Tuesday, October 21, 2014

Breast Cancer by State

On July 25th, my wife's life changed forever. 

At 47, she had experienced her first mammogram about a week prior and the surgeon found a very small calcification that looked suspicious and wanted to biopsy. She had no family history and we had no reason to believe that she was in any danger. We were wrong. The doctor came back and said that she had DCIS (Ductal Carcinoma In Situ) which equated to an early form of breast cancer in her case. Along with the diagnosis came a myriad of tough choices which we had to make over a relatively short period of time. She chose a double mastectomy with reconstruction. With the double mastectomy and pathology report complete, we have been advised by her surgeon that we are as medically "clear of cancer" as we can be.

As my wife was being prepared for surgery on the morning on October 7th, the anesthesiologist mentioned that there was a high rate of breast cancer in the state of West Virginia. They did not want to speculate as to why - maybe environmental conditions? That got me thinking. I tend to think of breast cancer as a "national" disease in that it seems to affect women all over the country similarly. What if that were not the case? What if there were higher rates of breast cancer in certain regions or states? What would that mean? And why?

According to the American Cancer Society, approximately 200,000 women will be diagnosed with breast cancer each year. The Joan C. Edwards Comprehensive Cancer Center reports that "about 12 out of every 100 women born today will be diagnosed with breast cancer at some time in their lives", which makes the threat of breast cancer a significant threat for all women. 

First of all, let's look at the good news about breast cancer. According to the American Cancer Society, the death rate from breast cancer has decreased by 34% since 1990. Much of this has to do with early detection, improved mammography technology including digital tomosynthesis, and raised awareness about breast cancer as a whole. Cost appears to be a problem associated with women choosing to be diagnosed in the first place. While there may be some common fears associated with mammography, chiefly pain and discomfort, the primary problem associated with women failing to receive a preliminary or regular mammogram appears to be access to health care insurance. The following chart from the American Cancer Society shows the rate of women seeking mammography based on access to health insurance and level of education: 

The areas in pink show the number of women who have health insurance who are seeking mammograms, roughly 71%, leaving 29% with insurance who are not seeking a mammogram. For uninsured women, the statistics show that over 2/3 of these women are not seeking a mammogram. It is important to know that women who would like to have a mammogram and do not have health insurance can contact the National Cancer Institute for a list of government agencies with phone numbers to call to receive information or financial aid to help pay or completely pay for a mammogram. 

Another interesting component to the chart from the National Cancer Society is that 75% of college-educated women are seeking mammograms while only 52% of non-college educated women are. There could be a correlation between college attainment and access to health insurance which would help to explain this disparity, as well as greater awareness of health risks, regular access to medical care, and genetic factors. According to a 2007 study by the National Center for Biotechnology Information, there was a strong link between level of education and risk of breast cancer. The site states that "breast cancer mortality rates were higher among women with less education than among women with more education" and that there was an increased risk for women of color over white women, "for black women [it was] 25.2 versus 18.6 per 100,000, respectively, for white women).It is important to note that there is no cure for breast cancer and that there is no discernible data to indicate what causes breast cancer or why there is a deliberate increased risk for less-educated women or women of color. Again, it could be due to increased environmental risks, cultural and genetic factors. According to a fact sheet from the Susan G. Komen organization, "White women have the highest breast cancer incidence rate of any racial or ethnic group. Under age 45, African American women have a higher incidence of breast cancer than white women." The bad news, according to that same fact sheet, is that "African American women are more likely to die from breast cancer. Studies have found that they often have aggressive tumors with a poorer prognosis (chance for recovery)." Again, there are a variety of complicated reasons as to why African-American women might be diagnosed later, have larger tumors and "poorer prognosis", which cannot be easily identified.

We can say with a degree of certainty that there is a higher correlation of seeking treatment by college-educated and health insured women over the less educated and at health-risk population. The Affordable Care Act (2011) has adopted some guidelines to ensure that women can receive mammograms if they so choose. According to the ACA's Healthy Women guidelines, "women’s preventive health care – such as mammograms, screenings for cervical cancer, prenatal care, and other services – generally must be covered by health plans with no cost sharing". The wording for this is somewhat vague and the Health and Human Services site does not give a great deal of information about specifics as to how this should be implemented on a case by case basis. The HHS site doe give some specific data on a state-by-state basis as to the rates of Medicaid coverage and some resources for more information as needed. 

This brings me back to my initial question - was the anesthesiologist right? Is there are a higher rate of breast cancer in one state over another? How about in one region over another?According to the National Cancer Institute, the following is a map of the United States which shows the rate of incidence of breast cancer by state from 2007 - 2011:

The states in dark blue (108-116 per 100,000) show the lowest instances, going into medium blue to light blue and light yellow being the average instances. Orange being the higher rate of instances and red (129-143 per 100,000) indicate the states with the highest incidents of breast cancer. (Nevada is the only state with a diagonal line pattern which indicates that there was insufficient data to add to this data set). We cannot derive anything regarding rates of health insurance coverage from this map (i.e., those who have insurance vs those who do not), but we can deduce that the states with the highest incidents of breast cancer are states with a largely white population, while the southern states with a larger Latino and African-American population are not as affected. Also, while many of the mid-western states have a largely white population, they are also more rural which might account for fewer numbers of reported incidents per the 100,000 population. 

This map, also from the National Cancer Institute, shows the rate of mortality from breast cancer, (with the colors corresponding with dark blue being the least occurring and red being the most frequent occurrence). We can see from this image that there is a correlation between higher rates of mortality in states with a larger African-American population, largely in the Southeastern United States with fewer in the northeastern, Midwest, and Pacific region. 

From the looks of these maps, (see above) it is apparent that West Virginia does NOT have the highest rate of breast cancer, not even close. How could the anesthesiologist get that wrong? Quite easily as it turns out. According to the National Cancer Institute, West Virginia is above the national average in occurrence for all cancers. The rate of all cancer in West Virginia is 478.6 with the national average (for all 50 states) being 459.8. Furthermore, of the 22 types of cancer listed, West Virginia was above the national average for 14 of them and equal to the national average in 2 more! There were only a couple of types of cancer that West Virginia was actually under the national average - 2 of them were breast cancers: Breast cancer in West Virginia averages at 110.5 with the national average being 122.7 and In Situ breast cancer (the type that my wife had) in West Virginia is 21.8 with the national average being 31.0. 

The final word is this - breast cancer is an elusive and insidious disease. It can strike women of all ages, race and ethnicity, but white women are more likely to contract it, educated women are more likely to get screened for it, and women of color are more likely to die from it. If anything, I hope that reading this hardens you, dear reader, to the fact that we must find a cure! We must to save the women that we love and respect.

Tuesday, January 14, 2014

Not Passing the Sniff Test

My wife and I live and work in Charleston, West Virginia and were, in fact, born and raised here. Growing up in the Kanawha Valley, we were always aware of the dangers of living in the Charleston area due to the large Union Carbide plant that loomed a few miles up the river from our homes. Over the years, there would be periodic chemical leaks and the air sirens would alert the residents to close their doors and windows and block airways into our homes for a short period of time to ensure that the air was not hazardous to breathe. To us, it seemed like a cost of living in "chemical valley", like it or love it. In 1984, a Union Carbide facility in Bhopal, India leaked an insecticide which killed 8,000 people immediately and 20,000 people since, according to GreenPeace. As Charleston residents, we have always been aware of the risk of any chemical-related accidents or problems in our area, but became somewhat complacent over the years as time went on and disaster never struck in a major way.  

The water crisis which has hit the state this week is far more serious than a twenty minute delay in keeping our windows closed and remaining indoors during a minor leak into the local environment. What we are facing now is far more devastating to residents and should be of grave concern to West Virginians and other U.S. states which rely on industry for sustenance. According to GreenPeace, "just 300 of the 6,000+ high-risk chemical sites across the U.S. put more than 100 million Americans at risk if attacked". This is an alarming albeit nebulous fact which should make one wonder: Do I live near a high-risk chemical site, and if so what can I do about it? Greenpeace has a list of the more than 12,000 chemical facilities in the United States. It is important for the citizenry to remain informed about what chemicals are being produced in their area so that they might be better informed about how to best protect themselves from possibly hazardous conditions. To some, this might sound like an alarmist or "doomer" perspective, but again, according to Greenpeace, this is a real risk to individuals and families across the United States. "One in three Americans is at risk of a poison gas disaster by living near one of hundreds of chemical facilities that store and use highly toxic chemicals" (GreenPeace.org). 

This issue of potential chemical spills and leaks is important because it can happen in rural as well as urban areas. According to the Greenpeace map, there are no less than 5 chemical sites in New York City area, 7 in the Detroit area, 9 chemical sites in the Philadelphia area, and 10 in the larger Chicago area. There is no evidence of any instances at plants in locations near these cities, but that does not mean that it cannot happen. A chemical spill in central Hubei province killed over 220,000 pounds of fish in 2013, following a spill that killed over 16,000 pigs the previous year. The BBC article noted that one man described the fish this way: "the dead fish covered the entire river and looked like snowflakes " (BBC.co.uk). The spill was responsible for $70,000 yuan  - or $11,000 - in daily earnings to the village's affected fishermen. This makes this spill not just an environmental cost. It is unclear at this point what the cost will be for the cleanup of the West Virginia chemical spill by the city and state as well as the amount of lost revenue for local businesses and individual employees - the cost could be in the millions of dollars, all told. 

According to a recent OpEd from Jeff McIntyre, the CEO of West Virginia American Water, the problem with the United States water supply is much more difficult and costly to restore than imaginable, due largely because our water infrastructure in some cases was installed over 100 years ago. According to McIntyre, "Much of our water and wastewater infrastructure in West Virginia, as well as nationally, was installed in the first half of the 20th century or just after World War II. In the oldest parts of Charleston, Huntington and other West Virginia cities, pipes [are] more than 100 years old" (WVGazette.com). Furthermore, McIntyre speculates that the cost to maintain the water supply in the U.S. going forward will run into the hundreds of billions of dollars. "The U.S. Environmental Protection Agency estimates more than $335 billion is needed to replace aging water infrastructure over the next 20 years. In its 2013 Report Card for America's Infrastructure, the American Society of Civil Engineers grades both water and wastewater infrastructure at a 'D' level. In West Virginia alone, the report cites $1 billion in drinking water infrastructure needs and $3 billion in wastewater infrastructure needs over the next 20 years" (WVGazette.com). As a result, our water system infrastructure even on its best day appears to be in fairly bad shape.

Why are we (the city, state and citizens) paying for the aftermath of a preventable disaster? The short answer is speed and cost-effectiveness, which might be partly to blame for the lax regulation of chemical and fossil fuel industries. Donna Lisenby directly links the spill of MCHM into the Elk river to the coal industry which uses the said chemical as part of the "coal cleaning" process. "Our continuing dependence on fossil fuels as a source of 'cheap' energy has many costs that are not reflected in our power bills and prices at the pump. In addition to billions of dollars in environmental damage, the Charleston [WV] spill illustrates another example of the coal industry imposing the costs of its inherently dirty practices on Americans, not to mention poisoning the water supplies of hundreds of thousands of people. This spill demonstrates yet again that 'clean coal is a dirty lie" (EcoWatch.com). This is important to note, because while the Charleston area is known as "chemical valley", the state of West Viriginia has been historically known for its coal production, a fossil fuel which powers a large part of the country's electric energy. Much has been made by the coal industry in West Virginia to buy approval from its citizens with the Friends of Coal, a non-profit marketing campaign paid for by the coal industry. While West Virginians might be the life-long friends of coal, coal is not their friend in return. According to a report produced by the National Mining Association, Wyoming has the all-time highest coal production on record in 2008 with 476,644 million tons of in 2008. West Virginia's best year of coal production was in 1947 with less than 40% of that of Wyoming, a mere 176,157 million tons and in fact, Pennsylvania beats out West Virginia in coal production with 277,377 million tons in 1918. Additionally, the U.S. Energy Information Administration gives a monthly account of coal production between the two largest coal producers (Wyoming and West Virginia) showing the disparity in production even as late as last month. According to the EIA, the state of Wyoming produced 387,000 tons of coal in the month of December 2013, while West Virginia only produced 116,000 tons, and those numbers are on track to continue to show the disparity in the industry between the two states. If that is the case, then it looks like West Virginia needs to take a closer look at who their friends are and who is going to befriend them in the future if their water supply is tainted. 

Yet another state that appears beholden to potentially dangerous industry is Louisiana, another state with limited options for making industrial friends. According to an article by Alexander Nazaryan from Newsweek magazine, Louisiana is also paying a high price for the privilege of housing potentially dangerous chemicals in an environmentally fragile area. The article is about a 750-foot sinkhole that is forming in the now deserted and unlivable town of Bayou Corne due to a mining-related disaster. While the sinkhole is a surprise to the families who have lost their homes to its increasing expansion, the potential danger has been known for quite some time. According to Nazaryan, the sinkhole is a byproduct of industry known by residents as "Cancer Alley."According to Nazaryan, "Cancer Alley, a stretch of about 100 miles between New Orleans and Baton Rouge, is home to some 150 petrochemical plants, making these swamplands perhaps the most industrialized (and polluted) region in the United States" (Newsweek.com). According to one longtime resident of Cancer Alley, "We have the best government in Louisiana that the oil and gas business can buy" (Newsweek.com). Having seen friends and neighbors live without access to potable water for the past five days (and counting), I would say that we have the best government that coal and chemicals can buy in West Virginia. 

At this point, you might be thinking to yourself, "thank god I don't live in crappy states like West Virginia and Louisiana who cannot afford to say no to industry, no matter how dangerous!" But, think again! NPR and The Center For Public Integrity have produced a map of the United States which shows the more than "17,000 facilities which have emitted hazardous chemicals into the air" (NPR.org). Most of the heaviest air pollution is in the NorthEastern seaboard and running down through the "rust belt" of Pennsylvania and Ohio, but there are sites offending in every state in the continental United States. This means that while a chemically-related air- or waterborne disaster has not happened to you, it does not mean that it can't or won't in the future. 

One of the most difficult aspects of this disaster was learning that the spill was discovered ONLY because residents reported an odor akin to licorice wafting from the river. If there was no scent associated with the chemical (MCHM), then it is possible that we would not have known there was a threat to the water supply until 100,000+ residents became deathly ill. This demonstrates that there is an inappropriate and dysfunctional system at work between the private industry who is rushing to produce chemicals and energy products at high speed and state governments who cannot or will not pay to regulate and maintain necessary infrastructure to keep us safe. 

There is a well-known story retold from generations of West Virginia coal miners that in earlier mining days, the work was quite dangerous to the men who went into the mines. There were no regulatory agencies at the time to provide for their safety, so the miners would reportedly bring a canary into the mine as a safeguard against methane gas levels in the trapped environment. If the canary died while the miners were working, they would know that the methane levels were dangerously high and to evacuate immediately. 

Fortunately, mining standards have improved drastically over the past hundred years in spite of recent mining disasters in the news. In the wake of water pollution due to a coal-related chemical company, I cannot help but feel that we are living in a new age of dangerous conditions, not in the mine this time, but in the state as a whole. It seems to me that if the proverbial canary drank out of the Elk River this week, it would probably croak. Does that mean that the residents should evacuate immediately? Probably not. With a large elderly population coupled with a large rural population, many of the residents of West Virginia have no desire to leave and possibly nowhere to go. Furthermore, with the number of chemical plants numbering in the thousands in the U.S. and the rate of air pollution and lack of funding for proper state and federal regulation, it looks like we are all canaries in the continental coal mine, hoping that the air we breathe and the water we drink lasts longer than the pollutants that follow. 

Monday, February 27, 2012

Weight Loss, At Your Own Peril?

 Qnexa has been approved by the FDA to be the first anti-obesity drug in the U.S.

They say that in treating alcoholism and drug addiction, that the chemical dependency is merely a symptom of a larger problem - simply not drinking will not be enough. The same could be said for the treatment of eating disorders, as we see with anorexia and bulimia.

If you are in the know regarding eating disorders, then you know that the consequences of not maintaining a healthy body weight can be severe. Anorexia Nervosa is probably the best-known eating disorder to the public. According to the University of Maryland Medical Center, Anorexia Nervosa is defined as "a psychiatric disorder characterized by abnormal eating behavior, severe self-induced weight loss, and psychiatric comorbidities." But, they are also quick to point out that the behaviors of controlling your intake of calories is not about food at all. It is about emotional control. "Anorexia is an emotional disorder that focuses on food, but it is actually an attempt to deal with perfectionism and a desire to gain control by strictly regulating food and weight. People with anorexia often feel that their self esteem is tied to how thin they are" (www.umm.edu). This is important to know, because unless we understand the underlying reasons for the eating disorder, then we would continue to chase the symptoms and never treat the disease. 

Anorexia Nervosa's counterpart, Bulimia Nervosa is equally devastating for the sufferer. According to the Mayo Clinic, Bulimia Nervosa has a differing set of symptoms, but is often times a misguided and hazardous attempt to control one's body image. "If you have bulimia nervosa, you are probably preoccupied with your weight and body shape, and may judge yourself severely and harshly for your self-perceived flaws" (www.mayo.com). Once again, it is not so much about the food as it is is the need to control your body image. "Because it's related to self-image — and not just about food — bulimia nervosa can be difficult to overcome. But effective bulimia nervosa treatment can help you feel better about yourself, adopt healthier eating patterns and reverse serious complications" (www.mayo.com).
But, what if your problem wasn't starving yourself into submission to a body image, but rather, an inability to control the amount of food that you take in - at any cost.
AND, what if there were serious physical side effects to having an eating disorder? There are...It is not difficult to imagine the human body like you would an engine. We are powered (fueled) by food after all, and if you don't give your body proper fuel at appropriate intervals, then you cannot imagine your body reacting very well. Imagine if you will, what would happen if you had a serious eating disorder, such as anorexia or bulimia. In the case of anorexia, you are forcing your body to run on very little fuel at all, which causes a caustic breakdown in your internal systems. Likewise, with bulimia, you are over-filling your system with food and then to offset the consumption, you are forcefully expelling the fuel by vomiting or laxatives or over-exercising to reduce your caloric intake.

The physical repercussions of this extreme behavior is devastating to that persons body. Even if they are capable of fully recovering from the eating disorder, which is not likely, they are still likely to face a lifetime of serious health problems, if they do not expire completely in the course. For example, someone with advanced anorexia could very likely experience any of the following health problems:
  • Abnormally slow heart rate and low blood pressure, which mean that the heart muscle
    is changing. The risk for heart failure rises as heart rate and blood pressure levels sink
    lower and lower.
  •  Reduction of bone density (osteoporosis), which results in dry, brittle bones. 
  • Muscle loss and weakness.
  •  Severe dehydration, which can result in kidney failure. 
  • Fainting, fatigue, and overall weakness. 
  • Dry hair and skin, hair loss is common. 
  • Growth of a downy layer of hair called lanugo all over the body, including the face, in
    an effort to keep the body warm. (www.nationaleatingdisorders.org).

Similarly, bulimia carries its own physical consequences to the body, from extreme neglect:
  • Electrolyte imbalances that can lead to irregular heartbeats and possibly heart failure
    and death. Electrolyte imbalance is caused by dehydration and loss of potassium and
    sodium from the body as a result of purging behaviors.
  • Inflammation and possible rupture of the esophagus from frequent vomiting.
  • Tooth decay and staining from stomach acids released during frequent vomiting.
  • Chronic irregular bowel movements and constipation as a result of laxative abuse.
  • Gastric rupture is an uncommon but possible side effect of binge eating.(www.nationaleatingdisorders.org)
Believe it or not, I am not all that interested in discussing anorexia (which affects between 0.5–1% of American women) and bulimia (which affects affects 1-2% of adolescent and young adult women) in this blog. What I really want to talk about is a new anti-obesity drug which has very recently been approved by the FDA, Qnexa.

Obesity is an area of eating disorders which is gaining much more attention now, then it has in the past, and for good reason. According to CDC data "about one-third of U.S. adults (33.8%) are obese" (http://www.cdc.gov/obesity/data/adult.html). In addition, the CDC reports that the obesity problem is getting increasingly worse over time, not better.

With such an emphasis on obesity - particularly childhood obesity and obesity in minority populations, there can be little doubt that we must do something! And something is being done, by way of Qnexa, the first anti-obesity medication to hit the market in a very long time. The only problem is that it is causing quite a stir in the medical profession...

In case you have not been reading the major newspapers, especially the "Health" section, as I do online, then you might not have heard about Qnexa.
Qnexa is the brand name for (phentermine and topiramate), two powerful pharmaceutical medications. According to Drugs.com, phentermine is a "stimulant that is similar to an amphetamine. Phentermine is an appetite suppressant that affects the central nervous system." Also, according to that same web site, "Adult obese subjects instructed in dietary management and treated with "anorectic" drugs lose more weight on the average than those treated with placebo and diet, as determined in relatively short-term clinical trials." According to the clinical trials associated with Phentermine, there was weight loss associated with the drug, but only "a fraction of a pound a week." Drugs.com also rightly points out that "The natural history of obesity is measured in years, whereas the studies cited are restricted to a few weeks' duration; thus, the total impact of drug-induced weight loss over that of diet alone must be considered clinically limited." This is important to note, considering that the trials were not terribly long, and their proven effectiveness was a fraction of a pound a week. You do not need to perform clinical trials to see that you could probably achieve the same outcomes through light aerobic exercise, three times a week! 

Furthermore, there are side effects to taking Phentermine:  Bad taste in mouth; changes in sex drive; constipation; diarrhea; difficulty sleeping; dizziness; dry mouth; exaggerated sense of well being; headache; impotence; nervousness; over-stimulation; restlessness; sleeplessness; upset stomach. That's not too bad, I guess, but you don't get any of these side effects from walking or light aerobic exercise either.

The second component of Qnexa is a bit more tricky and may be the reason that Qnexa was denied by the FDA its first time around, in 2010. Topiramate is an anti-seizure drug (typically) prescribed to control seizures, treat Lennox-Gastaut syndrome and treat migraine headaches. (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000998). So, why is an anti-seizure medication being introduced with an amphetamine to control appetite? I do not know. I am not a pharmacologist, so I cannot say what the benefits of the drug would be in suppressing appetite. What I can say is this - Topiramate can be quite hazardous to your health. 

When first investigating this new drug, I was primarily interested in the media buzz associated with the FDA approval. As I mentioned before, the FDA rejected Qnexa for approval due to serious side effects, such as heart disease and birth defects. Again, the side effects were attributed to Qnexa as a complete drug product, but I am suggesting that the culprit was Topiramate. This is a list of side effects for Topiramate, given by the NIH: numbness, burning, or tingling in the hands or feet, slowed reactions, difficulty concentrating, speech problems, especially difficulty thinking of specific words, memory problems, lack of coordination, confusion, nervousness, aggressive behavior, irritability, mood swings, depression, headache, drowsiness, weakness, excessive movement, uncontrollable shaking of a part of the body, uncontrollable eye movements, extreme thirst, weight loss, constipation, diarrhea, gas, heartburn, change in ability to taste food, swelling of the tongue, overgrowth of the gums, dry mouth, increased saliva, trouble swallowing, nosebleed, teary or dry eyes, back, muscle, or bone pain, missed menstrual periods, excessive menstrual bleeding, skin problems or changes in skin color, dandruff, hair loss, growth of hair in unusual places, ringing in the ears, difficulty falling or staying asleep, swelling of the hands, arms, feet, ankles, or lower legs, difficulty urinating or pain when urinating. This list of side effects would be comical if they were not serious. Notice that "weight loss" is a side effect of Topiramate. That would explain its inclusion as an anti-obesity drug. 

I innocently mentioned to a friend that I had heard that Qnexa was being approved by the FDA. My friend, whom I knew had a family history of migraines was outraged at the prospect of this drug being prescribed for any purpose other than its originally-intended purpose as an anti-seizure medication. She had been prescribed Topiramate for migraine headaches and experienced many of the side effects listed above. According to my friend, her time on the drug was nothing short of hellish.

According to my friend, she began experiencing side-effects two days after starting using the drug as prescribed. She described experiencing "chronic headaches" until the time that she stopped taking the medication. This is somewhat ironic considering that the family member was prescribed Topirmate as an anti-migraine medication. She also described the combination of side effects listed above, such as "slowed reactions", "speech problems" and "confusion." Listed in this way, they sound mild and tolerable if one really needs the medication. In my friends experience, these side effects were not mild in the least:

"Then it started knocking me out as soon as I'd take it. I don't mean grogginess, I mean I was GONE. Then as I upped the dose, instead of Wong knocked out, it wouldn't let me sleep. At. All. It made me extremely cold all the time. I had swelling in my hands and legs, my hair stared falling out and generally thinning, I was grasping for words CONSTANTLY. I could see it in my head no could see the milk carton in the fridge of the home of the people for whom I used to babysit, I could hear the baby crying, could see myself preparing a bottle with that milk an yet I couldn't get the word out of my mouth. Then it started happening all the time. I would be driving and all of the sudden not know where I was going. I'd have to pull over ad evaluate what time it was, determine what road I was on and then try to figure out of I was going home, to work, to pick up [my son], etc. there's a 4 month period from which I remember absolutely nothing"
Also somewhat ironic, while my friend does not have a weight issue, she gained "20 pounds in 2 weeks." That seems dramatic, especially for an ingredient in an anti-obesity medication. Again, I am not a physician or a pharmacologist. There could be a very good reason for prescribing Qnexa for anti-obesity medication, but I am just not buying it personally.

One thing that I know for certain is that, as a nation, we are addicted to two things: taking medicine and feeling good. And the pharmaceutical industry is aware of our propensity for wanting to take the path of least resistance when it comes to our overall health. Vivus, the company producing Qnexa states at the top of their page for Qnexa that "By 2030, if trends in the escalating rates of obesity continue, health care costs attributable to obesity may reach $956 billion, accounting for up to 18% of total health care costs, or $1 in every $6 spent on health care." I do not doubt the validity of this statement, but at the same time, Vivus stands to make billions of dollars in profits on the marketing of their drug to every doctor, clinic, hospital and medical facility who is treating the morbidly obese (approximately 3% of the U.S. population or 6.8 million people), according to the USAToday.And according to Forbes, Vivus will stand to be the ultimate winners in this, whether the drugs performs as expected or not. "Given past sales figures for diet drugs, Vivus can expect to make a boatload of cash on Qnexa and shareholders will smile all the way to the bank" (forbes.com). 

Another thing that I know for sure is that as a country, we have developed a very unhealthy relationship to our food. I have written a couple of blogs about how the population of African-Amerians is disproportionately slanted toward obesity, as is 1 in 3 children born after 2000. Unless we stop the trends that we have developed concerning food and nutrition, I am fearful that we will lose a whole generation of young people, particularly young women to either Anorexia Nervosa and Bulimia Nervosa at one of the spectrum and morbid obesity at the other. There is no pill that the FDA can approve which will change that.

Saturday, December 17, 2011

No Inmate Left Behind

On my 20 minute commute to work every day, I pass a regional jail. The shape and size of the institution is not nearly as remarkable as its placement to the area. While most jails and prisons are set way out of site of passers by, you could nearly hit the fence of this site with a rock from the freeway. The jail sits a top a small hill, which makes it look something like a medieval fort. It's narrow windows give the inmates inside a view of the O'Charley's restaurant and Target department store less than an eight of a mile away. Maybe the approximation to life is a daily reminder to the incarcerated what they are missing out on while they serve their time - I don't know.

Passing the jail to and from five days a week has raised my awareness of the secret population of incarcerated in our country. While my brother-in-law has been making his career out of being in and out of penitentiary through his adult life, I have rarely given any thought to what goes on "behind the walls" or what difference it makes to our society at large, until now. Having just this morning done some baseline research into this issue of incarceration, I came across some troubling data.

 Let's start with the good news. According to the Pew Research Center's Prison Count 2010 Report, "for the first time in nearly 40 years, the number of state prisoners in the United States has declined." Let's not wave the victory flag just yet though. According to the report there were 4,777 (0.3%) fewer "persons under the jurisdiction of state authorities" than last year. However, the total number of the nations prison population increased by 2,061 because of a small jump in Federal prisons. Further complicating the "good news," the Pew Research Center report said that "while the overall prison population has declined...In 26 states, the population dropped, with some posting substantial reductions...Meanwhile, the number of prisoners continued to grow in the other 24 states, several with significant increases" (Prison Count 2010, p. 2). In a nutshell, I guess that we could say that we lost 4,777 prisoners in 2009, but we probably gained some news in that time too - so it is a net zero?

According to the Pew Report, some states did lose significant numbers of prisoners. It should be recognized that not all states have the same size prison populations. California's prison population shrank by 2.5% from 2008-2009. Alaska's prison population grew 3.8% in the same period. According to the LA Times, California has shrunk it's prison population by 4,257, leaving them a total state population of 170,000 inmates (2010). Compare that to the rate of prisoners in Alaska at 5,069 (2006). Likewise, the state of Indiana grew the largest between 2008 and 2009 by 5.3%. This raises the viable question of "why Indiana?"  

This was a question which the political leadership of Indiana had to account for, since it is their citizens which are paying for the increased prison population. After the non-partisan Pew Research Center released their report in 2010 regarding this jump in the prison population, the state leadership went on the offensive. 
"Findings show that Indiana’s prison population grew by more than 40 percent in the last 10 years—three times faster than any neighboring state—while the state’s crime rate declined only slightly. The increase in the prison population is primarily due to an increasing number of property and drug offenders being sentenced to prison" (Pew Research Center, 2011).
 “'Last year, Indiana spent almost 680 million dollars on its prisons,' said Representative Matt Pierce (D), chair of the Criminal Code Evaluation Commission. 'The CSG report shows we can give taxpayers more for their money when it comes to public safety and ensure there is plenty of room for serious offenders who need to be off the streets.'” (Pew Research Center, 2011). But what are the taxpayers getting "for their money" as Rep. Pierce put it? Piece of mind knowing that the bad guys are safely tucked away behind bars? Safer streets? Not really, not according to the Pew Center data which said that the increased spending had little effect on the overall crime rate. 

This is a tough question nearly every state which is facing annual budget challenges. How do you ensure that the "bad guys" are in there, off the streets and being rehabilitated? And how do you for pay for the expense? Let us first evaluate how many people are incarcerated in the United States. This chart shows what the differing rates are of incarceration, United States being 700% higher than the rate of "Europe" as a whole. We are nearly that amount higher than our northern neighbor Canada. But why? Is the crime the U.S. that dramatically worse than it is overseas? Are we a chronically criminal society? Surely, this is not the case in the wealthiest and most free society that man has ever known...and, it's not true. We are not crime-ridden as much as we are "incarceration-happy." 

1 in 100 people in the United States is incarcerated or in the criminal justice system
(Public Safety Performance Project)

According to Pew Center data and other criminal justice statistics, our crime rate between 1923 - 1971 was on part with Euope, Canada, Australia and Japan (see above chart). "Prior to 1972, the number of prisoners had grown at a steady rate that closely tracked growth rates in the general population. Between 1925 (the first year national prison statistics were officially collected) and 1972, the number of state prisoners increased from 85,239 to 174,379" (Prison Count, 2010).  What changed? According to the Pew Center, "starting in 1973, the prison population and imprisonment rates began to rise percipitously" (Prison Count, 2010).  

"In the nearly five decades between 1925 and 1972, the prison population increased by 105 percent; in the four decades since, the number of prisoners grew by 705 percent" (Prison Count, 2010). 
 In the 1980's and 1990's, when I was coming of age, it was very popular for politicians, particularly Republican leaders to take a firm stance of being "tough on crime." Slate.com recently wrote a posthumous article about President Reagan's legacy of  being someone who saw it as  part of his moral leadership to crack down on those who would undermine our system of justice. Gerald Shargel writes, "with almost biblical reach, Reagan sought to smite what he perceived as the criminal menace. In the words of his attorney general, William French Smith, Reagan aspired to nothing less than readjusting the 'balance between the forces of law and the forces of lawlessness'" (Slate.com, 2004). President Reagan in his time was responsible for passing the Bail Reform Act (1984) along with the Sentencing Reform Act (1984), both of which took a politically and legally harder line on the accused. And while President Reagan cannot be single-handedly responsible for this legislation on his own, it was passed during his administration, and at a time when the public felt that the criminal element had been "coddled" by liberal forces at work in the 1970's. Principally among the bleeding hearts of the era who had clamored for prisoners rights were attorney's like William Kunstler.  

The Sentencing Reform Act states that revisions in the law needed to be added and amended to account for changes in the criminal environment. "Progressive-minded reformers were led to a search for alternatives to indeterminate sentencing by growing mistrust of a 'therapeutic state' and the dangers to liberty and fairness it potentially posed, and by the lack of strong evidence for the effectiveness of correctional treatment programs...In this new Progressive vision, the medical model of rehabilitation was replaced with legal and technocratic expertise, which could fashion penalties that were calibrated to the seriousness of the crime or that were optimal for maximizing the control of crime while minimizing the costs of criminal justice" (USSC.gov). That all sounds reasonable enough. If the people being incarcerated are not "getting the message that crime doesn't pay" an the "therapeutic state" is failing to deliver justice, then let's tighten up on the reigns of criminal justice! That would be fine, except that we now have a bloated criminal justice system which is not only over-taxed with processing criminal appeals, but a prison industry which can no longer house the "bad guys."
This chart shows the rate of incarceration in the United States from 1925 to 2008. The blue line shows the rate of incarceration for men, notice that it takes off between 1973-1975 like a rocket. The green line shows the incarceration rate for women, notice that it has only ticked up slightly. And the red line is the overall incarceration rate, which is also ticked up dramatically when it accounts for both men and women.  What this chart demonstrates is that crime in the 1920's, 30's, 40's, 50's and 60's was less than it is today, it just means that we are locking up a lot more people then we used to. So, who are these people? 

 According to the Department of Justice 2010 report, many of them are African-American men. 1 in 10 African-American men is incarcerated in the United States. At year end 2010, about 1 in every 48 adults in the U.S. was under supervision in the community on probation or parole, compared to about 1 in every 104 adults in the custody of state or federal prisons or local jails" (DOJ, 2011).
The Department of Justice reports that as of 2009, 7,076,200 Americans were in some form of supervision in the legal system, 2,266,800 of which were incarcerated:
4,055,514 were on probation
840,676 2,266,800 were on parole
748,728 were in jail
1,518,104 were in prison

What is troubling to me personally is not just that we have so many people being tried for crimes in our system, but that also means that have 1.5 million Americans who are not working, paying taxes, raising families or contributing to society at all. They are being held in a purgatory for which we must pay, at all costs. That might soon change though...

The "tough on crime" mentality that ruled the legal system in the 1980's and 1990's appears to be coming home to roost in the prison cell. It was reported in May of this year that the Supreme Court had ordered the release of "approximately 37,000 to 46,000 inmates" from the state of California (Fox News, 2011). The case has reached the Supreme court because it was reported that "inmates in the state's 33 prisons were being denied adequate medical care as required by the Constitution" (LA Times, 2011). Justice Kennedy wrote the majority opinion for the 5-4 court saying "if a prison deprives prisoners of basic sustenance, including adequate medical care, the courts have a responsibility to remedy the resulting Eighth Amendment violation" (Fox News, 2011). The case had cited "over-crowding" as the "primary cause" for needing to release prisoners. Some prisons were holding prisoners at 137% capacity, setting up beds in the recreational spaces and housing multiple inmates per cell because they simply had no room to put them. 

Also conflating the prison system is an aging prison population. NPR's Talk of the Nation addressed pressing concerns for prison authorities in October of this year. "An elderly man in a wheelchair, a woman who requires dialysis: These probably don't fit your image of the typical prisoner. But as prison rolls grow, so do the ages of inmates. Crime reforms of the 1980s and '90s meant mandatory sentences and reduced parole. That means more people growing infirm and dying in prison, and taking care of them is expensive" (NPR, 2011). Jonathon Turley, Director, Project on Older Prisons, George Washington University was a guest on the program, saying that this prison demographic was the "fastest growing." Dr. Turley also gave some perspective of this issue saying, "in Virginia, you have just one prison reporting that they had 900 inmates in 1990, and today, they have 5,000 that would fall into this category. So you have that's just one state" (NRP, 2011).The guests also reported from their studies into aging prison population that while they are considered "lower risk" meaning not as likely to fight other inmates or try to escape, their cost for medical care is much higher. "There's a lot of studies that indicate that people age faster in prison. In fact, many studies say that you're about seven years older if you have long-term incarceration in a prison. It's due to the stress. It's often due to bad lifestyles, with chemical dependency and other issues" (NPR, 2011).

This leads me back to the county jail that I pass on my way to work every day. Knowing what I know now about our prison system and the number of people being kept out of society, I no longer see that facility as being a holding center of the ill-gotten. Instead, I see it as a money pit for an already impoverished state (West Virginia). Something must be done to reform our system of law and order. North Carolina Department of Corrections recently reported that the cost of incarceration is $27,000 per year, or $76.00 dollars a day, per inmate. At that rate, we could easily afford to pay for those same people to go to vocational training, go to college, pay for their mental health treatment or any other host of viable options which would add value to our state, system and community, rather than keeping locked away behind high-walled prisons where they waste away their lives and our tax dollars. Obviously, there are some who cannot be rehabilitated or who would be unsafe for release to the public. But, for everyone of them it would appear that there are an additional 700 who might be safe for release. Just ask Japan, Australia, Europe, or the U.S. prior to 1973.

Sunday, December 11, 2011

Is It Lyme?

A friend of mine, who knows that I am interested in Public Health issues, asked if I had seen the documentary, Under Our Skin (2009). I had not, but upon  the great recommendation of my my friend "run, don't walk to see it" I did watch it. The film is startling to say the least in that it purports that we have a silent epidemic of Lyme Disease in this country. It is important to note that the film suggests that this is a controversial issue rather than a conspiratorial one.

According to the Center For Disease Control and Prevention (CDC), Lyme Disease is not a major issue for the bulk of Americans, particularly ones who live outside of the New England region of the United States. The CDC reports that "94% of Lyme Disease cases were reported in 12 states" (CDC,gov). According to the statistics from the CDC, the confirmed rates of infection of Lyme Disease are nearly completely limited to the Northeastern region of the United States. For example, Massachusetts has one the highest confirmed rates of Lyme Disease in 2009 with 4019. Connecticut had a high rate reported with 2,700 reported cases, but Pennsylvania had the highest reported rate of confirmed cases with 4950. Compare these rates with states in other areas of the country, you can see that it is not even closely correlated. The state of Idaho had 4 confirmed cases. Kansas had 18 confirmed reports, and Utah has reported cases with 6 in 2009.  

But, that's not to say that if you live outside of the Boston to New York corridor that you don't have to worry. Pennsylvania, which is not considered a part of New England had the highest confirmed rates. Likewise, other states, far a field from that region had an above average rate of confirmed cases. Wisconsin had 1952 confirmed cases, New Jersey had over 4,500 cases and even Virginia had almost 700 reported cases.

Also, according to the CDC data, the reported, confirmed cases have barely risen over the past sixteen years. Probable cases being the highest in 2009, but that doesn't necessarily mean that it was Lyme Disease, it was possible that the person had all of the physical symptoms but still tested negative for the disease.
It sounds like from the CDC perspective that this is not a very serious public health concern. To put the numbers in perspective, more people were hospitalized for heat sickness in 2009 then people reported having been infected with Lyme disease. If that is true, then why should I be concerned? This is where the film comes back into play. What San Francisco-based filmmaker Andy Abrahams Wilson brings to bare is that there is a large undercurrent of unrecognized chronic illness which some believe is untreated Lyme disease. Mr. Abrahams Wilson reports that the reason that he became interested in Lyme disease as a topic of documentation was because his sister had been stricken ill with the disease. "Mr. Wilson said that when his sister, who lived in upstate New York, first complained about the effects of Lyme Disease he thought that she was just trying to get attention and simply tired. Then when a close friend in San Francisco became ill." Considering that she lived in upstate New York, it would seem likely that she could have been bitten by a tick which is known to carry the Borrelia burgdorferi virus which causes Lyme disease. "'None of the doctors could diagnose what was going on with her and she was just getting sicker and sicker,' he said during a telephone interview from his office in California. 'She was starting to have neurological problems. She would forget who she was and where she was.'" It is this mystery component of the disease, which is driving the controversy about what Lyme disease is or is not, medically speaking.

In an interview with Vanity Fair magazine, Mr. Abrahams Wilson told reporter Frank DiGiacomo that he believes that the medical community is suppressing the amount of conflicting research and data in this area because they own the "patent" on treating Lyme disease. As long as the disease is confirmed strictly by"Erythema migrans (EM) or 'bull's-eye' rash" it does not count as being Lyme's disease (CDC). 

The film gives some conspiratorial credence to the idea that in 1980's "the government permitted hospitals and research facilities to patent and profit from live organisms such as the Lyme pathogen. ...that this led to a situation where researchers, instead of sharing their findings, tended to each hold onto their little piece of the puzzle, which made it difficult to put the big picture together" (Vanity Fair). Mr. Abrahams Wilson agrees with this statement, telling Vanity Fair that "I think it’s the beginning of the problem. The deregulation of medicine happened under Reagan, and ironically, Reagan died of Alzheimer’s. I think he was an avid hunter, and you wonder if there’s any connection there." (Vanity Fair). Mr. Abrahams Wilson suspects that if differing researchers and analysts were able to share their information, therefore connecting their dots, then we would have a more complete picture which would include a new diagnosis of Lyme's disease called Chronic Lyme disease

Chroic Lyme disease  might be akin to Chronic Fatigue syndrome (CFS), a disorder which is largely misunderstood. And while CFS is recognized by the CDC as an actual illness, it is categorized by "to severe, continued tiredness that is not relieved by rest and is not directly caused by other medical conditions" (Ncbi.nlm.nih.gov). Mysery illnesses such as CFS and chronic (late term) Lyme disease must be assessed and addressed by the medical community. The New England Journal of Medicine published a critical report on Chronic Lyme disease in 2007. The NEJM notes in the introduction that "the diagnosis is often based solely on clinical judgment rather than on well-defined clinical criteria and validated laboratory studies, and it is often made regardless of whether patients have been in areas where Lyme disease is endemic" (Nejm.org). That's not to say that the diagnosis is not legit as much as it is being diagnosed at the discretion of individual physicians, not as a nearly accepted view by the medical community. After several studies involving differing numbers of voluntary participants in double-blind studies gave inconclusive results for proving that chronic Lyme disease. "Although anecdotal evidence and findings from uncontrolled studies have been used to provide support for long-term treatment of chronic Lyme disease,  a response to treatment alone is neither a reliable indicator that the diagnosis is accurate nor proof of an antimicrobial effect of treatment...Furthermore, the published reports of uncontrolled trials of antibiotic treatment for chronic Lyme disease used poorly standardized case definitions and either undefined criteria for interpreting immunoblots or criteria that have subsequently been found to have very low specificity (approximately 60%)" (NEJM.org). In other words, we checked it out and we could not conclusively find any good evidence that it exists.

According to Infectious Diseases Society of America, there is no medical basis for Chronic Lyme disease diagnosis. Dr. Paul Auwaerter says that he receives patients who have been diagnosed by another physician as having chronic Lyme disease. Dr. Auwaerter says that often times, "the diagnosis is used very liberally by some physicians who have patients who have symptoms such as fatigue, muscle aches, headaches that aren't easily explained..which is not based on scientific fact" (Idsociety.org). The problem with this diagnosis, according to Dr. Auwaerter is that in a confirmed case of Lyme disease, a patient is given a prescription of antibiotics for a period of 14 days, wherein the symptoms subside for most people infected. The problem with a diagnosis, according to Dr. Auwaerter, is that people are being subscribed doses of antibiotics to be taken long term, which can produce bad outcomes as well. "It can create super-bugs, resistant bacteria, they can upset your GI [gastrointestinal] track. If people get intravenous catheters they can clot, gain infections and land them in the hospital." That sounds pretty bad, you anyone going in for intensive surgery assumes the same risks when they go under general anesthesia for surgery. 

This is all made more complicated because of the fallout of the phony research purported by Andrew Wakefield regarding the link between autism and vaccination. That is not to say that the because medicine cannot account for Chronic Lyme disease that it does not exist. The bar for conclusive medical research is so high that unless you can accurately project the exact same results to 95% of the population, then it cannot be counted on. That does not deter Andy Abrahams Wilson and other activists who say that Chronic Lyme disease is a viable problem. "The Center for Disease Control admits that their reporting is likely off from six to twelve fold, and that would make it over 300,000 [cases of Lyme] a year. I think, HIV is around 30,000 diagnoses a year. So, it doesn’t even compare. Granted, everybody’s who diagnosed with Lyme disease does not go on to develop serious chronic illness, especially if it’s caught early. But what’s happening is people are not being diagnosed early because doctors don’t know what to look for because the tests are not accurate, and because there’s no insurance code for chronic Lyme. On top of that, doctors don’t want to treat chronic Lyme disease because it’s just too much trouble" (Vanity Fair). 

In any case, I would highly recommend seeing Under Our Skin. Walk, don't run!

Wednesday, November 9, 2011

Sexual Child Abuse in 2010

Former Penn State football coach, Jerry Sandusky has been accused of molesting several young men while working as a football coach at Penn State. In the light of this most recent scandal, coupled with the the much larger child sexual abuse scandal by the Catholic church, it raises questions, in my mind at least. How much of a problem is child sexual abuse in our country? Is this pattern of abuse getting worse, or are more victims showing the amazing courage to come forward and tell the truth about their trauma? 

Nearly everyone thinks that they would know a child molester if they saw one. As epitomized by Stanley Tucci's role in The Lovely Bones (2009), it is the the awkward, creepy neighbor, with the comb-over and big mustache. He is a loner, has no children of his own and is obviously a serial-killing child molester! He has it written all over his face. In actuality, most people who prey on children are not strangers, nor do they have any outward appearance of their emotional state. The Center For Missing and Exploited Children, a non-profit organization has a wealth of data and resources on their web site for law enforcement, attorneys, parents and educators. One of the publications that they provide is the "registered sex offender map" which gives rates of sexual predators by state. It might surprising to some to learn that the state of Florida has the highest rate of sex offenders per capita at 55,999 (or 300 per capita). The state of Michigan comes in second with 47,329 (with a higher per capita rate of 447). The state with the highest number of sex offenders is California with 106,216 (or 285 per capita) but given that the land mass of the state is much larger, that figure can be deceptive. "The myth of the typical child molester as the dirty old man in the wrinkled raincoat has been reevaluated based on what we have learned about the kinds of people who sexually victimize children. 

The Center For Missing and Exploited Children (CFMEC) published a comprehensive portrait of who child molesters are (and are not) in 2010. "The fact is child molesters can look like anyone else and even be someone we know and like. In my opinion, however, the growing preference today to refer to sex offenders against children as predators has mitigated this recognition and progress" (Center For Missing and Exploited Children, 2010). The CFMEC report goes on to say that while there is a small fraction of dangerous predators who prey on young people, the more likely occurrence of an inappropriate encounter with a child is more likely to come from someone that the child knows and trusts. "Acquaintance molesters are still, however, one of the most challenging manifestations
of sexual victimization of children for society and professionals to face
" (Center For Missing and Exploited Children, 2010). Acquaintance molesters, they say, are harder to detect because they often times infiltrate voluntary positions where they can gain access to children in a casual setting. "The acquaintance molester, by definition, is one of us. He is not simply an anonymous, external threat. He cannot be identified by physical description and, often, not even by 'bad' character traits. Without specialized training or experience and an objective perspective, he cannot easily be distinguished from others" (Center For Missing and Exploited Children, 2010). This would explain why someone like Jerry Sandusky or a parish priest would be beyond reproach in their access to and interaction with children and probably why, when an accusation of molestation or child rape has been leveled, that it comes as such a complete surprise.

Is child molestation and child rape more prevalent that it once was?  It is hard to say. There is plenty of data to support that with the advent of the internet and chat rooms, that men have easier access to children pretending to be older and more sophisticated then they actually are. This scenario, of older men getting caught picking up young girls on the internet, famously plaid out in Chris Hanson's To Catch a Predator series only reinforces the "stranger danger" myth. There obviously are men trolling for children on the internet and on the city streets, but the actual instances and circumstances of proving a sexual violation with a child are much more difficult for prosecutors, police and CPS officials to prove. "How does an investigator prove intent or motivation? Can a crime have more than one motivation? Can we determine motivation from the offender? We know offenders are more reluctant to admit sexual motives than other types of motives (e.g., profit, revenge, anger, power). Does the offender always know his motivation? Potential ways to address this problem will be discussed later in this publication" (Center For Missing and Exploited Children, 2010). The motivations for violating children is as varied and broad as the types of children violated. It is not a simple offender/victim scenario, and this is likely to come to light as the Jerry Sandusky case becomes more public. 

The Center for Missing and Exploited Children reports that:
  • Approximately one in seven youth online (10 to 17 years-old) received a sexual solicitation or approach over the Internet. 
  • Four percent (4%) received an aggressive sexual solicitation — a solicitor who asked to meet them somewhere; called them on the telephone; or sent them offline mail, money, or gifts.
  • Thirty-four percent (34%) had an unwanted exposure to sexual material — pictures of naked people or people having sex.
  • Children revealed 27% of these episodes of unwanted exposure to sexual material to a parent or guardian.  Children reported 42% of the distressing encounters – episodes that made them feel very or extremely upset or afraid – to a parent or guardian.

  The Center for Missing and Exploited Children also reports that "the sexual victimization of children is overwhelming in magnitude yet largely unrecognized and under-reported. Research indicates that 1 in 5 girls and 1 in 10 boys will be sexually victimized before adulthood" (Center For Missing and Exploited Children). That figure is staggering if true. But, as we have seen in the above paragraph, "sexually victimized" is a very broad term. That can span from unwanted attention from adults to child pornography, child prostitution, molestation, rape, and sexual harassment and stalking. The NY Times reported recently that a high percentage of students, grades 7 - 12 reported being sexually harassed in school. "Over all, 48 percent of students surveyed said they were harassed during the 2010-11 school year. Forty-four percent of students said they were harassed 'in person' — being subjected to unwelcome comments or jokes, inappropriate touching or sexual intimidation — and 30 percent reported online harassment, like receiving unwelcome comments, jokes or pictures through texts, e-mail, Facebook and other tools, or having sexual rumors, information or pictures spread about them" (NY Times, 2011). This is not to confuse the issue of sexual harassment and sexual victimization, as defined by the CFMEC. It is instead, meant to demonstrate that there is a spectrum of sexual impropriety which is affecting generations of young people. And this says nothing of the age of sexting, wherein some young people are being charged with child pornography charges. 

If there is one bright spot in my sickening expose of child sexual abuse, it is this - child sex abuse is not the greatest threat of abuse facing our young people. The unfortunate statement to be made is that it is actually neglect by primary parents which is the biggest problem for young children in all 50 states. According to a Child Maltreatment 2009 report, neglect was by far the largest problem facing children. The data was collected and analyzed by the National Child Abuse and Neglect Data System (NCANDS), which is a database for law enforcement and child protective services. According to the 2009 report, powered by NCANDS data:  

People reporting sexual abuse: The three largest percentages of report sources were from such professionals as teachers (16.5%), law enforcement and legal personnel (16.4%), and social services staff (11.4%).
Anonymous sources (8.9%), other relatives (7.0%), parents (6.8%), and friends and neighbors (4.9%), accounted for nearly all of the nonprofessional reporters. 
Children must commonly abused: Victims in the age group of birth to 1 year had the highest rate of victimization at 20.6 per 1,000. Children of the same age group in the national population.
Victimization was split between the sexes with boys accounting for 48.2 percent and girls accounting for 51.1 percent. Less than 1 percent of victims had an unknown sex.

Most common types of maltreatment: More than 75 percent (78.3%) suffered neglect;
More than 15 percent (17.8%) suffered physical abuse;
Less than 10 percent (9.5%) suffered sexual abuse; and
Less than 10 percent (7.6%) suffered from psychological maltreatment.

Most common offenders: Four-fifths (80.9%) of duplicate perpetrators of child maltreatment were parents, and another 6.3 percent were other relatives of the victim; Of the duplicate perpetrators who were parents, four-fifths (84.7%) were the biological parents of the victim;
Women comprised a larger percentage of all unique perpetrators than men, 53.8 percent compared to 44.4 percent; and

Four-fifths (83.2%) of all unique perpetrators were between the ages of 20 and 49 years.

This figures, while helpful at a glance, only give the most obscure picture of child maltreatment in the United States. If you wanted to look at outcomes of reporting of child sexual abuse by state, you could. The U.S. Health and Human Services has a lot of data online in reports and interactive web sties that allow for users to select and aggregate their own data. For example, I wanted to compare the rates of child abuse amongst five states. I chose Arizona, Arkansas, California, Delaware, Florida, Illinois, Ohio and Texas to look at across the board. What was interesting (to me) was to see how varying types of abuse were reported for each state. No two states seemed to share a common thread of abuse or neglect in 2009. 

Alabama Arizona Arkansas California Delaware  Florida   Illinois     Ohio      Texas
Emotional abuse 0.4 0.6 1.2 16.2 32.0 1.3 0.1 6.0 1.0
Medical neglect 0.0 N/A 7.3 -- 1.1 2.1 2.1 1.4 3.2
Neglect 36.5 69.8 61.7 76.9 41.4 49.3 68.1 43.7 78.5
Physical abuse 47.7 25.0 18.1 10.6 17.5 9.8 20.7 34.4 20.5
Sexual abuse 22.7 8.8 22.0 6.9 7.5 4.4 15.0 17.8 9.1
Other 0.0 0.0 0.0 0.1 8.7 52.5 0.0 0.0 0.0
Missing data 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

The state of Florida had the highest rate of emotional abuse reporting with 32, compared with Arizona who had a reported emotional abuse of 0.7.

The state of Arizona had the highest rates of physical abuse reporting with 47.7. Ohio came in a distant second with a number of 34.4.  Arizona had the highest rates of sexual abuse reporting with 22.7.
And no state came in higher (in my sampling) than Texas for neglect at 78.5.

But what do these statistics mean? The HHS report notes that all of these instances of abuse are highly under-reported and this is merely the best data that we have to go on. The actual rates of neglect could easily be higher in another state if we had a more complete picture, but that is only possible when people report what they see and hear for investigation.

It would seem from the debacle at Penn State and the fallout which is ensuing, that the worst thing that you could do is to know that child abuse of any kind is occurring within your sphere of influence and fail to act. Early reports indicate that Joe Paterno's long and storied career at Penn State could easily be upended by his failure to report the child sexual abuse to the authorities at the time, although he did report the incidents to his superior as soon as he heard about them. Penn State University and their football program are no doubt learning the hard way, the realities which smacked the Catholic church a few years ago and continues to be a problem - it's not the crime that gets you, it's the coverup! 

Falsely reporting child abuse of any form is a very serious crime which carries very serious penalties up to $5000 fine and jail time. At the same time, if you or someone you know has been a victim of child sexual abuse, then you can report it. The Center For Missing and Exploited Children has a "push to talk" feature on their web site which will allow for you to confidentially report a sighting of child abuse. They also have a toll-free Hotline: (800) THE-LOST (800-843-5678) which you can call 24-hours a day. 

And the U.S. Department of Health and Human Services has the following hot-lines which you can call at any time to report abuse to receive help: 

Child Abuse
Childhelp's National Child Abuse Hotline
800-4-A-CHILD (800-422-4453)

Child Care
Child Care Aware
Domestic Violence
National Domestic Violence Hotline
1-800-799-SAFE (800-799-7233)
TDD 1-800-787-3224
Runaway Youth
National Runaway Switchboard
National Human Trafficking Resource Center
National Human Trafficking Resource Center

Child sexual abuse and sexual violence cannot be completely eradicated, but there are actions which we can take to help prevent it from happening again in the future.