tag:theconversation.com,2011:/us/topics/preventable-deaths-39013/articlesPreventable deaths – The Conversation2023-06-13T12:29:56Ztag:theconversation.com,2011:article/2046222023-06-13T12:29:56Z2023-06-13T12:29:56ZAnnual numbers of excess deaths in the US relative to other developed countries are growing at an alarming rate<figure><img src="https://images.theconversation.com/files/527599/original/file-20230522-14385-h3se2w.jpg?ixlib=rb-1.1.0&rect=0%2C15%2C5100%2C3802&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Homicides and the opioid epidemic both contribute to the rising U.S. death rates.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/people-at-a-funeral-royalty-free-image/104302939?phrase=U.S.+cemetery&adppopup=true">Rubber Ball Productions/Brand X Pictures via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>People in the U.S. are dying at higher rates than in other similar high-income countries, and that difference is only growing. That’s the key finding of a <a href="https://doi.org/10.1371/journal.pone.0283153">new study that I published</a> in the journal PLOS One.</p>
<p>In 2021, more than 892,000 of the 3,456,000 deaths the U.S. experienced, or about 1 in 4, were “<a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm#">excess deaths</a>.” In 2019, that number was 483,000 deaths, or nearly 1 in 6. That represents an 84.9% increase in excess deaths in the U.S. between 2019 and 2021. </p>
<p>Excess deaths refer to the actual number of deaths that occur in a given year compared with expected deaths over that same time period based on prior years or, as in this study, in other countries.</p>
<p>In my study, I compared the number of U.S. deaths with those in the five largest countries in Western Europe: England and Wales, France, Germany, Italy and Spain. Those five countries make for a good comparison because they are nearly, if not quite, as wealthy as the U.S. and their combined population is similar in size and diversity to the U.S. population.</p>
<p>I also chose those countries because they were used in an earlier study from another research team that documented a <a href="https://doi.org/10.1073/pnas.2024850118">34.5% increase in excess deaths</a> in the U.S. between 2000 and 2017. </p>
<p>The acceleration of this already alarming long-term trend in excess deaths in the U.S. was exacerbated by the fact that the U.S. experienced higher death rates from COVID-19 <a href="https://doi.org/10.1136/bmj.n1343">compared with similar countries</a>. However, <a href="https://theconversation.com/279-700-extra-deaths-in-the-us-so-far-in-this-pandemic-year-147887">COVID-19 alone does not account</a> for the recent increase in the number of excess deaths in the U.S. relative to comparison countries.</p>
<h2>Why it matters</h2>
<p>Rising living standards and medical advances through the 20th century have made it possible for people in wealthy countries to live longer and <a href="https://doi.org/10.1257/jep.20.3.97">with a better quality of life</a>. Given that the U.S. is the largest economic power in the world, with cutting-edge medical technology, Americans should have an advantage over other countries in terms of life span and death rates.</p>
<p>But in the last 50 years, many countries around the world have outpaced the U.S. in how fast death rates are declining, as revealed by <a href="https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/20220831.htm#">trends in life expectancy</a>.</p>
<p>Life expectancy is an average age at death, and it represents how long an average person is expected to live if current death rates remain unchanged throughout that person’s lifetime. Life expectancy is based on a complex combination of death rates at different ages, but in short, when death rates decline, life expectancy increases. </p>
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<p>Compared to about 20 other high-income countries, since around the mid-1970s <a href="https://www.npr.org/sections/health-shots/2023/03/25/1164819944/live-free-and-die-the-sad-state-of-u-s-life-expectancy#">the U.S. life expectancy</a> has been <a href="https://doi.org/10.17226/13497">slipping from about the middle, or median, to the lowest rungs</a> of life expectancy. So the relative stagnation in life expectancy in the U.S. compared with other countries is directly related to the fact that death rates have also declined more slowly in the U.S.</p>
<p>The U.S. has higher death rates than its peer countries due to a variety of causes.
Cardiovascular disease prevalence has been an <a href="https://doi.org/10.1161/CIRCRESAHA.116.309115">important driver of life expectancy changes across the globe</a> in recent decades. But while death rates from cardiovascular disease have continued to decline in other parts of the world, those <a href="https://doi.org/10.1073/pnas.1920391117">rates have stagnated in the U.S.</a>. </p>
<p>A key reason for this trend is the <a href="https://doi.org/10.1073/pnas.1716802115">rise in obesity</a>, as research shows that <a href="https://doi.org/10.1161/CIR.0000000000000973">obesity increases the risk of death from cardiovascular disease</a>. High prevalence of obesity in the U.S. also likely contributed to the <a href="https://doi.org/10.1136/bmj.n1343">relatively high death rates from COVID-19</a>. </p>
<p>Another cause is that the U.S. has disproportionately high death rates from intentional injuries in the form of homicides, <a href="https://doi.org/10.1097/TA.0b013e3181dbaddf">in particular those caused by firearms</a>. Moreover, it also has high death rates from unintentional injuries, <a href="https://doi.org/10.1111/padr.12228">in particular drug overdoses</a>. </p>
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<figcaption><span class="caption">People are being exposed to fentanyl without knowing it, and because the synthetic opioid is so highly potent, people are dying in unprecedented numbers.</span></figcaption>
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<h2>What other research is being done</h2>
<p>While these specific causes of deaths should clearly be health policy priorities today, there might be more fundamental causes to the elevated U.S. death rates. </p>
<p>In the early 1990s, young people in the U.S. between the ages of 15 and 34 were already dying at <a href="https://doi.org/10.1016/S1054-139X(01)00329-9">higher rates than their peers in other countries</a> from a combination of homicides, unintentional injuries – in large part from motor vehicle accidents – and <a href="https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline/">deaths from HIV/AIDS</a>. </p>
<p>Research is underway to understand the more <a href="https://doi.org/10.1097/PHH.0000000000001626">fundamental societal causes</a> that may explain the vulnerability of the U.S. population to successive epidemics, from HIV/AIDS and COVID-19 to gun violence and opioid overdoses. </p>
<p>These <a href="https://doi.org/10.1073/pnas.2014750117">include racial</a> and <a href="https://doi.org/10.2105/AJPH.2008.139469">economic inequalities</a>, which combined with a weaker social security net and lack of health care access for all may help explain larger health and death disparities compared to European countries.</p><img src="https://counter.theconversation.com/content/204622/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patrick Heuveline does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research shows that preventable deaths are increasing in the US at the same time that life expectancy keeps dropping.Patrick Heuveline, Professor of Sociology, University of California, Los AngelesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1939092022-11-30T13:35:39Z2022-11-30T13:35:39ZMore than 4 in 5 pregnancy-related deaths are preventable in the US, and mental health is the leading cause<figure><img src="https://images.theconversation.com/files/498087/original/file-20221129-14-ezp753.jpg?ixlib=rb-1.1.0&rect=27%2C27%2C4524%2C3064&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">According to the CDC's latest numbers, 65% of pregancy-related deaths occur in the first year following childbirth.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/a-young-woman-holds-her-newborn-baby-in-a-safety-royalty-free-image/834822152">Petri Oeschger/Moment via Getty Images</a></span></figcaption></figure><p>Preventable failures in U.S. maternal health care result in far too many pregnancy-related deaths. Each year, approximately <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths.html#">700 parents die from pregnancy and childbirth complications</a>. As such, the U.S. maternal mortality rate is <a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries">more than double </a> that of most other developed countries.</p>
<p>The Department of Health and Human Services declared maternal deaths a <a href="https://www.hhs.gov/sites/default/files/call-to-action-maternal-health.pdf">public health crisis</a> in December 2020. Such calls to action by the U.S. Surgeon General are reserved for only the most serious of public health crises.</p>
<p>In October 2022, the Centers for Disease Control and Prevention released new data <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html">gathered between 2017 and 2019</a> that further paints an alarming picture of maternal health in the U.S. The report concluded that a staggering <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">84% of pregnancy-related deaths are preventable</a>. </p>
<p>However, these numbers don’t even reflect how widespread this problem could be. At present, only 39 states have <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">dedicated committees in place</a> to review maternal deaths and determine whether they were preventable; of those, 36 states were included in the latest CDC data.</p>
<p>I am a <a href="https://www.adler.edu/programs/rachel-diamond/">therapist and scholar</a> specializing in mental health during the perinatal period, the time during pregnancy and postpartum. Research has long demonstrated <a href="https://www.mmhla.org/wp-content/uploads/2020/07/MMHLA-Main-Fact-Sheet.pdf">significant mental health risks</a> associated with pregnancy, childbirth and the year following childbirth. The CDC’s report now makes it clear that mental health conditions are an important factor in many of these preventable deaths.</p>
<h2>A closer look at the numbers</h2>
<p>The staggering number of preventable maternal deaths – 84% – from the CDC’s most recent report represents a 27% increase from the agency’s previous report, <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief_2019-h.pdf">from 2008 to 2017</a>. Of these pregnancy-related deaths, 22% occur during pregnancy, 13% during childbirth and 65% during the year following childbirth.</p>
<p>This raises the obvious question: Why are so many preventable pregnancy-related deaths occurring in the U.S., and why is the number rising?</p>
<p>For a pregnancy-related death to be <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf">categorized as preventable</a>, a maternal mortality review committee must conclude there was some chance the death could have been avoided by at least one reasonable change related to the patient, community, provider, facility or systems of care. </p>
<p>The <a href="https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf">most commonly identified factors</a> in these preventable deaths have been those directly related to the patient or their support networks, followed next by providers and systems of care. While patient factors may be most frequently identified, they are often dependent on providers and systems of care.</p>
<p>Take, for instance, the example of a new mother dying by suicide from a mental health condition, such as depression. Patient factors could include her lack of awareness about the warning signs of clinical depression, which she may have mistaken for difficulties with the transition to parenthood and perceived personal failures as a new parent. </p>
<p>As is often the case, these factors would have directly related to the inaction of health care providers, such as a failure to screen for mental health concerns, delays in diagnosis and ineffective treatment. This type of breakdown – which is common – would have been made worse by poor coordination of care between providers across the health care system.</p>
<p>This example illustrates the complexities of the failures and preventable outcomes in the maternal health care system. </p>
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<figcaption><span class="caption">The U.S. has a far higher rate of pregnancy-related deaths than other developed nations.</span></figcaption>
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<h2>The role of mental health</h2>
<p>In the CDC’s latest report, mental health conditions are the overall <a href="https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html">most frequent cause of pregnancy-related death</a>. Approximately 23% of deaths are attributed to suicide, substance use disorder or are otherwise associated with a mental health condition. The next two leading causes are hemorrhage and cardiac conditions, which combined contribute to only slightly more deaths than mental health conditions, at about 14 and 13%, respectively.</p>
<p>Research has long shown that <a href="https://doi.org/10.1001/jamapsychiatry.2013.87">1 in 5 women</a> suffer from mental health conditions during pregnancy and the postpartum period, and that this is also a time of <a href="https://doi.org/10.1016/j.ajog.2016.03.040">increased risk for suicide</a>. Yet, mental illness – <a href="https://doi.org/10.1542/peds.2010-2348">namely, depression</a> – is the most underdiagnosed obstetric complication in America. Despite some promising reductions in U.S. suicide rates in the general population over the last decade, <a href="https://doi.org/10.1001/jamapsychiatry.2020.3550">maternal suicide has tripled</a> during this same time period.</p>
<p>As it relates to maternal substance use, this issue is also worsening. In recent years, almost all deaths from drug overdose during pregnancy and the postpartum period involved opioids. A review from 2007 to 2016 found that pregnancy-related deaths <a href="https://doi.org/10.1016/j.ajog.2018.09.028">involving opioids more than doubled</a>. </p>
<p>Many of these issues stem from the fact that up to 80% of women with maternal mental health concerns are <a href="https://www.themotherhoodcenter.com/blogindex/2022/6/23/what-are-perinatal-mood-and-anxiety-disorders-pmads#">undiagnosed or untreated</a>. </p>
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<h2>Barriers to care</h2>
<p>In 2021, the first national data set of its kind showed that <a href="https://www.2020mom.org/blog/2022/11/14/us-maternal-depression-screening-rates-released-for-the-first-time?emci=d266ca19-ae66-ed11-ade6-14cb65342cd2&emdi=726c140a-d666-ed11-ade6-14cb65342cd2&ceid=8668229">less than 20% </a> of prenatal and postpartum patients were screened for depression. Only half of those who screened positive received follow-up care.</p>
<p>Research has long demonstrated widespread <a href="https://www.issuelab.org/resources/40013/40013.pdf">barriers and gaps</a> in maternal mental health care. Many health care providers do not screen for mental health concerns because they do not know where to refer a patient or how to treat the condition. In addition, only about <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care">40% of new mothers</a> even attend their postpartum visit to have the opportunity for detection. Non-attendance is more common among <a href="https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=0&sid=aa757e01-7bbb-4387-9f50-ee7cfd726f00%40redis">higher-risk populations of postpartum women</a>, such as those who are socially and economically vulnerable and whose births are covered by Medicaid. </p>
<p>Medicaid covers around <a href="https://www.cdc.gov/nchs/products/databriefs/db387.htm#section_3">4 in 10 births</a>. Through <a href="https://americanpregnancy.org/healthy-pregnancy/planning/medicaid-for-pregnant-women/">Medicaid benefits</a>, pregnant women are covered for care related to pregnancy, birth and associated complications, but only up to 60 days postpartum. Not until 2021 did the <a href="https://www.kff.org/policy-watch/postpartum-coverage-extension-in-the-american-rescue-plan-act-of-2021/">American Rescue Plan Act</a> begin extending Medicaid coverage up to one year postpartum. </p>
<p>But as of November 2022, only <a href="https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/">27 states</a> have adopted the Medicaid extension. In the other states, new mothers lose postpartum coverage after just 60 days. This matters a great deal because low-income mothers are at a <a href="https://doi.org/10.1542/peds.2010-2348">greater risk for postpartum depression</a>, with reported rates as high as 40% to 60%. </p>
<p>In addition, the recent CDC report showed that 30% of preventable pregnancy-related deaths happened between 43 and 365 days postpartum – which is also the time frame <a href="https://www.cdcfoundation.org/sites/default/files/upload/pdf/MMRIAReport.pdf">suicide most commonly occurs</a>. Continued Medicaid expansion would reduce the number of uninsured new parents and <a href="https://ccf.georgetown.edu/wp-content/uploads/2021/09/maternal-health-and-medex-final.pdf">rates of maternal mortality</a>. </p>
<p>Another challenging barrier to addressing maternal mental health is the criminalization of substance use during pregnancy. If seeking care exposes a pregnant person to the <a href="https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist">possibility of criminal or civil pentalties</a> – including incarceration, involvement with child protective services and the prospect of separation from their baby – it will naturally dissuade them from seeking treatment. </p>
<p>At this time, 24 states consider <a href="https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy">substance use during pregnancy to be child abuse</a>, and 25 states require health care professionals to report suspected prenatal drug use. Likewise, there are also tremendous barriers in the postpartum period for mothers seeking substance use treatment, due in part to the lack of <a href="https://doi.org/10.1111/famp.12501">family-centered options</a>. </p>
<p>With all these barriers, many pregnant and new mothers may make the difficult decision to not engage in treatment during a critical window for intervention.</p>
<h2>Looking ahead</h2>
<p>While the information described above already paints a dire picture, the CDC data was collected prior to two major events: the COVID-19 pandemic and the <a href="https://theconversation.com/roe-overturned-what-you-need-to-know-about-the-supreme-court-abortion-decision-184692">fall of Roe v. Wade</a>, which overturned nearly 50 years of abortion rights. Both of these events have <a href="https://www.axios.com/2022/07/05/maternal-mortality-death-abortion-ban-roe">exacerbated existing cracks</a> in the health care system and, subsequently, worsened the <a href="https://www.gao.gov/assets/730/723432.pdf">maternal health in the U.S.</a> </p>
<p>In my view, without radical changes to maternal health care in the U.S., starting with how mental health is treated throughout pregnancy and postpartum, it’s likely parents will continue to die from causes that could otherwise be prevented.</p><img src="https://counter.theconversation.com/content/193909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachel Diamond does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many of the preventable pregnancy-related deaths documented by the CDC are directly attributable to failures and barriers in the maternal care system.Rachel Diamond, Clinical Training DIrector and Assistant Professor of Couple and Family Therapy, Adler UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1674402021-12-19T19:54:22Z2021-12-19T19:54:22ZThe 8 deadly days of Christmas: how to stay safe from drowning in Australia this summer<figure><img src="https://images.theconversation.com/files/426334/original/file-20211014-13-uztxcg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5615%2C3732&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Christmas is coming – meaning Australians are about to enter our most dangerous time of year for fatal drownings. </p>
<p>The eight days from Christmas Day to New Year’s Day are the deadliest period for drowning, with 201 lives lost over the past 15 years, according to my new analysis. </p>
<p>Using coronial <a href="https://www.royallifesaving.com.au/research-and-policy/drowning-research/national-fatal-drowning-database#:%7E:text=The%20Royal%20Life%20Saving%20National%20Fatal%20Drowning%20Database%20features%20detailed,waterways%20since%201%20July%202002.">data</a> from the Royal Life Saving Society – Australia, my analysis shows a further 28 people drowned on Australia Day during the same 15 year period. My findings back up previous research, which found people are <a href="https://www.mdpi.com/2313-576X/4/4/42/htm">twice as likely</a> to drown in Australia on a public holiday than any other day. </p>
<p>But the danger isn’t limited to major holidays. January 10 inexplicably emerged from my analysis as a key date, with 32 people drowning over the past 15 years – more than on any other single day of the year.</p>
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<p>The sadly predictable spikes in preventable drownings mean many river rescue divers and surf life savers have come to dread summer.</p>
<h2>The personal toll of preventable drownings</h2>
<p>The Murray River is Australia’s leading river drowning black spot. </p>
<p>For more than 40 years, Peter Wright OAM, a volunteer rescue diver with the Corowa Rescue Squad, has performed the harrowing task of retrieving bodies – including children – from the river: </p>
<blockquote>
<p>I have this feeling of dread as summer approaches. I find myself avoiding going near the river, as seeing people behaving badly or irresponsibly really gets to me […] I know it’s not if, but when we will be called to search the river for the next drowning victim […] The look of abject grief and disbelief on the faces of relatives and the noise of wailing families haunts me to this day.</p>
</blockquote>
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<figcaption><span class="caption">‘Don’t panic, keep your head up’: Volunteer divers Stuart Dye and Peter Wright’s stories of avoidable drownings in the Murray River. Royal Life Saving Society – Australia.</span></figcaption>
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<p><a href="https://issuu.com/surflifesavingaustralia/docs/ncsr_2021">Data from Surf Life Saving Australia</a> paint a similar story. </p>
<p>The number of people who get into trouble at the beach spikes on public holidays. With an average of 20 rescues per day across the year in 2020/21, the period from Christmas Day to New Year’s Day sees this figure increase almost six-fold, with an average of 116 rescues per day.</p>
<p>According to Chris Jacobson, National Surf Life Saving Australia’s chair of lifesaving and a volunteer surf lifesaver of 20 years: </p>
<blockquote>
<p>Surf lifesavers are constantly on the go attending to numerous rescues during this period, in particular on Australia Day. We see people not swimming between the flags, ignoring lifesavers, drinking and overestimating their abilities, which therefore requires our members to go to their aid.</p>
</blockquote>
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<figcaption><span class="caption">Do you know how to spot a rip at the beach? Surf Life Saving Australia.</span></figcaption>
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<h2>5 factors driving more summer drownings</h2>
<p>So why are Australians more likely to drown in summer, particularly on public holidays? And how can you be safer this summer?</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/426138/original/file-20211013-23-13tvm8a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/426138/original/file-20211013-23-13tvm8a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/426138/original/file-20211013-23-13tvm8a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/426138/original/file-20211013-23-13tvm8a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/426138/original/file-20211013-23-13tvm8a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/426138/original/file-20211013-23-13tvm8a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1006&fit=crop&dpr=1 754w, https://images.theconversation.com/files/426138/original/file-20211013-23-13tvm8a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1006&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/426138/original/file-20211013-23-13tvm8a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1006&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Australia Day aftermath: a beer-filled raft beside the Murray River at Albury.</span>
<span class="attribution"><span class="source">Amy Peden</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p><strong>Alcohol</strong></p>
<p>Alcohol is a <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.12817">leading risk factor for drowning</a>. It impairs reaction time, impacts the effectiveness of cardiopulmonary resuscitation (CPR) and can result in risk-taking behaviour.</p>
<p>Our <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6256-1">breathalysing research at rivers</a> – which are the leading location for drowning in Australia – found the average blood alcohol concentration (BAC) for adult river users was significantly higher on the Australia Day public holiday, with an average BAC of 0.175%. That’s more than three times the legal limit for driving a car.</p>
<p>Several river users also registered BACs in excess of 0.350%, seven times the legal limit.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/rXEeN7a1ZxA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Drinking beside inland waterways is a key reason why so many people drown in them. Royal Life Saving Society.</span></figcaption>
</figure>
<p><strong>Participation and exposure</strong></p>
<p>More people in and around the water means more people at risk of drowning.</p>
<p>Our research shows higher numbers of people visit aquatic locations on holiday periods during summer, including the <a href="https://www.mdpi.com/2313-576X/5/4/66">Australia Day public holiday</a>. This is also sadly evidenced in the <a href="https://issuu.com/surflifesavingaustralia/docs/ncsr_2021">rescue</a> and <a href="https://www.royallifesaving.com.au/research-and-policy/drowning-research/summer-drowning-toll#:%7E:text=Summer%20Drowning%20Report%202020%2D21,Report%202020%2D21%20click%20here.">fatal drowning</a> data.</p>
<p><strong>Warmer temperatures</strong></p>
<p>This deadly period for drowning often coincides with hot temperatures. Warmer weather drives people to seek out water to cool off, but are also linked to <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6256-1">higher blood alcohol concentrations</a>. </p>
<p>Higher air temperature also lead people to <a href="https://www.mdpi.com/2313-576X/5/4/66">spend longer in the water</a>. </p>
<p><strong>School holidays</strong></p>
<p>School attendance has been shown to be protective against drowning, with school-aged children 5-17 years old <a href="https://onlinelibrary.wiley.com/doi/10.1111/jpc.14235">2.4 times more likely to drown during school holidays</a>. </p>
<p>The Christmas school holidays also coincide with this high-risk period and a number of public holidays. </p>
<p><strong>Visitors who don’t know local conditions</strong></p>
<p>In a normal, non-COVID summer, many Australians travel on their summer break, including to unfamiliar aquatic locations.</p>
<p><a href="https://www.mdpi.com/2313-576X/4/4/42/htm">Our research</a> shows visitors have increased drowning risk on public holidays compared to other days: 2.5 times the risk for people travelling within their own state, and 2.3 times the risk for those visiting other states or territories. </p>
<h2>How to stay safer by the water this summer</h2>
<ul>
<li>Check conditions of the river before you get in, observe how fast the current is going</li>
<li>Ask locals about the safest place to swim in a river</li>
<li>Swim between the red and yellow flags at the beach</li>
<li>Avoid alcohol around water</li>
<li>Always supervise young children in, on, or around the water</li>
<li>Always wear a life jacket when boating or using watercraft</li>
<li>Don’t drive, ride or walk through floodwaters, and don’t let children play in floodwaters</li>
<li>Learn CPR so you have the skills to act in an emergency.</li>
</ul>
<p>Those simple steps can save lives – and avoid so much needless pain, as volunteer rescue diver Peter Wright says:</p>
<blockquote>
<p>A drowning affects so many people. Not just the family but all those involved in the recovery, the police, ambulance and divers. It is often more difficult to cope with the pain-filled reactions of a family when you recover their loved one, than the task of diving in totally black, fast-running, snag-filled water, feeling for that lost individual. I just wish that people took water safety more seriously.</p>
</blockquote>
<p><em>For more water safety information, visit <a href="https://www.royallifesaving.com.au/">Royal Life Saving Society – Australia</a> and <a href="https://sls.com.au/">Surf Life Saving Australia</a>.</em></p><img src="https://counter.theconversation.com/content/167440/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Peden is an honorary Senior Research Fellow with Royal Life Saving Society - Australia and is the co-founder of the UNSW Beach Safety Research Group. She receives funding from the National Health and Medical Research Council.</span></em></p>Australians are entering our most dangerous time of year for fatal drownings. So what can you do to keep yourself and loved ones safer this summer?Amy Peden, Lecturer - Injury Prevention, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1266302019-11-26T13:37:50Z2019-11-26T13:37:50ZMedical errors still harm too many people but there are glimpses of real change<figure><img src="https://images.theconversation.com/files/303192/original/file-20191122-74572-kfjs22.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The U.S. is nowhere near the goal, set 20 years ago, of cutting medical errors in half.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/focus-on-hand-patient-hospital-ward-589302497?src=39815974-b5d4-4f3e-b60a-d4a34539cda5-1-1"> Thaiview/Shutterstock.com</a></span></figcaption></figure><p>In late November 1999, a TV producer called me about an alarming <a href="http://www.nationalacademies.org/hmd/%7E/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf">report</a> that 44,000 to 98,000 Americans were being killed each year by preventable errors in hospitals and another 1 million were being injured.</p>
<p>Could that be true? Based on my research, I replied, the estimate seemed low.</p>
<p>The To Err is Human report from the Institute of Medicine <a href="https://www.ncbi.nlm.nih.gov/pubmed/30395508">has been called a “seminal moment”</a> in the patient safety fight. The public furor sparked by the group’s assertion that medical mistakes were deadlier than breast cancer, auto accidents or AIDS prompted new laws, as well as vows to meet the Institute of Medicine’s goal of cutting medical errors in half in five years. </p>
<p>Twenty years after the report’s release, how safe is our medical care?</p>
<p>Your local hospital is almost certainly much more dangerous than it could be. The latest research says the “<a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.0738">frequency of preventable harm remains high</a>,” and danger in the doctor’s office and other outpatient settings is only now starting to be addressed.</p>
<p>But the good news, based on my research in this field, is that almost all hospitals are making some progress, while a small number of institutions have committed themselves to zero harm, providing hard evidence that care can be made far safer.</p>
<h2>Changing a culture</h2>
<p>Over the years, the definition of what constitutes a medical error has become both more precise, as detection methods have improved, and more expansive. The simplest approach to understanding the different types of treatment-caused harm is to look at two categories. The first type of error happens when the doctor or nurse’s intent was correct, but something went wrong – a medication overdose, a preventable infection, a sponge left in the patient’s body after surgery. The second kind of error is one of intent – the wrong diagnosis, for instance. The Institute of Medicine report mostly (though not exclusively) focused on the first kind of error and pointed to the direction hospitals should take. For years, few chose that road.</p>
<p>“When I said I was going to eliminate preventable injuries and deaths, people looked at me like I was a crazy,” a physician leader who started his health system down the “zero harm” path more than a decade ago told me when I interviewed him for this article. “But the whole history of medical progress is doing just that.”</p>
<p>The Institute of Medicine report relied on studies from the 1980s, as did my methodologically cruder estimate of 180,000 deaths <a href="https://www.amazon.com/Demanding-Medical-Excellence-Accountability-Information/dp/0226525880">in a 1997 book</a>. Newer research with varying definitions and measurement methods has produced varying conclusions. The closest to an “official” estimate may be a <a href="https://www.hhs.gov/about/strategic-plan/strategic-goal-1/index.html">statement</a> by the U.S. Department of Health and Human Services in its current strategic plan that “preventable medical errors potentially take 200,000 or more American lives each year.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/302294/original/file-20191118-66917-em3dul.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/302294/original/file-20191118-66917-em3dul.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/302294/original/file-20191118-66917-em3dul.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/302294/original/file-20191118-66917-em3dul.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/302294/original/file-20191118-66917-em3dul.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/302294/original/file-20191118-66917-em3dul.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/302294/original/file-20191118-66917-em3dul.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/302294/original/file-20191118-66917-em3dul.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There are pockets of progress on medical errors, but over 40% of hospitals earned a ‘C,’ ‘D,’ or ‘F’ grade on safety in an annual review.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/archer10/44662897652/">Dennis Jarvis/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Based on that figure, the 346 people killed in the crashes of two Boeing 737 Max jets within six months in 2018 and 2019 is equivalent to those dying from hospital-caused harm in a little over half a day.</p>
<p>Unlike airline crashes, of course, treatment-caused harm is mostly invisible to the public. <a href="https://www.nytimes.com/2019/07/23/us/neil-armstrong-wrongful-death-settlement.html">The occasional newsworthy scandal</a> only leaves the mistaken impression that “bad” doctors and nurses are to blame when something goes wrong.</p>
<p>But as a physician who lost a loved one to medical error <a href="https://www.huffpost.com/entry/how-hospitals-kill-our-loved-ones-and-conceal-it_b_58cbd60fe4b07112b6472c7d">wrote on HuffPost</a>, dangerous care persists because “genuinely caring and often highly expert people” work in a system that “devolves into routine and dangerous dysfunction.” It is the very routineness of that dysfunction that can blind clinicians and staff to its consequences.</p>
<p>“Nobody goes to work in the morning to harm a patient,” is a health care truism. Yet a <a href="https://www.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/2018hospitalsopsreport.pdf">national survey of hospital patient safety culture</a> found that 40% of respondents agreed that “hospital management seems interested in patient safety only after an adverse event happens.” Perhaps coincidentally, 43% of hospitals earned a “C,” “D” or “F” grade in the latest <a href="https://www.hospitalsafetygrade.org/about-us/newsroom/display/807485">report</a> from the Leapfrog Group, a nonprofit that publishes patient safety report cards on individual hospitals.</p>
<p>The challenge with regard to patient harm is changing from a culture that sees “inevitability” to one that is passionate about “preventability.”</p>
<h2>Pockets of progress</h2>
<p>The public impact of the To Err revelations receded long ago. Today’s spotlight shines on <a href="https://theconversation.com/why-thousands-are-getting-hit-with-unexpected-medical-bills-117955">surprise medical bills</a>, daunting drug prices and holes in health insurance. Still, 20 years’ time is a generation, and in today’s generation, there are glimpses of significant change.</p>
<p>In contrast to <a href="https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.22.2.103">the silence</a> that persisted for so long, groups such as the American College of Healthcare Executives, the American Hospital Association, the Joint Commission (the nation’s largest hospital accreditation group) and others are explicitly confronting the imperative to eliminate all harm. Hospital collaboratives <a href="http://www.ihi.org/Topics/CMSPartnershipForPatients/Pages/default.aspx">organized by the federal government and others</a> are providing guidance.</p>
<p>Most importantly, in my opinion, hospitals on the zero harm journey are sharing their stories, providing proof that aspiration can become implementation. Their ranks are not large, but they include institutions like Titusville, Florida’s Parrish Medical Center, which has <a href="https://patientsafetymovement.org/news/parrish-medical-center-awarded-patient-safety-movements-first-5-star-hospital-ranking/">not had a death from ventilator-related pneumonia</a> in a dozen years; the Ascension Health system, which has meticulously documented its yearly progress toward eliminating all preventable injuries and deaths in more than 60 hospitals; and St. Louis’ BJC HealthCare, which actually <a href="https://www.sciencedirect.com/science/article/abs/pii/S1553725019301862">did reduce patient harm by over half in just five years</a>, and then by 75% in 10 years, a success that contrasts sharply with the national results.</p>
<p>The leaders of these efforts describe a slow and painful culture change process. But it is nowhere near as painful as watching, as I have, a mother recount how her nine-year-old daughter died from a series of medical mistakes in a hospital where the mom had taken her child to save her life.</p>
<p>For the sake of our families, friends and ourselves, it’s time for community leaders to challenge local hospitals to understand that a different path is both urgent and possible.</p>
<p>[ <em><a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/126630/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael L. Millenson does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Twenty years after a landmark report on preventable deaths and injuries in hospitals, is the medical profession doing better?Michael L. Millenson, Adjunct Associate Professor of Medicine, Feinberg School of Medicine, Northwestern UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/909852018-05-31T13:50:20Z2018-05-31T13:50:20ZJuul: Why a trendy e-cig is causing a social – and public health – commotion<figure><img src="https://images.theconversation.com/files/221046/original/file-20180530-120502-j0wr2r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman exhaling after taking a hit from a Juul. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/vaping360/42226974632/in/photolist-27kshoL-24DV8rN-24DV8bN-262TbTg-KgEtrm-262Tc7c-24DV8HE-24DV7Sb-24DVaf7-262TeqR-27kscps-4cenrU-drCRt-drCQK-drCQm-a6kezT-27pzJ4V-27pzHpt-u58ox-262TcHc-2rwY1s-262ThH2-64gZJt-aEBW6c-4BxM6w-nVR1d9-bnSLfh-a6jKMc-drCZQ-27pzEhB-27pzC24-27pzGj2-drCtx-drCnw-drCoz-drCwG-drCGp-drCn5-24DVUyw-27pzCCp-drCpR-drCEe-KgFiKW-7nJLkz-262TauV-jp25EU-27pzGrX-262Taar-262Sc8M-fSnKDy"> vaping360.com/juul/juul-vapor-review/</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The U.S. Department of Health and Human Services has launched a <a href="https://therealcost.betobaccofree.hhs.gov/gm/hacked-ends.html?g=t">campaign to discourage e-cigarette</a> vaping. While it targeted all e-cigarette vaping, the campaign makes a powerful visual reference to <a href="https://truthinitiative.org/news/what-is-juul">Juul</a>, a device that can be recharged in a computer USB drive and <a href="https://www.nytimes.com/2018/02/16/nyregion/juul-teenagers-vaping-ecigarettes-dangers.html">has been reported</a> to be gaining popularity among youth, even though Juul Labs created it for adults who want to stop smoking. The HHS campaign depicts seemingly emotionless teenagers with USB ports where their mouths should be.</p>
<p>The campaign is part of a long, successful history of <a href="http://tobaccocontrol.bmj.com/content/7/1/5">fear-based</a> campaigns that have effectively <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1313940">“denormalized”</a> smoking. But, in the case of <a href="https://www.juul.com/">Juul</a>, is it a new public health threat? Or is it a disruptive technology that threatens to make combustible tobacco products, <a href="https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/health-risks-of-smoking-tobacco.html">which kill half of all smokers</a>, obsolete? In short, could it help or hurt public health?</p>
<h2>Harm reduction or harm extension?</h2>
<p>I am a public health scholar who has studied the history, ethics and evidence in scientific and policy debates over the value of e-cigarettes as a harm reduction strategy. Harm reduction is a public health strategy that involves providing individuals with addiction safer but not necessarily safe substitutes. Providing clean needles to injecting drug users to prevent HIV, substituting methadone for heroin, and even offering seat belts are all examples of harm reduction tactics.</p>
<p>Juul entered the market in 2015 without the legacy of having previously manufactured combustible products. <a href="https://support.juul.com/learn/read/juul-labs-announces-comprehensive-strategy-to-combat-underage-use">Juul Labs CEO</a> describes the company’s mission as “to eliminate cigarettes and help the more than one billion smokers worldwide switch to a better alternative.” The <a href="https://www.juul.com/">company’s website</a> invites visitors to “Learn about our mission to improve the lives of the world’s one billion adult smokers.”</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220861/original/file-20180529-80658-apn2he.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man and a woman holding a Juul device.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/vaping360/40466840100/in/photolist-24DV8HE-KgEnZ9-69pdnu-69pbGm-5AgiLh-5cZEYN-H88WKV-nXKmS-okvrq-2hjL6A-JjNVo-opxtg-opxJp-o95Kg-4Qtpoi-4p8DqY-bY4oYh-bY4n1A-gVbSxw-mVjKz-4QxB11-oYTwg-rruYDh-26iQPxs-okqb7a-vjJ6QN-6wkiPL-55cwuu-adxFE4-27pzGrX-3bhy3-bzmXXw-4R2YoN-6wg7rz-pzVnFu-mc2HH-WVY3T5-mbh2E-8B9Bgi-JgsjSF-21f5M8-JDkw7-V24Dah-6wkm5q-8786EM-dpZfRg-pFbtkX-fbxJx9-qBSZ4u-262Tc7c">Vaping360.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The device itself is trim and high tech. It looks like a long, elegant thumb drive and easily fits in a user’s hand. It is relatively expensive. The Juul <a href="https://www.juul.com/shop/devices/starter-kit">starter kit</a>, which includes the device, charger and four nicotine pods, costs US$49.99 on the company’s website. On May 30, 2018, the company was <a href="https://www.juul.com/shop/devices/starter-kit">offering a $20 discount</a> for people who were willing to sign up.</p>
<p>Juul has improved nicotine delivery to users, meaning that they get more nicotine, faster, than they do with other vaping products. Most products on the market use <a href="https://www.atsdr.cdc.gov/phs/phs.asp?id=1120&tid=240">propylene glycol</a> and glycerin as the solvents that allow the delivery of nicotine. Distinguishing Juul is its use of <a href="http://nationalacademies.org/hmd/reports/2018/public-health-consequences-of-e-cigarettes.aspx">nicotine salts</a>, a combination of a nicotine base combined with a weak organic acid. Nicotine salts allow for absorption of nicotine in a fashion similar to combustible products. A recent study has suggested that the nicotine hit from Juul is also <a href="https://cen.acs.org/analyticalChemistry/spectroscopy/E-cigaretteschemistry-explain-popularity-among/96/i22">less harsh on the throat</a>, which may produce a more pleasant experience for both seasoned smokers and new users. </p>
<p>Even without an aggressive marketing strategy, sales of Juul kits have increased 680 percent and sales of refills have increased 710 percent since 2017, according to RBC Capital Markets. Juul has quickly taken command of the e-cigarette market. On May 29, 2018, Wells Fargo Equity attributed 45.7 percent of e-cigarette market unit shares to Juul.</p>
<h2>Nicotine: Addictive but not carcinogenic</h2>
<p>Juul is increasingly viable as a safer alternative for smokers who are trying to quit. But it raises concerns about kids and e-cigarette experimentation.</p>
<p>For adults, nicotine is relatively benign; the tars resulting from tobacco combustion are deadly.</p>
<p>In 2000, the chair of a <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.94.2.192">Public Health Service expert panel</a> made the case that, if necessary, smokers could stay “on (nicotine replacement) medication for the rest of their lives because I know it saves lives.” According to the <a href="https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0">Royal College of Physicians</a>, nicotine is not a carcinogen. </p>
<p>But nicotine is a stimulant that can increases both heart rate and blood pressure, suggesting that <a href="https://truthinitiative.org/sites/default/files/ReThinking-Nicotine.pdf">“it may contribute to cardiovascular disease.”</a></p>
<p>Nonetheless, over the counter <a href="https://truthinitiative.org/sites/default/files/ReThinking-Nicotine.pdf">nicotine replacement</a> therapies have been established as safe and effective and are not associated with an increase in the risk of heart attacks.</p>
<p><a href="https://truthinitiative.org/sites/default/files/ReThinking-Nicotine.pdf">Smoking has been established as a leading cause of cardiovascular disease</a> and cancer. Thus, many in the public health and medical communities were prepared to accept lifelong dependence on nicotine replacement therapies like the patch and nicotine gum if they helped to sustain smoking cessation.</p>
<p>The <a href="https://www.cancer.org/healthy/stay-away-from-tobacco/e-cigarette-position-statement.html">American Cancer Society</a> issued clinical guidelines acknowledging the potential of e-cigarettes to help smokers who have not been successful with going cold turkey or FDA approved nicotine replacement therapies. It notes that smokers who can’t or won’t quit “should be encouraged to switch to the least harmful form of tobacco product possible; switching to the exclusive use of e-cigarettes is preferable to continuing to smoke combustible products.”</p>
<h2>A different story for teens</h2>
<p>Nicotine does, however, pose risks to the developing adolescent brain. </p>
<p>The <a href="https://www.cancer.org/healthy/stay-away-from-tobacco/e-cigarette-position-statement.html">American Cancer Society</a> states that “the use of products containing nicotine in any form among youth is unsafe and can harm brain development.” Public health experts and organizations supportive of e-cigarettes as a promising harm reduction strategy for smokers and staunch opponents of e-cigarettes agree that kids should not be using any type of product containing nicotine. </p>
<p>For this reason, Juul may represent a new kind of risk when it comes to kids. And because it is small and generates little aerosol, it is easy to conceal and use without attracting attention.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=384&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=384&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=384&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=483&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=483&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220859/original/file-20180529-80640-19jzxui.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=483&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Public health officials worry that vaping among teens can lead to cigarette smoking.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/686721556?src=hdmSPk0EyejhOgnwkFQfqA-1-16&size=small_jpg">Ostarcov Vladislav/Shutterstock.com</a></span>
</figcaption>
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<p>Juul has certainly captured teens’ attention. A Truth Initiative study found that, in a national sample of 1,012 people aged 15-17, <a href="http://tobaccocontrol.bmj.com/content/early/2018/04/07/tobaccocontrol-2018-054273">7 percent</a> reported ever having used a Juul. Twenty-one percent of the kids in this age group also recognized a photograph of a Juul. Recognition (34 percent) and past 30-day use (11 percent) were higher among those in the sample who were more affluent. Kids who are just experimenting may not realize that Juul delivers nicotine as efficiently as a combustible product, potentially increasing their risk of addiction. </p>
<p>The backdrop of this growing attention is one in which data on children and vaping remains contested. On the one hand, a landmark 2018 <a href="http://nationalacademies.org/hmd/reports/2018/public-health-consequences-of-e-cigarettes.aspx">National Academies of Science, Engineering, and Medicine</a> report concluded that “there is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes amongst youth and young adults.”</p>
<p>On the other, several years of painstaking, systematic reviews have led <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/684963/Evidence_review_of_e-cigarettes_and_heated_tobacco_products_2018.pdf">Public Health England</a> to conclude: “Despite some experimentation with these devices among never smokers, e-cigarettes are attracting very few young people who have never smoked in to regular use.” Both groups, it is important to underscore, agree that for adults, e-cigarettes are substantially safer than combustible products.</p>
<p>In May 2018, the former chair of the American Academy of Pediatrics Tobacco Consortium weighed in on the side of peril. Dr. Jonathan Winickoff described Juul in <a href="https://www.newyorker.com/magazine/2018/05/14/the-promise-of-vaping-and-the-rise-of-juul">The New Yorker</a> as nothing short of “bioterrorism” and declared that Juul already represents “a massive public-health disaster.” </p>
<p><a href="https://www.iowaattorneygeneral.gov/newsroom/attorney-general-miller-juul-labs-ecigarette/">Iowa Attorney General Tom Miller</a> sees promise in Juul and other products that deliver nicotine electronically. Miller, a longtime consumer advocate, has argued that public health has an obligation to inform the public that e-cigarettes are substantially safer than combustible products. While Miller said that Juul gives “cause for concern” when it comes to kids “it has not reached panic or epidemic stages.” </p>
<p>Meanwhile, the evidence on whether e-cigarettes help smokers quit remains limited and hotly contested. A recent <a href="https://www.nejm.org/doi/full/10.1056/NEJMsa1715757?query=featured_home&utm_source=STAT+Newsletters&utm_campaign=bd5d5c8814-MR&utm_medium=email&utm_term=0_8cab1d7961-bd5d5c8814-150488817&">New England Journal of Medicine study</a> has done little to <a href="http://www.kansascity.com/news/nation-world/article211771854.html">quell controversy</a>. Even as e-cigarettes continue to represent a increasing share of the tobacco market, smoking rates among adults and children <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2016">continue to decline</a> in both the U.K., where the <a href="https://www.bmj.com/content/358/bmj.j3262">lead public health agency</a> has explicitly endorsed e-cigarettes, and the U.S. </p>
<h2>Tobacco companies making their push</h2>
<p>As companies like the Altria Group, which manufacturers Marlboro, and Imperial Tobacco Group, which produces Winston and Kool, are successful at mimicking Juul and “getting into the (nicotine) ‘salt game,’” this will certainly fuel public health concerns that kids or even adults who never smoked will try a product like Juul and eventually graduate to a deadly combustible cigarette. And, indeed, careful monitoring will remain an imperative.</p>
<p>When it comes to kids, even if they do not represent a step on the way to combustible products, any product that delivers nicotine as effectively as cigarettes will remain a public health concern. And all e-cigarettes will continue to demand vigorous public health interventions, such as the April 2018 <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm605432.htm">Food and Drug Administration’s</a> “undercover nationwide blitz to crack down on the sale of e-cigarettes.”</p>
<p>But in my view, neither rigorous monitoring nor muscular efforts to prevent sales to kids make products like Juul as dangerous as cigarettes, which remain the <a href="https://www.cdc.gov/tobacco/data_statistics/index.htm">leading cause</a> of preventable death in the U.S. Combustible products are a genuine cause for fear, for both smokers and kids alike. </p>
<p>The most vexing challenge that Juul poses may be to tolerance: How will we view adults looking to quit smoking who either cannot or will not give up the pleasures of nicotine? Will the old consensus that lifelong treatment is acceptable hold when it’s a recreational rather than a pharmaceutical product?</p><img src="https://counter.theconversation.com/content/90985/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy L. Fairchild has received funding on the politics of e-cigarettes from the Robert Wood Johnson Foundation. She is currently funded for work on the history of e-cigarettes and harm reduction from the Wellcome Trust. She has received funding on the politics of fear from the Greenwall Foundation and the National Endowment for the Humanities. </span></em></p>Some experts believe that e-cigarettes can help people stop smoking cigarettes. But do they lead others, especially teens, to start? The question intensifies as teens take up Juul.Amy Lauren Fairchild, Associate Dean of Academic Affairs at the School of Public Health, Associate Vice President for Faculty and Academic Affairs at Texas A&M Health Science Center, Professor of Health Policy & Management, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/955292018-05-02T11:33:00Z2018-05-02T11:33:00ZHaving a severe mental illness often means dying before your time<figure><img src="https://images.theconversation.com/files/217222/original/file-20180502-153908-1v8by77.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-man-distress-concept-migraine-aura-141483535?src=WWCQ92S4-2Wfv5X9c6jWNA-1-62">Shutterstock/icsnaps</a></span></figcaption></figure><p>People with severe mental illness have at least a two-and-a-half times higher risk of dying than the general population. In essence, people with severe mental illness are dying for the same sorts of reasons as the rest of the us – but there are more of them and they are dying younger. We examined the causes of deaths of almost <a href="https://www.schres-journal.com/article/S0920-9964(18)30198-1/fulltext">400,000 people over ten years</a> to try and find out why. </p>
<p>We have known for a long time that people with illnesses such as schizophrenia and bipolar disorder die earlier than the rest of us <a href="https://www.rcpsych.ac.uk/pdf/APPG%20on%20Mental%20Health-%20Parity%20in%20Progress.pdf">by 10 to 15 years</a>. This means that while men in the UK are expected to live to about 78 and women 82 – if you have a severe mental illness and are known to mental health services, those ages drop to 68 and 72 years respectively. It’s called <a href="https://www.rcpsych.ac.uk/PDF/Position%20Statement%204%20website.pdf">premature mortality</a>.</p>
<p>This issue remains one of the major health injustices of modern life, comparable to premature mortality in those who are <a href="https://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf">socio-economically deprived</a>. But many of these early deaths are preventable.</p>
<h2>Tripling the risk</h2>
<p>In <a href="https://www.schres-journal.com/article/S0920-9964(18)30198-1/fulltext">our study</a> of almost 4m people, we compared deaths in the general population to those with severe mental illness who are seen in general practice and hospitals. Such a detailed examination of different causes of death has not been done before. Most studies have focused on just one type of healthcare setting. We found that not only did people with severe mental illness have at least a two-and-a-half times higher risk of dying than the general population, but that this rose to almost three times higher in those with a hospital admission.</p>
<p>Nearly two thirds of all the deaths in those with severe mental illness were from cardiovascular disease (heart attacks or strokes), respiratory disease (particularly pneumonia) and cancer (most commonly lung and bowel). For these common causes of death, even a small increase in risk of death above everyone else will have a huge impact in terms of numbers. It’s in these areas we can potentially save the most lives. We found a tripling of risk from respiratory disease and a doubling for cardiovascular disease (there was little difference for cancers) in those with severe mental illness.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/217225/original/file-20180502-153866-wnfwb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/217225/original/file-20180502-153866-wnfwb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/217225/original/file-20180502-153866-wnfwb6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/217225/original/file-20180502-153866-wnfwb6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/217225/original/file-20180502-153866-wnfwb6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/217225/original/file-20180502-153866-wnfwb6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/217225/original/file-20180502-153866-wnfwb6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Nearly two-thirds of all the deaths in those with severe mental illness were from cardio-vascular disease.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendered-illustration-heart-attack-128572196?src=zq6V_QBu842cKHi4MTx4AA-1-30">Shutterstock/By SebastianKaulitzki</a></span>
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<p>Other deaths from so-called natural causes were also particularly high when compared to the general population. These included those with severe mental illness who also had Alzheimer’s, Parkinson’s or dementia. It may be that we are better at diagnosing these illnesses in those already being seen in services or it may be that the age-related decline in cognition of those with severe mental illness is mislabelled. Understanding this will have implications for addressing it.</p>
<p>We found that the single biggest difference in mortality for those with severe mental illness compared to the general population was for those who died from ill-defined or unknown causes (13 times higher), followed by suicide (12 times higher) and substance misuse (eight times higher). These types of deaths were relatively uncommon compared to heart attacks and strokes but the risk compared to the general population was greater. </p>
<p><a href="https://doi.org/10.1111/j.1600-0447.1998.tb10069.x%20%20http://apps.who.int/iris/handle/10665/67774">Studies have shown</a> that deaths labelled “ill-defined” or “unknown” are often from suicide and heart disease. So although we know the risk of suicide in the severely mentally ill is disturbingly high compared to the general population (12 times higher for all those with a severe mental illness, 16 times if they had a hospital admission and 21 times if female) the problem may well be worse than we currently think. </p>
<p>The current <a href="https://www.gov.uk/government/publications/suicide-prevention-strategy-for-engl%20https://gov.wales/topics/health/publications/health/reports/talk2/?lang=enlink">national policy focus</a> on suicide prevention is important but it should also be looking at hospital and community settings for supporting those with severe mental illness. </p>
<h2>So what can we do?</h2>
<p>From a public health perspective, patients with severe mental illness should be considered a high risk population for physical illness. There needs to be improved access to care across the board. The onus is on developing services that people can engage with and addressing the causes of the causes (housing, deprivation, social connection).</p>
<p>For those with these long-term conditions getting to appointments and follow-up care can be challenging. Some of the differences we found relating to infections may be because those with severe mental illness present later than the rest of us, and so do worse. </p>
<p>Lifestyle factors also play a huge role. The significant emphasis on improving physical health care for people with severe mental illness through screening and management for cardiovascular and metabolic disorders, such as diabetes, is important. Families and friends should encourage them to engage in programmes to stop smoking and recreational drug use, increase activity and healthy eating, keep a healthy body weight and control high blood pressure and high cholesterol.</p>
<p>There are no easy answers. Long-term studies are also needed to look at links between between anti-psychotic treatment, lifestyle choices, social deprivation, metabolic indicators, age and genetics. There is also a need for intervention studies to assess if more novel prescribing, such as gardening or walking groups, may work better. But there is no doubt we need to find ways tackle this health injustice.</p><img src="https://counter.theconversation.com/content/95529/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ann John receives funding from MQ, MRC and Health and Care Research Wales. She is a Prinicipal Investigator at the National Centre for Mental Health and a Trustee of the Mental Health Foundation.</span></em></p>Our new study has found that people who suffer from severe mental illness are at a much higher risk of dying from preventable diseases and conditions.Ann John, Clinical Professor of Public Health and Psychiatry, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/779422017-05-28T20:09:12Z2017-05-28T20:09:12ZMany older people in care die prematurely, and not from natural causes<figure><img src="https://images.theconversation.com/files/170904/original/file-20170525-13231-1o56u8p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Premature death is still an issue if the patient is in a nursing home. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Most readers may be surprised to learn that frail older people living in residential aged care services, often referred to as nursing homes or care facilities, die prematurely. We tend to think the deaths of older people, and especially those in care, are due to natural causes. But although confronting to contemplate, residents die prematurely due to injury and violence.</p>
<p>Investigations into deaths of individual residents by the Coroners Court and the recent inquiry into <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/4ae57e8040d7d0d58d52af3ee9bece4b/Oakden+Report+Final+Email+Version.pdf?MOD=AJPERES&CACHEID=4ae57e8040d7d0d58d52af3ee9bece4b">Oakden</a> care facility in South Australia show vulnerable older people in care have been subjected to undue suffering and harm. The Federal Aged Care Minister Ken Wyatt has also <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2017-wyatt032.htm">commissioned an independent review</a> into aged care processes.</p>
<p>Our research published today in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a> found 15.2% of over 20,000 deaths of nursing home residents between 2000 and 2013 resulted from external causes (that is, an injury, violence or other external event).</p>
<p>The study collated information from all the investigations into deaths of individual residents by the Coroners Court over the past decade. The most frequent mechanisms of death were falls (2,679 cases, 81.5%), choking (261 cases, 7.9%) and suicide (146 cases, 4.4%).</p>
<p>The incidents leading to death usually occurred in the nursing home (95.8%), but the death itself usually occurred elsewhere (67.1%). This was typically at an acute care hospital where residents had been transferred. Somewhat surprising was the small proportion of people (1.2%) who died from adverse events related to their clinical care (such as medication errors). And these numbers are likely to be underestimated due to some deaths being misclassified as “natural”.</p>
<p>Our study provides the first detailed understanding of the number of deaths in nursing homes that shouldn’t be happening. Although coroners play an important role in identifying factors that may prevent death and injury, fewer than 3% of the external-cause deaths were examined by an inquest. Coroners also made no recommendations about preventing injury in 98.4% of all cases.</p>
<h2>Establishing how people die in care</h2>
<p>A better understanding of how, where and when older people die in nursing homes is the first step towards reducing harm, improving quality of care and improving quality of life. </p>
<p>The next step is understanding why these preventable deaths occur. This requires a detailed analysis of the circumstances of each death – by examining what was or was not done, and determining what other factors unrelated to the person’s underlying illnesses may have contributed to the death. </p>
<p>This type of analysis is <a href="http://qualitysafety.bmj.com/content/21/5/369">common in hospitals</a>, where the contributing factors leading to adverse events include considering the organisation’s culture, communication systems, governance arrangements, management and supervision of staff, workload, equipment and the physical environment.</p>
<p>Unfortunately, there is very little information about the circumstances of the premature deaths in aged care to enable a constructive review of the operations of a residential aged care service. This limits our ability to determine what needs to be done to prevent harm in care facilities in the future. </p>
<h2>What needs to be done</h2>
<p>Despite care facilities being actively monitored in a few different ways, there isn’t one entity responsible for reducing preventable harm by improving practice at a national level. The arrangements are complex, with multiple bodies involved. Each has a discrete function, often with specific boundaries set in legislation. </p>
<p>The <a href="https://agedcare.health.gov.au/">Commonwealth Department of Health</a> is responsible for monitoring funding and allocating approvals to operate aged care facilities. The <a href="https://www.aacqa.gov.au/">Aged Care Quality Agency</a> manages the accreditation process and the <a href="https://www.agedcarecomplaints.gov.au/">Aged Care Complaints Commissioner</a> handles the concerns of residents and their families.</p>
<p>We need to improve policy, practice and research to prevent these premature deaths in the future. The information to improve our aged care system exists and needs to be harnessed. This requires better access to information that is gathered and investing in analysing it.</p>
<p>Primary prevention is the priority. This requires collaborative efforts and partnerships between aged and health care professionals, forensic death investigators, coroners, governments and the aged care sector working together in developing evidence-based strategies in consultation with residents and their families.</p><img src="https://counter.theconversation.com/content/77942/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Ibrahim receives funding from the federal Department of Social Services, the Victorian Department of Health and Human Services (Ageing and Aged Care Branch), and the Department of Forensic Medicine, Monash University.</span></em></p>We tend to consider the deaths of older people, and especially those in care, are due to natural causes. But new research shows how many die from injuries and violence.Joseph Ibrahim, Professor, Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.