Using public health policy to raise revenues

The City of Cagayan de Oro practices the principle of transparency in governance in the name of public interest. One way is to televise the City Council session proceedings held each Monday afternoon. Sly winks of some wits infer that the exposure also benefits the actors in the drama, but I have no objection to the expense (of some of my tax money) as I learn how laws are made despite the caveat that it is unwise to know how sausages and laws are made.
Watching one such session, several months after the current city administration took office, the new city health officer proposed a novel health measure to protect community health. The proposal required all workers in the city, not just commercial sex workers and GROs (euphemism for prostitutes) and those employed in food establishments, to undergo a pre-employment physical examination and obtain the requisite health certificate. The physical exam entails the conventional routines of stethoscope listening to breathing, heartbeats, and other sounds, knee tap jerks, eye-ear-nose (perhaps genitalia) scrutiny, and a chest x-ray allegedly as an anti-TB measure. The last item seemed to me unjustified.
Despite my self imposed equanimity to avoid excitement and stress, I decided to appeal to the conscience of the august body and wrote a letter to a levelheaded member:

Letter to a City Councilor

I write to express my concurrence with your stance on the proposed ordinance requiring TB X-ray tests for workers in private firms. You may find the data I offer here of some value in the next reading.
The X-ray machine is a diagnostic tool for detecting internal images in a body, usually to confirm a doctor’s diagnosis of an ailment. But as you pointed out, the x-rays emitted by the device which has great penetrating power, overexposure could cause harm: sterility, skin disorders, cancer and radiation sickness. X-rays, cosmic and gamma rays are known as ionizing radiation and have sufficient energy to damage living tissue by smashing into its atomic structure and ionizing it by dislodging electrons.
The electromagnetic spectrum of radiated energy waves starts with low-frequency audible sound waves, above which are (in order of increasing frequency) radio and TV wave bands, the microwave band (ovens and telecom), infra-red radiation, visible light, and finally “ionizing radiation”: ultra-violet radiation, x-rays and gamma rays. Only the last three are known to cause biological damage, although concern over the biological effects of microwaves and high voltage power lines are under serious study.
(Writer’s comment: this portion enclosed in asterisks was deleted from the actual letter)*** Exposure to ionizing radiation is expressed in rads and rems, and small doses in thousandths or millirads and millirems. Rad stands for “radiation absorbed dose” and is a measure of energy per gram of body tissue. Rem is the measure of the relative mutagenic potential, or, in other words, the ability to do biological harm to the genes. For example, each of us receives on the average about 84 millirems of background radiation from natural sources each year. A nonfluoroscopic chest x-ray by comparison delivers 20 to 60 millirems. A single dose of 600 rems or more produces acute radiation sickness, like that which killed thousands of Japanese in the two weeks following the bombings of Hiroshima and Nagasaki
It is known that the effects of ionizing radiation are cumulative. The first x-ray that you ever received is still with you today, and its effect is compounded by each subsequent dose. That’s why established standards are stated in terms of allowable levels over a given period of time. The maximum exposure level for nuclear workers, for instance, is currently 5 rems (5,000 millirems) per year. Some experts say that there may be no safe level of exposure.
Shoe store fluoroscopes existed in the U.S. in the 40’s, as a sales gimmick. When studies found that cases of radiation-induced leukemia tend to peak 7-15 years after exposure., shoe store fluoroscopes were outlawed in most states in the late 50s (Adage: Good judgment comes from experience and much of that comes from bad judgment). The U.S. Public Health Service said the average device emitted between 7 and 14 roentgens per dose, but one study found that some machines emitted as much as 116 roentgens. (For comparison, a person standing within 1500 meters of ground zero at Hiroshima got hit with more than 300 roentgens. To think that X rays were once used to treat benign enlargements of the thymus, tonsils and adenoids, for instance, triggering many cases of thyroid cancer. Pregnant mothers and babies were routinely fluoroscoped by pediatricians, causing leukemia.
High frequency radiation has the ability to displace electrons from molecules in the body, thereby creating ionized molecules that undergo chemical changes. If these transformations take place in the chromosomes, the result may be cancer, while if they occur in the germ cells (which produce ova and sperm) the result may be sterility or birth defects. Experts say that if you’re planning a pregnancy, get a physical examination first so that any necessary x-rays can be taken prior to conception. Or, if you know or suspect that you’re pregnant, avoid all x-ray examinations of the back or lower abdomen unless there is a strong indication of a serious condition.
A pamphlet prepared by the U.S. Food and Drug Administration in cooperation the American College of Radiology suggest that while X-rays are often needed to establish an accurate diagnosis, there are conditions in which they are not medically necessary. The pamphlet provides tips for consumers on how to help their doctors and dentists use x-rays appropriately. It also includes a record card that enables the patient to keep track of the x-rays he has, the doctor who orders them, the purpose of each examination, its date and where the films are kept. ***
Decades ago, the American College of Radiology, which represents 13,500 board-certified x-ray specialists, joined several professional groups in urging restricted use of routine chest x-rays for job applicants, admission to hospitals, tuberculosis-screening programs and other purposes. The basis of their position was a study of U.S. FDA’s Bureau of Radiological Health which estimated that about a third of the X-rays performed in the U.S. are unjustified, costly and were not needed, since there was little likelihood that they would detect a disease, or change its treatment or outcome if they did.
The rhetoric of the City Health staff is plain hype and thus unconvincing. The data offered, about 1500-1800 TB patients treated yearly (but not increasing), is inconsistent with their claim that TB contagion has a geometric progression rate (one person infects 200 others). The spread of the disease, if any, cannot be considered sufficiently alarming to justify the proposition to invoke “police power” of the state, and therefore is highly inappropriate and objectionable.
Inordinate reliance on X-rays for TB prevention is not rational ─ it poses undue exposure to radiation risks to otherwise healthy taxpayers, as well as being an onerous imposition on them. Since TB bacilli are airborne in transmission, wouldn’t a no-spitting campaign be a more effective and lower-cost preventive? (Certainly, not a no-spitting ordinance, as it would go the way of the no-urination drive)
Sincerity in public health policy can be cheaply effected, as one doctor admitted, by good nutrition. Simple nutritious food builds a strong immune system, and, if augmented with good sanitation and personal hygiene, would protect public health from TB and other pathogens.
I do hope you would persevere in your role as City Council conscience.

EPILOGUE
The all-embracing ordinance proposal finally subsided into Ordinance 8847-2003 requiring each worker employed in licensed City establishments to pay an annual fee of P150 assessed by their employer for city coffers, in effect mutating from a public health measure into a revenue generating imposition. Status quo for the prostitutes.

OFWs

The press calls it a “brain drain” when alarms sounded about hospitals closing down due to deserting doctors emigrating for better paying jobs abroad, a looming medical crisis. By this time, thousands of nurses had embarked on the rampant exodus for employment in the U.S. and U.K. Yet they are only the latest overseas Filipino workers (OFWs) joining the 8 million or so working overseas that remit the dollars home, the group of Pinoys praised as heroes for helping to keep the nation from going down the drain of economic disaster.
These intrepid jobseekers in alien shores have not always been appreciated. The ubiquitous Pinoy nannies in Hong Kong and housemaids in Europe were a source of embarassment for Filipino globetrotting glitterati. The majority of OFWs works in menial jobs but gets paid many times more than similar jobs locally. Work abroad means he or she must endure not just the travails of the job but also the loneliness of separation from family, disrupted social life, strange language and alien customs
The OFW influence on Philippine society has profound implications beyond their economic clout. The average Filipino family consists of the two parents and three children, a family of five. Thus the 8 million OFWs represent half of the country’s population of 80 million. These Pinoys are learning the mores and rules of their host nation, and adapt to them or risk losing their job, their freedom, a hand or even a head. Repatriating OFWs return from a developed country with a higher respect and appreciation of law and order, so their potential to enhance and enrich Philippine culture is enormous. This enlightened class just might become the reformed Pinoy middleclass that will spearhead the renaissance of Philippine society, with the hope and promise of banished corruption, dismantled political dynasties, and laundered dirty politics
The first recorded migration of Filipinos was made by a group of sakadas (plantation workers), who arrived in Hawaii in December 1906, to work in sugarcane fields. This wave may have originated the OFW trend. My maternal grandfather was one of them, but returned to start a family in Luna, a remote town in La Union, (otherwise I wouldn’t be writing this now.) Of the eight million overseas Filipinos it is estimated that 2.3 million have settled in the United States as permanent residents. To mark the centennial of these pioneering Filipino migrants, Senate Majority Floor Leader Francis Pangilinan filed Senate Resolution 389 recently to commemorate the event. "It is only fitting for the nation to honor this momentous event because the country owes a lot to our kababayans [countrymen] in Hawaii. They have tremendously helped the Philippine economy remain resilient and stable with their remittances and investments in the country," Pangilinan said.
I was once an OFW, of sorts, having worked for an international food company in East Africa for over a decade. I was one of the team of four (3 Pinoys and an American) sent from DelMonte’s Mindanao facility to pioneer an expansion at a site located in Thika, famed for its flame trees, Kenya. Personal experience taught me that the most challenging phase of work in a foreign land is adjusting to the local people rather than them to us.
But going back to the fear of a looming medical disaster, will there be a crisis in the healthcare system? I don’t think so. Before the so-called exodus up to the present, Filipinos perceive community health as the availability of medical workers -- the surgeons, dentists, nurses, medical specialists and even alternative practitioners such as acupuncturists, iridologists, and physical therapists. Health is also equated with affordable medicines (chemicals that alleviate symptoms but do not remove the cause). But, in reality, most individuals enjoy a healthy life and think of medical assistance only when they are ill. The ailments are usually minor, not life threatening and are healed by time, the vast majority being colds, flu, LBM, stomach upset and hangover (the last two caused by over indulgence). In such cases, there is no mad dash to the doctor, except perhaps the hypochondriac, in which case the doc usually prescribes an OTC (over the counter) non-prescription pill and plenty of bed rest. So, why is the exodus a cause of worry?
Perhaps general anxiety would disappear if the public was better informed, and government adopted and fostered a policy of preventive medicine, rather than the traditional curative mindset favored by doctors and Pharma firms. Prevention is economical because it consists of three components that are entirely under the control of each individual family (with a bit of government assist): Hygiene (basically washing of hands), sanitation (cleaning domicile and surroundings) and nutrition (eating a healthy diet). This means that if one must eat with one’s hands, wash them first, particularly after defecating, shaking hands or handling money. Sanitation means keeping disease carrying vermin and pests (rats, flies and mosquitos) away from the house by good housekeeping and proper garbage disposal. Nutrition means that if we have to eat anyway, choosing healthful foods. Even the cheap foods can be nourishing and enjoyable.
Okay, those three methods zap the bad bugs that cause infections which include such nasties as HIV, TB, dengue, malaria, meningitis, cholera, dysentery But how about the chronic diseases such as diabetes, heart disease, stroke, hypertension, cholesterol, arthritis, asthma, and cancer? Against chronic diseases, at least 80% of heart disease, stroke, and type 2 diabetes, and 40% of cancer could be avoided through healthy diet, regular physical activity, and avoidance of tobacco use.
. The concept is fundamental, easy to understand and apply, and best of all, cheap.
Note that in both infectious and chronic disease nutrition plays a vital role in prevention of disease. This is because food contains the chemicals that the body metabolizes to sustain the immune system that combats the development of disease. Medical science, particularly the pharmaceutical companies, synthesize chemicals from plants and formulate these into medicines that doctors prescribe (in appropriate dosage to avoid harm since all medicines are poison.) In comparison, Nature, over the millenia has been packaging edible plants into foods in dosages that can be dealt with by the human body.Begrudging the loss of doctors and nurses won’t stanch the outflow. Looking after ones health personally would be more productive, the DIY (do it yourself) principle.

Chronobiology

At about 4 A.M. I wake up and start my day. At first the routine is rigid -- flick on the hot water dispenser, wash face, boot computer, mix a mug of instant coffee spiked with powdered milk, sweetener and Ovaltine loaded with vitamins and minerals, then fill up the mug with hot water from the dispenser spigot. Next, I surf the Net on the computer while leisurely sipping the hot coffee. Two hours later at about six a.m. the stomach makes a few rumbling noises, a prompt to proceed post haste to the toilet seat. After doing my thing and washing up, I’m back in front of the computer ten minutes later.
At a quarter to seven, I turn off the computer to prepare for the first of the day’s chores, feeding my five pet mongrel dogs. Conforming to the tight schedule is accomplished without mechanical aids. Well, not exactly. I glance at the computer clock before signing off
At first I used an alarm clock to form into habit my sleep/wake cycle. After a few weeks, the body rhythm was set, and I wake up unaided, rendering the alarm clock redundant. The six o’clock rumbling prompt, however, initiated its own schedule and thereafter became quite demanding. I learned from experience that ignoring the schedule was messily unwise.
By this time my awe of the clockwork precision of the sleep/wake and stomach rumbling processes was compelling and decided to look deeper (mostly in the Web) into this phenomenon of involuntary body functions such as breathing, heartbeat, hunger, and, of course, the potty urge. The effort led to a fascinating adventure into chronobiology. It seems we humans (and other living creatures) have a natural body clock, and we can ignore it only at our own peril.

Tick tock goes the body clock
Modern medical science has an expanding branch of Chronobiology --- the study of rhythmic processes inside living creatures --- that has emerged as a new way of thinking about life and death. It is now known that all living creatures including humans, exhibit biological rhythms. Some are short and can be measured in minutes. Others last days or months. The peaking of body temperature is a daily rhythm; the menstrual cycle is a monthly rhythm.
The master timekeeper in our bodies helps synchronize us with such cycles as day and night and coordinate hundreds of functions inside us. A biologist specializing in circadian rhythm says the body maintains billions of internal clocks that regulate daily peaks and troughs of blood sugar level, enzyme production, hormone synthesis, temperature, heart rate, metabolic pathways, sleeping and eating patterns, and mental acuity. There isn’t a function in our bodies that doesn’t have its own rhythm. The absence of rhythm is death.
All of us follow a general pattern of peaks and troughs, but the exact timing vareies from person to person. A lack of awareness about these rhythms can aggravate medical symptoms and hinder early diagnosis. By studying and increasing our knowledge of our individual rhythms and let them set the pace of the day we can enhance or reduce risks to our health, and live a happier life by organizing ourselves to work with our natural rhythms
Best (peak) times of the day:
Morning – cognitive tasks, manipulating words and figures mentally
Afternoon – manual dexterity, body temperature, learning for long term memory, memorizing speeches; peak adrenalin and cortisol, hair and nails grow fastest
Afternoon to early evening – coordination and response, peak sense perception of taste smell, sight, hearing and touch, liver active
Midnight to early morning -- short-term memory (cramming)

Although chronobiology is not new to medical science, it's still in the process of being accepted by the medical community. That's because most doctors are not taught about chronobiology - they are taught something that seems to contradict it. The prevailing concept taught in medical schools is one of homeostasis, meaning that the body is held constant.
The worst time of day when health risks are greatest is from 6 a.m. to 10 a.m. the time when heart attack and stroke is most likely to occur, and also for asthma, bronchitis, cancer and emphysema.. The danger of heart attack happening two to three hours after awakening is explained this way. While sleeping, blood pressure and temperature drops. But when awakening come morning, the body gets a surge of chemicals called catcholamines. Heart rate increases and blood vessels constrict, raising blood pressure and reducing blood flow to heart muscle and might cause ischemia or angina, even sudden death from myocardial infarction. At this time, the blood is near its peak in thickness Blood platelets are most likely to stick together and tend to clot. If arteries are coated with hardened plaques of cholesterol, some fragments may break loose and cause the clots leading to heart attacks. The stress of preparing for work and sending kids to school adds physical stress and emotional tension.

In The Body Clock Guide To Better Health, the authors list more than 30 conditions and diseases affected by body rhythms, and the worst times of day for certain symptoms:
Midnight-6:00 a.m. – Asthma, Migraines, Gallbladder attacks, Heartburn, Kidneys slow down urine rate so lower dose of medication; slow saliva secretion allows bacteria to grow and mouth stink
6:00 a.m.-noon - Hay fever, Rheumatoid arthritis, Heart attacks, Immune system weakest, Noon-6:00 p.m. – Osteoarthritis, Blood pressure, slowest reaction speeds,
6:00 p.m.-midnight – Backache, Skin irritability
Chronobiologists have found that the severity of symptoms varies throughout the day. By keeping track of these variations one can schedule doctors' appointments and daily activities like exercise, at optimum times.
Franz Halberg, M.D., who is known as the father of chronobiology and who coined the term circadian rhythms, says blood pressure readings, which vary throughout the day, provide an example. "At a yearly doctor visit, a single blood pressure reading can be perfectly normal. You can be completely asymptomatic at the time, but still be at high risk for stroke," says Dr. Halberg.
One of chronobiology's most significant impacts on medicine is chronotherapy, the synchronization of drug delivery with body rhythms. This involves both restructuring the times of day existing medications are taken and developing a new breed of "body time-savvy" drugs called chronotherapeutics. "Certain ones have special drug-delivery technology -- their release is synchronized to the peaks in the disease symptom cycles to help manage symptoms more effectively," says author Smolensky.
"We should be tracking our moods, our alertness, and even our children's sleep cycles". "Body rhythms are part and parcel of our existence." By staying in tune with the most important clock of all, we can lead a healthier, more harmonious life.

Travel over many time zones creates mental dissonance. Jet lag lethargy is a striking example of the disruption of the circadian rhythm, as modern-day travelers experience when they fly over many time zones. Airlines have exerted steps to minimize the discomfort (it cannot be eliminated), partly through the diet. The theory is that protein meals trigger the body’s production of catecholamines, chemicals the brain needs for activity. High carbohydrate foods increase the levels of serotonin and tryptophan that help the body fall asleep.
According to experts, jet lag is most severe in people past 45 years of age, exactly such groups as diplomats and businessmen travelers entrusted with important political and business decisions.
The body’s circadian clock is controlled by the hypothalmus, a tiny structure in the brain.. Through a complicated series of molecular processes, it serves as a pacemaker for a variety of cyclical functions, including sleep-wake cycles, body temperature and the secretion of hormones like melatonin, a substance secreted by the pineal gland, a peanut size structure in the brain. It is known to control the biological clock and instrumental in establishing the daily rhythms.. Melatonin secretion drops with ageing, and by age 60, is only half the amount produced at age 20. Coincidentally, there is a growing enthusiasm for taking a food supplement containing melatonin believed to slow down ageing, boost sex life and inhibit growth of cancerous cells.
“All drugs are poisons, what matters is the dose” - Paracelsus, Swiss doctor, early 1500
For example, the modern wonder drug Botox popular in cosmetics is derived from the botulism toxin (a hazard in the canning industry) a deadly substance even in minute amounts. When doctors prescribe drugs, the Rx includes intructions specifying how often and how much dosage is to be taken, often with the words “with meals” to regulate absorption. However, it ignores the ups and downs of the body clock that can optimize the effect of the drug if synchronized with cirdadian rhythm.
The myth of the existence of “larks” or morning people and “owls” or evening people has been proved true and confirmed. Morning people show heart rates peak between 1 and 2 p.m. while evening people peak between 5 and 6:30 p.m. Larks perform best during morning hours when their adrenalin stimulant production is highest. Owls improve performance towards evening.
In earning a livelihood, some are required to work shifts --- regular (8a.m. to 4 p.m.), night (4p.m. to midnight), graveyard (midnight to 8a.m.). Many contracts between a company and its labor union have collective bargaining agreements that specify rotating workers to the cycle of three one-week shifts. According to chronobiologists, this has adverse effects on the workers, as they don’t get a chance to adjust to their cycles of the previous week. But many organizations have schedules that suit their operations but ignore the effects of workers’ circadian rhythm on individual efficiency and alertness. Shift work is suspected as a prime cause of accidents, notably the Chernobyl nuclear disaster, Bhopal blast, Three-Mile nuclear accident and the Exxon Valdes grounding oil spill.
Even the 5-day work, and certainly the Ate Glue extended holidays policy, tend to create disruptions to body clocks of working individuals during weekends. The break from work tempts them to enjoy the weekend and make sudden changes to the normal weekday routine schedule of mealtime, work and sleep, by staying up late Friday and Saturday.
Studies also show that body clock woes may lead to some chronic diseases, notably diabetes and obesity. Personally, I have long ago learned to obey my body signals and prompts, and that old dogs can learn new tricks.

Introduction to Winks and Blinks Blog

Upon retirement, I took up writing as a hobby to stay active mentally. I wrote a weekly article in a tabloid paper but quit when I sensed that my written opinions were not in harmony with the advocacies of the paper’s publisher. Since then, I would express my opinions and rant in an occasional letter to a newspaper editor on some current hot issue. Now it seems that the writing bug has inflicted an op-ed relapse. Blogging is my latest mode of shouting in the wilderness. “I shot an arrow into the air. It fell to earth I knew not where.” Who knows, someone may even read the blogs titled Winks and Blinks. As in the tabloid articles, the topics are free wheeling and free-style, but usually of public interest and at times of an emerging issue.
In my college days, idle hours were whiled away filling in crossword puzzles. No doubt the pastime helped build up my vocabulary, a golden passport to college entrance and pre-employment tests in the mid-20th century. Now that chronobiology has converted me into a social class which polite society labels as senior citizen (instead of fogy, senile, senescent, fossil or some such colorful epithet), I detect a occasional loss in my grasp of some words, perceptively the early warnings of memory loss and harbinger of senility, dementia or Alzheimer’s (the long goodbye). Searching for remedies, I recall the admonition of a grade school English teacher about vocabularies --- use the word three times and it’s yours; if you don’t use it, you lose it. Using mnemonics helped a bit. Writing e-mails to friends and relations, letters to editors, and articles in an op-ed column accomplished much more. It demanded frequent trips to consult the dictionary, but the effort provided an incidental health bonus: exercise. The activity reduced couch potato time gawking at TV.
Surfing health websites about the ageing brain and memory confirmed that an active brain does stave off memory loss. Medical research found that the brain is like a muscle --- the more you use it, the stronger it gets and it stays strong longer. A brain stimulated by reading, learning and other activities requiring thought and imagination helps avert memory loss, although illness such as diabetes, stress, insomnia, high cholesterol and high blood pressure, even prescriptive medication, cause memory to deteriorate with age.
In the foreword to Winks and Blinks, wink is defined as “to close one eye momentarily in teasing, frivolous or flippant manner.” A definition of blink is omitted, but it is a means of communicating non-verbally by body language usually by closing and immediately opening both eyes. Its use as a signal was cited in a recent U.S. TV news snippet that showed a gravely ill woman in a coma. She was in this state for several months and was kept alive with liquid food via a feeding tube. Although in comatose state, she was aware of what was happening around her, seeing and hearing but unable to communicate verbally. Authorities decided her case as hopeless and detached the feeding tube to let her die. For eight days the tube was detached. All this time the husband resolutely disagreed, and threatened a lawsuit if the feeding did not resume, forcing a reattachment of the feeding tube. Her husband, as a last desperate resort, tried to talk to her by asking questions and telling her to blink in reply, indicating a “yes”. It worked and she made a full recovery. She said each blink was extremely exhausting and needed several minutes to rest between blinks.
Another meaning of blink in the context of Winks and Blinks articles is “to look with surprise or dismay” My profile? I am a bloody Flip, the pejorative word for Pinoy or Filipino (a native of the Philippines) as denigrating a word as the Ugly American WASP --- white Anglo Saxon protestant. You bet I am a senior citizen, as grumpy as they come and proud to be one, senior that is. But pride cannot replace the nostalgia of remembering dear friends and kin who have departed this life, who enriched my own life by inspiring me with their virtues and humbling me with their faults. Sure, longevity is a privelege but has drawbacks, I suppose. No more poker or bridge playmates.