How has medicine changed in the past 20 years? A look at dementia, cancer care and chronic disease

The 21st century began with the first draft of the human genome, and with it, the promise of immense new powers to treat, prevent and cure disease.

In high-income countries like Australia, rates of heart disease were falling, and life expectancy was rising.

Over the past two decades, lots has changed about the factors that affect our health, wellbeing and how long (and well) we live.

So what do we know now that we didn’t then, and how far have we come?

As part of Radio National’s Big 20 series, Dr Norman Swan speaks to three leaders in their field to find out what’s happened in dementia research, cancer care and chronic disease over the last 20 years.

Chronic disease has been getting worse

Dr Norman Swan talks to Professor Chris Murray, director of the Institute of Health Metrics and Evaluation at the University of Washington.

Dr Swan: Take us back to the year 2000. What was the pattern of disease?

Professor Chris Murray: In the year 2000, right before the big push globally on reducing health problems in low income settings, we were pretty much nearing the peak of the HIV epidemic and, particularly in sub-Saharan Africa, we still had a very large number of deaths under age five — 12 million or so a year.

We hadn’t yet had the big efforts to control malaria. And many middle-income countries were right in that transition from a profile of disease burden dominated by infectious diseases and starting that shift towards cancer, heart disease, chronic kidney disease.

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In the high-income world — Australia, Europe, North America — the [disease burden] looked pretty similar. It was already heavily dominated by heart disease and cancer, chronic kidney disease, but there was less obesity back then, there was less diabetes, and we were still back in the heyday of heart disease coming down pretty rapidly.

Dr Swan: What has happened in the two decades since?

Professor Murray: We’ve seen really dramatic progress bringing down child death rates.

In a place like Niger in West Africa, the improvements are just spectacular. You’ve probably halved child death rates in that period … bringing [it] down below the 5 million mark because of antiretrovirals for HIV.

There has been real progress on controlling malaria because of bed-net programs. So just lots of progress racked up, until COVID, on a number of fronts in the low-income world.

Then at the other end of the spectrum in the high-income world, we’ve seen heart disease progress slow, and in some places reverse.

We’ve seen this steady rise of obesity and bringing with it diabetes, high blood sugar, bringing up blood pressure levels in some countries, despite all the therapies that exist for them.

In the middle-income world we’ve seen progress but we’ve seen the rise of ambient air pollution in the last two decades. It’s becoming a bigger and

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First Diversity Week at Stanford Medicine tackles tough topics in medical education, health care | News Center

People are a composite of many interconnected identities, Lassiter said, and taking an “intersectional” point of view is helpful in assessing how diverse, equitable and inclusive a workplace is. As an example, Lassiter described a case study of a particular organization that touted the number of women and people of color in their workforce. 

 The “statistics sound great on the surface, but … when we look at the data from an intersectional perspective, we see that the women in the organization are mostly white women, and the largest group of men in their organization is white men,” Lassiter said. 

 “When organizations say, ‘We’ve increased our numbers of women,’ who are those women?” Lassiter said. Similarly, when groups claim, “’We’ve increased our numbers of people of color,’ who’s included in [their definition of] people of color?” These are the questions that the framework of intersectionality helps us address, Lassiter said.

Diversity, equity and inclusion in medical education

We have to be willing to employ the same kind of rigor we apply to studies of science and medicine to efforts designed to eliminate bias and racism and promote diversity and inclusion, several speakers said.

In 2017, a 10-month program called Leadership, Education and Advancing Diversity, or LEAD, was created to pair Stanford Medicine residents and fellows with mentors who are Stanford Medicine faculty or educational administrators. 

“I had no idea how impactful this work would be,” Carmin Powell, MD, clinical assistant professor of pediatrics, told attendees at the Diversity and Inclusion Forum on Oct. 9. Powell co-directs LEAD with Lahia Yemane, MD. 

Every month, LEAD’s participants take part in discussion-based lectures on various topics related to equity, diversity and inclusion. They also work with their mentors to develop a presentation to deliver at the annual Diversity and Inclusion Forum.

 In just four years, LEAD has tripled in size, growing from 30 scholars and mentors to more than 100, Powell said. Part of the program’s success is its engagement with medical residents and fellows early in their careers, making equity, diversity and inclusion a part of their training.

Knowledge is key

Educating yourself on the history of racism and how to foster diversity and inclusion is essential, said Marc Nivet, executive vice president for institutional advancement at the University of Texas Southwestern Medical Center and keynote speaker at this year’s Diversity and Inclusion Forum.

“If you get nothing else out of today’s talk, I would just implore you to read and to get educated,” Nivet said. 

“You can no longer be an effective leader, period — not just in academic medicine — but period, without being much more elevated in your ability to understand these issues,” he said. “And that comes from reading and learning.”

Learning, trying new things and sharing what does — and doesn’t— work is important for progress, Nivet explained. “I think we don’t share the results of failure, which is typical in academic medicine. We don’t get points for writing about failures or initiatives that didn’t work and why

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Microsoft may earn an Affiliate Commission if you purchase something through recommended links in this article



Microsoft may earn an Affiliate Commission if you purchase something through recommended links in this article



Microsoft may earn an Affiliate Commission if you purchase something through recommended links in this article



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Lynnwood dentist says stress of COVID is grinding on patients, but routine care remains vital

Stress from the coronavirus pandemic has people gnashing their teeth and avoiding dental care.

LYNNWOOD, Wash. — The dentist’s office was a scary place for many people long before the coronavirus pandemic. For some, it’s even scarier now. 

People are avoiding dentists because they worry it isn’t safe — and that’s creating another set of health issues. 

The ongoing global pandemic is quite literally grinding people down to their breaking point.

“This patient said she started to notice herself clenching and grinding,” said Dr. Bradley Jonnes of Lynnwood’s Cedar View Dental, pointing to an X-ray. “She actually broke the tooth off at the gum line.”

Jonnes said, prior to the pandemic, he’d see a broken tooth every couple of weeks. Now he sees several a week.

“People come in and I ask them what changed, and they say, ‘Look at the world! It’s stress. I’m definitely clenching and grinding now.'”

Fear of contracting COVID-19 also has people putting off check-ups, turning small problems into big ones. Routine cavities can become root canals.

After dental offices across the country were completely shut down at the beginning of the pandemic, the American Dental Association changed its policy, designating check-ups as “essential” services.

When asked whether a check-up truly is “essential,” Jonnes responded, “That’s an interesting question. Sometimes we do a check-up and we find a lot more, so we can prevent a lot more. In some cases, it saves people time and money and pain and hassle by doing that check-up. We screen for oral cancer and other issues. We never know what we’re going to find until we get in there.”

Washington state is now allowing dentists to operate as they did prior to the pandemic with additional requirements, including screening of patients for symptoms and thorough cleaning of facilities.

Though not required, Jonnes uses a hand-held fogger to coat his office with a natural disinfectant every day.

He wears both an N95 and additional surgical mask during each procedure. A hospital grade air purification system filters the air in the office every 15 minutes.

“The good thing is, we now have a track record,” said Jonnes. “When we were first opening, we didn’t know how COVID and dentistry would be affected. Talking with my colleagues, the American Dental Association and the national association, we can see dental offices have been safe.”

The American Dental Association reports less than 1% of the nation’s 200,000 dentists have tested positive for coronavirus, compared to more than 200,000 health care workers who have been infected.

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Can’t visit the dentist? Here’s how to take better care of your teeth

For many of us, the routine trip to the dentist is just one of the ways in which our lives have been disrupted in 2020. The British Dental Association (BDA) estimates that, since the March lockdown, dentists in England have provided nearly 19m fewer treatments than in the same period last year.



a close up of a person holding a toothbrush: Photograph: Daniel Day/Getty Images


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Photograph: Daniel Day/Getty Images



Does it matter what type of brush or toothhpaste you use?


© Photograph: Daniel Day/Getty Images
Does it matter what type of brush or toothhpaste you use?

What do you need to know about dental emergencies, and what more can you do to care for your teeth? We asked the experts.

What dentistry services are currently available?

Although some routine dental treatments are now available again, in the UK, surgeries’ operating capacity has been reduced and some are triaging patients according to their level of need and risk.

If you would like to see your dentist, it is advisable to contact them by phone or email to see if it is necessary for you to visit. For up-to-date advice on accessing dental care in the UK, see the NHS website.

What is the risk of catching coronavirus at the dentist?

Although they are assumed to be at high risk of contracting Covid-19, a recent study of nearly 2,200 US dentists found that fewer than 1% tested positive in June. Professor Damien Walmsley, scientific adviser to the BDA, says dentists’ routine attention to infection control puts them at an advantage. “It’s almost second nature to us.”

A heightened potential risk of coronavirus transmission is in the use of instruments such as dental drills or ultrasonic scalers, which create a fine mist.

How are dentists adapting?

The profession is still adapting its procedures as more becomes known about how the virus spreads. For example, some dentists have switched to handheld tools that are slower, but create less spray. “Everything’s a bit of a compromise,” says Walmsley.

Access to services is improving. In England, the “fallow time” during which a treatment room must remain empty after any aerosol-generating procedure was recently reduced from an hour to 15-20 minutes (depending on ventilation), enabling dentists to see more patients.

What can I do to care for my teeth while I can’t get to a dentist?

“The majority of dental problems are preventable,” says Walmsley. Brushing your teeth in the morning and at night, for two minutes each time, will generally be enough to prevent tooth decay and gum disease. Studies have shown, however, that people brush for an average of 43 seconds. “Four minutes a day is not a lot to ask,” says Dr Nigel Carter, the chief executive of the Oral Health Foundation.



a person brushing the teeth: We should be brushing our teeth for two minutes twice a day. Photograph: 10’000 Hours/Getty Images


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We should be brushing our teeth for two minutes twice a day. Photograph: 10’000 Hours/Getty Images

What kind of toothpaste should I use?

Any toothpaste with fluoride will do. Not only does it help to prevent tooth decay, but it slows down the rate of progression of any existing decay. Carter is concerned by the increasing

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Health care: Trump takes last swipe at Affordable Care Act before Election Day

The Centers for Medicare and Medicaid Services on Sunday gave the state permission to stop using the federal exchange, Healthcare.gov, for enrollment in the individual market and shift to a private sector Georgia Access Model, starting in 2023.

State officials argue that the move will give residents access to a broader array of options from web brokers, health insurance companies and agents — which will have a greater incentive to enroll consumers in coverage. They estimate the waiver will lower premiums and increase enrollment by 25,000 people.

Advocates, however, fear that it could shift healthier people to less comprehensive, non-Obamacare plans and leave those with pre-existing conditions facing higher premiums for Affordable Care Act policies. Plus, consumers could unknowingly sign up for skimpier policies.

“Consumer could end up in insurance plans that don’t cover everything they think it would cover,” said Tara Straw, senior policy analyst at the left-leaning Center on Budget and Policy Priorities.

Share your story: How have you been helped or hurt by Obamacare?

What’s more, the Georgia waiver would eliminate residents’ ability to go to a single website to see all their options. Instead, they would have to navigate a fragmented system of broker and insurers — similar to what existed prior to the landmark health reform law, Straw said. This would likely decrease coverage and raise premiums.

The waiver does not meet the federal requirements for approval, including covering as many people with the same affordable and comprehensive coverage as without the waiver, Straw said. This will open up the approval to legal challenges.

The agency opened the door for states to create alternatives to Obamacare in 2018. The Peach State, which has the nation’s third highest uninsured rate at 13.4%, is the first to seek this enhanced power to reshape its individual market.

About 433,000 Georgians were enrolled in Obamacare exchange plans, as of February, according to federal data.

The approval came on the same day as open enrollment for 2021 began and 10 days before the Supreme Court is set to hear oral arguments in a case that could bring down the law.

The Trump administration is backing a coalition of Republican-led attorneys general, including Georgia’s, who argue that Obamacare’s individual mandate was rendered unconstitutional after Congress reduced the penalty for not having insurance to zero as part of the 2017 tax cut law. As a result, the entire health reform law must fall, they argue.

Health care has taken center stage in the 2020 presidential campaign. Former Vice President Joe Biden’s campaign has hammered President Donald Trump for trying to take down the law and its protections for those with pre-existing conditions. Trump has repeatedly said he has a replacement plan that would continue those safeguards but has yet to produce one.
The administration has pursued multiple avenues to overturn the Affordable Care Act in its first term. After efforts to repeal the law in Congress failed in 2017, officials started undermining it from within, including shortening the annual enrollment period to
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Citing cancer experience, Ron Rivera advocates for Affordable Care Act

“We need to have the Affordable Care Act, whether in its current structure or it’s been changed or corrected or fixed or being added onto,” Rivera said. “We need to have something for the folks of the United States of America. For us not to have affordable, quality healthcare, and be the richest nation in the world, that’s kind of disappointing.”

On Monday, Rivera spoke at length about the importance of voting in Tuesday’s election, as well as democracy writ large. He said it’s been “really cool” to hear players discuss current affairs, and he noted that the spectrum of political ideologies in the locker room was “huge.” The enthusiasm for engagement was echoed in a Monday blog post by team president Jason Wright, who wrote the team believed in “big, meaningful and comprehensive community activities versus a collection of small one-off ventures.”

“For example, we will continue to have a robust set of activities around social justice because the players on our team and our employees care about those issues,” he added. “Voting is one component, but there is much more we can and will do.”

Rivera reiterated Monday the importance of participation in democracy, saying that the thing that bothers him most is when people don’t vote. In past years, Rivera has gotten up early to be one of the first people at the polls. He loves the “I voted” stickers. This year, he and his wife Stephanie and daughter Courtney filled out their ballots and put them in the mailbox. On Tuesday, he said he plans to turn the television on around 5 p.m. and click between local and national stations to monitor elections.

“People always ask me: ‘Who did you vote for?’” the coach said. “I always tell them, ‘I voted American.’ I believe I voted for who I believe is going to be the best person for us.”

After his cancer diagnosis in July, Rivera has become an advocate for improved healthcare. The coach has grown more outspoken over the last three months, and he’s sometimes gone as far to call for “universal” healthcare. The message on Monday was more tempered, framed around the ACA, but the root of his activism remains personal. Rivera, 58, is now one year older than his brother Mickey was when he died of pancreatic cancer in 2015.

This season, the coach has been limited at times by chemotherapy and other treatments. He’s thought about others in the same fight during his time in the hospital, those who might not have a five-year contract worth millions.

“After seeing what I went through, and knowing what the cost has to be, you worry about the folks that can’t afford what I had,” he said. “I almost don’t want to say it’s unfair, but it is. These folks deserve every opportunity [to receive quality healthcare]. It just kind of struck a chord with me.”

On Monday, the coach mentioned an upcoming fundraiser for Inova Health System, the Northern Virginia hospital company where

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New Northwestern Medicine location provides patients local access to highest level of thoracic surgery care

Patients in Chicago’s northwest suburbs now have local access to the surgery team that performs state-of-the-art minimally invasive and robotic chest surgery, treatment for cancers of lung and esophagus, and lung transplantation at Northwestern Memorial Hospital.

Dr. Ankit Bharat, who performed the United States’ first double lung transplant on a patient with COVID-19, began to see patients in McHenry on Oct. 20.

        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        

 

The new office location at Northwestern Medicine McHenry Hospital will be open to patients who have diseases of the chest, including the airways, lungs, esophagus, diaphragm and chest wall. Bharat and his surgical partners will receive referrals from medical oncologists, pulmonologists and other physicians who care for patients in the McHenry County area.

“Our goal is to provide unparalleled care of the highest quality to our patients, close to home,” Bharat said. “We are committed to providing the entire gamut of treatments for both simple and complex problems in the chest.”

“Our patients can have appointments and follow-up care in McHenry, and if they need specialized surgeries we perform them in Chicago. This approach provides patients the best of both worlds — convenience for appointments and access to highly advanced surgeries when they’re needed.”

Nick Rave, president of Northwestern Medicine McHenry Hospital, said patients will benefit from the relationships between the physicians and hospital teams.

“Our patients want the peace of mind that they’re doing all they can to address their health issues,” Rave said. “By bringing these experienced thoracic surgeons to McHenry, we’re making it easier for people who are already balancing family life, work and a health diagnosis.”

        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        
        

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IMRT New Standard of Care for High-Risk Cervical Cancer

For women who receive radiotherapy after undergoing hysterectomy for high-risk cervical cancer, image-guided intensity-modulated radiotherapy (IG-IMRT) is superior to three-dimensional conformal radiotherapy (3D-CRT) at reducing late gastrointestinal (GI) toxicity and is similarly efficacious, according to new findings.

“IG-IMRT should represent the new standard of care for postoperative pelvic radiation therapy in women with gynecological cancers,” said study lead author Supriya Chopra, MD, of the Tata Memorial Center in Mumbai, India.

She noted that the study, known as PARCER, is the first in gynecologic cancer to show the impact of advanced technology in reducing long-term morbidity and thus improving the experience of survivors.

At 4 years, rates of late GI toxicity of grade 2 or higher in the IG-IMRT and 3D-CRT arms were 19.2% and 36.2%, respectively (P = .005). Rates of toxicity of grade 3 or higher were 2.0% and 8.7%, respectively (P < .01).

Chopra presented the results at the American Society for Radiation Oncology (ASTRO) 2020 Annual Meeting, which was held online.

Postoperative radiotherapy is indicated for women with cervical and endometrial cancers who have high-risk features, but long-term follow-up has shown an increase in GI symptom burden and toxicity in long-term survivors after adjuvant radiotherapy.

“The uptake of IMRT has been relatively slow in gynecological cancers,” said Chopra. She explained that previous data suggested a benefit with the use of IMRT, but long-term postoperative effects were unclear.

The new data amount to a “practice-change use” of IMRT for this indication, said Sue Yom, MD, PhD, of the University of California, San Francisco, who was not involved with the study. “I see this as having potentially important future impacts on clinical practice.”

I see this as having potentially important future impacts on clinical practice.
Dr Sue Yom

Yom explained that although there have been studies in the United States on the use of postoperative IMRT for pelvic cancer, “this is the first phase 3 study that has shown definite long-term advantages with the use of IMRT, and I would consider it confirmatory.”

In 2015, the preliminary results of PARCER were presented at the plenary session at ASTRO. The results showed that patients treated with IG-IMRT had fewer late GI toxicities at a median follow-up of 20 months. However, the difference between groups was not statistically significant in this earlier analysis.

Now at 49 Months’ Follow-Up

The study was conducted in three clinical sites of Tata Memorial Center and included a total of 300 patients with cervical cancer. The patients had undergone type III hysterectomy and had intermediate- or high-risk features, or they had undergone type I/II hysterectomy necessitating adjuvant chemoradiotherapy. They were randomly assigned to IG-IMRT (n = 151) or 3D-CRT (n = 149). Most patients (117 in the IG-IMRT arm and 114 in the 3D-CRT arm) received concurrent chemotherapy.

The primary endpoint was late GI toxicity of grade 2 or higher. Follow-up included clinical and quality-of-life evaluations, which were conducted every 3 months for 2 years and then every 6 months for years 2 to

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COVID is killing health care workers. Where’s the outrage? Why don’t we try to stop this?

In the United States, we value the lives of those who protect us. According to the FBI, 89 law enforcement officers died in line-of-duty incidents last year. Each of those deaths is a tragedy, often marked by funeral processions of hundreds of squad cars from around the country. We mourn those deaths because we know the officers died protecting us. Perhaps that’s one reason we see so many “Defend the Police” yard signs.

What would the country do if more than 1,000 police officers — more than a tenfold increase — died in a single year? There would be outcries from the White House and both sides of the political aisle. We’d see House and Senate hearings to identify who was at fault, what was wrong and how to safeguard our police. Those hearings would culminate in a bill to provide new funding and equipment to protect our law enforcement officers. The bill proudly would be signed in an Oval Office ceremony amid great fanfare.

Yet during COVID-19, we’re seeing a group of public servants dying in the line of duty with comparatively little fanfare. As of last week, 1,336 health care worker deaths from COVID-19 exposure on the job have been reported to an investigative database. Another study using more inclusive criteria puts the total at hundreds more.

Recipe for disaster, lost lives

The victims range from food service workers to nurses to specialist physicians. Health care worker deaths are not tracked as systematically as law enforcement deaths, but a 2002 study found that 80-260 health care workers die annually of work-related infections. If correct, that suggests COVID-19 has caused about a tenfold increase in those deaths — the same increase that would provoke political outrage if it struck police officers. Yet after the initial flurry of “support our heroes” signs early in the pandemic, health care worker deaths have drawn comparatively little attention.

The obvious question, the one the Trump administration should be asking, is why this is occurring. Several factors contribute, but the most important is that the more COVID-19 cases occur, the more COVID-19 patients require health care, especially those most ill. The more patients are receiving health care, the more health care workers are exposed. And the more health care workers are exposed, the more likely that some of them will acquire on-the-job infections.

National COVID-19 Remembrance on Oct. 4, 2020, in Washington, D.C.
National COVID-19 Remembrance on Oct. 4, 2020, in Washington, D.C.

The answer to the question “Why have so many health care workers died in the U.S.?” is simple: “Because our national leaders have so mismanaged the outbreak.” When you have an administration that degrades its own public health scientists, denies the value of masks and social distancing that has been so effective around the world, and misleads the public as to the seriousness of the COVID-19 pandemic, that’s a recipe for disaster that has claimed over 1,300 people who committed themselves to our health.

COVID-19: My stepfather died alone as Trump throws unmasked rallies

America’s own Government Accountability Office

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