References to the human papillomavirus (HPV) vaccine and cervical cancer have become inescapable on television, at the doctor’s office and online. And until recently, young women have been the only ones targeted in the push for HPV vaccination.
Rhonda Dyar, nurse manager of the health department in rural Hart County, Ga., says this hype surrounding HPV immunization definitely influences patients who come to her clinic.
“People will ask about the vaccine because they’ve seen it on television,” said Dyar. “When [they] refuse it, it’s because they’ve heard false information.”
What her patients aren’t talking about – and what isn’t mentioned in ads – is that HPV is a health concern for men as well as women.
Half of all sexually active women and men will be infected with HPV at some point in their lives. Most will never know since these infections usually come and go without a sound.
However, two strains of the virus are to blame for cervical cancer, 90 percent of anal cancers and a small percentage of other genital cancers that occur in both sexes. Two others are associated with most cases of genital warts.
Despite this and the fact that the CDC’s Advisory Committee on Immunization Practices (ACIP) allows physicians the option to vaccinate males, Dyar says she’s never been asked to administer an HPV vaccine to a male.
But now a study shows that HPV immunization protects men and boys – in addition to women – against infection.
The international study found that the vaccine Gardasil – designed to thwart infection by the four strains of HPV that cause warts or cancer – prevents initial HPV infection and genital warts in males aged 16 – 26. The report was published in the February 3rd issue of the New England Journal of Medicine.
Blocking HPV infection in males could reduce HPV-related diseases in both sexes, says Dr. Joel Palefsky, an infectious disease specialist at the University of California, San Francisco, and one of the lead researchers.
So the next step is to vaccinate everyone, right?
It’s not that simple, according to Jane J. Kim, an assistant professor of health decision science at Harvard University.
The decision to universally vaccinate depends on several factors, with cost effectiveness being the ultimate influence. And right now, she says, it looks like vaccinating both sexes is not the most effective use of health dollars.
“For the prevention of cervical cancer, vaccinating young girls is where you get the most benefit,” Kim said. “Boosting their vaccination rates would be most cost effective.”
The percentage of fully vaccinated girls in the United States is low, under 30 percent, but has been rising. As long as those rates continue to increase, Kim says, vaccinating boys won’t add much benefit for the money being spent.
But if uptake in females remains static or drops, it makes more sense to vaccinate boys along with girls. Cost effectiveness could also increase if vaccine prices go down or if proof of their benefits continues to grow.
And the benefits do appear to be growing.
While ACIP currently recommends routine HPV vaccination only for females, the FDA recently approved the vaccine for prevention of anal cancer, which is most common in men who have sex with men. Since it’s hard to target that high-risk population, and since vaccination is most effective before sexual activity begins, many say the solution is routine immunization of both sexes at an early age.
“If ‘all’ you’re doing is preventing genital warts, then it’s probably not cost effective to vaccinate boys for that,” said Palefsky. He hopes the new data on vaccine effectiveness in preventing anal cancer, along with reassessment of the cost effectiveness model, will encourage ACIP to recommend the vaccine for routine use in both sexes.
Implementing routine vaccination of males, however, is easier in theory than in practice, especially for populations already experiencing barriers to HPV prevention. In Southern and rural areas HPV vaccine coverage is lower and cervical cancer rates higher due to poor access to health care, low health funding and inadequate health education.
In Hart County, the cost of vaccination and not understanding the risks of HPV can affect vaccination rates, says Dyar. HPV vaccines are among the most expensive, and the health department is one of the only places to provide affordable vaccine options.
Dyar also believes it would be challenging to persuade parents and young men to vaccinate for HPV. Males tend to avoid medical attention anyway, she says, and sexually transmitted infections carry a stigma. And that stigma might double in rural areas for the other target population – men who have sex with men.
Overall, Dyar says, patients often don’t grasp the real meaning of HPV infection and how vaccines can prevent it as well as related diseases.
The answer to such barriers, Palefsky says, is education. “People need to understand better the connection between HPV and the diseases that we’re trying to prevent.”
For the last few months, students from Prof. Patricia Thomas’ Health and Medical Reporting class and Mark E. Johnson’s Documentary Photography course have been collaborating on stories looking at health care issues in the rural counties around Athens. Through words, photos, audio and video, they have investigated the issues of concern around the area, from athletes to gangs, teen pregnancy to aging.
- Danielle Moore looks at the life of a high school student with a baby who still wants to go to college.
- Just out of high school, a new father prepares to enlist, reports Seth McKelvey.
- Teen pregnancy rates are cyclical so Parents as Teachers tries to use education to break the cycle reports Brian Miller.
- While the numbers of gang members have fallen over the last decade, James Hataway looks at the ongoing issues with them through the eyes of the Boys and Girls Club.
- More than 4,000 kids, some of them former gang members, are part of the Boys and Girls Club as they search for a family and a healthier life, reports Laurie Moot.
- Three dots tattooed near her eyes indicate the gang life a Gainesville woman used to be a part of, reports Allison Carter.
- Autumn McBride reports that mental and emotional stress from gang membership can have a long term effect on the health of teenagers.
- Tommy McGahee reports that the AARP has stepped in to help out with activities at the local senior center.
- The money side and the people side in the decision to cut the number of hours a senior center is open reports Beth Farrar.
- Finding stability and remaining a member of society is a struggle for a local resident, reports Jacqueline Reedy.
- Beth Cooper looks at how Florence’s Manor has helped a woman find balance and purpose in her life.
- Time in jail can cause depression, but mental health issues are also a reason for being incarcerated according to inmates interviewed by Charles-Ryan Barber.
- Marona Graham-Bailey reports on the shortage of mental health professionals.
- With the largest population of older adults in the South, Brian Creech reports Georgia residents are finding ways to age gracefully.
- At Highland Hills, Patricia Andrews reports that exercise is key to happiness and health.
- Rachel Bailey finds that social activity and friendships help keep senior residents healthy.
- Lesley Onstott reports that art programs that enhance creativity can promote health and longevity for seniors.
- Anna Doliantis looks at the challenges of rural emergency medical services and the turnover rates of personnel.
- Safety for student athletes is a primary concern as Olglethorpe County High School doesn’t have a full time medical trainer, reports Dorothy Kozlowski.
- Jim Diffly reports that emergency medical service personnel are training more to maintain a high quality of service because of both a low number of calls and the 18 mile distance to the nearest hospital.
The Internet plays a major role in the lives of adolescents, and approximately half of them use online social networking Web sites such as MySpace.
“One of the concerns about teenagers using social networking Web sites is the worry about them attracting unwanted attention,” said Dr. Megan Moreno, assistant professor of pediatric and adolescent medicine at the University of Wisconsin School of Medicine and Public Health.
Moreno was lead author of a pair of studies on teens and their display of health risk behaviors in a past issue of Archives of Pediatrics and Adolescent Medicine.
Her research team found that more than half of teens who use social networking Web sites display health risk behaviors in their profiles, such as making references to sexual behaviors and substance abuse.
“Media is a very powerful influence on teens, and teens learn what normal attitudes and behaviors are from watching television,” said Moreno.
“So when you combine those and say ‘here is a form of media created and displayed by other teens,’ now you have what’s often called a ‘super peer.’”
Latraveon Burton, a 15-year-old from Hull, Ga., understands this phenomenon.
“Some people describe themselves totally different than what they are,” Burton said.
Although Burton does not have a little sister, he said if he did, he would carefully monitor her activity on MySpace.
“It depends on who she was talking to,” he said. “I wouldn’t want her to talk to older boys. I wouldn’t want her to pick up any ideas of what she sees on other people’s pages.”
He whispered the word “sex” as one of his concerns, and drugs as another.
Latraveon has been using MySpace since the summer when he set up his account with his mother.
His mother, Shantika Burton, 35, a departmental secretary for Athens Regional Pediatrics, supervises her son carefully.
“I get him to pull it up and check it,” she said, “and make sure he’s using the appropriate stuff on it.”
Latraveon’s mother does not like him using profanity, and you won’t find references to sex or drugs on his profile.
“She knows who my friends are and what they are saying,” said Latraveon. “She makes sure they aren’t saying anything bad.”
But not all parents monitor their teenager’s computer usage closely.
“Of all the things that parents monitor, in terms of television, and where their kids are, Internet behavior is one of the lowest,” said Moreno. “Parents really are not doing supervision in terms of Internet use.”
In Madison County, Ga., where Hull is located, Web sites such as MySpace cannot be accessed from school grounds.
“Social networking Web sites are blocked,” said Martha Vaughn, media specialist at the Freshman Academy, where the ninth graders attend separately from grades 10-12.
“They’ve been blocked for as long as I can remember,” said Vaughn, who has been working in the Madison County school system for close to 15 years.
MySpace can be accessed from the Madison County Library in Danielsville.
Other than the filters on the computers themselves, there is no supervision of what teenage patrons do on the computer, said Jennifer Ivey, youth and outreach specialist at the library.
“If a parent is letting them come into the library unsupervised, and they are aware that they have access to the computers,” Ivey said, “it’s out of our hands.”
Though there are some health risks to using social networking sites like MySpace, the sites themselves are not inherently dangerous, Moreno said.
“It’s not that MySpace is bad and we need to shut it down,” she said. “These sites, they can’t be good or bad. The way that you use them determines what kind of outcome you are going to get.”
Latraveon said he uses MySpace mostly to talk to his friends and listen to music.
Moreno suggests that parents look at MySpace as a tool. “Instead of just saying this is all bad,” she said, “say ‘how can I use this tool?’”
Much like how Latraveon and his mother pull up his MySpace profile together, Moreno suggests parents share the MySpace experience with their teenager.
“After dinner some night, sit down in front of their profile and say ‘hey show me what you like, show me what your interests are,’ and spend
some time saying ‘hey, I didn’t know you liked that movie. I didn’t know your friends are doing this.’” Moreno said.
“That way if you do see something that is dangerous, you’ve got a little more clout to talk to them about it, because you’re showing them that you’re interested in them as a person not just, ‘what can I snoop on your profile to get you in trouble?’”
“Treat MySpace like everything else in your teen’s life,” Moreno said. “And that’s to be involved, be supportive and provide guidance.”
MADISON COUNTY, Ga.– The depression she’s talking about is deeper than sadness, said Amanda Bass. “It’s hopelessness, helplessness,” she said. “It’s faithlessness. It’s not believing that you’ll ever get better.” Bass, 32, has bipolar disorder, a mental illness characterized by mood swings, ranging anywhere from severe depression to mania. Bass remembers struggling with the disorder since she was eight years old. “I cried a lot,” she said. “I wasn’t able to have a happy childhood.”
The National Alliance on Mental Illness estimates that six percent of Americans suffer from serious mental illness. Bipolar disorder accounts for more “years lost due to disability” than heart disease or cancer, according to the World Health Organization, which rates the disorder as the sixth leading cause of disability worldwide. Research supported by the National Institute on Mental Health found that in a given year’s time, 60 percent of individuals with mental illness will go untreated.
This is especially likely to happen in rural areas like Madison County, Ga., where Bass now lives. The federal government has officially designated the county as a place with a shortage of mental health professionals. Hospitals and doctors are available in nearby counties, but these are far away and a ride is not always easy to find. As a result, people with mental illnesses often get the wrong care or no care at all.
In a state that ranked 45th in overall state agency mental health spending in 1999, budget cuts continue to be made to the Georgia Division of Mental Health, Developmental Disabilities and Addictive Diseases, including for this 2009 fiscal year. “We are in a crisis,” said Advantage CEO Cindy Darden.
Madison County is one of 66 rural Georgia counties underserved in the area of mental health. “There are a lot of communities where they have no mental health professionals at all, in any capacity,” said Katherine Cummings, executive director of the Georgia Rural Health Association.
For Bass, who grew up in Millen, Ga., the closest child psychiatrist was an hour’s drive away in Augusta. Such specialists are still in short supply – no matter where in Georgia a family lives – but in rural areas, “the shortage is exacerbated,” Cummings said.
Georgia Department of Human Resources outsources Madison and 9 other counties’ mental health care to Advantage Behavioral Health Services, a private company. But in Madison, the only facility it operates is for developmental disabilities. People who have mental illnesses must travel –sometimes more than 25 miles.
For most of Amanda Bass’s life, being physically distant from medical treatment has been a fact of life. For years, her parents drove from their home in rural Jenkins County to Augusta so she could be seen by a specialist. Twenty years later, not much has changed. “If you’re able to see somebody,” said Cummings, of the rural health group, “most likely you are making a commitment to travel out of town for all of your treatment.”
Bass was a teenager when she and her family found a doctor closer to home. A psychiatrist who mostly treated adults accepted Amanda as a patient, and she discovered that having a doctor nearby made all the difference. Through a great deal of trial-and-error experimentation, they eventually found a combination of medications that effectively stabilized her mood. “If it didn’t do right,” Bass said of the drugs, “I would go see him and we would try something new.”
“In 2004, I found the cocktail of all cocktails,” said Bass. Although she still struggles with maintaining a job and is currently without one, Bass said she functions much better than she used to, especially in terms of managing her own finances. “It made me feel like I was being an adult finally,” she said. Bass also finds that she tends to her hygiene better and pays more attention to her physical appearance. But not everyone with bipolar disorder has attained the level of stability that Bass has.
NIMH reports that as many as one in five bipolar patients with bipolar disorder commits suicide. “If you look at rural communities,” Cummings said, “most of them are not equipped to deal with severe mental health emergencies” – such as the threat of suicide or actual suicide attempts. For individuals with mental health emergencies where there is a significant distance between their home and the closest mental health provider, unfortunately, emergency rooms must often serve as a holding-station.
EMS has only one option of where to transport patients who have not been medically cleared due to injury or mental state, said Jody LaDuke, a paramedic at the Madison County EMS in Danielsville. “We can’t take anybody, no matter what the problem is, anywhere except for an emergency department,” he said.
“The ER is not where people need to go for mental health services,” Cummings emphasized, but there are often no other options in rural areas. “People end up where they are not supposed to be,” Cummings said.
Jails are another one of these places. The Georgia Sheriff’s Association estimates that at least 20 percent of those incarcerated in county jails have a serious mental illness such as bipolar disorder. “We do have some that definitely have mental illness,” said Capt. Danny Bennett, who supervises the Madison County Jail.
Bass has been to jail more than once, though never for more than 24 hours. In 2002, when she was living in Tennessee, her roommate called the police. “I became extremely violent when I was off my medication, and I ended up assaulting my roommate at the time,” Bass said. Because she did not have an extensive record, Bass was not charged and released the same day.
In Madison County, Bennett said, the jail can petition to have a judge issue a court order to transport inmates who are a danger to themselves or others to the Augusta State Medical Prison, two hours away, where psychiatric services are available.
A new state bill was recently passed on May 4. HB-228 calls for the creation of a Department of Public and Behavioral Health from the Division of Mental Health, Developmental Disabilities and Addictive Diseases and the Division of Public Health. Set to become effective on July 1, the bill would bring higher visibility, more leverage, and better advocacy to mental health issues, Darden said. With more attention focused on mental health issues, for residents like Amanda Bass, effective mental health treatment could become the standard of care.
BOGART, Ga. – Lil Berry is a petite, white-haired lady of 87 whose mint-green dress matches her living room chairs. “I’m fortunate in my life,” says this retired Air Force nurse and survivor of both breast and liver cancer. “I’ve seen a lot of things and I’ve been well taken care of.” Newspaper articles and photos detailing Berry’s time as an army wife and nurse are scattered on the living room table and the rich smell of brewing coffee fills her apartment at Highland Hills.
Berry’s daughter, Sandy Berry, emerges from the kitchen with a cup of coffee in each hand. “Mom is a true optimist,” she says, “and that seems to have carried her through quite a bit.” Sandy lives only a mile away from Highland Hills and visits often. She sometimes stays overnight in her mom’s apartment, and the two go out to dinner or on a family outing at least once a month. “That has been good for all of us,” Sandy says.
Georgia has the largest population of older adults in the South, according a report compiled by the University of Georgia’s Institute of Gerontology. As in other parts of the country, the growth of this population outstrips the growth of healthcare services they’ll need during the coming decades. Georgia ranks 45th in terms of the physical and mental wellbeing of it’s elderly residents, and Georgia’s annual Medicaid allocations, per person, are $100 below the national average,
Although those numbers sound bleak, some Georgia residents are aging gracefully in clean, well-lighted places like Highland Hills, an assisted living complex in Oconee County, just outside Athens. The catch is that living in a place like this can cost more than $2,000 a month.
Berry and her late husband, Army Colonel James Berry, were not rich. But they were thrifty and they planned ahead. . The couple retired to Black Mountain, N.C. in the early 1980’s after being stationed in such far-flung places as New Guinea, Germany, and Japan. After James passed away, Lil kept living on her own and made smart financial decisions that allowed her to remain independent.
Then seven years ago, when Berry was eighty, she was diagnosed with an autoimmune disease and decided it was time to move closer to her children in Georgia. She sold her home in Black Mountain and moved to Iris Place, an independent living complex on the edge of Athens, GA. Amenities for apartment dwellers include a gym, attractive communal dining room and housecleaning service for apartment dwellers.
Berry loved the community at Iris Place, but didn’t always want what the chef prepared. Two years ago she relocated to Highland Hills, an independent living facility that also offers cleaning and communal meals, but where Berry also has a kitchen of her own. Highland Hills also has a personal care wing that she could easily move to if her mobility and health decline.
Living in Black Mountain, a mecca for retirees, it was obvious to Berry that many of her friends were finding it harder to get around on their own, and harder to keep up with home maintenance. People canceled bible study meetings and sometimes refused to even walk to the mailbox when it snowed. Berry did not want to live like this, so she and Sandy began researching independent living complexes near Athens.
“I would recommend to anyone in their eighties that they move into a retirement home,” said Berry. “A house comes with so many responsibilities, and when things break, it becomes a stress just to keep up with it all.”
At Highland Hills, the minimum monthly charge for a one-person apartment is $1,774; for a couple the cost is $2,119. These prices include transportation to the grocery store and doctors’ appointments, maintenance and gardening, dinner in a communal dining room, optional laundry and housekeeping services, regular social activities, 24-hour emergency care staff and an emergency call system in bedrooms and bathrooms.
For the Berry’s, on-site emergency care and call systems provide a sense of security. Highland Hills is part of the St. Mary’s Health System, and emergency medical transport to the hospital is there when needed. Lil called the ambulance once, when she was struck by a serious case of flu. “Most people hate the hospital, but it is a good place to be when you need to be there,” Lil said. After a serious bout, she was back in her apartment within a week. Lil and Sandy don’t like to talk about what an abrupt downturn in Lil’s health would mean, especially if she needed to move to a nursing home.
Nursing homes routinely get a bad rap from marketers and managers for independent living centers, who praise their facilities’ superior sense of community and quality of life. “I’ve managed independent living centers, I’ve managed assisted living centers and I’ve managed nursing homes,” said Ron Cox, an administrator at Iris Place. “Let me tell you this: there’s something about a nursing home that just makes people give up.”
Nursing home residents experience more depression, pain, incontinence and mobility impairment than adults living at home or in assisted care, according to a team of Chinese and American researchers led by public health Professor Jye Wang at Chang Jung Christian University in Taiwan. These factors impair daily activity levels, which worsens mental health the researchers report in the February 2009 issue of the Journal of Gerontology, a quarterly journal published by the Gerontological Society of America. Although the researchers speculate that people who move into the nursing home from some other type of group facility may experience less depression, they haven’t established this. It makes sense to Ron Cox, however, whose experience is that an abrupt transition from complete independence to a skilled nursing facility can be traumatic. He believes that independent living facilities offer a more gradual transition.
Individual and family attitudes largely determine how well people do in assisted living, said Beth Guthrie-Johnson, the sales coordinator for Highland Hills. “If the people who live here see it as a way to maintain their independence, then they tend to live longer and be a bit happier.” Families who see nursing homes as cold and impersonal, a setting to be avoided as long as possible, often perceive the progression from independent living to assisted living as a highly desirable alternative. If people move in before they experience too many problems, like Berry, they have more tools help them stay independent.
Berry navigates her apartment with ease and cook what she wants without worrying about home maintenance. Several of her less-mobile neighbors get around thanks to walkers, respirators, wheelchairs, automatic scooters or human help.. They view caregivers and devices not as burdens, but as ways of staying in command of their own lives. “Even when people pay someone to take care of them,” said Cox, “they still exert a bit of their own independence.”
When staying in their own apartment no longer makes sense, Highland Hills residents can move into a personal care unit that provides daily assistance with bathing, dressing and medication, as well as three prepared meals each day. “We offer built-in levels of different care,” said Guthrie-Johnson. Though Lil and Sandy Berry don’t talk about this very often, one reason Lil moved to Highland Hills was the assurance that should the need arise, she could move easily from independent living into personal care without leaving the building, let alone the county.
Even in Oconee County, whose citizens have the highest per capita income in the state, not everyone will be able to afford Iris Place or Highland Hills. Only people who can write a monthly check for $2,000 or more live at Iris Place, although military veterans get a discount and VA benefits sometimes help with costs.
Most Highland Hills residents also pay their own way, although certain long-term care insurance policies cover assisted living facilities like this one. “The type of people who want to come here know whether or not they can afford it,” said Cox. “We’ve never had to turn anyone away based on lack of funds.”
It is often said that money can’t buy happiness, but maybe that is not universally true. Money, at least, buys more options.
Family members, elderly adults, caregivers and medical professionals share the belief that older people are healthier if they have autonomy and self-determination, according to a survey conducted by University of Texas medical ethicist Dr. Eugene V. Boisaubin, Writing in the Summer 2007 issue of the Journal of Medicine and Philosophy, the authors emphasize that people who depend on Medicare and Medicaid can’t afford upscale retirement homes, and typically rely on their families for care.
“I work, and I know that I could not give my mom the type of care and independence she has now if she lived with me,” Sandy said. Lil, like many of the other residents at Highland Hills, has a private caregiver who helps clean her apartment, prepare meals and take Lil on errands. “She pampers mom,” said Sandy, “but I think a fair bit of pampering can be healthy.”