Modifying Your Alzheimer’s Risk

One of the most feared illnesses today is Alzheimer’s disease. Aloysius Alzheimer, a German psychiatrist and neuropathologist, first described the characteristic brain changes and associated dementia more than one hundred years ago.  Despite the rapid advance of medicine and technology over the intervening century, we still know far too little about this devastating and incurable disease.

Diagnosing Alzheimer’s dementia requires expensive testing looking for particular damage due to accumulation of beta-amyloid and tau protein, which cause the signature plaques and tangles in the brain. As a result, many patients with dementia never get tested and may not get labeled with actual Alzheimer’s disease. Regardless, most dementia – 80% – is the result of Alzheimer’s.

Alzheimer’s disease can last more than a decade, starting with mild cognitive impairment (MCI) and relentlessly progressing to more difficulty solving problems, personality changes, getting lost, forgetting people or significant life events, and ultimately losing the ability to care for oneself, to toilet, to speak, to walk. Some people progress more rapidly than others. The Alzheimer’s Association website https://www.alz.org/ can be a great resource for caregivers or those wanting more information.

Unfortunately, currently available prescription medications, which may help somewhat with mental function, mood, behavior, and ability to perform activities of daily living (like bathing, dressing, eating, etc.), do little to change the course of the illness or the rate of decline. We don’t yet have a magic bullet.

Genetic factors can increase risk of dementia, but most dementia cases occur sporadically in older adults in whom multiple genes influence risk.  We cannot – yet – modify our genes. Changing our lifestyle, however, is one way to improve the odds of developing dementia, even for those with high genetic risk.  Many of the dietary and lifestyle habits and activities recommended to improve overall health (think heart disease, cancer, diabetes) may also be of some benefit with dementia.

One Mediterranean-type diet, which researchers named the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diet, focuses on foods that impact brain health: leafy green vegetables, berries, nuts, olive oil, fish, wine in moderation, and avoiding red meat.    The point is these broad dietary recommendations are not new and not exclusive to affecting Alzheimer’s risk. Let’s just call it healthy eating.

In addition, physical and mentally stimulating activities – such as reading or crossword puzzles – are important as we age. Both diet and exercise may help with Alzheimer’s risk by virtue of preventing conditions like diabetes, hypertension, and coronary artery disease that can exacerbate cognitive decline. Most older adults cannot keep up the same rigorous workout routine they might have when they were younger. But exercising at least 150 minutes a week, whether by biking, walking, swimming, gardening or doing yard work, can increase the flow of blood to the brain, improve the health of blood vessels and raises the level of HDL cholesterol, which together help protect against both cardiovascular disease and dementia.  One study found that people who engaged in more than six activities a month—including hobbies, reading, visiting friends, walking, volunteering, and attending religious services—had a 38% lower rate of developing dementia than people who did fewer activities.  Along with physical and mental activity and a healthy diet, individuals who avoid smoking tobacco have a lower dementia risk. 

There is mixed evidence about the use of fish oil supplements to improve thinking and memory in Alzheimer’s.  Given the benefit for cardiovascular health, it is reasonable for most people to take a fish oil supplement.   Vitamin D deficiency has been identified as an independent risk factor for the development of dementia of any cause, and supplementation is recommended for patients in whom deficiency is diagnosed.  Finally, no dietary supplement has been proven to be effective in boosting memory or preventing dementia. It is wise to talk to your doctor about the risks and benefits of any over-the-counter medications or supplements you are taking.

As with any recommendations, we must acknowledge that playing by the rules will not guarantee we will prevent Alzheimer’s (or any other disease, for that matter). Probably two-thirds of the risk of developing Alzheimer’s simply can’t be modified.  But adopting a healthy lifestyle with heart- and brain-healthy diet and exercise habits will lessen your chances of developing any number of chronic and life-threatening illnesses. When we all work toward that goal, our entire community is healthier. That’s worth striving for!

How and Where People Die – Is it Good?

All of us, at some point, have pondered what it means to have a “good” death. A common theme is to fall asleep in one’s own bed and simply not wake up. Woody Allen famously said, “I’m not afraid of death; I just don’t want to be there when it happens.” The underlying desire is comfort, serenity, peace.

According to the Centers for Disease Control (CDC), the top ten causes of death in the United States in recent years were heart disease, cancer, accidents, lung diseases, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.   These top ten account for three out of four deaths, and most are chronic diseases marked by decline over years with increasing need for medical care and hospitalization along the way. Yet all along there is this denial of illness and death.

We used to be familiar with death. Before the 1940s – prior to antibiotics, chemotherapy, heart surgery – people usually died in their homes over the course of a few days or weeks.  Sir William Osler, frequently described at the Father of Modern Medicine (d. 1919), called pneumonia – a leading cause of death in his time – the “friend of the aged” because it was an “an acute, short, not often painful illness.”  With the advent of the intensive care unit (ICU) and an ever-expanding medical-industrial complex, we now have approximately 4 million ICU admissions per year and about 500,000 ICU deaths annually.  The contrast between death at home versus in a technology-overrun ICU could not be more stark. In 2010, 28.6% of Americans died in the hospital.  Yet nine out of ten Americans say they would prefer to die at home if they were terminally ill and had 6 months or less to live. 

Unfortunately, death in the hospital is rarely pretty. Believe me; hospitals do not want patients dying in their facilities. It messes with statistics and quality ratings. It is also far more expensive.  So, if hospitals don’t want us dying there, it costs more money, and we say we would prefer to die at home, where is the disconnect?

There are several problems. Doctors don’t like talking with their patients about death and dying. Doctors don’t want to appear to be giving up hope by talking about end-of-life care, nor do they want to appear helpless, as if nothing more can be done. Patients, having watched one too many TV medical dramas, believe that technology and medicines are so good now that they can overcome any illness, even at the very end of life.

Perhaps the most egregious of these technological and communication disconnects at the end of life is with a procedure called cardiopulmonary resuscitation – the “Code Blue” you hear overhead periodically in hospitals. A code blue is an actual life-threatening emergency situation in which a patient is dying – typically their heart has stopped beating and/or breathing has ceased – and an entire medical team works to revive him/her with medications, chest compressions, intubation, electrical shocks, and more.

Cardiopulmonary resuscitation (CPR) can be life-saving in the community setting when a person suffers a heart attack or drowning, for example. According to 2014 data, nearly 45 percent of out-of-hospital cardiac arrest victims survived when bystander CPR was administered.

For hospitalized patients who suffer cardiac arrest (essentially, who die), the overall rate of survival from a “full code” procedure leading to hospital discharge is barely 10 percent. But most people, when asked in a scientific study, believe the survival rate to be more than 75 percent.  Unfortunately, the quality of life of patients who do survive resuscitation in the hospital is often not good. Rarely do the few survivors return to their previous functional status, which in hospitalized patients was probably poor to begin with. There can be brain damage from prolonged lack of oxygen, bruising and pain from broken ribs, and need for prolonged rehabilitation or nursing home placement.

But unless you – or a family member speaking for you – explicitly states otherwise, this likely will happen to you if you are coded in the hospital. And despite the resuscitation attempt, you will very probably die anyway. Is this really what you want your minutes to look like?

The good news is that we have far more control over where and how we die than one may think. First, talk with your spouse and your kids – and your doctor! – about how you wish to die and where you wish to die if you were to find out you had a terminal illness. Second, make every effort to write your wishes down. In Texas, there is a document called a Living Will available online at https://hhs.texas.gov/laws-regulations/forms/miscellaneous/form-livingwill-directive-physicians-family-or-surrogates. Both English and Spanish versions are available. This Directive to Physicians and Family or Surrogates lets you, the patient, tell your doctors and others what types of treatments you do or do not want if you are terminally ill and no longer able to make medical decisions.

In addition to this advance directive, Texas law provides for two other types of directives that can be important during a serious illness. These are the Medical Power of Attorney and the Out-of-Hospital Do-Not-Resuscitate Order. Don’t wait until a crisis to make your wishes known. It may be too late.

Finally, hospice care is available through Medicare, Medicaid, and most private insurers to help patients achieve the “good” death they say they want, not by hastening death, but by helping terminal patients to fully live the life they have left as comfortably as possible and most often at home.

Vaping Dangers are Frightening

Over the last few months, a rapid rise of vaping related acute lung disease has come to light. Both the CDC and the Food and Drug Administration (FDA), which regulates electronic nicotine delivery systems (ENDS, which includes products known as “e-cigarettes”), are actively engaged in investigating this outbreak, which some are calling an epidemic.  Certainly, vaping is epidemic among our youth.

As of the end of September, the number of confirmed or probable cases of life-threatening vaping-related lung disease has risen to 805 across 46 states and the US Virgin Islands. About three-quarters of the reported cases are male; nearly 4 in 10 are age 21 or younger.   Most importantly, all reported cases have a history of e-cigarette product use or vaping. Patients often require ICU and ventilator support. Thirteen people have died so far.

Authorities don’t know which chemical(s) are responsible for these vaping-related illnesses. An early idea was that only illicit THC products (black market marijuana oils) were to blame, but this evidently is not the case. Yes, these illnesses are more prevalent among THC vapers than users who self-report using only nicotine products, but vapers who don’t use THC are also getting sick. Vitamin E acetate is also being considered as a potential cause, but no single chemical has been consistently identified in all of the samples tested. At the present time, no particular device, brand, flavor or substance has been definitively linked.

According to the Centers for Disease Control and Prevention (CDC), symptoms of lung injury reported by some patients in this outbreak include  cough, shortness of breath, and chest pain, nausea, vomiting, or diarrhea, fatigue, fever, or abdominal pain. These symptoms usually have a rapid onset over a few days, but some patients have reported that their symptoms developed over several weeks. A lung infection does not appear to be causing the symptoms. NPR reports that in all confirmed cases, patients reported vaping within 90 days of developing symptoms, and most had vaped within a week of symptom onset. 

What should you do?

If you vape, stop. There are other ways to control nicotine addiction. Playing Russian roulette with your lungs is not smart and not cool. Certainly, anyone who vapes should not buy products off the street or add any substances, like THC or CBD oils.  If you have recently vaped and you have symptoms, see a healthcare provider, and let them know of your concern. They can notify the health department or CDC if necessary.

Vaping is not a harmless fad. Our lungs are elegant, fragile, life-giving organs that don’t react kindly to smoky chemicals, whatever the source. The acting head of the FDA admitted recently in testimony before a House subcommittee that the FDA “should have acted sooner” to contain the youth vaping epidemic.  And the CEO of Juul, maker of vaping products that targeted kids with enticing flavors like mango, grape, and strawberry lemonade, stepped down amid intensifying scrutiny of the brand’s marketing practices.  His replacement, unfortunately, is a seasoned tobacco executive, so don’t expect Juul to give up the fight. Too much money is at stake.

But our kids’ health and future is at stake as well. We must remove flavored e-cigarettes from the marketplace. And any marketing practices that target kids with addicting and dangerous products are unacceptable. E-cigarette products flooded the marketplace and were never appropriately reviewed. Frankly, the FDA dropped the ball on this, and people are dying as a result. Finally, until and unless sales to kids can be prevented, online sales of e-cigarettes should be stopped.

Let’s hope our federal agencies can act quickly and forcefully both to identify what is causing these illnesses and deaths and to regulate access to e-cigarette products. If the federal government won’t act, our state legislators should. The health and safety of our kids is at stake.

How to Lose Weight and Improve Health

Weight loss is always high on most people’s New Year’s resolution list. For something that is desired by so many of us, it is surprising how difficult it is to achieve and how controversial or ineffective the proposed methods are. Half of all Americans ages 20 and over say they've attempted to lose weight in the past year.  Exercising more and eating less are the two top strategies people use to try to lose weight. Yet so often we fail.

Our focus needs to shift to healthy living as opposed to weight loss alone. No single diet can be recommended for everyone, because – and you knew this already – what works for one person may not work for another.  Of all the individual diet programs out there, Weight Watchers (now called WW, to move the emphasis away from weight loss) seems to be more effective than others, at least according to US News & World Reports.  Noom is a more recent (and expensive) addition to the behavioral change and app-integrated weight loss arena. What these programs recognize is that weight loss is more than just counting calories (or, as is the case in the WW system, points). Weight loss requires behavioral change, community, and a lifestyle of eating healthier and moving more.

Though we don’t know enough about the genetics involved in weight loss and weight gain, the observation that some people have to work harder than others to stay thin or lose weight appears to be supported by scientific data. Apart from genetics, some people’s intestines are 50% longer than others. (Shorter guts absorb fewer calories.) Differences in gut microbiomes can alter how people process food.  Cooking increases digestion of food and absorption of calories.

All of this means that just counting calories is not the answer to weight loss. The old adage calories in, calories out is simply false. That’s because a calorie is not a calorie. If that were the case, a diet of donuts alone would be fine. But it turns out the rate your body absorbs calories may be as important as the amount of calories you take in. In other words, that sugary donut hits our bloodstream far faster than calories from more complex carbohydrates or from fat and protein.  And, those quickly absorbed sugars are far more likely to create body fat – and make you paradoxically hungrier in the process.

For years, the culprit of the obesity epidemic was thought to be dietary fat. Low-fat, high-carb diets were all the rage. Only recently has it come to light that sugar companies secretly funded studies designed to blame fat for making us fat. But low-fat, high-carb diets didn’t work; we kept getting fatter. For an entire polemic on the subject, check out The Case Against Sugar by Gary Taubes. It is enough to scare anyone off sugar. That is not to say that we know for certain the extent to which sugar is responsible for the obesity epidemic. Gina Kolata, writing in the New York Times, notes that a number of societal factors may have contributed to the obesity epidemic, from growing portion sizes, the popularity of restaurants and fast food, snacking, the cultural acceptance of obesity, and even the decline in smoking.  The science is not settled.

That’s not to say that you shouldn’t watch what you eat. Keeping a food diary can help you understand what and how much you are eating and the types of calories you are consuming. A study of nearly 1,700 participants showed the best predictors of weight loss were how frequently food diaries were kept and how many support sessions the participants attended. Those who kept daily food records lost twice as much weight as those who kept no records.  I wrote about my so-called Bar Code Diet many years ago and that if I couldn't scan it or enter it into my phone, I didn't put it in my mouth.  That – along with regular exercise with a group of friends, who kept me accountable – did help me lose weight and keep it off.

What can you do realistically on your own and without added expense?

1. Keep a food diary. You may not be aware of just what you consume in a given day. For the technologically savvy, phone apps like MyFitnessPal and Lose It! can be helpful. Remember, some days you may have more success than others. Just keep going.
2. Avoid high fructose corn syrup and sugary drinks, and cut your daily sugar intake significantly.  Having an occasional celebratory dessert is fine. But make it a rare and portion-controlled treat, if for no other reason than sugary foods are seductive and lead to overeating.
3. Focus on overall healthy behaviors, eating fewer processed foods, and increasing physical activity as opposed to weight loss per se. That includes avoiding smoking and excess alcohol intake as well as taking advantage of a host of other preventive, screening, and early detection programs. Weight is just a number; health is a lifestyle.
4. Be a part of a community or small group. Accountability – both for diet and exercise – is a great motivator and reinforcer. Fat shaming doesn’t work; encouragement and support does.

Emphasizing physical activity and healthy behaviors at all ages is key to reducing morbidity and improving health outcomes in communities. Far from ignoring obesity, when we emphasize a lifestyle that includes awareness and adjustment of eating habits and sets exercise goals (such as increasing walking speed, strength gains, etc.), our overall health – and the health of our community – will improve. And you know what? We will lose weight along the way.

A True Community Health Needs Assessment

The IRS requires charitable hospital organizations to conduct a community health needs assessment (CHNA) every three years and to adopt an implementation strategy to meet the community health needs identified through the CHNA. CHI St. Luke’s Health Memorial recently completed their 2019 Community Health Needs Assessment and will now begin the process of developing, adopting, and implementing a strategy to address identified needs. Much of this strategy will depend on working together with community stakeholders, many of which participated in the assessment data collection and interview process. Additional data was obtained from sources such as the Texas Department of State Health Services, the US Census Bureau, the Centers for Disease Control and Prevention, the Episcopal Health Foundation, and the Robert Wood Johnson Foundation’s County Health Rankings.

The 2019 CHNA was created by the Center for Community Health Development at Texas A&M University at the request of CHI in collaboration with multiple non-profit community organizations, churches, school districts, and individuals. The entire CHNA is published on the CHI website at www.chistlukeshealthmemorial.org/about/health-needs-assessment/. Because CHI St. Luke’s Health Memorial is a regional health system, the assessment covered not only Lufkin and Angelina County, but a seven-county region that included Polk and San Augustine counties, where CHI facilities also are located.

I have a number of thoughts after reviewing this recent assessment.

1. The health of a community is dependent on far more than just availability of health care. This is well-demonstrated by both the Robert Wood Johnson Foundation’s County Health Rankings (www.countyhealthrankings.org/) and the Episcopal Health Foundation (www.episcopalhealth.org/en/research/county-health-data/). To improve health, we must identify and address everything from education level and health behaviors to racial, ethnic, and socioeconomic factors that affect a community’s health.

2. The 2019 CHNA is community-driven, and solutions to our health needs must include the community as well. So many partners exist, including Burke, the Angelina County & Cities Health District, the Coalition, our many school districts, DETCOG, the Texas Forest Country Partnership, and, of course, our city and county governments. All will need to be engaged in moving the needle to improve the health of our communities.

3. The role of the hospital in the community has changed. In the past, hospitals were primarily a destination to deal with an acute episode, like having surgery or managing a heart attack. Now, hospitals must be part of the chronic care management team for patients with heart disease, diabetes, cancer, mental health issues, and more. Hospitals are being graded – and paid – on how successfully they keep patients out of the hospital, if you can believe it! That requires coordination with community partners to ensure that people get the care they need both before and after they require care in a hospital facility.

4. Risk factors – behaviors – such as smoking, obesity, and exercise must be addressed, as well as substance abuse and mental health needs. We are doing this already, to some extent, across organizations and municipalities. More can be done.

5. Education is widely recognized as one of the primary social determinants of health. The St. Luke’s region has a lower proportion of residents with a college degree (14.2%) than either Texas (28.7%) or the US (30.9%). Within the region, the rate varies from a low of 11.6% in Jasper County to a high of 16.7% in Angelina County, yet both are significantly lower than Texas or the US. Household income and insurance status, which are closely linked to education level, also impact community health. Affecting change in these areas will require a generation of effort.

6. One of the key findings of the CHNA – and one that will require a lot of thought and planning to address – is the inadequacy of local and regional transportation. Lack of transportation impacts access to preventive services and early detection of illness as well as access to treatment and follow up.

As a result of the needs identified in CHI’s 2019 CHNA, with few exceptions, premature death rates in our region are higher than the State in virtually every category. This CHNA must not be an exercise on paper only. Follow up must happen. We have a good idea now of the need. We also have strong communities with excellent resources that can come together to find and implement solutions. Our health depends on it.

Achieving Equitable Cancer Care Access in Texas

Much is known about what influences the health of a community, including individual health behaviors as well as social and economic determinants of health.[1] Health equity has been defined to mean that everyone has a fair and just opportunity to be as healthy as possible.[2] Being un- or under-insured puts people at serious disadvantage when it comes to access to healthcare and potential for positive health outcomes.

The Affordable Care Act (ACA, or Obamacare) provides an opportunity for states to expand health coverage to low-income families through the Medicaid program. Multiple recent analyses demonstrate that Medicaid expansion is having an especially positive impact in rural areas in expansion states.[3] Many expansion studies point to improvements across a wide range of measures of access to care.[4] Finally, research shows that Medicaid expansions result in reductions in uninsured hospital or other provider visits and uncompensated care costs, whereas providers in non-expansion states have experienced little or no decline in uninsured visits and uncompensated care.[5]

Texas is one of thirteen states that has chosen not to expand Medicaid. The majority of states not participating in Obamacare expansion are in the Deep South,[6] and these states are also the states in the lowest quintile in overall health as ranked by United Health Foundation.[7] (The State of Texas ranks 37th in overall health in the United States.[8])

That’s not to say the State of Texas doesn’t spend a lot of money on healthcare. According to the Comptroller’s office,[9] healthcare spending represents nearly half the state budget - $42.9 billion in fiscal 2015 – spread across various agencies. Seventy percent, or $30.3 billion, went to spending for Medicaid and CHIP. That spending also includes direct support of various institutions.

For example, the University of Texas MD Anderson Cancer Center, which markets itself heavily as “the nation’s top hospital for cancer care for 14 of the past 17 years”[10] and “one of the nation’s top two hospitals for cancer care every year since the [US News & World Report America’s Best Hospitals] survey began in 1990,”[11] has an operating budget of $5.2 billion and over 20,000 employees.[12] Of that $5.2 billion, 4% - $210.1 million – is general revenue appropriated by the State of Texas.[13]

As a radiation oncologist, I practice in the shadow of MD Anderson, even though I live 120 miles north of the Texas Medical Center. It is a long shadow. That shadow is often comforting, like an old friend. But it is a shadow that discriminates with strict financial barriers and selective insurance contracts. There is a joke in the medical community that the first and most important biopsy you get at MD Anderson is a wallet biopsy – no pay, no play.

MD Anderson does participate in the Texas Medicaid Program and has a financial assistance program for cancer patients who meet residency and certain financial eligibility requirements.[14] Uncompensated care in fiscal year 2018 at MD Anderson totaled only $170.4 million,[15] certainly less than the $210.1 million appropriated by the State of Texas and less than 3.3% of their operating budget. Modern Healthcare looked at the proportion of charity care provided by the country's 20 biggest not-for-profit hospitals and hospital systems by revenue in 2015 and 2016 and found that the average proportion of operating expenses devoted to charity care was 5.21%.[16]

In fiscal year 2017, MD Anderson provided care to a mere 420 people who primarily had no insurance and who met their financial assistance program requirements.[17] That is barely one unique patient a day at an institution that sees 141,600 patients a year.[18] MD Anderson’s first core value[19] is: “Caring: By our words and actions, we create a caring environment for everyone.” But not everyone gets in.

MD Anderson has a huge and wealthy donor base as well. As just one example, their Moon Shots Program,[20] launched in September 2012, has received $464 million in private philanthropic commitments so far.[21] In 2018 alone, 9.5% of their budget – $498 million – came from restricted grants and contracts and philanthropy.[22]

Let me say, I am in awe of the research that comes out of MD Anderson. They have every right to be proud of their #1 ranking and of having a Nobel Prize-winning scientist on staff.[23] The knowledge that comes out of an institution that sees 141,600 patients a year is staggering. The training of health care providers, including at Harris Health System facilities, is excellent. But I grieve when Texas residents who need the care MD Anderson can provide are prevented from going there.

Ultimately, quality health care is not just about rankings; it must be about access to care as well. As a state-supported institution, MD Anderson needs to loosen its requirements for providing uncompensated care and be willing to negotiate and accept reasonable contracts with insurance providers, especially Medicare Advantage and Obamacare plans. After all, a hospital cannot be “best” if it isn’t best for all. (That is not to let insurance providers off the hook. I have no doubt they shy away from contracting with MD Anderson, knowing less expensive care can be had elsewhere.)

The State of Texas should require minimum levels of charity care and insurance plan participation when hundreds of millions of state dollars are being allocated. State legislators, in view of the substantial economic[24] and health[25] benefits associated with the expansion of Medicaid, should invest in increased health insurance coverage in Texas via the Affordable Care Act. And finally, health care ranking organizations like US News & World Report should include access to care and charity care metrics when ranking hospitals.[26] These are the right – and equitable – things to do.

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[1] https://www.angelinaradiation.com/blog/county-health-where-do-we-begin

[2] https://www.rwjf.org/en/library/research/2017/05/what-is-health-equity-.html accessed 7/5/19

[3] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[4] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[5] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[6] https://familiesusa.org/product/50-state-look-medicaid-expansion accessed 7/4/19

[7] https://www.americashealthrankings.org/learn/reports/2018-annual-report accessed 7/5/19

[8] https://www.americashealthrankings.org/learn/reports/2018-annual-report/findings-state-rankings accessed 7/5/19

[9] https://comptroller.texas.gov/about/media-center/news/2017/170131-health-care-spending.php accessed 7/3/19

[10] https://www.mdanderson.org/newsroom/md-anderson-ranked-no-1-for-cancer-care-in-national-survey.h00-159226512.html accessed 7/1/19

[11] https://www.mdanderson.org/patients-family/becoming-our-patient/why-md-anderson.html accessed 7/1/19

[12] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[13] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[14] https://www.mdanderson.org/about-md-anderson/business-legal/office-of-health-policy/uncompensated-care-program.html accessed 7/5/19

[15] 2019 Quick Facts report of fiscal year 2018 data https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/1/19

[16] https://www.modernhealthcare.com/article/20170424/BLOG/170429935/how-much-charity-care-do-not-for-profit-hospitals-provide accessed 7/7/19

[17] https://www.mdanderson.org/about-md-anderson/business-legal/office-of-health-policy/uncompensated-care-program.html accessed 7/4/19 How does MD Anderson serve the low-income population?

MD Anderson has a long tradition of providing quality cancer care for many low-income residents of Texas.

In FY17, MD Anderson provided care to 420 people who primarily had no third-party insurance and who qualified for partial or full financial assistance under MD Anderson’s patient financial assistance program. The estimated unreimbursed cost associated with these patients was $17.5 million.

In addition, MD Anderson provided care to 3,717 people whose primary source of insurance coverage was a state or locally sponsored governmental program such as Medicaid, CHIP, Harris County Hospital District or other Texas county-specific indigent program. The estimated unreimbursed cost associated with these patients was $12.5 million.

MD Anderson’s combined estimated unreimbursed costs for these two categories of patients in FY17 was $30 million.

For the past 23 years, MD Anderson also has provided cancer services at Lyndon B. Johnson General Hospital for low-income Harris County residents. This program is staffed by MD Anderson faculty physicians, nurses and others at an annual cost to MD Anderson of $4 million. The MD Anderson program at LBJ General Hospital more than 1,000 new patients and had more than 12,000 follow-up patient visits in FY13.

[18] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf At MD Anderson, everything we do revolves around our patients. In Fiscal Year 2018, more than 141,600 people sought the superior care that has made MD Anderson so widely respected — 45,000 of whom were new patients.

[19] https://www.mdanderson.org/about-md-anderson.html accessed 7/4/19

[20] https://www.mdanderson.org/cancermoonshots.html accessed 7/5/19

[21] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/5/19

[22] https://www.mdanderson.org/documents/about-md-anderson/about-us/facts-and-history/quick-facts.pdf accessed 7/5/19

[23] https://www.mdanderson.org/newsroom/nobel-prize.html Jim Allison, PhD

[24] https://www.perrymangroup.com/media/uploads/reports/perryman-economic-benefits-of-expanding-health-insurance-coverage-in-texas-03-2019.pdf accessed 7/7/19

[25] https://www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march-2018/ accessed 7/5/19

[26] Why did U.S. News adjust for socioeconomic status? In 2014, the National Quality Forum, an influential standard-setting body, recommended considering socioeconomic status in certain evaluations of hospital performance. Since our objective is to enable a patient who is consulting our ratings to make apples-to-apples comparisons among hospitals, it follows that we should adjust for patient attributes such as age, sex and socioeconomic status. https://health.usnews.com/health-care/best-hospitals/articles/faq-how-and-why-we-rank-and-rate-hospitals accessed 7/4/19

Money, Insurance, and Health: An Unfair Relationship

Money doesn't buy happiness, or so they say. But money can buy better health. Add one more difference between the haves and the have nots.

There are many determinants of health. Some behaviors are more under our individual control than others. The Big Three, as I like to call them – smoking, diet, and exercise – would, at first glance, seem to be entirely personal choices. That would be untrue.

Social and economic factors are a major determinant of health. These factors include education level, employment, income, family and social support, and community safety. Each of these factors is correlated with financial well-being. In fact, these social and economic factors as a whole are more important even than individual health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, since health behaviors also correlate strongly with educational level, employment, income, etc. In other words, we cannot address health behaviors in isolation; we must simultaneously address education, jobs, social services, and community safety if we are to improve health.

Another significant determinant of health – the one that gets the most national attention – is access to and quality of healthcare. In the United States, that access is governed primarily by insurance coverage. Every country rations healthcare; in the United States, we just happen to ration it by separating the insured from the uninsured, and that is very much along economic lines. A privileged few are wealthy enough to be able to pay out of pocket for whatever care they need, but they rarely need to. They have insurance. Good insurance. They can afford to pay their deductible, however high it may be. The working poor, however, have some income but little or no savings and often no health insurance coverage at all. They are the ones who get hit with the entire, undiscounted bill for their care. Bankruptcy is an all-too-common result.

Our healthcare system does make some patchwork provision for the truly indigent, but no one should kid themselves that charity care is in any way equivalent – either in breadth of coverage or ease of use – to what we want for ourselves. Even those with insurance are burdened with astronomical deductibles and copays that most simply can’t afford. These persistent financial burdens can force patients to choose less expensive procedures or to go without care altogether.

And then there is Obamacare.

Implementation of the Affordable Care Act, aka Obamacare, started in 2010, when 16% of the US population – more than 40 million people – were uninsured. Healthcare provided since the advent of Obamacare is, as promised, both more affordable and more available. The percentage of people without health insurance has been cut in half.

The dirty little secret is that many healthcare providers don’t take Obamacare plans, funneling patients into inadequate primary care networks and forcing them to drive long distances for more specialized care. In other words, even under Obamacare we continue to ration care with money-related barriers. No question, Obamacare is far from perfect, but it is still better than nothing.

Ray Perryman, considered by many to be the Texas economist par excellence, issued a report in April 2019 titled Economic Benefits of Expanding Health Insurance Coverage in Texas. In this report, Dr. Perryman states, "Health care needs do not simply go away because individuals do not have insurance coverage. Instead, medical issues tend to escalate and lead to higher costs and worse outcomes. Texas would gain over $110 billion in new Federal health spending during the first 10 years." For the callous who are only interested in the economic benefit accrued to the state’s coffers, this report delivers that in spades.

Guess what, though? According to the Perryman Group report, expanding health insurance coverage in Texas also would result in enhanced “health and wellbeing of individuals directly affected by receiving coverage” as well as “reductions in the numbers of uninsured, fewer emergency room visits, improved health outcomes, enhanced employment and productivity, and other desirable developments.” That is a win-win, my friends.

There has been little political appetite to expanding coverage in Texas for fear of “socialized medicine” and an ever-more-intrusive Federal Government. I get it. We can have differences of opinion about whether and how much healthcare is a “right”, how much “responsibility” is required along the way, and the role of government in healthcare. But, leveraging $9.00 in federal resources for every $1.00 in state funding that results in improved health and return on investment is a bet I would make any day of the week.

Our individual and community health depends on many things. Money – or lack thereof – is the most insidious factor. Improving the health of an entire county, as measured by the Robert Wood Johnson County Health Rankings, will require a concerted effort on both the public and private sector fronts and with both large and small scale efforts. Expanding health insurance coverage in Texas via the Affordable Care Act would be an impactful place to start.

Suicide: More Common Than Ever

A Rice University classmate and friend of mine – a 57 year old woman and mother of two – committed suicide on Easter Sunday. She was going through a divorce, but many of her college friends had been in contact with her one way or another in the weeks (and even the day) before she died. She seemed strong, resilient. Defiant, even. None of us saw it coming. Maybe we should have.

The suicide in 2018 of 55 year old fashion designer Kate Spade captured our collective attention, because here was a wildly successful woman who, by outward appearances, appeared to have everything going for her. Yet according to her husband she suffered from depression and anxiety (others report bipolar disorder) for years. Even so, her death came as a surprise.

Suicide in middle-aged women is on the rise. Kate Spade is not the only celebrity woman to kill herself. Actress Margot Kidder, film producer Jill Messick, model L’Wren Scott, and Mary Richardson Kennedy, estranged wife of Robert F. Kennedy, Jr., have committed suicide in recent years. In fact, the suicide rate among middle age women (age 45-64) has jumped by an astounding sixty percent since 2000. The increase for women is more than double the increase for men. No one knows why.

Mental illness, substance abuse, loneliness and financial and relationship problems have all been linked to rising suicide rates. In a 2018 Wall Street Journal article, psychiatrist Samantha Boardman is quoted, saying “Life satisfaction hits an all-time low in middle age,” and, “Depression and stress are particularly high in this age group. Juggling responsibilities and managing multiple roles takes a toll and can lead to feeling overwhelmed, a loss of control and despair.” But why are people less able to cope today?

Of course, with any one suicide you don’t always know the reason(s). Did the person leave a note? (My friend didn’t, but in retrospect, some of her communications signaled a finality.) Was the suicide planned, or was it an accident? (My friend’s appears intentional.) And as the recent uptick in suicides after the Netflix series 13 Reasons Why is reported to demonstrate, suicide may be suggestible. For the survivors, questions are inevitable and often unanswerable. (Support groups are available for suicide loss survivors and can be of great benefit.)

According to the National Institute of Mental Health (NIMH), there are multiple risk factors for suicide, and interventions and treatment will of necessity vary depending on individual circumstances. Medical therapies are most appropriate when the risk of suicide is related to underlying depression, anxiety or other mental illness. As much as we are a society that likes to medicate our problems away, medication is only a part of the solution for some, but not all, patients at risk for suicide. There is no magic bullet – or pill – for suicide prevention.

Psychiatrist Amy Barnhorst, writing in the New York Times, warned that suicide prevention is often difficult because family members rarely know someone they love is about to attempt suicide. Often that person doesn’t know herself. She advocated “tried-and-true” strategies for working with people at risk of suicide, like limiting access to what she called “lethal tools” (drugs and firearms primarily) and working as a society to improve access to resources like alcohol and drug treatment and individual therapy. “Antidepressants can’t supply employment or affordable housing, repair relationships with family members or bring on sobriety,” she wrote.

Knowing how to gauge how overwhelmed a person is, or the point beyond which there is no return, is hardly a scientific enterprise. And yet we must try, individually, as family, and as a society. Lots of people think about suicide, as it turns out (I did, as a teen). Thankfully, most never act on those thoughts (I didn’t). Common teaching is that if we think someone is depressed, we should talk to them specifically about their emotions, not judgmentally or dismissively, and even ask if they are thinking of hurting or killing themselves. That can open the door to getting professional help.

But data are conflicting about how open people are with their feelings and intentions. One study said nearly eighty percent of suicide victims deny suicidal thoughts before killing themselves. Others say that one-half to two-thirds of people who attempt suicide express thoughts about committing suicide, even if only one-third of those ever make an attempt. How do we identify and screen for those at risk for suicide? We must be willing to have an open conversation on multiple levels. Patricia Todd, a licensed professional counselor and mental health advocate who is herself the mother of a suicide victim, believes that we have a moral obligation to educate the minds and hearts of those around us about all things mental health. Only then can we begin to eradicate the debilitating stigma that is too often attached to suicide.

Our primary care providers (PCPs) are on the front line of mental health care in this country. Reportedly, three-quarters of those who commit suicide have been seen by a primary care provider in the year prior to their suicide. One might conclude that our PCPs would know patients the best and could screen patients for suicide risk. Knowing how busy PCPs are – and how little face time they have with each patient they see – it is unrealistic to expect that mental health screening questions be a routine part of every visit or intake history and physical exam on every patient. Indeed, the US Preventive Services Task Force (USPSTF), an independent panel of experts that makes evidence-based recommendations about clinical preventive services, looked into this and concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in adolescents, adults, and older adults in primary care. Nonetheless, all physicians should be willing and ready to dig deeper when patients express feelings of depression, despair, and hopelessness.

Facebook, after all, is looking. Businessinsider.com reported that Facebook has been monitoring users’ posts since 2017 for warning signs that they might be at risk of suicide, and has even sent emergency responders to users’ houses more than 3,500 times. Who knew? And based on what criteria? My friend who committed suicide was a regular Facebook poster, and Facebook apparently didn’t tag her as being at risk.

Radiologists and researchers in Pittsburgh believe they have found a way to distinguish between individuals with and without suicidal thoughts with a brain imaging technique known as functional MRI (fMRI). Even if this proves to be accurate, this is hardly a practical or cost-efficient method to screen people. It is a provocative idea nonetheless. It makes sense that suicidal brains think differently.

The bottom line is we cannot – yet – rely on computer algorithms or brain scans to identify those at risk of committing suicide. Until we have a better understanding as to why more people are killing themselves – and how to identify those at risk – every one of us must be vigilant.

What can you do? First, know what to look for. NIMH warns that suicidal thoughts or actions are a sign of extreme distress, not a harmless bid for attention, and should not be ignored. The Centers for Disease Control and Prevention (CDC) lists twelve suicide warning signs: feeling like a burden; being isolated; increased anxiety; feeling trapped or in unbearable pain; increased substance use; looking for a way to access lethal means; increased anger or rage; extreme mood swings; expressing hopelessness; sleeping too little or too much; talking or posting about wanting to die; making plans for suicide. The National Alliance on Mental Illness (NAMI) urges that any person exhibiting these behaviors should get care immediately: putting their affairs in order and giving away their possessions; saying goodbye to friends and family; mood shifts from despair to calm; planning, possibly by looking around to buy, steal or borrow the tools they need to complete suicide, such as a firearm or prescription medication.

Communities are starting to put together Crisis Intervention Team (CIT) programs, working with law enforcement, mental health experts and community and religious leaders to respond more effectively to those experiencing a mental health crisis. Communities that don't have this type of formal program should get one started.

If you know someone exhibiting these warning signs, take action. The CDC lists five simple steps to help someone at risk: 1.Ask; 2.Keep them safe; 3.Be there; 4.Help them connect; 5.Follow up. If you or someone you know is in crisis, call the toll-free National Suicide Prevention Lifeline (NSPL) at 1-800-273-TALK (8255), 24 hours a day, 7 days a week. Another option is to chat online with someone at www.suicidepreventionlifeline.org. These services are free and confidential.

Dental Health is Community Health

We need to return to adding fluoride to our water supply.

The Centers for Disease Control and Prevention (CDC) states that fluoridation of community water supplies is one of the ten great public health achievements of the 20th century in the United States. It ranks up there with vaccinations and control of infectious diseases. According to the CDC, fluoridation of drinking water, which began in 1945 and now reaches three out of four Americans, is both safe and inexpensive. The benefit? Reductions in tooth decay (40%-70% in children) and of tooth loss in adults (40%-60%).

Fluoridation of the water supply is race-blind and socioeconomic status-blind. It benefits children and adults regardless of access to dental care. According to dental association reports, on an individual basis, the lifetime cost of fluoridation is less than the cost of one dental filling. For communities, every $1 invested in water fluoridation saves $38 in dental treatment costs. This is a straightforward example of the benefit of public health.

The Texas Department of State Health Services runs the Texas Fluoridation Program (TFP) specifically to improve the health of Texans by preventing tooth decay through community water fluoridation. TFP assists public water systems in the engineering design, installation, and maintenance of water fluoridation systems; monitors the adjusted fluoride level in the drinking water; and maintains the US Centers for Disease Control and Prevention (CDC) fluoridation database for the State of Texas. The Texas DSHS notes that community water fluoridation is recommended by nearly all public health, medical, and dental organizations. The US Department of Health and Human Services’ Community Preventive Services Task Force completed its most recent review of community water fluoridation in April 2013; it recommended water fluoridation based on strong evidence of effectiveness in reducing tooth decay across population groups.

This is also an equity issue. A dental public health publication concluded that water fluoridation is the most effective and practical method for reducing the gap in decay rates between low-income and upper-income Americans. The Hispanic Dental Association has called fluoridation a valuable tool in the reduction of oral health disparities. Another public health paper noted that school performance is indirectly affected by fluoridation because children with poor dental health are nearly three times more likely to miss school and are four times more likely to earn lower grades.

Most water has some fluoride, but usually not enough to prevent cavities. The City of Lufkin 2017 Annual Water Quality Report – the most recent available online – states the fluoride level at the time was 0.722 ppm. The City of Lufkin website, on their FAQ page, continues to state that they add fluoride “at a constant concentration of 1 part per million gallons” and that it is added “as a deterrent to tooth decay.” But according to the CDC, the City of Lufkin’s water system, which supplies a population of more than 42,000 (not just Lufkin, mind you!), now has a fluoride concentration of 0.3, below what is recommended.

I confirmed with our City Manager, Keith Wright, that the City of Lufkin stopped fluoridating water last year. The rationale was that people get fluoride in many ways now, and it seemed unnecessary. In addition, there was concern about conflicting reports of health effects.

Chronic fluoride toxicity is usually caused by excessive fluoride concentrations in drinking water or the use of fluoride supplements. With controlled, measured fluoridation, there is minimal risk with significant public health benefit. A New England Journal of Medicine Journal Watch commentary noted that there may even be an added benefit for older women by increasing bone mineral density with less risk of hip fracture. As for fluoride from other sources, I love the way the Texas Oral Health Coalition, Inc. puts it: “Community water fluoridation and brushing with fluoride toothpaste complement each other, like seat belts and air bags in automobiles. Both work individually, but together they provide even better protection.”

The US Public Health Service’s recommendation for the optimal level of fluoride in community water systems is a ratio of fluoride to water calibrated at 0.7 parts per million. They reached this number after years of scientifically rigorous analysis of the amount of fluoride people receive from all sources, not just fluoridation of the water supply.

What about cost? The Texas Department of State Health Services Fluoridation Program estimates the cost of fluoride additive at $4011/year to the city, based on Lufkin’s average production rate and current average fluorosilicic acid price at $2.00/gallon. I don’t know exactly how accurate those numbers are, but it is obvious we are not talking a lot of money here.

Bottom line? Lufkin needs to return to fluoridating our water supply. And the Texas legislature should consider requiring municipalities to maintain recommended fluoride levels in municipal water supplies. After all, dental health is part of public and community health.

Continue CPRIT Cancer Research Funding

The Cancer Prevention and Research Institute of Texas (CPRIT) was created in 2007 when Texas voters supported legislation setting aside $3 billion for cancer research and prevention. Since then, results have been measurable and effective. In addition to clinical services that have reached every county in Texas, more than 1,200 grants have been awarded to fund cancer research, product development, and cancer prevention. That amounts to up to $300 million in grant funding annually with 90% dedicated to cancer research. Those dollars have brought world-class research teams and amazing recognition to Texas.

One CPRIT scholar, Jim Allison, PhD, chair of Immunology and executive director of the Immunotherapy Platform at The University of Texas MD Anderson Cancer Center, was awarded the 2018 Nobel Prize in Physiology or Medicine for launching an effective new way to attack cancer by treating the immune system rather than the tumor. Another, Sean Morrison, PhD of The University of Texas Southwestern Medical Center, was elected to the National Academy of Medicine. A CPRIT grantee, Livia Schiavinato Eberlin PhD, an assistant professor of chemistry at The University of Texas at Austin, won a MacArthur Foundation Fellowship, unofficially called a “Genius Grant”.

CPRIT is governed by an appointed nine-member Oversight Committee, who operate under a Code of Conduct and Ethics. CPRIT grants are merit-based and peer reviewed and given to Texas-based entities and institutions for cancer-related research, product development and the delivery of cancer prevention programs.

In my area, the Angelina County & Cities Health District participates with researchers at UT Tyler and with the American Cancer Society to provide colorectal cancer screening and prevention services to indigent and uninsured patients in the East Texas area. This is but one example of how CPRIT funding reaches a local community and an underserved population.

But CPRIT funding is at risk. Legislators are being asked to authorize $600 million in funding for CPRIT over the next two years as well as to pass a bonding authority bill that would ensure sustainability of CPRIT for another 10 years. Programs like CPRIT cannot limp along a year or two at a time; they need sustained funding in order to plan, implement, complete, and report out research and prevention successes and failures.

Some have questioned whether or not CPRIT funding, while “unquestionably noble”, is really an essential function of state government. I get it. But, CPRIT is more than cancer research and prevention. It is an investment in our state and our economy. More than 98,000 jobs have been created and $10.9 billion in economic activity has been generated through CPRIT programs. Ray Perryman, president and CEO of the Perryman Group, an economic and financial analysis firm based in Waco, Texas, said that for every dollar taxpayers have invested into CPRIT since 2007, Texas has gained $2 in tax revenue.

Public opinion is behind CPRIT as well. According to a poll conducted by Public Opinion Strategies, 70% of Texans would support reauthorizing the legislature to increase the bond issue for CPRIT by another $3 billion to extend the program for another 10 years. Nine out of ten voters (89%) say it is important for Texas to remain a national leader in cancer research and prevention by providing state funds for CPRIT.

Texas is doing the right thing when it comes to cancer research and prevention. We can all get behind CPRIT: for cancer research, for Texas, and for our future.

We Need Tobacco 21 Legislation Now

Who knew that candy apple, bubble gum, cherry cola, marshmallow, orange soda, s’mores, chocolate, and taffy were literally so addictive? Every one of those flavors – and thousands more! – are available in e-cigarettes today. Tobacco and e-cigarette use – seductively called vaping – are increasingly sucking our youth into a lifetime quicksand of addiction with health and financial costs certain to follow.

A coalition of many partners, including the American Cancer Society Cancer Action Network, American Heart Association, American Lung Association in Texas, Texas Medical Association, Texas Hospital Association, and numerous health systems throughout the state, have come together as Texas 21 to save lives by preventing tobacco use. One simple legislative change that Texas 21 supports can impact hundreds of thousands of lives down the line: raising the age to buy tobacco products to 21.

Almost all smokers start before age 21. In Texas alone, more than 10,000 kids become daily smokers every year. Lest you think raising the age to buy tobacco products to 21 is a radical idea, six states have already done so, as well as hundreds of cities across the country (including San Antonio in 2018). In fact, more than a quarter of the nation is covered by such T21 legislation.

My home county – Angelina County in deep East Texas – has the dubious distinction of ranking dead last in Texas for health behaviors according to the Robert Wood Johnson Foundation (accessible online at www.countyhealthrankings.org). Our higher than average adult smoking rate is a major factor in that determination. If we are to change the health behaviors of an entire county, we must address some factors more globally. Smoking is one of them.

Raising the smoking age to 21 will not have a big economic impact on retailers, as only 2% of US cigarette sales go to those under age 21. But the long-term impact on our taxes, of which too much goes to smoking-caused healthcare, will be significant. In Texas, Medicaid costs caused by smoking amount to almost $2 billion annually. Total annual healthcare costs in Texas directly caused by smoking reach nearly $9 billion. If fewer kids start smoking, we will – over time – see a significant decrease in smoking-related expenditures. Not to mention that our kids will enjoy longer and healthier lives.

Our children are so vulnerable to influence when they are in their early teens. On average, kids in the US try smoking for the first time even before they are 14 years old. They get their first cigarettes from older teens. Most high school seniors can legally buy cigarettes even before they graduate high school, because the legal age to purchase currently is 18. This gives younger teens easy access to nicotine and tobacco though their peers.

States and cities that have enacted T21 legislation have seen a significant drop in youth smoking initiation. The Institute of Medicine (now the Health and Medicine Division of the National Academy of Medicine) notes that raising the tobacco sale age will not only significantly reduce the number of adolescents and young adults who start smoking, it will reduce smoking-caused deaths and immediately improve the health of adolescents, young adults and young mothers who would be deterred from smoking, as well as their children.

It’s not just about cigarette smoking, though. E-cigarettes must be included in any T21 legislation. The tobacco industry, seeing overall declines in US smoking rates, cleverly (and sinisterly) purchased e-cigarette companies and began refining and marketing these nicotine delivery systems to our kids. Vaping became mainstream.

The power of the tobacco industry to addict people to nicotine is evident in the fact that e-cigarette company Juul – in which tobacco giant Altria owns a large stake – has grown quickly to be worth as much as $38 billion by some estimates. Juul’s annual revenue is said to be $2 billion. Addicting teens with flavors like mango, creme brulee, and mint has resulted in more kids using electronic cigarettes than regular cigarettes. In fact, e-cigarette use among youth is now considered to be an epidemic.

Juul and other vaping devices are not toys. Evidence continues to build that for young people, using e-cigarettes increases the likelihood of smoking cigarettes. Some of the chemicals in e-cigarettes are harmful as well. And the effects of nicotine on developing brains are not fully known. Especially worrisome is evidence that nicotine can cause impaired brain development, especially of the prefrontal cortex, which affects judgement and impulse control. To flavor a highly addictive chemical and sell it to children is not only sinister and dangerous; it is appallingly profitable for the very tobacco companies who have been driving up our healthcare costs killing us with cancer, heart disease, COPD, and many other illnesses for decades.

What can we do right now? Polls show nearly 70 percent of voters across party lines favor T21 legislation. Over half of voters strongly favor it. Sen. Joan Huffman and physician Rep. John Zerwas have introduced Senate Bill 338 and House Bill 749 — both of which include e-cigarettes — to protect kids from tobacco addiction and save lives by raising the tobacco age in the state to 21. This something we can all agree on. Let’s pass T21 legislation in Texas this session.