Tagged Public Health

Dealing With The Lingering Effects Of A Mass Shooting

Veronica Kelley was working at an office building across the street from the Inland Regional Center in San Bernardino, Calif., in December 2015 when a county employee and his wife entered with semiautomatic rifles and opened fire, killing 14 and wounding 22. Most of the victims were co-workers of the gunman.

The couple went on to wound two police officers later that day before being fatally shot by police.

Since then, Kelley, the 52-year-old director of the county Department of Behavioral Health, has broadened the department’s focus to caring for people struggling with psychological trauma from mass shootings — no matter how they’re insured. (The department also coordinates services for low-income people with serious mental illness and substance-use disorders, and youths with serious emotional disturbances. Most are uninsured or have Medi-Cal, the state’s Medicaid program.)

Kelley and her department have seen firsthand how the psychological wounds of mass trauma can linger indefinitely. In the San Bernardino shooting, more than 400 people were either victims, witnesses or first responders. Kelley and her team also noticed how the trauma expands beyond those who were nearby: people who lost friends or relatives to the carnage, those who live or work near the notorious crime scene — or even people who were traumatized by watching news coverage.

After the three recent mass shootings in Gilroy, Calif., El Paso, Texas, and Dayton, Ohio, which killed 36 — including two gunmen — and wounded at least 51, the number of people indirectly affected by mass gun violence continues to multiply.

“What we notice is that there’s a slight uptick in attempted suicides” when there are other mass shootings, Kelley said. “We see a slight uptick in attempts and hospitalizations around our anniversary as well.”

The increase in suicide attempts is the reason Kelley closely monitors national news. After the recent spate of mass shootings, she alerted her crisis response team to be prepared for more requests to respond to mental health crises — and sent emails to all county department heads to keep an eye on their employees. San Bernardino is California’s fifth-most populous county, home to about 2.2 million people. With 22,000 employees, the county government is the largest employer in the county.

Kelley’s department also sends emails to survivors and posts social media messages for the public, reminding people about the potential recurrence of post-traumatic stress disorder. Separate messages linking to a suicide hotline number and the Disaster Distress Helpline were posted on the department’s official Facebook page — without gory details or even mention of the crimes — after Gilroy, El Paso and Dayton.

“Unfortunately, we’ve been forced to become pretty effective at this kind of work,” Kelley said.

California Healthline’s Anna Almendrala spoke with Kelley about what her department has learned about the long-term psychological effects of surviving a mass shooting, and the triggers that can set recovery back.

The following interview has been edited for length and clarity.

Q: Three high-profile mass shootings in eight days. What is going through your head right now?

We weren’t surprised. Unfortunately, I think when you’ve been in a mass shooting, it kind of presents you with your new reality. But I think you don’t really fully understand it until it happens in your community.

Q: In addition to the uptick in suicide attempts among San Bernardino survivors with each new mass shooting, did you notice an impact on mental health for residents who were not directly involved?

I think our shooting really helped educate people about the importance of wellness, and an increase in understanding that mental health and addiction are just one part of our whole physical wellness.

We’ve been reached out to by folks who are not Medi-Cal beneficiaries who are in need. And by folks, I mean bigger organizations, and bigger communities, like businesses.

The golf courses had never called us to come out to talk to them about mental health. And then they did.

Q: What advice do you have for people in places like Gilroy, El Paso and Dayton?

One of the things we really focus on is getting people to get off social media, stop watching the news and don’t read about this stuff over and over again.

Get active. We know the way to treat a traumatized brain is to kind of reboot it like you do with a phone or a computer — turn it on and off. The natural way to reboot a brain is physical exercise.

Our brains need to recover, and so they need uninterrupted sleep. They need natural sleep, not sleep that’s impacted by weed or alcohol.

Q: What needs to change when it comes to addressing mental health issues stemming from mass shootings?

Remembering that behavioral health first responders exist. Acknowledging the need for that. You call the fire department when a building is on fire. You can call behavioral health first responders as well.

We created community crisis response teams, and we respond to any sort of crisis. We’ve developed a system of care where we actually get referrals, including from law enforcement, and we actually deploy with law enforcement to these crisis calls.

Also knowing that recovery from trauma is different for everybody, and it takes however long it takes. The only way to get through it is actually to go through it.

Q: How do mass shootings differ from responding to other traumas, like fire or natural disasters?

Most of us know what fire looks like. We’ve created a fire in our living room in the fireplace, or we’ve been out camping. We know if there’s an earthquake, duck and cover.

But we are not all taught active shooter training. We haven’t all witnessed what someone getting gunned down with an automatic weapon looks like, and so we just aren’t as accustomed to it.

Also, when you have someone who takes a weapon and a lot of ammunition and then goes after human targets, that’s different. The trauma is more personalized. It is more horrific. I would say it is terrible to die in a fire, but I would say that it is more violent to die being shot 50 times.

Q: So you’re saying there’s something about being able to see the perpetrator?

Right. And especially that feeling of betrayal for our own county employees. That was a theme for a lot of them. He was one of them; they had just had a baby shower for him. He was considered part of the county family. And so it’s far more personal than if there was just a fire.

Q: You spoke to your counterpart in Santa Clara County, Toni Tullys, after the Gilroy shootings. What did you say?

One of the things I reminded her about, because it’s summertime and we’re still close to the Fourth of July, is that people shoot off fireworks. It is really triggering and activating for people who experience a shooting to hear fireworks go off.

If you’re going to go out, you might want to plan so that you get somewhere early. While that sounds horrifying that you would have to be so deliberate in living, it is helpful to reduce triggers and to be prepared in the event that something happens.

That’s what we were advised from the folks who survived Sandy Hook and from the Colorado shootings. We want to take all the things we’ve learned and share them.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Coordinating Care Of Mind And Body Might Help Medicaid Save Money And Lives

Modern medicine often views the mind and body on separate tracks, both in terms of treatment and health insurance reimbursement. But patients with psychological disorders can have a hard time managing their physical health.

So some Medicaid programs, which provide health coverage for people with low incomes, have tried to coordinate patients’ physical and mental health care.

The goal is to save state and federal governments money while improving the health of patients like John Poynter of Clarksville, Tenn.

Poynter has more health problems than he can recall. “Memory is one of them,” he said, with a laugh that punctuates the end of nearly every sentence.

He is recovering from his second hip replacement, related to his dwarfism. Poynter gets around with the help of a walker, which is covered in keychains from places he has been. He also has diabetes and struggles to manage his blood sugar.

But most of his challenges, he said, revolve around one thing: alcoholism.

“I stayed so drunk, I didn’t know what health was,” Poynter said, with his trademark chuckle.

Nevertheless, he often used Tennessee’s health system back when he was drinking heavily. Whether because of a car wreck or a glucose spike, he regularly visited hospital emergency rooms, where every bit of health care is more expensive.

The Case For Coordination Of Mind-Body Care

Tennessee’s Medicaid program, known as TennCare, has more than 100,000 patients in circumstances similar to Poynter’s. They’ve had a psychiatric inpatient or stabilization episode, along with an official mental health diagnosis — depression or bipolar disorder, maybe, or, as in Poynter’s case, alcohol addiction.

Their mental or behavioral health condition might be manageable with medication and/or counseling, but without that treatment, their psychological condition is holding back their physical health — or vice versa.

“They’re high-use patients. They’re not necessarily high-need patients,” said Dr. Roger Kathol, a psychiatrist and internist with Cartesian Solutions outside Minneapolis. He consults with hospitals and health plans working to integrate mental and physical care.

As studies have shown, these dual-track patients end up consuming way more care than they would otherwise need.

“So, essentially, they don’t get better either behaviorally or medically,” Kathol said, “because their untreated behavioral health illness continues to prevent them from following through on the medical recommendations.”

For example, a patient’s high blood pressure will never be controlled if an active addiction keeps them from taking hypertension medication.

Coordinating mental and physical health care presents business challenges because, typically, two different entities pay the bills, even within Medicaid programs. That’s why TennCare started offering incentives to reward teamwork.

Paying For Performance

TennCare’s interdisciplinary program, known as Tennessee Health Link, was launched in December 2016. The first year, the agency paid nearly $7 million in bonuses to mental health providers who guide patients in care related to their physical health.

TennCare has a five-star metric to gauge a care coordinator’s performance, measuring each patient’s inpatient hospital and psychiatric admissions as well as visits to emergency rooms. Providers are eligible for up to 25% of what’s calculated as the savings to the Medicaid program.

Studies show this sort of coordination and teamwork could end up saving TennCare hundreds of dollars per year, per patient. And a 2018 study from consulting firm Milliman found most of the savings are on the medical side — not from trimming mental health treatment.

In experiments around the U.S. among varied patient populations, savings from care coordination at times have been elusive. A TennCare spokesperson said it’s too early to tell whether its program is either improving health or saving money. As a start, though, TennCare reports these dual-track patients are visiting the ER less often.

While there’s a strong financial case for coordination, it could also save lives. Studies show patients who have both a chronic physical condition and a mental illness tend to die young.

“They’re not dying from behavioral health problems,” noted Mandi Ryan, director of health care innovation at Centerstone, a multistate mental health provider. “They’re dying from a lack of preventive care on the medical side. So that’s where we really started to focus on how can we look at this whole person.”

But refocusing, she said, has required changing the way physicians practice medicine, and changing what’s expected of case managers, turning them into wellness coaches.

“We don’t really get taught about hypertension and hyperlipidemia,” said Valerie Klein, a care coordinator who studied psychology in school and is now an integrated care manager at Centerstone’s office in Clarksville, Tenn.

“But when we look at the big picture,” Klein said, “we realize that if we’re helping them improve their physical health, even if it’s just making sure they got to their appointments, then we’re helping them improve their emotional health as well.”

Klein now helps keep Poynter on track with his treatment. Her name appears regularly on a wall calendar where he writes down his appointments.

Poynter calls Klein his “backbone.” She helped schedule his recent hip surgery and knows the list of medications he takes better than he does.

Klein acknowledges it’s a concept that now seems like an obvious improvement over the way behavioral health patients have been handled in the past.

“I don’t know why we didn’t ever realize that looking at the whole person made a difference,” she said.

This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.

KHN’s ‘What The Health?’: Gun Violence And The Politics Of Public Health

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Three mass shootings in eight days have refocused the nation’s attention on the problem of gun violence — and restarted the long-running debate over guns as a public health issue.

Although Congress is on its summer break, before lawmakers left Washington they passed a two-year budget deal to make it easier to fund health programs — but it also cements funding restrictions like the Hyde Amendment, which bans most federal abortion funding.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Margot Sanger-Katz of The New York Times and Mary Agnes Carey of Kaiser Health News.

Among the takeaways from this week’s podcast:

  • Mass shootings — like the weekend recent violence in El Paso, Texas, and Dayton, Ohio, and the earlier attack at the Gilroy, Calif., garlic festival — prompt calls from officials for more screening and treatment options for mental illness. However, experts — who generally support more mental health services — say it’s not clear extra services would reduce these episodes.
  • Among measures invoked by Republicans in response to the shootings is implementing red-flag laws, which would allow officials and family members to get authorities to temporarily take guns away from people having a mental health crisis. Seventeen states have such laws, and initial research suggests they help reduce suicides.
  • Before leaving town last week for its August recess, the Senate passed a two-year budget deal. It would solidify policy riders such as the Hyde Amendment, which bans the use of government funds for abortions except in limited circumstances, such as to save a mother’s life. The new budget would also remove spending caps that could have caused significant cuts in health programs like the National Institutes of Health and the Centers for Disease Control and Prevention.
  • Canadian officials have raised concerns about the Trump administration’s announcement that it might approve a pilot program allowing states to import drugs from Canada, where they are much cheaper than in the U.S. Canadians say they are worried about the U.S. draining their drug supply.
  • The administration’s change in rules about abortion counseling, as outlined in the federal reproductive health program, Title X, has left some health centers that are bowing out with a problem: Contraceptive supplies they bought under Title X can’t be used. They are looking to the federal government for guidance on what they should do with those supplies.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: The Washington Post’s “2020 Democrats Are Fighting Over Universal Health Care Details. Voters May Not Want That,” by Paige Winfield Cunningham

Mary Agnes Carey: The Washington Post’s “Proponents of Stricter Gun Control Face a Reality Check in the Senate,” by Paul Kane

Alice Miranda Ollstein: Governing’s “America Has a Health-Care Crisis — in Prisons,” by Alan Greenblatt

Margot Sanger-Katz: Balloon Juice blog’s “The Upcoming Strange Politics of the ACA,” by David Anderson

To hear all our podcasts, click here.

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Fentanyl Deaths In San Francisco Soar Almost 150% In Largest Uptick The City Has Ever Seen

Health experts say fentanyl wasn’t available in California to the degree it was in the eastern U.S. until several years ago. The epidemic has unfolded in three waves, says
UCSF professor Daniel Ciccarone. “Wave one: pills. Wave two: heroin. Wave three: fentanyl.” News on the opioid epidemic looks at naloxone’s impact on lowering death rates in Massachusetts and investors’ worries over lawsuits, as well.

Detroit Man Who Was Deported To Iraq Dies After Family Says He Couldn’t Access Needed Insulin

Jimmy Aldaoud spent most of his life in the United States but was deported as part of increased immigration enforcement efforts. In Iraq, he was unable to get the insulin needed to treat his diabetes, his family says. “Jimmy Aldaoud … should have never been sent to Iraq,” Rep. Andy Levin (D-Mich.) said. “My Republican colleagues and I have repeatedly called on the executive branch to cease deportation of such vulnerable people. Now, someone has died.” Meanwhile, nearly 700 immigrants were arrested Wednesday in a raid that left children coming back from school to empty homes.

Federal Experts’ Advice On HPV Vaccine Could Leave Adults Confused

Vaccination decisions are usually pretty straightforward. People either meet the criteria for the vaccine based on their age or other factors or they don’t. But when a federal panel recently recommended an update to the human papillomavirus (HPV) vaccine guidelines, it left a lot of uncertainty.

The panel recommended that men and women between ages 27 and 45 decide — in discussion with their health care providers — whether the HPV vaccine makes sense for them.

But some public health advocates criticize that advice because it doesn’t provide doctors and patients clear guidance about who in this expansive age group are good candidates. They worry that many people may get immunized who won’t benefit, adding needless cost to the health care system and possibly shortchanging people overseas, where the vaccine is in short supply.

“My concern is that there will be a whole lot of people or doctors recommending this vaccine,” said Debbie Saslow, managing director of HPV and gynecological cancers for the American Cancer Society. “But I think that the benefit is so small and we just don’t have guidance.”

The human papillomavirus is the most common sexually transmitted infection in the United States; nearly everyone who’s sexually active will get it at some point. People typically clear the virus on their own and often don’t even realize they’ve been infected. But in some people, HPV remains in the body and may cause several types of cancer as well as genital warts.

Every year, HPV causes more than 33,000 cancers, including more than 90% of cervical cancers as well as cancers of the vagina, vulva, penis, anus and the area at the back of the throat called the oropharynx, according to the Centers for Disease Control and Prevention.

More than 40 types of HPV affect the genital area. Merck’s Gardasil 9, the vaccine used in the United States, provides protection against nine types, which together are associated with the majority of HPV-related cancers and cause 90% of genital warts.

Because HPV is so common among people who are sexually active, the best time to vaccinate is before people start having sex and risk being exposed to the virus. The CDC’s Advisory Committee on Immunization Practices recommends HPV vaccination for all 11- and 12-year-old girls and boys. Catch-up immunizations for young people outside that age window are recommended through age 21 for men and 26 for women (the proposed HPV vaccine update would change the catch-up vaccination guideline for men to align it with the age-26 cutoff for women).

In its June meeting, the immunization committee, which includes public health experts, recommended widening the vaccination window to include adults between 27 and 45.

But rather than give the thumbs-up for everyone in that age group, the panel said people should engage in “shared clinical decision-making” with their health care professional to decide if the vaccine is right for them.

“ACIP made this type of recommendation because most people in this age group are not likely to benefit from getting the vaccine,” Kristen Nordlund, a spokeswoman for the CDC, wrote in an email.

The vaccine won’t protect people against types of HPV to which they’ve already been exposed, and many sexually active people have been exposed to at least some HPV types by their late 20s.

That makes it tougher for the vaccine to have an impact in this age group. According to an economic modeling study presented at the ACIP meeting, under current guidelines that recommend immunization through age 26, 202 people would have to be vaccinated to prevent one case of HPV-related cancer. When the recommendations are broadened to include people through age 45, the number that would have to be vaccinated to prevent one case of cancer increases exponentially to 6,500.

However, it’s unlikely that people in the older group have been exposed to all nine types of HPV the vaccine protects against.

Jennifer Sienko was surprised recently when her physician suggested that she consider getting the HPV vaccine. (Courtesy of Jennifer Sienko)

“There’s some sense that you can get some protection against some future cancers,” said Dr. William Schaffner, professor of preventive medicine and infectious diseases at Vanderbilt University School of Medicine, who is the ACIP liaison for the National Foundation for Infectious Diseases.

Yet, patients — and their doctors — would be hard pressed to know if immunization would be beneficial.

“The problem is that no individual person is likely to know which individual type of HPV they’ve been exposed to,” said Dr. Christopher Zahn, vice president of practice activities at the American College of Obstetricians and Gynecologists.

Vaccine experts have some suggestions about which people older than 26 might consider getting the three-shot series. They include people with multiple sex partners and those who are newly single and dating after being in a monogamous marriage or relationship.

Jennifer Sienko is in a better position than most people to evaluate whether to get the vaccine. She is co-director of the National HPV Vaccination Roundtable, a coalition of groups aimed at reducing HPV cancers that is hosted by the American Cancer Society.

But she was recently surprised when a new doctor asked the 40-year-old if she wanted the vaccine. She opted against it.

Sienko, who lives in Chicago, has been married to her second husband for three years, and that contributed to her decision. But perhaps, she said, it would have been different when she was single for a time.

“So there may have been a window where, had the vaccine been indicated for older women, perhaps between my marriages I would have looked into that,” she said.

The CDC is reviewing the ACIP recommendation. If it approves the recommendation, experts hope the CDC will provide further guidance on determining who the vaccine is appropriate for.

If the CDC approves broadening the age for the vaccine in consultation with a health care provider, most insurers would cover the costs, which can run a few hundred dollars per dose. Under the Affordable Care Act’s preventive coverage rules, patients generally won’t have to pay anything out of pocket for it.

Obesity Plagues Hispanics And Blacks In Colorado, Nation’s ‘Healthiest’ State

LEADVILLE, Colo. — Colorado stands out on the map of U.S. obesity rates, a cool green rectangle surrounded by more alarming shades of yellow, orange and red.

But upon closer inspection, Colorado weighs in as two states: one dangerously heavy and one fit and trim.

There are the mostly well-educated, affluent whites, many of whom were drawn to Colorado by high-paying tech jobs and myriad outdoor opportunities.

By contrast, the adult obesity rates among minorities are much higher — 29.9% for blacks and 27.7% for Latinos, far worse than the 21.6% rate for non-Hispanic whites. While those figures beat the nation’s overall obesity rate of 39.8%, a large portion of state residents still struggle to eat healthily and live active lifestyles.

(Courtesy of the Centers for Disease Control and Prevention)

“People see and hear, ‘Oh, Colorado, healthiest state in the nation,’” said Wendy Peters Moschetti, director of food systems for LiveWell Colorado, a statewide nonprofit promoting healthy eating. “But when you dig deeper, there’s the Colorado paradox. Colorado is importing health.”

Few places illustrate that contrast as clearly as Leadville, a Lake County town of 2,759 nestled among the Rocky Mountains, and best known as the home of an eponymous 100-mile ultramarathon. Though Lake County is near the glamorous resorts of Vail and Breckenridge, Leadville and its surroundings are filled with trailer parks, home to the workers who make the tourism economy hum.

Many other states, counties and cities register similar disparities on the scales of obesity, healthy eating and exercise. The overarching statistics mask underlying problems, making it hard to attract attention and resources for those in need.

“Lots of people think of Leadville as really healthy. How can Leadville have an obesity problem?” said Katie Baldassar, director of the local public health department’s Lake County Build a Generation project. “What we really see in Colorado is an equity problem. And we see that in Leadville.”

Screen Time Versus Mountain Time

The adults here commute to jobs in the ski towns on the well-to-do sides of mountain passes. “They clean hotel rooms over in Vail. They work construction over in Breckenridge,” Baldassar said. “And they’re experiencing the double-headed monster of food scarcity and obesity.”

Their children attend public schools, where 70% of students are Hispanic. Despite the outdoor opportunities that surround them, nearly twice as many students in Lake County fail to meet physical activity guidelines as those in the more affluent Summit and Eagle counties nearby. Obese children tend to become obese adults.

And so, in early July, a group of 8- and 9-year-olds, formally known as Crew 5 of the Rockies Rock summer program, trudged up a mountain trail toward Mosquito Gulch. Many of the children had never gone hiking or fishing before joining the program, and most would have been spending a more sedentary summer without it.

“Probably watching my tablet or TV,” said Leonandro Lopez, 9, who led the other kids in song during the hike. “I don’t like getting my body moving.”

The Get Outdoors Leadville! program takes kids outdoors for seven hours a day, five days a week, exposing them to the outdoor recreation that draws tourists to the mountain city.(Markian Hawryluk/KHN)

The program is run by Get Outdoors Leadville!, which receives funding from state lottery dollars. Most of the families pay the lowest tuition on its sliding scale, about $30 to $50 for a two-week session.

Participants get healthy meals and snacks through the program, a key benefit in a county where 67% of kids qualify for free or reduced-price lunches during the school year, and 24% live below the poverty line.

The program takes kids outdoors for seven hours a day, five days a week, exposing them to the outdoor recreation that draws tourists to Leadville.

“We hope that our participants get familiar with these local places,” said Cisco Tharp, healthy kids director for Get Outdoors Leadville! “And can tell their families, ‘Hey, we can go here and we can do this.’”

Lake County’s obesity levels mirror those in the rest of the state, with Hispanics faring worse than many of their neighbors.

“It’s a common characteristic of the way we observe obesity levels throughout the country,” said John Auerbach, CEO of Trust for America’s Health, a nonprofit that issues an annual state-by-state obesity report. “Obesity is more likely to be prevalent among those with lower incomes and among certain populations of color, in particular, African Americans, Latinos and American Indians.”

That is true in part because these populations may have less access to healthy foods, beverages or safe community spaces for physical activity, said Dr. Ruth Petersen, who runs the Centers for Disease Control and Prevention’s Nutrition, Physical Activity and Obesity division. Minority neighborhoods see more marketing of unhealthy foods and beverages, while fresh fruits and vegetables are often nonexistent — or more expensive than in wealthier neighborhoods that can attract supermarkets.

Groceries in Leadville cost 18% more than the national average, according to a recent community food assessment, while incomes in Lake County languish far below the state average. The sole grocery store in Leadville stocks bottles of oxygen for tourists struggling with the thin air, but has barely half an aisle of fresh produce.

Swiss Chard And Playgrounds

County residents are trying to make healthier food and exercise more accessible.

The Cloud City Conservation Center is growing vegetables locally, a significant challenge given the 10,000-foot elevation and short growing season. The farm consists of a pair of greenhouses — a geodesic dome and a hangar-like tunnel — draped in plastic sheeting.

The Cloud City Conservation Center grows vegetables in Leadville, Colo., in a pair of greenhouses, and sells the produce through a community-sponsored agricultural program that provides 30 families with a weekly box of fresh vegetables. Ten of the spots are set aside for low-income families in a community where fresh produce is otherwise expensive and limited.(Markian Hawryluk/KHN)

The farmers grow plants that provide the best harvest in the least space, including Swiss chard and lettuce, cabbages and peas. That means no tomatoes, although that’s what everybody wants.

“The vegetables that grow best in this climate may be less popular, but they are the best for you,” said Kendra Kurihara, Cloud City’s executive director.

Cloud City sells its produce through a community-sponsored agricultural program that provides 30 families with a weekly box of fresh vegetables. Ten of the spots are set aside for low-income families, who get twice the value for food stamp dollars. But the demand exceeds the supply, with 45 families stuck on a waiting list.

Schools have also revamped recess and the playgrounds.

Just six years ago, students at the Lake County Intermediate School would race to finish their lunch the fastest, knowing the first kids out the door had the best chance to get one of the eight swings, the only usable piece of equipment on the school’s playground.

A group of parents banded together, hoping to raise $1,000 to buy balls and jump-ropes. With foundation help and private fundraising, they ended up with a $500,000 playground redesign. When the designers asked the children what they wanted, the kids asked for more swings.

“That was all they knew,” Baldassar said. “They couldn’t imagine anything else.”

The playground they built features giant rope spider webs for climbing, slides built for speed, hanging lily pads for balancing — and, yes, swings. It was a turning point for the school district, she said, that has paid dividends with higher test scores and improved academic performance.

Still, Joan Brucha, Healthy Eating Active Living unit manager at the Colorado Department of Public Health and Environment, said funding for obesity prevention work in Colorado comes to about 27 cents per state resident. “You can’t make meaningful change on that level,” she said.

According to the CDC, the U.S. spends 31 cents per person on obesity prevention efforts. CDC officials say they target limited resources to areas where obesity rates are highest.

And that makes it a lot harder for Colorado to make its case. Funding from the state tobacco tax also is available to counter obesity, but it’s not enough to make a difference in Lake County or the rest of the state.

In 2011, Democratic Gov. John Hickenlooper set a goal of reducing obesity rates by 10% by 2020. Just months from the deadline, the state isn’t anywhere close to achieving it.

Series Of Restrictive Arkansas Abortion Laws Including 18-Week Ban Blocked Again By Federal Judge

U.S. District Judge Kristine Baker granted a preliminary injunction preventing the state from enforcing the restrictions: an 18-week ban, a mandate that physicians performing abortions be board-certified or board-eligible in obstetrics and gynecology, and a ban on anyone seeking the procedure because of a Down syndrome diagnosis. Abortion news comes out of Alabama and Illinois, as well.

Judge In Opioid Litigation Against Drugmakers Likes Proposal Put Forth By Thousands Of Cities, But States Say It Cuts Them Out

The fate of who gets to manage settlements from opioid lawsuits against drug companies is playing out as the October trial approaches. Federal Judge Dan Polster is overseeing the consolidation of some 2,000 cases from a negotiating bloc of thousands of U.S. cities and towns affected by the opioid crisis. “There has to be some vehicle to resolve these lawsuits,” said Polster. Also, opioid distributors offer their solution to settling claims. News on the opioid epidemic also looks at soaring use of naloxone, abuse by older people, and involuntary treatment, as well.

For Many Latinos, The Hatred-Driven El Paso Shooting Is ‘The Death Of The American Dream’

Latinos, regardless of immigration status, across the country were shaken by the shootings — a lethal exhibition of the increased racism and vitriol directed toward them. “It’s really hard to be alive as an immigrant right now and to not be sick and exhausted,” said Karla Cornejo Villavicencio, 30. “It feels like being hunted.” Meanwhile, experts warn that mass shootings can come in clusters and be contagious. In other news from the shootings: a look into the El Paso medical center that handled the victims; President Donald Trump plans to visit the cities; experts question if the death penalty would really be a deterrent; and more.

Ohio Governor Lays Out Gun Violence Plan That Includes ‘Red Flag’ Laws, Background Checks, Monitoring Social Media

Following the shooting in Dayton, Ohio, Gov. Mike DeWine faces demands that he “do something” from grief-stricken Ohioans. DeWine on Tuesday announced that he would push for measures that he thinks can pass the Republican-controlled state legislature, which has a history of knocking down similar efforts.

The New West: Smoke In The Sky, A Purifier At Home

When the Camp Fire began to rage in Paradise, Calif., last November, the owners of the family-run Collier Hardware store in nearby Chico faced a situation unlike any they’d seen.

A business that might welcome 200 customers on an average day, Collier was suddenly dealing with five times that number — “and they all wanted the same thing,” co-owner Steve Lucena said.

Alarmed by dense smoke, shoppers were snapping up portable air purifiers and breathing masks in staggering numbers. Collier Hardware sold nearly 60,000 adult-sized masks in a couple of weeks, and gave away thousands more that were specially designed for children.

“With the purifiers, we had multiple people unloading them from the truck, and they were sold before we could get them all the way into the store,” Lucena said. “People didn’t care what model it was or how much it cost. We’d normally sell four to six in a year, and we sold 100 in a day.”

As hot, dry weather settles upon the West this summer, fears of massive wildfires — and the smoke they produce — are again taking hold. It’s true not only in areas directly threatened by fire, but even those hundreds of miles away where people expect to be shrouded in lung-clogging smoke.

The health risks are real, and they’re already part of a future that public-health experts — and those who sell air-quality products — are anticipating.

“We aren’t depending on wildfire season to make a profit, because we don’t hope for another year of fires,” said Joceline Barron, a spokeswoman for Los Angeles-based Rabbit Air, which makes portable purifiers.

“But we know the market does profit from that season,” she said. “When the wildfires were going on, our phones were ringing all the time.”

Sales of portable air purifiers in California alone are expected to rise dramatically over the next few years, from roughly 469,000 units in 2017 to a predicted 720,000 in 2023, according to a study by TechSci Research presented at a recent meeting of the California Air Resources Board.

Across the country, annual sales of home air filters are expected to cross $1 billion by 2023, according to a report by Research and Markets.

“Interest in effective air purification has significantly risen in recent years due to wildfires,” said Jaya Rao, chief operating officer and co-founder of Molekule, a maker of a $799 purifier. Sales of the unit have doubled each year since it debuted in 2017, Rao said.

“We have seen people buy solely for the purpose of wildfires, whether proactively or in the moment, but we have also seen that the wildfires have raised a general awareness about the need for good air purification every day,” she said.

Workers at Molekule got a close look at the impact of wildfire season last year, when the company was so besieged by orders that it began distributing them out the front of its San Francisco corporate office “to provide relief the fastest,” Rao said.

Researchers from Harvard and Yale in 2016 produced a list of more than 300 counties throughout the West that will be at the greatest risk of dangerous pollution in the coming decades due to “smoke waves” emanating from increasingly intense wildfires. Among the most vulnerable are heavily populated areas such as San Francisco, Alameda and Contra Costa counties in Northern California, and King County in Washington.

Wildfire smoke is dangerous because of its concentration of noxious fine particles, which measure 2.5 micrometers or less (a human hair, by comparison, measures 70 micrometers) and which, unlike common dust, can be inhaled into the deepest recesses of the lung.

In addition to eye and respiratory tract irritation, this particulate matter — PM2.5 in scientific shorthand — can exacerbate heart and lung issues, including asthma and chronic obstructive pulmonary disease (COPD), and may lead to premature death. Children, older people and those with respiratory illnesses are particularly at risk.

“It can be pretty dense. It seeps through the walls and, of course, doors and windows when they’re opened,” said Linda Smith, chief of the California air board’s health and exposure branch.

While much is still unknown about the long-term effects of exposure to wildfire smoke, the microscopic particles are regulated as an air pollutant. A study published last year in the journal GeoHealth found that the number of deaths linked to the inhalation of wildfire smoke in the U.S. could double by the end of the century, to nearly 40,000 per year.

Air purifiers essentially function as scrubbers, removing bacteria, viruses and PM2.5 as the air passes through them. The air resources board recommends their use to limit the effects of wildfire smoke in the home. It maintains a list of devices approved for use in California.

Portable air-cleaning units were once considered specialty purchases, but sales-driven competition has flooded the market, forcing prices down. Where a high-end portable purifier might cost $800 or more, several models now cost less than $100. Shoppers can find models with well-known consumer appliance names like Dyson, Hunter, Honeywell and Whirlpool as well as scores of more obscure manufacturers. Several websites have attempted to evaluate air purifiers, including the size of the room they can effectively clean.

For Jamie Buffington of El Macero, Calif., near Sacramento, the connection was simple enough. Though she had considered buying a purifier because of the pollen in her area, the memory of being inundated with wildfire smoke inspired action earlier this summer.

“The smoke last year was awful,” Buffington said. “I’m ready now.”

Buffington said she bought a unit for the master bedroom of her home, and very quickly went back online to order two more, for rooms at a family cabin near Lake Tahoe. During wildfire season last year, she said, “it was terrible down here and terrible up there. It makes sense to have them in both places.”

Indeed, throughout the West and beyond, communities well removed from fires can find themselves fighting through severe smoke and ash, as shifting winds push the plumes hundreds or even thousands of miles.

Oregon’s Department of Environmental Quality recently reported that unhealthy air conditions were on the rise throughout the state, including urban areas like Portland that are far from the wildfires.

Smoke from the Camp Fire was noted across the continent and as far away as New York City.

And while cities and towns will do what they can — officials in Seattle, for example, announced in June the retrofitting of five buildings to use as “clean-air shelters” on smoky days — the choice for many residents will be closer to home.

Back at Collier Hardware, the Lucena family has adjusted its stock. Collier keeps plenty of breathing masks on the shelves, Steve Lucena said, and at least a handful of air purifiers are now in the store at all times. Access to an Ace Hardware supply warehouse in Roseville about an hour and a half away means reinforcements can be obtained quickly.

They are reinforcements the family hopes never to need.

“We know we’ll have fires,” Lucena said. “We just hope they won’t be anything like last year. But we will be ready.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

States Given Until End Of Year To Outline Overhaul On How They Approach Opioid Use By Their Medicaid Populations

Along with the opioid guidance, CMS also is directing states to design and implement a program to track and manage the prescribing of antipsychotic medications for children in Medicaid. Other Medicaid news comes out of New York, Louisiana and Kansas, as well.

Flurry Of States Passed Red Flag Laws, But There’s Little Research On Their Impact At Reducing Gun Violence

President Donald Trump and other lawmakers are boosting the idea of red flag laws, which allow loved ones and law enforcement to take guns away from someone they suspect may hurt themselves or others. Although there’s strong evidence that they reduce suicides, beyond that little research has been done on such protection orders’ effectiveness. Furthermore, psychology experts say a significant number of mass shooters are in their late teens to early 20s, when signs of severe mental illness may not yet be observable.

Following Cries Of ‘Do Something,’ Ohio Governor To Lay Out Proposal On Gun Violence

Gov. Mike DeWine (R-Ohio) said anything was on the table but that any changes must be consistent with the Second Amendment and must be able to pass the Republican-dominated legislature — which could be a tall order. Republican state lawmakers previously opposed former Gov. John Kasich’s attempt to pass a red flag law.

Calif. Governor Expands State Task Force To Deal With Extremism, Demands Gender Be A Part Of Gun Violence Conversation

California has some of the strictest gun laws in the country, and Gov. Gavin Newsom (D-Calif.) is taking further action following the weekend shootings. Newsom also said that leaders must address the fact that most shooters are male while talking about prevention. Meanwhile, data show that California’s new ammo background check legislation blocked more than 100 illegal sales in July. Media outlets look at how gun violence is being addressed across the country in the wake of the attacks.

Modern Wildfires Pose New Health Risks For Firefighters

As California’s wildfire season gets underway in earnest this month — with crews working to contain a 14,000-acre blaze in rugged Modoc County on the Oregon border — new research underscores the risks that modern wildfires pose to firefighters’ long-term health.

Studies long have linked firefighters’ on-the-job exposure to chemicals and toxins in urban blazes with an increased risk of cancer. More recently, as urban-style development reaches into once remote stretches of California’s mountains and forests, wildfires are decimating not only vast swaths of forest but also whole communities of homes and businesses. That means firefighters are dealing with exposure to the intense heat produced by burning vegetation as well as fuels and carcinogens more common in urban fires. And, wildfire crews typically aren’t equipped with the bulky protective gear urban firefighters wear.

A University of California-Berkeley study released in July underscores the potential risks: It found elevated levels of mercury and other toxins in the blood of firefighters who had battled the deadly Tubbs Fire, which destroyed thousands of homes in Napa and Sonoma counties in 2017.

Tony Stefani, a retired San Francisco Fire Department captain, started the San Francisco Firefighters Cancer Prevention Foundation in 2006 to educate his colleagues about job-related cancers and promote early detection. After 27 years on the job, Stefani was diagnosed with transitional cell carcinoma, a rare cancer of the urinary system, and successfully treated. Stefani, 68, spoke with California Healthline about the cancer risks firefighters face and prevention options. The interview has been edited for length and clarity.

Tony Stefani, a retired San Francisco Fire Department captain, started the San Francisco Firefighters Cancer Prevention Foundation to educate colleagues about the cancer risks inherent to firefighting. (Courtesy of Tony Stefani)

Q: What do we know about the link between firefighting and cancer?

We know there is a definitive link between cancer and firefighting. An important study is the 2010 study conducted by the National Institute for Occupational Safety and Health examining causes of death for more than 30,000 firefighters back to 1950. We’re considered to be a healthier group of people in the workforce — firefighters stay in shape and have good medical coverage. But the study found we had higher rates of multiple cancers, including oral, digestive, prostate and breast cancers. The study also linked the number of fires a firefighter fought with a higher risk of a cancer diagnosis.

Q: The UC-Berkeley study found firefighters deployed to the Tubbs Fire had higher levels of mercury in their blood than crews not deployed. (Mercury is a neurotoxin that can damage lungs, kidneys and other organs; it has not been linked definitively to cancer.) What do you hope comes from this kind of research?

What we want this study to bring about is change to better protect women and men fighting these wildfires. The firefighters from San Francisco and other jurisdictions had severe toxic chemical exposures. They were not suited up for residential fires. They were in lightweight wildfire gear. They did not wear self-contained breathing apparatus, which can weigh 30 to 40 pounds.

Q: How does your foundation work with firefighters?

The foundation provides free cancer screenings and free genomic testing if insurance won’t cover it. We pay for second opinions and medical transport costs — for example, if firefighters are sent to another state for clinical trials. We’ve also been involved in studies that show a direct correlation between cancer and the firefighting profession. We have no paid employees. Our money comes from firefighters.

Q: What changes would you recommend to protect firefighters? How well are government leaders responding?

The current San Francisco Fire Department administration is excellent and making a lot of changes, including cultural change where firefighters are taking better care of themselves before and after fires.

Every firefighter should have a complete blood panel and urinalysis done every year [to look for] indicators of cancer. It’s not easy to get people into the doctor’s office, but if fire departments encourage that and have it covered by insurance, that would be great.

The equipment is changing, but not every department can afford new equipment. A lot of the personal protective equipment that firefighters wear is embedded with fire retardant chemicals that are themselves a problem. Even though firefighters are protected, some of these toxic chemicals can get into a firefighter’s skin.

Departments also have to look at how to better protect their firefighters [traveling to help] during wildfires, including limiting the time they’re in that environment. When these strike teams go out, they can work from 12 to 24 hours at a time, with a 24-hour rest period. That’s a long time to be exposed. I know that departments will run themselves to the bare bones to help another department. That’s the nature of the brotherhood and sisterhood we live in.

Q: There was a time when firefighters saw protective equipment as burdensome or unnecessary. Do you see that culture changing?

When I entered the San Francisco Fire Department in 1974, it wasn’t mandatory to wear self-contained breathing apparatus. You were fighting fires without any breathing apparatus. I thought I was in good shape and didn’t have to wear it. Which was false — even though I was in excellent condition, at 49 I was diagnosed with this cancer.

After the fire’s out and during the overhaul process — looking for hot spots, cleaning out every structure down to the studs — all that stuff was off-gassing, and firefighters were taking a beating.

There’s a new generation of firefighters, and they’re well aware of cancer risks and the downside of firefighting. Firefighters now wear that breathing apparatus. They also do gross decontamination after every fire. You’ll see a firefighter being hosed down and cleaned off. They’ll change clothes and uniforms now.

We used the same turnout coats and pants until they turned into rags. It was about status; it showed you were working hard. It’s slowly eroding, that culture. There’s always going to be a few who still think they’re indestructible, but when they or a friend gets sick, it’s a completely different story.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.