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H E A L T H,   S A F E T Y,   &   S O C I A L   I S S U E S

Using telemedicine techniques,
ophthamologist views a patient's eye
injury remotely; ©Ira Wexler/Folio Inc.

Doctors, A Click Away

The Internet has the potential to alter radically the practice of medicine in the United States — far beyond the impact of the many Web sites now serving consumers. It could transform where and how doctors treat patients, and speed the transfer of vital information in critical situations. For public health officials, it could mean better tracking of the spread of infectious disease. But before these and many other applications can be developed, some high hurdles first must be cleared, says a new report from the National Research Council.

Ensuring that an Internet-based system can support a variety of high-tech medical activities — from accessing the medical records of an emergency room patient to allowing a doctor to make an electronic “house call” — will require capabilities that exceed those of most e-commerce transactions. The need for privacy and reliability is heightened in medical settings, and these factors must be incorporated into the system from the start. To make that happen, the health and information technology industries must begin to work more closely to design these systems, the report concludes. The National Library of Medicine could play an important role in bridging the gap between these industries so new technologies are developed and made widely available.

Until medical practitioners and health organizations have evidence of the effectiveness and trustworthiness of Internet-based systems, they will be hesitant to spend resources on developing them — especially in today’s cost-conscious environment. To combat this reluctance, federal agencies with a big stake in health care — such as the departments of Health and Human Services, Defense, and Veterans Affairs — should launch a series of demonstration projects using their own systems as testbeds where the problems can be worked out, the report recommends.

Still, these steps will not be enough. A number of tough regulatory issues will have to be worked out. Regulations governing the protection of electronic personal health records have to be finalized. Rules for reimbursing doctors for remote medical consultations need to be developed and promulgated. Also, issues of interstate licensure will have to be addressed if care providers are to practice across state lines. — Bob Ludwig & Neil Tickner

Networking Health: Prescriptions for the Internet. Committee on Enhancing the Internet for Biomedical Applications: Technical Requirements and Implementation Strategies, Computer Science and Telecommunications Board, Commission on Physical Sciences, Mathematics, and Applications (2000; ISBN 0-309-06843-6pr; pre-publication copies available from National Academy Press, tel. 1-800-624-6242; $35.00 plus $4.50 shipping for single copies).

The committee was chaired by Edward Shortliffe, professor and chair of the department of medical informatics, Columbia Presbyterian Medical Center, New York City. The study was funded by the National Library of Medicine.


Antioxidants, Anyone?

The body’s cells are constantly under attack by a normal, but damaging, physiological process called “oxidative stress.” And like an oversized umbrella on a rainy day, nutrients known as dietary antioxidants — namely selenium and vitamins C and E — help protect cells from this damage.

Although the protective role of antioxidants has been demonstrated, researchers continue to investigate whether these nutrients perform another important job: reducing the risk of chronic diseases — including cancer, cardiovascular disease, eye diseases, and neurodegenerative diseases. But a direct connection between antioxidants and the prevention of such health conditions has yet to be well-established, says a new report from the Institute of Medicine. Whether beta-carotene and other carotenoids act like antioxidants when consumed also remains unknown.

Insufficient evidence exists to support claims that taking antioxidants, even in high doses, reduces the risk of chronic disease, the report says. In fact, huge doses may lead to health problems rather than confer benefits. The report does call for increases in daily intakes of vitamins C and E to exploit their role in maintaining good health, however. And it recommends an even larger amount of vitamin C for smokers, who are more likely to suffer from biological processes that harm cells and deplete the nutrient.

For the first time, the report also sets a ceiling on daily consumption of selenium and vitamins C and E to reduce the risk of adverse side effects from overuse. These ceilings, or upper levels, represent the maximum intake of a nutrient that is likely to pose no risk of adverse health effects in most people, including sensitive individuals.

Specifically, women should consume 75 milligrams of vitamin C per day, and men should take 90 milligrams daily, the report says. Smokers need an additional 35 milligrams daily. The report sets the upper level for vitamin C, from both food and supplements, at 2,000 milligrams daily for adults. Intakes above this amount may cause diarrhea.

For vitamin E, both women and men should consume 15 milligrams of alpha-tocopherol from food each day. This is equivalent to 22 International Units (IUs) of “natural source” vitamin E or 33 IUs of the synthetic form. The upper level — based only on intake from vitamin supplements — is 1,000 milligrams of alpha-tocopherol per day for adults. This amount is equivalent to roughly 1,500 IUs of “d-alpha-tocopherol,” sometimes labeled as natural-source vitamin E, or 1,100 IUs of “dl-alpha-tocopherol,” a synthetic version. People who take more than these amounts may have an increased tendency to hemorrhage because vitamin E can act as an anticoagulant.

Women and men should consume 55 micrograms of selenium each day, the report advises. The upper level, based on nutrients from all sources, is 400 micrograms daily. More than this amount could cause selenosis, a toxic reaction marked by brittle hair and nails.

When it comes to carotenoids, some of which are sources of vitamin A, available scientific data on their effects are inconsistent. People should use caution before taking these nutrients in high doses, the report says. It recommends beta-carotene supplementation only for the prevention and control of vitamin A deficiency.

On the whole, much more research is needed to investigate the role of dietary antioxidants and carotenoids in disease prevention, the report notes. Additional research also is needed to explore the nutrient requirements of specific groups of people, including children and the elderly; to look into how selenium, vitamins C and E, and carotenoids interact with each other and with other food components; and to examine in well-controlled clinical trials how nutrient consumption above the upper levels may affect human health.

Third in a series on Dietary Reference Intakes (DRIs) for healthy Americans and Canadians, the report expands on the Recommended Dietary Allowances that the National Academies have set periodically since 1941, and on Canada’s Recommended Nutrient Intakes. DRIs contain four categories of reference intakes, which include sets of values intended to help people maintain their health, and a set to help them avoid taking too much of a nutrient. The first DRIs report examined calcium, phosphorus, magnesium, vitamin D, and fluoride. The second report set DRIs for choline and the B vitamins. Additional reports will be issued for trace elements and other vitamins; electrolytes and water; protein, carbohydrates, fiber, and fats; and other food components. — Vanee Vines

Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Carotenoids. Panel on Dietary Antioxidants and Related Compounds; Subcommittees on Upper Reference Levels of Nutrients, and on Interpretation and Uses of Dietary Reference Intakes; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes; Food and Nutrition Board; Institute of Medicine (2000, approx. 523 pp.; ISBN 0-309-06935-1pr; pre-publication copies available from National Academy Press, tel. 1-800-624-6242; $45.00 plus $4.50 shipping for single copies).

The panel was chaired by Norman I. Krinsky, professor of biochemistry, Tufts University School of Medicine, Boston. The standing committee on DRIs is chaired by Vernon R. Young, professor of nutritional biochemistry, Massachusetts Institute of Technology, Cambridge. The subcommittee on upper reference levels and the subcommittee on interpretation and uses of DRIs were chaired by Ian C. Munro, principal, CanTox Inc., Mississauga, Ontario, Canada, and Suzanne P. Murphy, researcher, Cancer Research Center, University of Hawaii, Honolulu, respectively.

The study was funded in part by the U.S. Department of Health and Human Services; Health Canada; Institute of Medicine; DRIs Private Foundation Fund, including Dannon Institute and International Life Sciences Institute; and the DRIs Corporate Donors’ Fund. Corporate fund contributors include Daiichi Fine Chemicals Inc., Kemin Foods Inc., M&M/Mars, Mead Johnson Nutrition Group, Nabisco Foods Group, Natural Source Vitamin E Association, Roche Vitamins Inc., U.S. Borax, and Weider Nutrition Group.


Kids and Internet Porn

Easy access to the World Wide Web offers children opportunities to explore educational resources, develop online friendships, and connect with experts in subjects ranging from algebra to soccer. But with so much information available only a few clicks away, Internet access also raises concerns about minors’ exposure to pornography and other inappropriate material on the Web.

©PhotoDisc

Many argue that parents and teachers should control what children see and read online. But as a practical matter, kids are likely to have some degree of unsupervised access to the Internet. Because of this, some policy-makers are exploring legal means to penalize individuals or groups that make inappropriate material available to children online. In other instances, political leaders have urged third parties such as Internet service providers to restrict access to pornography. Increasingly, the public expects technology to resolve the issue.

A new Research Council study will look at the advantages and disadvantages of different technical, social, and economic approaches to shielding children from online pornography, and whether these approaches could be used to control children’s access to other types of inappropriate Web content. It also will review how selected communities have dealt with the issue.

The study’s goal is to provide a better understanding of various policy options to inform the national debate. A final report is expected in spring 2002. — V.V. (See listing under New Projects.)


A Better Safety Net

Although the nation is experiencing record levels of prosperity and the longest period of economic expansion in its history, some 44 million Americans have no medical insurance, and the number is rising. To get treatment, many of these people must turn to the “health care safety net” — a loose collection of clinics, public hospitals, and public health departments around the country that provide a significant level of free care to the uninsured.

This increasing burden comes at a time when many health care providers in the safety net are finding it harder to break even, largely because of changes in Medicaid and eroding government subsidies. In combination, these pressures have put unprecedented financial strain on the safety net, says a new report from a committee of the Institute of Medicine.

To bolster the system and help safety net providers cope, the report recommends a new, targeted federal initiative. Competitive three-year grants could pay for facility improvements that would help providers strengthen their ability to survive, as well as pay for medical services provided to the most vulnerable populations.

While Congress and the administration would determine the size of this initiative, the committee estimated a minimum cost of $2.5 billion over five years. Money for this could come, in part, from the federal budget surplus and unspent funds from government efforts to expand medical coverage, such as the federal-state children’s health insurance program.

Because no single entity in the federal government currently has responsibility for tracking the needs of all safety net providers, the report recommends the creation of a government oversight body — one that is independent, nonpartisan, and expert. It would assess the health care needs of the uninsured, monitor the financial stability of the safety net, and evaluate the impact of changing government policies — particularly recent changes in the Medicaid program.

Medicaid — the joint federal-state program for the poor — is the largest single revenue source for most safety net providers. Over the past several years, almost half of the states began converting their Medicaid programs to managed care, and encouraged a greater range of providers to participate. While this kind of system has the potential to improve quality and give patients a choice of where to seek treatment, many safety net providers have suffered because the payment rates under managed care often are lower, and in some cases inadequate, the committee found. Additionally, the new competition has siphoned away patients.

To adapt to this changing environment, safety net providers have made improvements and emulated the competition — bolstering operating efficiency, administrative and information systems, and customer service, the committee said. Some also have tried to broaden their patient base to include those with better insurance coverage — balancing the provider’s survival against its traditional mission of serving the neediest populations. — N.T. & B.L.

America’s Health Care Safety Net: Intact but Endangered. Committee on Changing Market, Managed Care, and the Future Viability of Safety Net Providers, Office of Health Policy Programs and Fellowships, Institute of Medicine (2000, approx. 450 pp.; ISBN 0-309-06497-X; available from National Academy Press, tel. 1-800-624-6242; $42.95 plus $4.50 shipping for single copies).

The committee was chaired by Stuart Altman, professor of national health policy at Brandeis University, Waltham, Mass. The study was funded by the U.S. Health Resources and Services Administration, U.S. Department of Health and Human Services, the Commonwealth Fund, and the Medi-Cal Policy Institute of California.


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The Aging Mind

As the nation’s baby boomers move closer to retirement and health care improvements continue to extend life expectancies, the proportion of older Americans is growing faster than ever — and with it, concerns about how to maintain mental competence in one’s golden years.

Against this backdrop, recent scientific findings have shed more light on how aging affects memory, language, and other cognitive functions. For example, scientists have discovered that as people age, cognitive decline may be linked more with changes in the health of the nervous system than with brain cell depletion.

Advances in neuroscience, behavioral science, and cognitive science have opened the door for the development of techniques and technologies that may preserve mental acuity in older people and, in turn, improve the quality of their lives. These might be as novel as transplanting genetically engineered cells to replace dysfunctional neurons or as familiar as intellectual and physical activities to stimulate the mind and body.

A new report from a Research Council committee identifies three key areas where scientific gains have created opportunities for breakthroughs in understanding how aging affects mental capabilities: neural health, the role of life experiences in shaping the brain, and the structure of the aging mind. The report urges the National Institute on Aging (NIA), part of the National Institutes of Health (NIH), to pursue comprehensive research projects in these areas.

Because such studies cut across several disciplines, NIA also should consider new funding strategies that would encourage collaboration among behavioral, life, and social scientists involved in this work, the report says. Likewise, the agency should seek more opportunities to examine these issues with other institutes within NIH to make the most of federal research dollars. — V.V.

The Aging Mind: Opportunities in Cognitive Research. Committee on Future Directions for Cognitive Research on Aging, Board on Behavioral, Cognitive, and Sensory Sciences, Commission on Behavioral and Social Sciences and Education (2000, 288 pp.; ISBN 0-309-06940-8; available from National Academy Press, tel. 1-800-624-6242; $35.00 plus $4.50 shipping for single copies).

The committee was chaired by Laura L. Carstensen, professor of psychology, Stanford University, Stanford, Calif. The study was sponsored by the U.S. Department of Health and Human Services.


A Final War on TB

The fight against tuberculosis (TB) in the United States has been marked by an ironic neglect. At those moments when the tide of infection has receded — creating the opportunity to eliminate the disease — funding to support such efforts instead has been eliminated. Largely as a result of this neglect, the disease made a major comeback between 1985 and 1992. Even worse, often fatal drug-resistant strains of the disease emerged.

Fortunately, renewed control efforts sent TB into retreat as they once again began to address the highest priorities — identifying new cases of tuberculosis, and ensuring the completion of treatment. Now, cases in the United States are at an all-time low, dropping at a rate of 7 percent per year, and policy-makers once again face a choice. A new report from the Institute of Medicine urges them not to relax their efforts, but to aggressively pursue a policy to eliminate tuberculosis in the United States. A failure to finish off a fatal disease that is treatable and curable would simply be unacceptable.

The key to success is preventing cases before they occur, the report says. Often those who are infected don’t even know it, because TB can lie dormant for years. These latent infections are a reservoir for future outbreaks, and identifying and treating them will deprive TB of a safe harbor.

Roughly 40 percent of all new cases in the United States are among the foreign-born. Therefore, the report calls for aggressive new efforts to intensify screening of prospective immigrants from nations with high rates of the disease.

Under current procedures for entry, applicants for permanent residency are first tested for active, contagious tuberculosis. If an active but noninfectious case of the disease is suspected, entry is granted. Further testing and treatment is supposed to follow after arrival in the United States.

A better system would add a tuberculin skin test to identify latent infections when individuals from other countries apply for entry, the report says. Treatment for latent infection and active disease would then take place in the United States, and have to be completed in order to qualify for permanent residency. Implementing such a program would be a major undertaking. Funding should be a federal responsibility; Congress must make sure that local, state, and federal agencies get the needed resources.

Yet this will only address part of the problem. Those applying for temporary visas would not be covered. Currently, the government does not require them to undergo any medical testing, and setting up such a program would require further evaluation. But the report does encourage schools and employers to consider providing TB screenings and treatment.

In addition, an estimated 7 million foreign-born individuals already in the United States have undetected TB infections. Many may be citizens. Public health officials should work closely with community health organizations to conduct voluntary, culturally sensitive outreach programs to identify these individuals and get them treatment, the report says.

For other high-risk groups, such as inmates in correctional institutions, the report recommends mandatory skin testing. But for HIV-infected individuals, homeless people, substance abusers, and others at high risk of infection who would be very difficult to identify, public health officials should coordinate with community-based organizations in voluntary outreach efforts.

Beyond screening, the United States must recognize the global reality: While the TB epidemic is waning here, it rages around the world. The United States must take a more-active role in providing resources and research to fight the disease in those countries where it thrives. — N.T.

Ending Neglect: Eliminating Tuberculosis in the United States. Committee on the Elimination of Tuberculosis in the United States, Board on Health Promotion and Disease Prevention, Institute of Medicine (2000, approx. 260 pp.; ISBN 0-309-07028-7pr; pre-publication copies available from National Academy Press, tel. 1-800-624-6242; $45.00 plus $4.50 shipping for single copies).

The committee was chaired by Morton N. Swartz, professor of medicine, Harvard University School of Medicine, Boston. The study was funded by the Centers for Disease Control and Prevention.


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