As we begin the year, we look back at the health care news that most captured our attention during the past 12 months. We solicited responses from some 40 nurses, including AJN 's contributing editors and members of the editorial and international advisory boards, hospital administrators, researchers, and practicing nurses.
Frightening News: SARS
Of all the health-related news and events of 2003, the ubiquitous images of white masks over mouths-constant reminders of our vulnerability to sudden acute respiratory syndrome (SARS)-may be among the most memorable. A recent report by the Robarts Centre for Canadian Studies in Toronto indicates that between March and June, some American and Canadian newspapers carried as many as 25 articles a day on the crisis. The World Health Organization (WHO) reports that last year 8,098 people contracted SARS, 774 of whom eventually died. Researchers for the WHO said a vaccine is at least two years away.
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While these numbers are alarming, SARS is by no means the frontrunner as the most threatening infectious disease: every year, 2 million people around the world die of tuberculosis and at least 1 million die of malaria. But SARS hit a nerve with many, perhaps because it illustrated that an infectious disease travels as effortlessly around the globe as its carrier: all that's needed is a body and an airline ticket.
Contentious News: People vs. Pharmaceuticals
Skyrocketing prices for prescription medications are causing many Americans to fill their prescriptions beyond national borders-particularly in Canada-and according to an ABC News-Washington Post poll, 70% of Americans believe this should be legal.
In response, the trade group Pharmaceutical Research and Manufacturers of America spent $8.5 million in 2003 lobbying against a bill that would allow the importation of government-approved medications. The group contends that lost revenue would harm pharmaceutical research and development and that imported medications may be harmful because the Food and Drug Administration (FDA) doesn't control them. Many companies, including Eli Lilly, have gone so far as to limit sales to Canadian companies to amounts that they estimate are sufficient for the Canadian market only.
But Americans are for the most part shrugging off the industry's warnings, as are some states. In October Minnesota governor Tim Pawlenty introduced a plan to facilitate the importation of U.S.-manufactured medications through a Web site that enables Minnesotans to purchase medications from preapproved Canadian pharmacies at prices negotiated by the state. And lawmakers in Massachusetts have asked the FDA and the Department of Health and Human Services (DHHS) to reverse their opposition to reimportation of medications from Canada. The FDA has in fact relaxed its position, stating that it isn't considering legal action against cities and states pursuing prescription drug importation. The power struggle continues.
Seniors, who are likely to be dependent on prescription medication, are among those most affected by rising prices. According to a report released last year by Families USA, the price of the 50 prescription medications used most frequently by the elderly rose 3.4 times the rate of inflation in 2002.
And in November, after a contentious battle in the House and the Senate, lawmakers passed a bill that will include prescription drug coverage with Medicare. The plan will impose premiums and deductibles on all but the poorest beneficiaries. Medicare will pay approximately 75% of drug costs, up to $2,250; after that, coverage ceases until the person has paid $3,600 out of pocket (which doesn't include premiums), after which the beneficiary pays 5% of costs. The thornier issue, however, is the extent to which Medicare should compete directly with private health plans. For more information on the bill, go to http://thomas.loc.gov.
Bad News: Access to Health Care
According to the 2003 Annual Employer Health Benefits Survey by the Kaiser Family Foundation and the Health Research Educational Trust, private health insurance premiums increased by 13.9% in 2003-the largest increase since 1990-and employers passed on the higher costs to their employees. Those who are unemployed or who do not receive insurance from their employers have an even more difficult time affording health care.
Recent figures released by the U.S. Census Bureau reveal that the total number of uninsured Americans rose to 43.6 million. According to a 2003 report by the Commonwealth Fund, a nonprofit group that sponsors research on health and social policy, nearly half of all Hispanics under the age of 65 had no health insurance in 2001. And a report by the Kaiser Commission on Medicaid and the Uninsured notes that children of legal low-income immigrants are also at a disadvantage: 51% of these children have no health insurance, compared with 16% of children whose parents are American citizens. (Most legal immigrants are ineligible for Medicaid during their first five years in the United States.)
Medicaid coverage, however, offers no guarantee of care. State budget cuts have led to cuts in health care services and closure of some programs and clinics. When state reimbursements to providers stalled, many health care providers dropped Medicaid clients, leaving thousands without care.
The high number of uninsured people troubles most Americans. In a recent poll conducted by ABC News and the Washington Post, 80% of those surveyed said they would support a universal health insurance program, even if such a program meant an increase in taxes.
Invisible News: Bioterrorism Preparedness
Efforts made to better protect the public against a biological attack, while not always visible, have had noticeable effects on the health care system-both positive and negative. According to a report by the Center for Studying Health System Change, a policy research organization, increased attention paid to bioterrorism has put public health in the spotlight, improved collaboration between local organizations and the federal government, enhanced emergency communications and the tracking of diseases in communities, and increased readiness to respond to disasters.
But bioterrorism preparedness has also diverted funds and health care workers' time and energy from some core public health initiatives, such as obesity and diabetes prevention programs. And the implementation in late 2002 and early 2003 of a smallpox vaccination program for emergency response workers, health care providers, and military personnel raised concerns not only about the financial and human resources it requires, but also about the vaccine's safety: according to the Centers for Disease Control and Prevention, of the 38,759 civilians (as of October 31, 2003) and 517,958 troops (as of October 3) who'd received the smallpox vaccine, there have been 18 reports of heart problems, such as angina, heart attacks and inflammation, and three people died. To compensate those harmed by the vaccine, the DHHS introduced the Smallpox Vaccine Injury Compensation Program, but it's unlikely to convince many health care workers to get vaccinated, especially in light of how many professional organizations and institutions have withdrawn their support for the initiative.
Old News: The Nursing Shortage
According to the latest report from the U.S. Health Resources and Service Administration (HRSA), the number of vacant nursing positions will grow to more than 800,000 by the year 2020. A review of the literature on the nursing shortage published in the April issue of the Journal of Advanced Nursing showed that even though enrollment in nursing colleges and universities increased by 3.7% in 2003, the increase is too feeble to satisfy the future demands of an aging population. The good news is that the numbers of men and minorities choosing nursing as a career are increasing slightly. According to HRSA, 5.9% of employed nurses in 2001 were men, up from 5.4% in 1994, and 12.3% of nurses were from one or more racial or ethnic minority groups, up from 10% in 1996.
One of many recent public and private nurse recruitment and retention initiatives, the Nurse Reinvestment Act, introduced in 2001, received a $30 million boost for 2004, bringing the total funding for this act and other federal nursing-development programs to $143 million, which still falls short of the $250 million nursing groups said was needed.
Momentum is building in several states to legislate minimum nurse- patient ratios, and it's hoped that improved working conditions will bring nurses back to the bedside. California was the first state to pass mandatory nurse-patient ratios, and implementation is scheduled for this month. At the federal level, the ANA succeeded in having safe staffing legislation introduced in the House and Senate. Representative Lois Capps (D-CA) introduced HR 3656, the Quality Nursing Care Act of 2004, on December 8. See The Politics of Caring, page 29.
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To Die For
Why such an alarming increase in preventable disease?
Of the dozens of health-related headlines appearing in 2003, a surprising number were related to purportedly modifiable behavior. Here are some of the leading themes.
Weighty issues. In its first issue of 2003, the Journal of the American Medical Association (JAMA) reported that 44.3 million adult Americans-roughly one in five-were obese; between 1991 and 2001 the rate of obesity rose 74%. And a Centers for Disease Control and Prevention (CDC) data brief issued in July reported that 64% of the adult U.S. population is either overweight or obese. Among all children ages nine to 15, 9 million (15%) are overweight or obese.
Obesity and diabetes. According to the JAMA report, the prevalence of diagnosed diabetes rose 61% between 1991 and 2001. And the most recent National Diabetes Fact Sheet (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf) reports that an estimated 18.2 million Americans have either diagnosed or undiagnosed diabetes. Compared with adults of healthy weight (a body mass index [BMI] of 18.5 to 24.9), those with a BMI of 40 or higher were more than seven times as likely to be diagnosed with diabetes and more than six times as likely to be diagnosed with hypertension.
Glimmers of hope. In October 2000 the CDC's Division of Nutrition and Physical Activity launched a state-based program aimed at preventing chronic diseases, especially obesity. Twenty state health departments participated, and several states have since reported results indicating success. For example, a public relations campaign in Clarksville, West Virginia, more than doubled the community's consumption of low-fat milk (from 18% to 41% of all milk sales); a middle-school health-promotion program in Massachusetts led to an increase in the consumption of fruit and vegetables among girls and a decrease in the number of hours both girls and boys watch television. And last August the Food and Drug Administration launched a new initiative, the Obesity Working Group, aimed at determining what, if anything, its agencies can do to fight the rise in obesity. The panel is currently soliciting information from consumer groups, researchers, and restaurateurs, and according to a Food and Drug Administration spokesperson, the panel will issue its recommendations next month.
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Smoking. Despite decades of increasingly stark warnings about the health risks of smoking, an estimated 46.5 million adult Americans still smoke; one in every five deaths can be considered tobacco related. This despite abundant evidence linking smoking to chronic heart and lung disease and to cancers of the lung, mouth, larynx, esophagus, bladder, kidney, and cervix.
The results of one federal project, the American Stop Smoking Intervention Study (ASSIST), show that strong public policy measures can influence behavior, according to a report published in the November 19, 2003, issue of the Journal of the National Cancer Institute. ASSIST worked with local and state tobacco-control groups in 17 states to employ strategies aimed at reducing the prevalence of smoking. Over the eight-year course of the project, the prevalence of smoking decreased 3.02 percentage points (from 25.19% to 22.17%) in participating states but just 2.11 percentage points (from 24.4.1% to 22.30%) in nonparticipating states. In a press release on the program's results, Scott Leischow, chief of the National Cancer Institute's Tobacco Control Research Branch, noted that "if all 50 states and the District of Columbia had implemented ASSIST, there would now be about 280,000 fewer smokers nationwide."
Why don't people change? For more than half of the current U.S. population, the answer matters greatly. Historically, smoking-cessation and weight-control programs (such as Smokenders, Weight Watchers, and Overeaters Anonymous) have approached behavior change by focusing on individual responsibility and peer support. While such programs have undoubtedly helped many, other routes to change must be found.-Sylvia Foley, senior editor
World Health Roundup
Heat wave shock wave.
Last summer's European heat wave, which according to INSERM, France's national institute of health and medical research, killed 14,802 mostly elderly people in France, prompted reforms in French health programs. The government is cancelling a public holiday-the religious holiday on the Monday after Pentecost-to help finance improvements in care for the nation's elderly and disabled. The public and private sectors alike will have to contribute 0.3% of payrolls-which should amount to a total of about $2 billion per year that will be added to existing funds.
The right to sight.
According to the World Health Organization (WHO), 40 million to 45 million people worldwide are blind and another 135 million have poor vision. In 80% of cases, vision loss is caused by such conditions as cataract, trachoma, ocular onchocerciasis (river blindness), or vitamin A deficiency that can be prevented or cured.
The WHO and the International Agency for the Prevention of Blindness have created a tool kit, called Vision 2020: the Right to Sight, to help governments and health professionals eliminate avoidable blindness by the year 2020.
More African woe.
African women are 175 times more likely than women living in developed countries to die during childbirth, according to a recent United Nations report. In 2000 the death rate among sub-Saharan women was 920 per 100,000 live births; in developed countries it was 20 per 100,000 live births.
Keeping Track of HRT
A timeline of the often-confusing HRT studies.
Hormone replacement therapy (HRT) had been widely prescribed to women worldwide for years, mostly to prevent heart disease or hot flashes or strengthen bones. But in July 2002 scientists at the National Heart, Lung, and Blood Institute (NHLBI) halted its study (the Women's Health Initiative) of 16,000 women receiving combined HRT three years before they had planned to because of significant and unexpected findings: HRT was associated with increased risks of breast cancer, thromboembolism, coronary heart disease, and stroke. Throughout 2003 the public was deluged with study results and information, some supporting the NHLBI study; others not. Here is our attempt to clear things up (although the definitive answers may not be available for years to come).-David Belcher, associate editor
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