retinol, and free radical-fighting antioxidants. “Retinoids [like retinol or prescription Retin A] have a proven track record for stimulating collagen production,” says Downie.

10 Sun Protection

Neutrogena Ultra Sheer Dry-Touch Sunblock SPF 85 ($11; walgreens.com’) While there isn’t a single sunscreen out there that can shield you from every damaging UV ray, this one-with a whopping SPF of 85-comes about as close as possible. “This is without a doubt the best sunscreen on the market for the price,” raves Tedaldi. “Who says SPF 85 is a waste? I think it’s fantastic! The higher the number, the longer it takes you to get red in the sun,” she says. And since your face is constantly exposed to UV rays (both indoors and out), there’s no better place to wear something with such powerful protection. Testers loved it because it “absorbed well” and felt light “despite the high SPF.”

Lancome Bienfait Multi-Vital Glow SPF15 Sunscreen ($46; lancome- usa.com) This all-in-one product protects (with SPF plus antioxidant vitamins E and C), nourishes (with essential minerals zinc, copper, and magnesium), adds intense moisture (with hydrating fatty acids), and imparts a gorgeous glow when used for several days in a row. “Not only did my dry skin completely drink it up, but after having it on for a few hours, I got a nice trace of bronze color,” said one tester “Talk about instant gratification!” 11 Self-Tanners

Jergens Natural Glow Express Body Moisturizer ($8; at drugstores) If you still find yourself cringing at the thought of self-tanners for fear of streaking, dark splotches, missed patches, or looking a little orange, this daily moisturizer is made for you. Even the most timid testers were thrilled with the natural color that built up so gradually, no one would ever suspect it came from a bottle. “There’s a reason so many women consider this product a must-have: The result is really subtle, and the application is basically goof-proof,” says Bemis.

Clarins Delicious Self Tanning Cream ($40; us.clarins.com) Die- hard self-tanners deemed this tinter fast-acting and sweet- smelling. “Within minutes I had a totally realistic-looking tan,” said one. “It actually smelled good too, like chocolate,” said another. The secret ingredients? No surprise there-pure cocoa, cocoa bean, and cocoa butter, which not only give the cream its aroma but also help soothe, nourish, and protect skin (the polyphenols in the cocoa have an antioxidant effect).

12 Antiperspirant/Deodorant

Secret Clinical Strength Hypoallergenic Anti-Perspirant/ Deodorant ($7; drugstore.com) Our testers really put this product through its paces-a long walk through the city on a steamy summer day, a rigorous Spinning class, a stress-inducing business presentation-before declaring it a hands-down winner. It contains the maximum amount of aluminum zirconium trichlorohydrex GLY (a sweat-stopping ingredient) you can find over the counter. “This is a good nonprescription product for serious sweaters,” says Rigel.

13 Shampoo and Conditioner

Aveda Smooth Infusion Shampoo and Conditioner ($20 each; aveda.com’) Testers loved that this duo left their hair softer, smoother, and more manageable. “Together they tamed my worst case of the frizzies,” said one tester Both lightweight formulas contain an infusion of organic aloe, maize, and guar bean, which work synergistically to seal cuticles and de-fuzz frazzled hair strand by strand.

Garnier Fructis Shine Burst Fortifying Shampoo and Conditioner ($7 each; at drugstores) Often, shine-enhancing products will give your hair some gleam, but because they contain waxes, they’ll also weigh it down. This cleaning and conditioning pair takes a different approach, relying on cyclodextrin, a lightweight, sugar-based substance, to magnify the shine you have rather than coat your strands with heavier sheen-boosting ingredients. Both also have a blend of vitamins B3 and B6 plus fructose and glucose to nourish even the most parched hair. “The creamy formulas gave my dry, curly hair the extra hydration it so desperately needed,” noted a Shape editor.

14 A Hair Styling

Aussie Opposites Attract Strong Hold & Touchable Feel Spray Gel ($3; at drugstores) Strong hold is not normally synonymous with soft, touchable hair-unless, of course, you’re using this spray gel. “My hair looked incredibly smooth after styling,” said one tester. “But it never felt stiff or crunchy.” Designed to work on all hair types (oily, dry, or normal) and textures (curly or straight), this gel also features nourishing botanicals, like mango extract, that keep tresses healthy and strong.

Tresemme Touchable Curls Shaping Milk ($4; at drugstores) Our curly haired testers responded passionately to this lightweight cream styler, which gives natural curls better definition and also keeps frizz to a minimum, even on high-humidity days. “It helped me get full, healthy, absolutely flawless corkscrews,” said one. “I could finger-style my hair into place in the morning and not have to worry about it again for the rest of the day,” said another.

Biolage Styling Shine Endure Spritz ($14; biolage.com for salons) Think of this finishing spray as a two-in-one product: It shields hair from the damaging effects of heat stylers and prevents future fraying and split ends with special polymers that adhere to and strengthen hair. Testers loved that it upped their sheen quotient and held their styles all day. “I sprayed it on in the morning, and by dinner my hair was just as shiny.”

15 Hair Color

Best Color: Clairol Perfect 10 by Nice ‘n Easy ($12; at drugstores) Even apprehensive first-time colorists were surprised by the ease and efficacy of this at-home coloring kit. “I thought I’d make a gigantic mess trying to do this myself, but the coloring cream wasn’t at all watery or drippy,” said one tester. And due to a high-tech formula that contains fast-acting lightening molecules, your new hue is ready in just 10 minutes. “The color I got looked exactly like the model’s on the box,” said a Shape editor.

Best Glaze: John Frieda Luminous Color Glaze Clear Shine ($10; at drugstores) This no-hassle glaze infuses hair with incredible shine and gives any color (natural or chemically enhanced) a boost. Since it’s free of ammonia, dye, and peroxide-which can be damaging to strands if used too oftenit’s safe to massage in every day in the shower or leave in for 20 minutes once a week as an intensive mask.

16 Hair Removal

Best Razor: Gillette Venus Embrace razor ($10; at drugstores) For five years running, Shape readers and editors have chosen a Gillette Venus razor as their favorite shaver. “I’ve been using and loving the original Venus since it came out, but this is a huge improvement,” said one tester. What’s new: The latest Venus features five blades that adjust themselves individually as you shave so they maintain contact with skin at all times, even over awkward-to-reach areas, like ankles, knees, and your bikini line.

Best Depilatory: Nair Shower Power Exfoliating With Skin Renewal Micro-Beads ($7; at drugstores) “I’ve never been a big fan of depilatories, but this one finally converted me,” said one tester, impressed by how smooth and hair-free her legs got in a matter of minutes. Just slather on the extra-thick formula in the shower (amazingly, it won’t wash off), then, after five minutes, remove it with the exfoliating sponge in the package. “I loved not having to sit around with my legs covered in sticky stuff,” said a tester. And the results seemed to last for days. “I could get away with using it just once or twice a week,” said another tester.

Best Shave Gel: Skintimate Signature Scents Moisturizing Shave Gel in Flirty Mango ($3; at drugstores) To get a close shave, experts agree you need both a good razor and shaving cream or gel. “An emollient formula like this one, with olive butter and vitamin E, plumps up the hair, making it softer and easier to cut. Plus, it helps the razor glide easily over skin, minimizing the potential for nicks,” says Downie. Testers also appreciated this gel’s “fruit salad-like” scent.

17 Mood-Boosting Fragrances

Celine Oion Sensational Eau de Toilette ($32; jcpenneycom) Testers couldn’t stop spritzing on this “light, spring-like scent,” which many described as suitable for day or night-as well as for any occasion. The luxurious but not overwhelming floral-fruity blend includes notes of pear, plum, and apple. “It smelled sophisticated but not like something my grandma would have worn,” said one tester.

Covet Sarah Jessica Parker Eau de Parfum Spray ($52; nordstrom.com) “Even though it isn’t heavy, this fragrance lasts and lasts,” noted a tester. The seductive aroma features a spicy mix of crushed geranium leaves, Sicilian lemon, and French lavender blended with sweet chocolate, magnolia, amber, and musk. “And the bottle is so gorgeous, you’re happy to display it on your dresser,” added one Shape editor.

18 Hand, Foot, and Nail Care

Ahava Dermud Intensive Nourishing Hand Cream ($25; ahavaus.corri) Dry, irritated skin is no match for the mineral-rich mud from the Dead Sea in this ultra-luxurious hand cream. “My normally cracked hands got softer and smoother than they had been for years,” said one Shape editor, who also commented that, for such a thick formula, the cream sunk in very quickly. “This product can even help soothe serious skin irritations, like dermatitis and psoriasis,” says Bemis.

OPI Manicure Pedicure Green Tea Scrub ($15; opi.com for stores) Testers described this mani-pedi scrub as a “15-second mini spa treatment you can do in the shower.” Formulated with a combo of exfoliating, natural sugar crystals; fruit-derived alpha hydroxy acids; and antioxidant green tea, the scrub earned praise for “instantly softening heels.”

Sally Hansen Color Fast Dry Quick Nail Color Pen ($8; at drugstores) Testers labeled this polish “perfect for your purse.” The unique magic marker design makes it possible to touch up chips and smudges in just seconds. Best of all, the vibrant color dried quickly. “It’s the ultimate fast fix for a woman on the go,” said a tester.

beauty fact

FOUNDATION SHOULD BE INVISIBLE ON SKIN

19 Foundation

Neutrogena Mineral Sheers Powder Foundation ($13; at drugstores) “Mineral makeup is often less irritating than more chemical formulas, which is why it’s so popular among people with sensitive or very allergic skin,” says Rigel. In addition to being gentle, though, it offers real coverage. “It made my skin completely even without looking mask-like,” said one tester. The sheer formula also contains soy and antioxidants to help smooth and protect skin, as well as an SPF of 20.

Stila oil-Free Sheer Color Tinted Moisturizer SPF 30 ($36; stilacosmetics.com’) Testers unanimously loved this nongreasy formula, which covered flaws without appearing too heavy. And because it’s available in eight shades, testers of all hues were able to find a match. “I’m biracial, and I usually have trouble getting a color that looks natural, but not this time,” said one tester. 20 Eye Makeup

CoverGirl LashBlast Waterproof Mascara ($8; drugstore.com’) “I truly loved this mascara!” exclaimed one tester, who said it gave her “long, thick, fat lashes.” The lightweight, waterproof formula didn’t clump or feel stiff (a frequent complaint about waterproof mascaras). Testers also confirmed that the mascara really delivered on its promise to add volume.

Estee Lauder Double Wear Zero-Smudge Lengthening Mascara ($20; esteelauder.com) This mascara was deemed ideal for everyday use, lengthening and not budging for hours, thanks to a unique lash- extending brush and flake-free formula. “It made my lashes stand out so much, I barely needed any other eye makeup,” said one Shape editor.

Chanel Inimitable Waterproof Mascara MultiDimensionnel ($28; chanel.com) Designed for all-out glamour, this waterproof formula delivers faux-like effects that last for hours. “It never felt heavy,” reported one Shape editor, “yet it was easy to remove.”

21 Lip Color

Revlon Renewist LipColor ($9; at drugstores) The fact that this lipstick both looks good and is good for lips made it a favorite among our testers. Available in 24 eye-catching shades, it’s packed with pro-collagen to boost moisture and reduce Np lines, plus it has an SPF of 15. “I chose it for the color, but I was happy knowing the SPF would keep my lips protected from sun damage,” said one tester. “It had the perfect creamy texture,” said another.

Bare Escentuals BareMinerals 100% Natural LipColor ($15; bareescentuals.com’) This nourishing, all-natural lip color gets its rich tones from minerals. The range of 16 shades drew raves from testers, who found them all wearable. Infused with sesame, macadamia, and coconut oils, the hydrating lipsticks left testers’ lips soft for hours. “I never needed to reach for my lip balm!” said one.

22 Blush/Bronzer

Physicians Formula Organic Wear 100% Natural Origin Bronzer ($14; at drugstores) This bronzer contains a healthy combination of organic rice silk (to absorb shine) and jojoba seed oil (a natural skin softener), and it’s formulated without potentially irritating synthetic colors, fragrances, parabens, or preservatives. “It’s suitable for people with all kinds of skin,” says Downie, “not just sensitive types.”

Victoria’s Secret Very Sexy Makeup Mosaic Blush ($18; victoriassecret.com’) Why choose just one shade of blush when you can get five in one sleek compact? This well-coordinated mix (there are six combinations to suit all skin tones) blends as you brush it on to leave behind a natural-looking flush with just the slightest hint of shimmer. “I don’t usually wear makeup because it feels heavy on my skin, but I could barely even tell I had powder on my skin,” said a tester.

23 Tooth Care

Colgate Total Advanced Whitening Toothpaste ($4; at drugstores) What good are white teeth if your mouth isn’t healthy? This toothpaste not only brightens teeth, it also fights germs, plaque, and tartar. “My teeth felt the way they do after a professional cleaning,” said one tester. Many also mentioned the peppermint taste. “It totally erased the taste of the onion bagel I had at lunch from my palate,” said a Shape editor.

Supersmile Whitening Oral Rinse ($14; supersmile.com) The oral care line that started a whitening revolution has done it again. Testers raved about how clean and fresh this minty, alcohol-free pre- rinse made their mouths feel. “I thought this was just like any other mouthwash until people started asking me if I just had my teeth whitened,” said one tester. “Now I won’t go a night without using it before brushing!”

SHOP!

Click on shape .com/awards for links to the products shown here so you can buy them and try them for yourself.

Our Beauty Editorial Advisory Board

Jeanine Downie, M.D., is the director of Image Dermatology in Montclair, N.J., is boardcertified, and frequently appears on the Today show as a consultant. She tries every product before telling her patients to use it.

Mary Bemis is a spa expert who launched insidersguide tospas.com and is the founding editor in chief of Organic Spa magazine. When testing products, she looks for efficacy as well as how a product makes you feel overall.

Darrell S. Rigel, M.D., is a clinical professor of dermatology at New York University Medical Center and president of the American Society for Dermatologie Surgery. He believes in low-cost, high- quality skin care.

Ruth Tedaldi, M.D., is the founder of Dermatology Partners Inc., in Wellesley, Mass. She also practices cosmetic dermatology at the Sports Club/LA in Boston. What matters to her when trying new products? Results!

beauty fact

TODAY’S ANTIAGERS ARE MORE EFFECTIVE THAN EVER

beauty fact

KEEP HAIR HYDRATED IT’S THE BEST WAY TO PREVENT DAMAGE

beauty fact

A SEXY SCENT CAN GIVE YOU CONFIDENCE

Best New Brand

Be Fine (from $16; befine.com), a new line of plant-based skin care, earned high marks from Shape editors and testers. The biggest crowd pleaser: Eye Blossom Miracle Eye Serum ($30), which contains natural ingredients like ftaxseed oil and cucumber and ” lightens dark circles after just a few applications. Spa expert Mary Bemis compares using it to a cold compress: “It refreshed my skin and depuffed my eyes.” The product also features peptides, which help stimulate collagen production, thickening the skin so shadows become even less noticeable over time. Testers were also impressed by the single-dose packaging (each pod contains enough serum to last a week).

Copyright American Media, Inc. Sep 2008

(c) 2008 Shape. Provided by ProQuest LLC. All rights Reserved.

By Anonymous

june 2008 “Ashlee Simpson has fallen down and picked herself up many times-which inspires me to reach for my dreams no matter what.”

rave review

As a longtime exercise enthusiast, I was becoming bored with my routines-until I started subscribing to Shape. I tear out all the workouts, stick them in plastic inserts, and keep them in a binder. Now I have tons of great workout ideas and can shake things up whenever I want to!

Jen Zeman

Maryland

Weighing in on Ashlee

I wanted to thank you for putting Ashlee Simpson on your June cover. She’s talented, she’s beautiful, and she’s fallen down and picked herself up many times-which inspires me to reach for my dreams no matter what.

Jennifer Blanchard

Texas

I wonder about Ashlee Simpson as your cover choice. I subscribe to Shape for inspiration, and a young celebrity with a nice body does not motivate me. I too would have energy all day long if I were 23 and had the money for a personal trainer! Show me someone who is 40, or 35 even, to push me to get in shape.

Lisa Petersen Primeau

Missouri

I don’t know why Ashlee Simpson was on your cover. She’s a young woman with a not-so-distinguished singing career who has avoided the topic of her obvious plastic surgery and is now pregnant-not a model for physical fitness or healthy eating. She seems more appropriate for the cover of a teen magazine.

Loren Hamilton

New York

A celeb with curves: Hooray!

Thanks for including actress Natasha Henstridge in your latest issue [“Celebrating Body Confidence With Natasha Henstridge”]. I think she’s one of the most beautiful women in Hollywood, and I was pleasantly surprised to read that she’s a size 8. It just goes to show you don’t need to be super-skinny to be beautiful. Keep up the good work!

Laura Shirey

Texas

Getting to my goal weight

I loved the no-deprivation diet [“Your Ultimate Bikini SlimDown”]. I’m trying to lose those stubborn last 10 pounds, and this program is perfect-it doesn’t leave me feeling hungry or run- down. I intend to stick with it until I can fit into my old jeans again.

Kim Wiegmann

Illinois

A good-living essential

Since discovering my inner athlete a year ago, I’ve lost more than 60 pounds-and been given a second chance at life. I have lupus, an autoimmune disorder, and now that I’m exercising regularly, it’s gone into remission, and I feel stronger, fitter, and healthier than ever. Shape’s advice-packed pages have inspired and encouraged me along my journey. Thank you.

Joanne Kinnaird

New Zealand

My roommate and I both entered college as healthy girls who exercised and watched what we ate. But the freshman 15 isn’t a myth: We put on weight, as did most of our friends. Fortunately, your magazine helped us get back in shape-and it continues to motivate us every month.

Omer Rachel Weizman

New York

this month’s debate

Last month on shape.com, we asked you:

If your significant other gained weight, would it bother you?

47% YES

“I stay in shape not only to feel good about myself but also to be attractive to my man. If he gained weight, I’d think he didn’t care enough to look his best for me.”

JODI LADGE

CALIFORNIA

“It would worry me because I would see it as a sign that food was filling some sort of void.”

EVELYN SMITH

ILLINOIS

“I struggle with my weight, so if my in-shape spouse packed on pounds, I’d get discouraged.”

MANDY MORRONE

ARKANSAS

“If my boyfriend put on a lot of weight, I would definitely speak up out of concern for his health-just as I would if he started drinking every night or smoking.”

ANGELA CAROLA

NEW JERSEY

53% NO

“Everyone’s weight fluctuates from time to time; that’s life. As long as he was within a healthy range for his height, my feelings for him wouldn’t change.”

BRITTANY WILLIAMS

WASHINGTON

“If my boyfriend gained a few extra pounds, there would just be more of him to love.”

KRISTIN JOHNSON

OREGON

“I’m not with him because of his weight, I’m with him because he makes me happy.”

JESSICA VALLIERE

NEW YORK

“In 10 years of marriage, I’ve gone up and down. My husband has continued to love me regardless of my size, and I would do the same for him.”

MELINDA POWELL

ARIZONA

voice your opinion

Log on to shape.com/ readerdebate and share , your thoughts with us and fellow Shape readers.

You told us…

“My feel-gorgeous wardrobe essential”

A healthy body Image can do wonders for your confidence-but so can the perfect cocktail dress or pair of pumps. Your favorite look- pretty pieces:

Do-no-wrong denim

“My best pair of jeans hit me in all the right places and do my curves justice.”

Jill Havran

Iowa

Instant hourglass

“When I want to feel puttogether and sophisticated, I can always count on my black wrap dress.”

Beth Ann Coombs

New Jersey

Best foot forward

“My yellow heels catch the eye-and I’m comfortable enough with my legs to enjoy the attention.”

Niki Platz

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By Zabos, Georgina P Northridge, Mary E; Ro, Marguerite J; Trinh, Chau; Vaughan, Roger; Howard, Joyce Moon; Lamster, Ira; Bassett, Mary T; Cohall, Alwyn T

Objectives. Profound and growing disparities exist in oral health among certain US populations.We sought here to determine the prevalence of oral health complaints among Harlem adults by measures of social class, as well as their access to oral health care. Methods. A population-based survey of adults in Central Harlem was conducted from 1992 to 1994. Two questions on oral health were included: whether participants had experienced problems with their teeth or gums during the past 12 months and, if so, whether they had seen a dentist.

Results. Of 50 health conditions queried about, problems with teeth or gums were the chief complaint among participants (30%). Those more likely to report oral health problems than other participants had annual household incomes of less than $9000 (36%), were unemployed (34%), and lacked health insurance (34%).The privately insured were almost twice as likely to have seen a dentist for oral health problems (87%) than were the uninsured (48%).

Conclusions. There is an urgent need to provide oral health services for adults in Harlem. Integrating oral health into comprehensive primary care is one promising mechanism. (Am J Public Health. 2002; 92:49-52)

Although the oral health status of the US population has greatly improved over the last 30 years, profound and growing disparities exist among certain populations.1-4 The most disadvantaged include people of color, the working-class poor, and people with chronic illnesses and disabilities. National, state, and local data to accurately quantify the nature and magnitude of these disparities in oral health are notably lacking.5

The surgeon general’s report Oral Health in America calls for new efforts to eliminate disparities in oral health status and rates of oral disease. In particular, it uncovers the hidden epidemic of dental and oral diseases that largely affects poor people of color and those with chronic illnesses and disabilities.1 The report also stresses the serious consequences that poor oral health has on overall health and well-being. Adults in Harlem suffer from high excess morbidity and mortality6, yet very little is known about the prevalence or impact of oral diseases in the population. Oral health disparities have been attributed in part to differences in the utilization of oral health services and access to primary oral health care.7-10 A better understanding of the underlying reasons for underutilization in poor populations of color is urgently needed. The Harlem Health Promotion Center, a joint project of Harlem Hospital Center, the Mailman School of Public Health of Columbia University, and the Centers for Disease Control and Prevention, conducted the Harlem Household Survey (HHS) to better understand and address the determinants of excess morbidity and mortality among adult residents of Harlem. This report presents the results of the survey’s oral health assessment.

In particular, we characterized the burden of oral health complaints among Central Harlem adults, determined whether or not they received dental care for their self-reported problems, and identified factors that facilitated their utilization of dental care services.

METHODS

Study Design

The HHS was conducted from 1992 to 1994 in Central Harlem, a largely African American community located in northern Manhattan, New York City. Because previous research has demonstrated that people of color and the poor are underrepresented in household surveys,11 the sampling frame of the HHS included those dwellings and places where people live that are often missed by conventional US census listing protocols; these include single-room occupancies, cars, and cardboard boxes. Details regarding the sampling frame, survey design, and instrument have been previously described.12 Of the 963 adults selected, 695 successfully completed the interview, for a response rate of 72%. All interviews were conducted in person by trained community residents with a structured questionnaire; they lasted from 60 to 90 minutes. Respondents were compensated $10 for participating. The survey covered a range of topics, including 50 self-reported health complaints, 3 modules on primary care- sensitive conditions, preventive health practices, and social class measures. Detailed questions on health behaviors were included to afford better understanding of determinants of premature mortality in Harlem.

Health insurance was also queried about. Nonetheless, the HHS did not ask specifically about dental coverage. In New York State, Medicaid includes comprehensive primary oral health care coverage, Medicare has no dental component, and private insurance may or may not cover oral health services.

Oral and General Health Assessment

Participants were queried systematically from a list of 50 common symptoms and health conditions about whether or not they had experienced any complaints in the past 12 months. For each condition identified, participants were asked if they had sought medical treatment. The oral health assessment consisted of the question “During the past 12 months, have you had problems with your teeth or gums?” Those who answered yes to this question were asked “Did you see a dentist for problems with your teeth or gums?” Possible responses were yes and no.

In addition, the HHS queried specifically about 3 ambulatory care- sensitive conditions: asthma, diabetes, and hypertension. For each of these 3 conditions, participants were asked, “Have you ever had [asthma, diabetes, hypertension]?” Those who answered yes were asked, “How old were you when you had [the identified condition]?” and “When did you last see a doctor?”

Data were entered and analyzed with SPSS 7.0 (SPSS, Inc, Chicago, Ill). Two-tailed chi^sup 2^ tests were used to test for differences in proportions between groups identified by known determinants of oral health-namely, age group, sex, social class (highest degree earned, current work status, annual household income), and health care coverage. Multivariate logistic regression was also performed, but the extremely high level of interdependence among the variables precluded meaningful interpretation of the results.

RESULTS

Sociodemographic Characteristics

HHS participants were broadly representative of the general population of Central Harlem on the basis of figures from the 1990 census (Table 1). Females were slightly overrepresented in the HHS sample (59% vs 55% in the 1990 census), probably because of their greater willingness to participate in health surveys such as ours. The sample was predominantly Black non-Latino (87%). Although 3 of every 5 households in both the HHS and the 1990 census earned above the poverty level of $13359 for a family of 4, this amount is considerably lower than what is needed to adequately provide for the housing, nutrition, and health care needs of Harlem residents.

Of more than 50 health complaints that were part of the survey, problems with teeth or gums (30%) were the most frequently cited (Table 2). The percentage of Harlem adults suffering from dental problems was greater than the percentage suffering from hypertension, asthma, or diabetes.

Compared with their counterparts, adults reporting problems with their teeth or gums tended to be unemployed, to have lower household incomes, and to either lack health insurance or have public insurance (Table 3). No statistically significant differences were found between those who reported and those who did not report dental problems by age, sex, or education.

We also investigated whether the significant variables identified in the bivariate analyses in Table 3 would continue to help explain oral health complaints when entered into a multivariate analysis. Prior to the inclusion of these variables as independent measures into a logistic regression model, we examined the interrelationships among these items. Unfortunately, the extremely high level of interdependence among these variables precluded deriving maximum likelihood estimates of association in a logistic regression model. Employment was highly related to household income (chi^sup 2^^sub 1^=161.9, P<.001) and health care coverage (chi^sup 2^^sub 2^=275.9, P<.001), and income was highly related to health care coverage (chi^sup 2^^sub 2^=196.1, P<.001).

Among participants reporting oral health complaints (n=209), two thirds (66%) reported having seen a dentist for the complaint. Persons who had private insurance (87%) were more likely to have sought treatment from a dentist than those who had public insurance (62%) or were uninsured (48%).

DISCUSSION

It is striking that the most commonly self-reported health complaint among Harlem adults in this community-based sample was problems with their teeth or gums (30%). Unfortunately, no data were collected on the severity of these complaints, which merits further study. In comparison, only 10% of those participants surveyed in a special supplement on oral health in the National Health Interview Survey (NHIS) in 1989 reported fair or poor oral health.13 Furthermore, a previous study found that Harlem residents were less likely to identify dental problems than providers were.14 National data from National Health and Nutrition Examination Survey III (NHANES III) suggest that among dentate adults (those with any natural teeth), nearly 50% of African Americans have untreated coronal tooth decay, compared with 25% of Whites.15 No significant differences in self-perceived dental problems were found by sex, age, or education. Those with lower educational attainment were somewhat more likely to report problems with their teeth or gums than were those with higher educational attainment. The lack of an association with age is notable given that the prevalence of caries and periodontal disease increases with age. In Harlem, it may be that a high disease burden at a young age becomes the norm, and therefore older residents do not report more oral health problems than younger residents. Data from national surveys (NHANES III and the 1989 NHIS) have shown that men rate their oral health more highly than do women (although women have fewer oral health problems than men) and that lower educational achievement is associated with greater perceived oral health needs.15,16 The association between self-perceived oral health needs and age remains inconclusive.17 The lack of differences in this study may be due to self-report and community perception of oral disease. Education, which may be an indicator of an individual’s knowledge of oral hygiene and ability to navigate the health care system, may be a secondary issue when financial barriers to accessing care are great.

Even in Harlem, a poor community of color, differences by social class are evident. In particular, those with lower household incomes and the unemployed are more likely to report dental problems than are other adults in Harlem. This may reflect barriers to preventive or restorative dental care.

It is disturbing that a third of those who suffer from dental problems did not seek care. Among those who did, having insurance coverage was significantly associated with receipt of care. Those with private coverage were less likely to report having dental problems and more likely to report seeking treatment when problems existed than were those with public coverage or no coverage. Note that having private insurance does not necessarily mean that dental coverage is provided. It is likely that the strong relationship between having private insurance and seeking treatment for dental complaints is due in part to higher income and social class among those with private health insurance.

These hypotheses cannot be explored in the HHS owing to the limited data collected on oral health. Still, this study contributes to what is presently known regarding the unmet oral health needs of Harlem adults, as there is a woeful lack of other population-based oral health data on this population. These findings therefore merit attention and signal the need for additional research into how best to provide comprehensive health care, including dental care. Receipt of oral health services for people in need may be improved if those services can be integrated into comprehensive primary care programs.

This problem is particularly vexing because the New York State Medicaid program has one of the most comprehensive dental benefit packages among the 50 states, providing coverage for people of all ages. This suggests that there are other barriers to care that need to be examined (e.g., geographic accessibility and availability of dentists who both accept Medicaid and provide culturally competent care).18

As previously noted, requisite to any agenda for improving the health of vulnerable populations is the capacity of local, state, and national agencies to align preventive health and disease control policies.19,20 In the case of oral health, new and innovative models of care for communities traditionally confronted with shortages of health professionals are needed.21 For dental and medical providers, educational curricula need to incorporate a wider body of knowledge concerning the relationship of comorbid infections and other systemic health conditions with poor oral health status.22 The correlation between poor oral health status and other chronic conditions among socially and economically disadvantaged communities illustrates the high level of unmet need for both general and dental health care. Those who are most likely to have oral health problems are also most likely to suffer from other chronic health conditions. 4,5 Therefore, integrating oral health services into comprehensive primary care services may improve access to dental care.1,23,24

Referring to the release of the surgeon general’s report on oral health, Allukian20 echoed the need to “reconnect the mouth to the rest of the body in health policies and programs.” For far too long, oral and dental have been a neglected epidemic. We need to document the depth of oral health disparities among the most vulnerable groups in our society. Simultaneously, we must integrate oral health care into comprehensive primary care and aggressively pursue policies that will eliminate disparities in oral health.

Originally published as: Georgina P. Zabos, DDS, MPH, Mary E. Northridge, PhD, MPH, Marguerite J. Ro, DrPH, Chau Trinh, MS, Roger Vaughan, DrPH, MS, Joyce Moon Howard, DrPH, Ira Lamster, DDS, MMSc, Mary T. Bassett, MD, and Alwyn T. Cohall, MD. Lack of Oral Health Care for Adults in Harlem: A Hidden Crisis. Am J Public Health. 2002;92:49-52.

References

1. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.

2. Healthy People 2000 Oral Health Progress Review. Washington, DC: US Public Health Service; 1999.

3. Drury TF, Garcia I, Adesanya M. Socioeconomic disparities in adult oral health in the United States. Ann NY Acad Sci. 1999;89:322- 324.

4. Oral Health: Dental Disease Is a Chronic Problem Among Low- Income Populations. Washington, DC: US General Accounting Office; 2000. Publication GAO/ HEHS-00-72.

5. A Plan to Eliminate Cranial, Oral, and Dental Health Disparities. Rockville, Md: National Institute of Dental and Craniofacial Research, National Institutes of Health; 2001.

6. McCord C, Freeman HP. Excess mortality in Harlem. N Engl J Med. 1990;322:173-177.

7. Vargas CM, Crall JJ, Schneider DA. Sociodemographic distribution of dental caries: NHANES III, 1988-1994. J Am Dent Assoc. 1998;129:1229-1238.

8. Isman R, Isman B. Oral Health America White Paper: Access to Oral Health Services in the US. 1997 and Beyond. Chicago, Ill: Oral Health America; 1997.

9. Warren RC. Oral Health for All: Policy for Available, Accessible, and Acceptable Care. Washington, DC: Center for Policy Alternatives; 1999.

10. Milgrom P, Reisine S. Oral health in the United States: the post-fluoride generation. Annu Rev Public Health. 2000;21:403-436.

11. Moon Howard J. Health Status of Urban African Americans: The Relationship Between Living Arrangement and Reachability in Inner- City Communities [doctoral thesis]. New York, NY: Columbia University; 1997.

12. Fullilove RE, Fullilove MT, Northridge ME, et al. Risk factors for excess mortality in Harlem: findings from the Harlem Household Survey. Am J Prev Med. 1999;16(suppl 3):22-28.

13. Bloom B, Gift HC, Jack SS. Dental services and oral health. Vital Health Stat 10. 1992; No. 183:1-95.

14. Brunswick AF, Nikias M. Dentists’ ratings and adolescents’ perceptions of oral health. J Dent Res. 1975;54:836-843.

15. Adesanya RM, Drury TF. Black/White Disparities in the Oral Health Status of American Adults. Rockville, Md: National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.

16. Drury TF, Redford M, Garcia I, Adesanya M. Identifying and Estimating Oral Health Disparities Among US Adults. Rockville, Md: National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.

17. Atchison KA, Gift HC. Perceived oral health in a diverse sample. Adv Dent Res. 1997;11:272-280.

18. US General Accounting Office Report to Congressional Requesters. Factors Contributing to Low Use of Dental Services by Low-Income Populations, Oral Health. Washington, DC: General Accounting Office; 2000. Publication GAO/HEHS-00-72.

19. Atchison KA, Davidson PL, Nakazono TT. Predisposing, enabling and need for dental treatment characteristics of ICS-II USA ethnically diverse groups. Adv Dent Res. 1997;11:223-234.

20. Allukian M Jr. The neglected epidemic and the surgeon general’s report: a call to action for better oral health. Am J Public Health. 2000;90:843-845.

21. Andrulis DP. Community, service, and policy strategies to improve health care access in the changing urban environment. Am J Public Health. 2000;90: 858-862.

22. Zabos GP. HIV related primary oral health care, linking teaching and service. Paper presented at: American Association of Dental Schools 74th Annual Session and Exposition; March 15-19, 1997; Orlando, Fla.

23. Isman RE. Integrating primary oral health care into primary care. J Dent Educ. 1993;57:846-852.

24. Zabos GP, Trinh C. Bringing the mountain to Mohammed: a mobile dental team serves a communitybased program for people with HIV/AIDS. Am J Public Health. 2001;91:1187-1189.

About the Authors

Georgina P. Zabos, Marguerite J. Ro, Chau Trinh, and Ira Lamster are with the School of Dental and Oral Surgery, Columbia University, New York, NY. Georgina P. Zabos, Mary E. Northridge, Marguerite J. Ro, Chau Trinh, Joyce Moon Howard, Mary T. Bassett, and Alwyn T. Cohall are with the Harlem Health Promotion Center, Mailman School of Public Health, Columbia University, New York, NY. Roger Vaughan is with the Heilbrunn Center for Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY.

Requests for reprints should be sent to Georgina P. Zabos, DDS, MPH, Columbia University School of Dental and Oral Surgery, Division of Community Health, 154 Haven Ave, New York, NY 10032 (e-mail: [email protected]). This article was accepted September 16, 2001.

Contributors

G.P. Zabos, the principal investigator of the oral health project, wrote the proposal, supervised all aspects of the study, and was responsible for most of the writing and interpretation of the findings. M. E. Northridge designed the analyses and contributed substantially to the writing and interpretation of the findings. M. J. Ro conducted the analyses and contributed to the interpretation of the findings. C. Trinh performed the preliminary analyses and contributed to the writing. R. Vaughan provided statistical consultation and contributed to the interpretation of the findings. J. Moon Howard was investigator on the project and was involved in the conceptualization of the paper. I. Lamster reviewed preliminary drafts and provided consultation as needed. M.T. Bassett provided initial funding of the project and conceptualization of the paper. A.T. Cohall, the principal investigator of the Harlem Health Promotion Center, provided access to the database.

Acknowledgments

This study was supported by the Centers for Disease Control and Prevention as part of its core funding for the Harlem Health Promotion Center (grant U48/CCU209663-06, special interest project 4- 97).

The authors thank Colin McCord, Ann Brunswick, and Conrad Graves for helpful comments on previous drafts of this paper.

Copyright American Public Health Association Sep 2008

(c) 2008 American Journal of Public Health. Provided by ProQuest LLC. All rights Reserved.

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— Contra Costa Regional Occupational Program — Tuition free computer training to adults in MS Office and Web Design. Part of the Contra Costa County Office of Education. $45 per nine-week session (180 hours of classroom training); full- and part-time programs available. In conjunction with the Employment Development Department. 399 Taylor Blvd. suite 110, Pleasant Hill. 925-934- 5653, http://pclab.cccoe.k12.ca.us.

— Delta Networking Partners — Meets 8:30-10 a.m. Tuesdays. One membership per profession. Eskaton Lodge, 450 John Muir Parkway, Brentwood. Contact: Jennifer Fink, 925-516-3840, www.deltanetworkingpartners.org.

— East Bay SCORE, Chapter 506 — The non-profit volunteer organization is a partner with the United States Small Business Administration. Its members are business people with experience providing free counseling and mentoring and monthly low fee workshops. Visit www.eastbayscore.org.

— EastBay Works Career Center Brentwood — Hours: 9 a.m.-5 p.m. weekdays. For a calendar of events, visit www.eastbayworks.com. Sessions held at 281 Pine St., unless otherwise noted. All services free. Registration: 925-634-2195.

— EastBay Works Concord Business and Career Center — “Bio Tech Information Sessions.” Sessions held at 4071 Port Chicago Highway, Suite 250, Concord, unless otherwise noted. Registration: 925-671- 4500. Visit www.eastbayworks.org.

— EastBay Works Career Center Pittsburg — Hours: 9 a.m.-5 p.m. weekdays. For a calendar of events, visit www.eastbayworks.com. Sessions held at 415 Railroad Ave., unless otherwise noted. All services free. Registration: 925-439-4875.

— EastBay Works West County Career Center — Sessions held at 2300 El Portal Drive, Suite B, San Pablo, unless otherwise noted.

Mondays-Thursdays: “Senior Service America,” for adults, 55 and older.

Mondays-Fridays: The State of California Employment Development Department will have representatives on site to answer questions regarding supportive services for veterans, and for those who need information about unemployment insurance and disability claims; by reservation only, in English and Spanish languages. The EDD will also have personnel dedicated to serving veterans; by reservation only.

Mondays: “Special Services Orientation and WIA Information Sessions,” 10:30 a.m.; Typing test, 9:30 a.m.-3:30 p.m., by appointment; the center is open until 7 p.m.

Tuesdays: “Filipino SmartCard Tours,” 11 a.m.; “SmartCard Tours in Spanish,” 1:30 p.m.; “Out-of-School Youths and Young Adults Orientation,” 3 p.m.; “Career/College Counseling,” by appointment. A Contra Costa College counselor will be available.

Wednesdays: Typing test, 9:30 a.m.-3:30 p.m. by appointment; “Steps to Success/Interviewing Techniques Workshop,” 9 a.m.; Department of Rehabilitation, 9 a.m.-noon by appointment. Services to individuals with disabilities; “Steps to Success/Master Application Workshop,” 11 a.m.; “Career Choices Workshop,” 11 a.m.; Youth tours, 2-4 p.m. (first and third Wednesdays monthly); “Basic Computer Workshop,” 3-4 p.m.; “Introduction to the Internet,” 4-5 p.m.; “Career/College Counseling,” by appointment. A Contra Costa College counselor will be available.

Thursdays: “Steps to Success/Resume Writing Workshop,” 11 a.m.; “Job Development Workshop,” 1-5 p.m. by appointment, for people with disabilities and who want to work; “Introduction to the Internet: Surf the World Wide Web,” 4-5 p.m.; “Career Choices Workshop,” 4- 4:45 p.m.

Fridays: Typing test, 9:30 a.m.-3:30 p.m. by appointment; “SmartCard Tours in Spanish,” 1:30 p.m.

Registration: 510-374-7440.

Elite Leads Networking — “Writing Class,” 12:30 p.m. third Tuesdays monthly. 210 Porter Drive No. 205, San Ramon. First class is free. Contact: Sharyn, 925-939-1801.

— Exchange Club of San Ramon Valley — Meets for lunch at noon second Wednesdays monthly. Features guest speakers and business networking. Guests are welcome with luncheon reservations. Contact: Karen Stepper, president, 925-275-2412, www.srvexchangeclub.org.

— Experience Unlimited, Contra Costa — Meets 9:30-11:30 a.m. Tuesdays. Registration and networking begins at 9 a.m. A no-fee, nonprofit, volunteer organization helping professionals who are seeking new jobs. Temple Isaiah of Contra Costa, 3800 Mt. Diablo Blvd., Lafayette. 925-602-0166; www.euccca.org.

— Fairfield Real Estate Investment Club — Meets 7-9 p.m., with registration 6:30-7 p.m., second Thursdays monthly. Placer Title Company, 1300 Oliver Road, Suite 120, Fairfield. $20. Reservations not required. Contact: Dennis Downing, 925-348-6250, www.fairfieldreic.com.

— The Financial Planning Association of the East Bay — Meets 7:15 a.m. first Wednesdays monthly. Intended for other financial planning professionals or employees of related companies. Round Hill Country Club, 3169 Round Hill Road, Alamo. Registration in advance: $20 members; $30 nonmembers, includes breakfast. At the door: $30 members; $40 nonmembers. Contact: Bonni Hendricks, 925-686-4819.

— Fremont Rotary Club — Meets noon-1:30 p.m. Wednesdays. Meet business and community leaders. Guests welcome. Contact: John Rehnberg, 510-574-0797.

— Job Connections — Meets 9-11:30 a.m. Saturdays. A no-fee, volunteer organization supporting people that are unemployed, underemployed, or in a career transition in their search for employment. Community Presbyterian Church, 222 W. El Pintado, Danville. Visit www.JobConnections.org.

— JumpStart The Entrepreneurs Network — Meets 8-9:30 a.m. with networking until 10 a.m. first and third Wednesdays monthly. A synergistic alliance of entrepreneurs sharing information support and business tools; inspiring growth and success. A ‘cuppa Tea, 3202 College Ave., Berkeley. Contact: Michael Wesson, 510-467-7121, www.jumpstartten.com.

— Lady’s Choice Investment Club — 7 p.m. second Mondays monthly. For interested women to learn about stock investing. Visitors welcome. 925-447-8572, [email protected].

— LeTip International, Diablo Valley chapter — Meets 11:30 a.m. Thursdays. A structured, productive program to teach members the networking skills necessary to grow each other’s businesses by providing qualified business referrals. Membership is limited to one business per profession. Tahoe Joe’s, 999 Contra Costa Blvd., Pleasant Hill. Reservations: Orry Matin, 925-602-4444, Ext. 108.

— LeTip International, Fremont chapter — Meets 7:16 a.m. Tuesdays. Guests welcome without reservation. Denny’s, 5280 Mowry Ave., Fremont. Contact: Dr. Gary Wong, 510-796-7000, www.letipoffremont.com.

— LeTip International, Oakland chapter — Meets 7:16 a.m. Wednesdays. Structured networking to generate leads for business owners and professionals. Complimentary breakfast on first visit. La Estrellita Cafe, 446 East 12th St. (at 5th Avenue), Oakland. Contact: Sharyn, 510-655-6318.

— LeTip International, San Leandro chapter — Meets 7:16 a.m. Thursdays. The business lead and exchange organization invites business owners and business professionals to its weekly business lead or exchange breakfast. Breakfast complimentary on your first visit. Englander Restaurant, 101 Parrot St., San Leandro. Contact: Raelynn Gatchell, 510-278-7052, www.sanleandroletip.com.

— LeTip International, San Ramon chapter — Meets 7:16 a.m. Wednesdays. An opportunity for business owners and professionals to exchange business leads, gain a new sales force and leverage your business. Breakfast complimentary on your first visit. Marie Callender’s, 18070 San Ramon Valley Blvd., San Ramon. Contact: Douglas Herz, 925-227-6633, www.sanramonletip.com.

— Mt. Diablo Business Women — Meets 5:45-8:30 p.m. second Thursdays monthly. Networking and dinner. Lafayette Park Hotel, 3287 Mt. Diablo Blvd., Lafayette. $37 members, $44 guests, in advance. Hotline: 925-429-9253; www.mtdiablobusinesswomen.org.

— Opportunity Junction: On the Road to Self-Sufficiency — Helping low-income Contra Costa residents gain the competence and confidence to support themselves and their families. Offering technology, literacy and personal development instruction combined with real world experience. Main programs include a comprehensive job-training and placement program that incorporates computer training, life skills, paid experience, Career Club, case management, mental health services and long-term follow-up and drop- in evening program with classes in English as a Second Language and computer basics. Program open to those 18 and older. 3102 Delta Fair Blvd., Antioch. No cost to participants. Register in person. Contact: 925-776-1133, www.opportunityjunction.org.

— Premier Network Group of East County — Referral group meets 7:15 a.m. Thursdays. Mimi’s Cafe, 5705 Lone Tree Way, Antioch. Contact: Jason Matthews, 925-628-8016 or [email protected].

— Regional Occupation Program’s Technology Center — Offering full- and part-time “Microsoft Office” and “Web Design and Development” classes to adults and high school students, 16 and older, who live anywhere in the San Francisco Bay Area. Learn how to effectively use the most popular office applications and how to create standards-compliant Web sites for yourself or your employers. ROP Technology Center, 1800 Oak Park Blvd., Suite A, Pleasant Hill. 925-942-3436, www.JobSkillsNow.com.

— Rotary Club of Dublin — Noon-1:30 p.m. Tuesdays. Guests welcome. Radisson Hotel, 6680 Regional St., Dublin. 925-931-0800.

— Rotary Club of Lafayette — Meets noon Thursdays. 12:15 p.m. lunch; 12:30 p.m. program. Oakwood Health Club, 4000 Mt. Diablo Blvd., Lafayette. Guests welcome. Contact: Michael Heller, 925-682- 3577.

— Rotary Club of Lamorinda Sunrise — Meets 7 a.m. Fridays. Postino’s Restaurant, 3565 Mt. Diablo Blvd., Lafayette. Guests welcome. Visit www.lamorindasunrise.org.

— Rotary Club of Walnut Creek Sunrise — Meets 7-8:30 a.m. Tuesdays. Scott’s Seafood Bar & Grill, 1333 N. California Blvd., Walnut Creek. Guests welcome. Visit www.wcsunriserotary.org.

— San Joaquin Delta College and Small Business Development Center — Business orientation held at noon second Thursdays monthly. Get information on legal requirements and government regulations, sources of financing, how to get free help with your business, and receive a copy of the “Resource Guide to Starting & Operating a Small Business.” Cosponsored by the Tracy District Chamber of Commerce. Tracy District Chamber of Commerce, 223 E. 10th St. $15. Reservations: 209-835-2131.

— Senior Community Service and Employment Program — Recruitment is under way for program participants. Assists eligible, enrolled older workers, 55 and older, to receive on-the-job training through local partner host sites, to receive appropriate training, job- search preparation and placement assistance. Space is limited. Call 209-579-1105, 9 a.m.-4 p.m. Mondays-Thursdays.

— Sistaz N Motion — “Dynamic Networking Mixer,” meets 12:30- 3:30 p.m. second Saturdays monthly. Committed to helping women entrepreneurs acquire knowledge, training, skills, resources and access to the business community. Crescent Park Multicultural Center, 5004 Hartnett Ave., Richmond. New guest speakers welcome. 510-253-5469, [email protected], www.sistaznmotion.com.

— Sustainable Business Alliance — Meets for lunch first Fridays monthly in alternate Berkeley and Oakland locations. “East Bay Green Drinks Happy Hour,” 5:30-8 p.m. third Wednesdays monthly, Triple Rock Brewery and Alehouse, 1920 Shattuck Ave., Berkeley. Open to new members. A membership organization for companies committed to greater sustainability in their business policies and practices. Contact: 510-451-4001, www.sustainablebiz.org.

— Tri-Valley Mastermind Group — 7:30-9 a.m. second and fourth Tuesdays monthly. For business owners interested in growing their business via reciprocal referrals. Membership limited to one person per profession. Faz Restaurant, 5151 Hopyard Road, Pleasanton. Rick Benitez, 925-260-6051.

— Tri Cities Networking Group — Meets 7:30-8:40 a.m. Tuesdays. For business owners to network with and learn from each other in a friendly, upbeat and supportive setting. Original Pancake House, 39222 Fremont Blvd., Fremont. Contact: Michael Mauldin, 510-301- 6525.

— Women In Financial Services — Meets 8-9:30 a.m. fourth Fridays monthly at an area restaurant. $20 includes breakfast, networking and a speaker. Contact: Joyce Feldman, 925-242-0684.

— Women’s Business Connection of Lamorinda — Meets 7:30-8:45 a.m. Fridays. Network and exchange referrals. Il Fornaio Restaurant, 1430 Mt. Diablo Blvd., Walnut Creek. Visitors welcome. Reservations: 925-210-9296. Information: www.wbclamorinda.com.

— Women’s Stock Study Group — Meets 7 p.m. third Wednesdays monthly. Education is the group’s main purpose. Heritage Estates, 900 E. Stanley, Livermore. 925-846-6911, 925-484-1319.

— Workforce Development Board of Contra Costa County and Contra Costa Small Business Development Center — The online business portal ContraCostaMeansBusiness.com. offers information, resources, services and expertise for Contra Costa County entrepreneurs and small business owners. The site is a one-stop source for information on more than 50 business topics. Visit ContraCostaMeansBusiness.com.

Toastmasters

Amador Valley Toastmasters — Meets 7-8 a.m. Thursdays. Guests welcome; introductory breakfast is complimentary. Mimi’s Cafe, 4775 Hacienda Drive, Dublin. Contact: Linda Wardell, 925-455-8397, [email protected].

— Andeesheh Toastmasters Club — Meets 10:30 a.m.-noon Saturdays. Learn to develop communication and leadership skills which foster self-confidence and personal growth. 1433 Madison St., Oakland. Contact: Faz Binesh, 510-760-8400, [email protected].

— Antioch Toastmasters — Meets 7:15-8:15 a.m. Tuesdays, Mimi’s Cafe, 5705 Lone Tree Way. Contact: Mitchell Hardin, 925-978-2523, [email protected].

— Benicia Toastmasters Capitol Speakers Club — Meets 7:30-9 p.m. Wednesdays. Visitors welcome. Chamber of Commerce Building, conference room, rear entrance, 601 First St., Benicia. Contact: Houston Robertson, 707-751-0473, or [email protected].

— Better Communicators Club — Meets noon-1 p.m. first, third and fifth Wednesdays monthly. MWH Global, 1340 Treat Blvd., Suite 300, Walnut Creek. Contact: Craig Vassel, 925-934-0150.

— Cherry City Toastmasters — Meets noon-1 p.m. Tuesdays. San Leandro Library, 300 Estudillo Ave., San Leandro. 510-351-1244, [email protected], www.cherrycitytoastmasters.org.

— Concord Breakfast Toastmasters Club No. 2056 — Meets 7-8:30 a.m. Tuesdays. Kensington Place, 1580 Geary Road, Walnut Creek. Contact: Ken Smith, 925-639-0305, or [email protected].

— Concord/Clayton Toastmasters — 7 a.m. Mondays. Aegis of Concord, 4756 Clayton Road. 925-682-7211, www.toastmasters.org.

— Confidence Builders Toastmasters of Concord, Club No. 3972 — Meets 7:15-8:35 p.m. Tuesdays. Feb. 13 and 27 at John Muir Medical Center Concord Campus, Medical Pavilion Classroom, 2740 Grant St.; Feb. 20 at Contra Costa Water District Center, Board Room, 1331 Concord Ave., Concord. Contact: Marion, 925-686-1818, or visit www.geocities.com/cbt3972/.

— Creating Communicators Toastmasters Club No. 684665 of Brentwood — Meets 12:10-1:10 p.m. Thursdays. Straw Hat Pizza, 6680 Lone Tree Way, Brentwood. Contact: Clay, 925-325-9966.

— Danville A.M. Toastmasters — Meets 7-8:30 a.m. Tuesdays. Guests welcome. Father Nature’s Shed, 172 E. Prospect Ave., Danville. Contact: Gayle Studt: 925-833-8001, [email protected]; www.danvilleamtoastmasters.org.

— Danville Toastmasters — Improv portion meets 7:30-9 p.m. Wednesdays. Improve your confidence and public speaking skills in as little as eight weeks. Guests welcome. Diablo Valley College, Room 217, 3150 Crow Canyon Place, San Ramon. Contact: Bill Frink, [email protected], www.danvilletoastmasters1785.com.

— Diablo Champagne Breakfast Club — “Friday Mornings in Walnut Creek,” meets 7-8:30 a.m. Fridays except Dec. 28. Hone your speaking and leadership skills. Drop-in guests are welcome at no charge. Kensington Place, 1580 Geary Road, Walnut Creek. Map and details: www.diablochampagne.org. Contact: Dan Russell, 925-671-2259, [email protected].

— Diablo Toastmasters No. 598 –Meets 7-9 p.m. Thursdays. Develop communication and leadership skills. Visitors welcome. Sizzler, 1353 Willow Pass Road, Concord. Contact: Louis Stifter, 707- 747-5017, [email protected].

— Diablo View Toastmasters, Club No. 4160 — Meets 7:55-9 a.m. Tuesdays. To support and encourage development of professional and personal speaking skills. Guests welcome. San Ramon Community Center, 12501 Alcosta Blvd., San Ramon. Contact: Josh Taves, 925- 791-2233.

— Dramatically Speaking Toastmasters — Meets 9-11 a.m. second Saturdays monthly. Kaiser Building, 1950 Franklin St., Oakland. Newcomers welcome. Photo ID required to get into the building. Newcomers welcome. R.S.V.P.: Mary Anne Lunning, 510-581-8675, [email protected].

— East Bay Toastmasters — Meets 7-8:15 p.m. Mondays. East Bay Church of Religious Science, 4130 Telegraph Ave., Oakland. 510-652- 5912, [email protected].

— F.A.T. Toastmasters — Meets 7:45-9 p.m. Thursdays. Newark Library, 6300 Civic Terrace Ave. [email protected], http:// fat.freetoasthost.ws.

— Goal Achievers Toastmasters — Meets 7:30-9 p.m. Mondays. Improve your communication and leadership skills in a safe and fun environment. Guests and drop-ins welcome. Round Table Pizza, Banquet Room, 3637 Mt. Diablo Blvd., Lafayette. Contact: Brendan Murphy, 925- 947-0219, [email protected].

— Livermore Lunch Bunch Toastmasters Club — Meets noon-1 p.m. Mondays. Develop communication and leadership skills in a supportive environment that fosters self-confidence and personal growth. Robert Livermore Recreation Center, 4444 East Avenue, Livermore. Contact: Valerie Curcuro, 925-606-6841, [email protected], www.livermoretoastmasters.org.

— Rossmoor Toastmasters — Meets 7:15-8:30 p.m. first and third Wednesdays monthly. Multi-Purpose Room 3, Gateway Club Complex, Rossmoor Parkway entrance, Walnut Creek. For map, visit www.rossmoor.com. For club information, call Marie, 925-943-5446.

— Singles Toastmasters– Meets 7:30-9 p.m. Mondays. Meet singles and improve your leadership and communication skills in a safe and fun environment. Guests and drop-ins welcome. Round Table Pizza, 3637 Mt. Diablo Blvd., Lafayette. Contact: David Olkkola, 925-932- 8858, [email protected].

— Sunrise Toastmasters Club — Meets 7:15-8:30 a.m. Thursdays. Kaiser Permanente Medical Center, 1425 S. Main St. (at Newell Avenue), third floor, Oak Room No. 3, Walnut Creek. Contact: Paul Rowan, 925-938-7116.

— Sun Valley Toastmasters Club 998 — Meets 7-8 a.m. Wednesdays. Holiday Inn Restaurant, 2730 N. Main St., Walnut Creek. Contact: Joann Juhala, 925-757-8274.

— Talksics Toastmasters Club No. 6718 — Meets noon-1 p.m. second and fourth Wednesdays monthly. Central Contra Costa County Sanitary District, 5019 Imhoff Place, Martinez. Free. Contact: Russ, 925-229-7255.

— Toast of Richmond, Club 7957 — Meets noon-1 p.m. Mondays. Develop communication and leadership skills in a fun and supportive environment. Richmond Chamber of Commerce, 3925 Macdonald Ave., Richmond. Contact: [email protected].

— Toastmasters Communicators Club — Meets noon-1 p.m. first and third Wednesdays monthly. Guests welcome. Montgomery Watson Harza offices, 1340 Treat Blvd., third floor, Walnut Creek, near Pleasant Hill BART station. Contact: Iris, 925-975-3453, or [email protected].

— Top of the Hill Toastmasters – Castro Valley — Meets 7-8:15 p.m. Thursdays. Guests welcome. Develop and practice important communication and leadership skills in a positive learning environment. The Neighborhood Church, 20600 John Drive, Room D2. Contact: Dave Smith, 510-733-0984, [email protected].

— Walnut Creek Toastmasters No. 8629 — Meets 7-8:15 p.m. Wednesdays. Those interested in improving their presentation, speaking and leadership skills are invited to attend. Aegis, 1660 Oak Park Blvd., Pleasant Hill. First meeting is free. Contact: Paul, 925-639-6776, walnutcreek.freetoasthost.net.

— West County Toastmasters — Meets 12:15-1:15 p.m. Thursdays. Mechanics Bank, Hilltop branch, downstairs conference room, 3170 Hilltop Mall Road., Richmond. Contact: Ed Brounstein, 510-223-1230.

(c) 2008 Oakland Tribune. Provided by ProQuest LLC. All rights Reserved.

By TOM MUHA for The Capital

Most people have gotten away for a well-deserved rest on their summer vacation. Rene, however, has been waiting to go to the beach until this week. Now she’s gritting her teeth trying to survive until she’s able to escape from her stressful life.

Rene has a high-pressure job managing a group of people in a high- tech company. Her boss gives her the big projects to tackle. On the one hand, Rene likes being seen as someone who can handle important assignments. But on the other hand, Rene feels as if she lives in a pressure cooker. Deadlines loom. The pressure builds as the project stumbles along from one problem to another. Employees make excuses. Anxiety mounts as the fear of failing to meet expectations becomes a very real possibility.

Rene doesn’t sleep well during these times. She wakes up with a feeling of dread as she anticipates dealing with another day of demands.

The other day, Rene was in the middle of a meeting when the alarm on her Palm Pilot went off signaling it was time for her to leave to take her daughter to a doctor’s appointment. She could feel her heart pounding as she stifled the voice within her that wanted to scream, “STOP! Just stop and let me get away from all of this for awhile.”

The problem with Rene’s approach to managing stress is she lets it build up until it boils over and she’s at her breaking point. Even when she is able to get away, she’s so exhausted it takes days to recuperate. About the time she has to come back home is when she’s recovered sufficiently to get into the restorative part of the vacation where she can fully engage in having fun with her husband and kids. By then it’s time to head home and get back into the daily grind.

Allowing stress and anxiety to accumulate is bad for our body. It also makes our mind miserable, ruins our relationships and saps our spirit. Stress floods our mind with fight-flight-freeze emotions. When we’re besieged by anger, anxiety and depression, our critical words and antagonistic actions contaminate our relationships. When our life isn’t working well, our spirits sag as we wonder, “What’s the purpose?”

Stress causes our arteries to clog and our blood pressure to rise. It causes our brain cells to break down, diminishing our memory and concentration. It compromises our immune system leaving us vulnerable to everything from colds to cancer.

What works to manage stress well isn’t just going on a great vacation a couple of times a year. It’s managing to enjoy our daily lives.

That’s what Linda does. She, too, is a manager who’s bombarded by demands at work and at home. But Linda never stops smiling. She can plunge into stressful situations when she needs to and emerge unscathed.

People such as Linda have learned to use smiling as a way to regain their physical and emotional equilibrium very quickly.

Smiling, studies have shown, short-circuits your fight-flight- freeze stress responses. It’s impossible to stay stressed out when you start smiling. Not only will it change the way your body and brain are reacting, smiling will create a contagious response from those around you.

To manage your stress moment by moment, learn to recognize your early warning signs. It may be that your neck muscles tighten, or your pulse starts to pound. Stress symptoms also are being signaled when your negative emotions are aroused.

Whenever your stress reaction starts to fire off, take several slow, deep breaths and resist saying anything for a moment. Loosen your shoulders and hold your head up straight. Then smile. That will disrupt your old pattern of reacting and allow you to view your situation from a different position – one in which you’re calmer, slower and have your sense of humor back. Your brain will be able to see a much wider range of responses.

Learn this lesson and you won’t have to wait for vacations to enjoy your life. You can be like Linda – able to smile away your stress reactions. Awareness of your stress allows you to adapt immediately. Deep breathing creates a gentle feeling of relaxation that can spread up from your chest and onto your face in the form of a smile.

—

Dr. Tom Muha is a psychologist practicing in Annapolis. His previous articles are archived on his Web site: www.achievinghappiness.com. He welcomes your comments and questions. To contact him, call 443-454-7274 or e-mail him at drtom@achieving happiness.com. {Corrections:} {Status:}

(c) 2008 Capital (Annapolis). Provided by ProQuest LLC. All rights Reserved.

By HUMPHREYS, Lyn

AN OUTSPOKEN New Plymouth advocate for the return of medically- skilled managers to run public hospitals has retired.

Malaysian-born Jaswan Singh, 65, retired from hospital work in June after 33 years in New Plymouth, most of which have been spent treating Taranaki skin complaints.

He left New Plymouth in 1972 to train as a dermatologist in Cambridge, England, returning to take up the specialty in 1977.

Dr Singh has championed the move for the management of the public health system to be returned to the control of the medically- trained.

“When I first came the hospital was run by Mr Donald King, who was the superintendent and a surgeon. Since those times, things have gone downhill because there are now more administrators than doctors,” he said.

“And they don’t listen to what we say because they think they know better than us.”

He regrets that his resignation now leaves Taranaki Base Hospital without a skin specialist — as is the case in many of the other regional hospitals across New Zealand.

However, Dr Singh is continuing in his private practice at Nobs Line.

At the recent TDHB meeting, chief executive Tony Foulkes officially thanked Dr Singh for his many years of service.

Dr Singh continues to be a strong advocate for Taranaki people to protect their skin and ensure they have regular checks for cancers.

New Zealand, Australia and the Falkland Islands have the highest rates of melanoma in the world. Taranaki people are among those most at risk, he says.

“Taranaki has very intense sunlight and the wind makes it four times more damaging because it dries out the skin and makes it more vulnerable.”

Many people were unaware that sunblock takes 30 minutes to work, so it should be applied half an hour before exposing skin to the sun.

Sunblock should also be used throughout winter, he said.

“Today the burn time is 18 minutes.”

Regular skin-checks are a must.

“Something that grows that shouldn’t be there needs to be diagnosed. Most I treat on the spot.”

For more complex surgery he refers his patients to Auckland micrographic surgeon Kevin McKerrow. “He is very skilled.”

Dr Singh says the most exciting development in the control of the most deadly of skin cancers, melanoma, is a vaccine expected to be available in three to five years.

While he says he would love to retire in his country of birth, after all these years his home is now here with his wife, Delwyn, whom he met and married in New Plymouth.

“I see it as home now,” Dr Singh said.

The couple has three children, Rohan, Suraya and Sanjay and “4 1/ 2 grandchildren”.

(c) 2008 Daily News; New Plymouth, New Zealand. Provided by ProQuest LLC. All rights Reserved.

By RANKIN, Janine

Health board to end contract with Feilding’s Ranfurly Manor. —- —————- Neglect of elderly patients at Feilding’s Ranfurly Manor has prompted the MidCentral District Health Board to tell proprietor Ted Hewetson he won’t have a contract by December.

The director of Silvercare Ltd and husband of celebrity chef Annabel Langbein will get a letter telling him the contract to run the hospital and rest home will be terminated.

But board funding manager Mike Grant said he wanted to talk to Mr Hewetson about ways Ranfurly can stay in business after that.

“This does not mean Ranfurly necessarily has to close,” he said.

Cases of patients left without oxygen, others lying wet in their beds, and having to cry out for help when they fell because call systems didn’t work are catalogued in a board- commissioned report on the home.

It was the first time the board had terminated a contract with a rest home provider in the five years it has been responsible for residential aged care.

It’s a step Mr Grant describes as “significant”, after appointing a statutory manager, nurse Irene McLean, to help put systems in place to reduce the risks of serious harm to residents at Ranfurly in July.

But it had become clear Mr Hewetson was not playing an active part in finding solutions, he said.

“The issues in the rest home are systemic. We were after seeing some understanding of those issues, and a demonstration that they would overcome those issues and put in place the necessary resources to do that. That’s not been evidenced. We were not convinced.”

The board’s next priority was to find a permanent solution that would keep Ranfurly’s doors open.

Ranfurly is the largest provider of residential aged care services in the district, with 38 hospital and 12 rest home beds.

It was one of the facilities chosen by the board to take over care of residents when it closed Clevely Hospital in Feilding in 2005, on the basis that it had a proven track record.

Silvercare’s most recent Health Ministry certification to run Ranfurly for three years was cleared in February 2007.

But in July this year the Central Region’s technical advisory services auditors found there was a lack of leadership at Ranfurly that was placing residents and staff at risk of serious harm.

They were concerned the manager in charge since September last year had no clinical qualifications, and did not have the skills, resources or knowledge to manage the business and rest home.

Of the 40 staff, some had no contracts or job descriptions. At least six staff were directly related to the manager.

They found standards for infection control and keeping health records had been breached, and there were inadequate policies about the use of restraint.

The director should take a more active role in ensuring Ranfurly complied with a range of legal, contractual and industry standards, they said.

Mr Grant said the board wasn’t satisfied the director was doing all he could to act on that recommendation.

The board is also monitoring services at Karina Rest Home in Palmerston North, operated by a related company, Silvercare Management Ltd, of which Mr Hewetson is a director.

——————–

(c) 2008 Evening Standard; Palmerston North, New Zealand. Provided by ProQuest LLC. All rights Reserved.

By TODD, Rebecca

Ancient Maori eating habits are coming under the spotlight in a bid to improve modern diets and wellbeing.

The Social Report 2008, which has just been released, shows health-related outcomes for both Maori and Pacific people have not improved in several areas, such as obesity rates, hazardous drinking and participation in physical activity.

Partly as a result of high-fat diets, Maori have, on average, the poorest health of any ethnic group in New Zealand, with abnormally high rates of cardiovascular disease, diabetes, stroke and heart failure.

At the NZ Dietetic Association’s national conference this month, health researcher Christina McKerchar will address the dramatic changes in Maori eating habits during the past 200 years in a talk called From Kereru to KFC.

Obtaining food in pre- European times was a prized accomplishment and a symbol of hospitality and generosity, she said.

This culture carried through to today, but with high-fat foods now readily available, KFC was replacing the traditional diet of birds, fish and vegetation.

Health Sponsorship Council research has shown some Maori regard healthy eating as “too expensive” and requiring too much time, effort and planning.

It found healthy food awareness was high, but understanding of the importance of healthy eating was low.

The Canterbury District Health Board’s executive director of Maori and Pacific health, Hector Matthews, said changing eating habits was a struggle.

“A lot of people think healthy eating is a choice, but if veges are $30 a kilo, it’s not a choice for probably half the country.”

Matthews said encouraging healthy eating on marae was key.

Community garden projects, where people grew their own vegetables, and programmes providing fruit in schools were targeting low-decile groups where Maori were dominant, he said.

Tairawhiti District Health Board senior dietician Hiki Pihema said few Maori asked for assistance with healthy eating.

“The whole whanau needs to be brought into the picture, as often bad habits start in childhood,” she said. “Kids often go from house to house to house, and the whanau as a whole needs to be aware and take some responsibility for healthy eating habits as a group.

“Unfortunately, in many places today, fizzy drink is cheaper than milk, but milk is still the better choice, and water is free. These and other messages need to reach more Maori and create change.”

Victoria University lecturer Dr Evan Roberts has been awarded $150,000 from the Health Research Council to look at how colonisation affected Maori health.

“Consistent long-term measures of health will increase our understanding of the social determinants of health and how political and economic change affected the health of the New Zealand population,” he said.

“One of the motivating factors is to understand the roots of today’s obesity crisis.”

The research will be based on height and weight data available through prison and military records and health surveys.

(c) 2008 Press, The; Christchurch, New Zealand. Provided by ProQuest LLC. All rights Reserved.

Authorities worked Monday to determine what caused a medical helicopter to crash near Greensburg, Ind., killing the pilot, a flight nurse and a medic.

Pilot Roger Warren, nurse Sandra Pearson and medic Wade Weston were aboard the Air Evac Lifeteam helicopter when it crashed Sunday afternoon, WRTV, Indianapolis, reported.

The helicopter was leaving a fundraiser and carried no patients, WTHR-TV, Indianapolis, reported Monday. Witnesses told police they saw something fall from the helicopter just before it crashed.

Officials from the National Transportation Safety Board were to examine the crash scene Monday.

THE recent suspension of a Glasgow doctor for prescribing a deadly drug and the cost of care for the elderly are two closely related subjects.

Doctors now prolong life without any clear guidance on the consequences. The unnecessary, and in some cases unwanted, prolongation of life is part of the problem of healthcare for the aged.

This is a new problem. The old lady in the chimney corner has no place in a modern household. Houses are too small to hold three generations.

Emancipated women will no longer become geriatric nurses to the grandparents of their children and their husbands won’t do it. The aged must go into care.

To many the idea is repugnant, particularly as it is now a doctor’s duty to keep us alive into dribbling senility.

Yet agecare has become big business.

Granny and grampa hutches have become a feature of modern Argyll.

They can be seen as examples of a caring community. I see them as prisons. I won’t go there. I have lived free and I will die free.

There are two ways I can think of to avoid a grampa hutch. People should be encouraged to make living wills.

My medical records contain a provision that should I no longer be fit to give instructions for my medical care nothing is to be administered except analgesics and soporifics. My life is not to be needlessly prolonged. I want to die decently. Also, my family know that when life becomes a burden I shall go out into the night with a bottle of whisky, drink myself insensible and the cold will let me cease upon the midnight with no pain.

Archbishop Conti may say that it is playing God to give people drugs to die with decency. We already play God. We do so by extending the allotted span of three score years and ten. I type these words aged 83, having had my life prolonged by a heart by- pass operation eight years ago.

My much-loved father died because 40 years ago that operation wasn’t available to him. If we can play God by prolonging life, why can’t we play God by terminating it? It is one of the great moral issues of our time.

Ian Hamilton, Lochnabeithe, North Connel, Argyll.

THANK goodness NHS Greater Glasgow and Clyde have seen sense and decided to allow Dr Iain Kerr to continue as a GP after his suspension, by the GMC Fitness to Practise panel, ends. Dr Kerr is quite plainly a caring, compassionate doctor who has dedicated his working life to his patients.

Thank God also for the “people power” of his patients and colleagues, who have supported him throughout this time.

Sheila Duffy, 3 Hamilton Drive, Glasgow.

Originally published by Newsquest Media Group.

(c) 2008 Herald, The; Glasgow (UK). Provided by ProQuest LLC. All rights Reserved.

By IAN BRUCE DEFENCE CORRESPONDENT

ONE in six American soldiers in Afghanistan and one in eight in Iraq are taking daily doses of prescription antidepressants, sleeping pills or painkillers to help them cope with the stresses of combat, according to figures contained in a US Army mental health advisory team report seen by The Herald.

The findings mean that at least 20,000 troops are on medication such as Prozac or diamorphine while serving in the front line or on equally dangerous convoy escort or driving duties in conflicts where insurgents regularly target the supply chain.

While the vast majority would have been barred automatically from combat roles in earlier wars on medical and safety grounds, the pressure to provide up to 200,000 soldiers at any given time for the two major deployments has led to a relaxation of the rules.

Most of those affected are on their second or third tour of duty and 10per cent are predicted to be at high risk of developing “stress illnesses” including post-traumatic stress disorder.

The Pentagon admitted that medication was tolerated because those sent to Afghanistan or Iraq were “younger and healthier than the general population” and had been screened for mental illnesses before enlisting.

It also said it had no way of knowing exactly how many troops were taking medicinal drugs because an unknown number brought the pills with them from home rather than having them issued by a military doctor.

Official military surveys claim that while all soldiers deployed to an active war zone will feel stressed, roughly 70per cent will recover completely soon after a tour ends.

Another 20per cent will suffer “temporary stress injuries” which can bring on symptoms such as insomnia, panic attacks and growing feelings of depression, but which should also pass relatively quickly.

By contrast, the British military has a “zero tolerance” policy on drug use – either recreational or medicinal – which precludes service in frontline units.

Random drug tests where UK soldiers are found to have illegal narcotics in their system lead to automatic dismissal, while those on prescription medicines for injuries or behavioural disorders which might affect their performance or put others lives at risk are relegated to administrative duties.

The need for the US to maintain garrisons of 147,000 men and women in Iraq and 33,000 more in Afghanistan, plus units running the logistics chain in neighbouring countries, means that the US Army, National Guard and Marine Corps are overstretched by rolling, year- long deployments which have intensified over the past five years.

The US Army’s annual mental health surveys have been running since 2003 and show that almost 30per cent of troops on their third deployment suffer from psychological problems as a result of seeing friends and colleagues killed or maimed.

Colonel Charles Hoge, one of the leading US military psychologists, told the Pentagon and a Congressional inquiry last year that the current 12month gap between tours is insufficient to allow soldiers to “reset themselves” before facing the horrors of roadside bombs and ambushes again.

Britain tries to ensure ts troops, who serve six-month tours, have a 24-month “harmony” break between each combat assignment .

Meanwhile, 18 sailors on a Royal Navy warship have tested positive for a class A drug, the Ministry of Defence said yesterday The crewmen were caught during routine testing on board HMS Liverpool, which is deployed in the South Atlantic.

A spokeswoman said the drug involved was cocaine and internal disciplinary action was being taken The test had been carried out after the crew had a “run ashore” on a break in Brazil.

Originally published by Newsquest Media Group.

(c) 2008 Herald, The; Glasgow (UK). Provided by ProQuest LLC. All rights Reserved.

Text of report in English by state-run North Korean news agency KCNA

Pyongyang, September 1 (KCNA) – The DPRK is concentrating its efforts on developing health foods.

Public health and biological science research institutions have developed various kinds of specially efficacious health foods.

They are made with natural medicines including Panax schinseng and Ganoderma growing in the northern highland of the country. Among them are anti-radiation honey and eye strain relieving honey. Their everyday administration helps people swiftly relieve from mental and physical fatigue and prevent heart diseases and thrombosis.

Yanggeron manufactured by a folk method with a long history is a sort of tonic which gives youthful vitality to the user.

The nutritive pine flower pills contain materials needed for the human body such as various vitamins, microelements, essential amino acid and polysaccharide which are good for health promotion.

Besides, active nutrient pills, functional health food, and nutritive powder and nutrient jelly, health food complexes, are also popular among the people.

Kumsamsu, Chongjiryong, Chongsinjong, Chonghyolsodangjong, Poganjong, Unicolon and others which are potent for health protection find their way to foreign markets.

Originally published by KCNA, Pyongyang, in English 0844 1 Sep 08.

(c) 2008 BBC Monitoring Asia Pacific. Provided by ProQuest LLC. All rights Reserved.