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Temporary trailers at Minneapolis site will house bodies. Live ones.

It was an understandable misunderstanding.

The list of planning applications made to the city of Minneapolis included a request to put four temporary trailers in a parking lot next to The Depot on Washington Avenue South for something called a Medical Examination Center. 

A Medical Examination Center? Might this have to do with recent reports of overcrowding at the Hennepin County Medical Examiner’s office? Could it be a plan to create more morgue space? Thanks to The Depot’s skating rink, there’s already ice-making equipment on site, after all.

The answer is interesting, just not that interesting. Though similar in name, the “Medical Examination Center” and the “Medical Examiner’s Office” are as different as night and day. Well, life and death, anyway.

Starting next month, once the elaborate complex of trailers are installed beneath the former Milwaukee Road train shed, federal medical personnel will begin measuring the health of Hennepin County residents. Hence the need for a Medical Examination Center. 

It’s all part of the National Health and Nutrition Examination Survey, a service of the federal Department of Health and Human Services, and taken since 1960 to gather data on the overall health of Americans. After sending an introductory letter to residents in 15 randomly selected areas of the county, surveyors fan out to conduct in-person interviews. Some of those interviewed are then asked to head to the trailers for testing: body measurements, blood tests, urine samples, hearing tests, lung tests, dental exams.

So these aren’t just ordinary trailers. They include labs for the taking and analysis of those samples, a dental office, examination rooms and rooms to take hearing and lung tests and to conduct body measurements like height, weight and bone density.

Participants are compensated and receive reports on the examinations. If a health issue is found, the staff makes referrals to local health providers. “It’s good stuff,” Hennepin County Public Health Director Susan Palchick said of the data collected by the survey. “It’s used quite a bit in public health.”

It is from the collection of this data that the federal government estimates the prevalence of public health problems, which are used to form federal health policies and programs. The data is also used by health researchers and has been used to identify previously unknown conditions, such as the presence of lead in children or the increase in diabetes. The body measurements of children were used to create the growth charts used by pediatricians.

Hennepin County will be one of 15 counties in the United States surveyed this year. More than 5,000 people will be examined across the country. Palchick said the program in Hennepin County will conduct 809 home interviews and to do physical exams and testing on 347 residents. The last time they survey team was in the county was 2003.

“They have the system down pat,” Palchick said. “They’re here for a relatively short amount of time.” According to the request for permits, the survey team will be in those trailers between April 13 and June 10.

The city approved the application with a few caveats. Don’t alter the exterior of the Milwaukee Road Depot without getting approval from the Heritage Preservation Commission and make sure the use isn’t “detrimental to the public health, safety and warfare of the general public.”

Hopefully they meant welfare.

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Congress undermines public trust by overriding mammography guidelines, authors say

Last December, Congress slipped into its $1.15 trillion spending bill a measure that “undermines women’s rights to make informed decisions based on the best scientific evidence,” according to a commentary published recently in the Journal of the American Medical Association (JAMA).

That measure requires health insurers to follow the U.S. Preventative Services Task Force’s (USPSTF) breast cancer screening guidelines from 2002 rather than the task force’s two more recent ones, including its latest, which was issued just a few weeks ago.

The 2002 USPSTF guidelines recommended that average-risk women undergo mammography screening every one to two years beginning at age 40. After an exhaustive examination of the most recent scientific evidence, the task force updated their guidelines in 2009 and again this year to recommend that biannual screenings start later, at age 50.

“Essentially, Congress is requiring health insurers to ignore modern scientific assessments and instead use 14-year-old guidance,” write Dr. Kenneth Lin, a family medicine physician at Georgetown University, and Lawrence Gostin, a law professor at the same institution, in the JAMA commentary.

That action has important ramifications that go beyond the issue of breast cancer screening, they add, for it also weakens the public’s trust in the value of evidence-based science.

Political backlash

Some background: One of the requirements of the Affordable Care Act (ACA), which was passed by Congress late in 2009 and was signed into law by President Barack Obama in 2010, is that private insurance plans must provide “first-dollar” coverage (no co-payments, coinsurance or deductibles) for any preventive service that receives an “A” or “B” grade from the USPSTF. (Those grades mean there’s a “high certainty” that the service’s net benefit for patients is “moderate” or “substantial.”)

Created in 1984, the USPSTF is an independent panel of experts with backgrounds in prevention and evidence-based medicine. They volunteer to assess the best evidence on various preventive services, and then make clinical recommendations regarding those services. Those recommendations are published in peer-reviewed journals (and on the USPSTF’s website), and are periodically updated.

In 2009, the USPSTF gave only a C grade to mammography screening for women aged 40 to 49 who are at average risk of developing breast cancer. This recommendation caused an instant and sometimes vicious backlash from medical groups, such as the American College of Radiology and the Medical Imaging and Technology Alliance, as well as from a few women’s health organizations.

The USPSTF’s updated guidelines were widely (and angrily) misinterpreted, however. Many people believed the task force was saying that women under the age of 50 should be denied access to mammography screening.

“A C grade is commonly misunderstood,” explain Lin and Gostlin. “It does not advise against screening, but rather it indicates moderate certainty that there is small population-level benefit. Clinicians should discuss C-rated services with patients using an individualized assessment of the patients’ risk factors and preference.”

And although insurers do not have to offer “first-dollar” coverage for a C-graded service, that was never really going to be the case with mammography.

As Lin and Gostlin point out, “Importantly, irrespective of USPSTF recommendations, most insurers have offered mammography coverage for women aged 40 through 49 years.”

Wrongly framed

One reason for all the controversy was that the USPSTF guidelines were framed by critics as a form of health-care rationing.

“Yet the Task Force uses a rigorous scientific methodology focusing on net health benefits and does not take economic cost into account,” the two Georgetown professors explain.

Furthermore, the USPSTF is not alone in its interpretation of the evidence regarding mammography screening.  In Great Britain, for example, the National Health Service currently recommends that average-risk women be screened every three years starting at age 50 . And late last year, the American Cancer Society, shifted its recommended starting date for routine mammography from 40 to 45

“By declining to acknowledge scientific progress, Congress may do more harm than good to women’s health,” write Lin and Gostin. 

There is also a real risk, they add, that Congress may soon begin to erode the Task Force’s independence.

“The House’s version of 2016 omnibus spending bill (which was not included in the final legislation) would have denied funding for any future USPSTF mammography recommendation,” they explain. “Some members of Congress have gone further, proposing to alter the Task Force’s composition to include ‘stakeholders from the medical products manufacturing community.’”

Political second-guessing

So far, the USPSTF has withstood the pressures on its independence and scientific integrity, but will they be able to continue doing so in the future? 

Yes — if the public demands that Congress stop second-guessing the task force’s independent experts.

“When Congress required [the government] to link insurance coverage policy to outdated public health guidance, it was making a scientific judgment for which it is distinctly unqualified,” write Lin and Gostlin. “In effect, legislators implicity concluded that a rigorous assessment of numerous research studies during the past 14 years is not relevant to women’s health today.”

“Congress’s paternalistic response to USPSTF mammography screening recommendations vividly illuminates the social costs of politically mandated care,” they add. “Rather than benefiting women, political interference with science can discourage shared decision making, increase harms from screening, and foster public doubt about the value and integrity of science.”

FMI:  The commentary was published online in JAMA on Jan. 18, where it can be read in full.

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Yellow margarine was illegal in Minnesota until 1963

Courtesy of the Minnesota Historical Society
During the 1910s, oleo mixed with a small percentage of dairy butter — often called “butterine” — became increasingly common and popular.

During the late 1800s, dairy farmers in Minnesota and other states faced what they considered a serious and immediate threat to their livelihoods: the growing popularity of a butter substitute called oleomargarine. For nearly a century, the dairy industry and its legislative allies waged a series of campaigns to prohibit or limit the manufacture and sale of margarine. No state retained its anti-margarine laws longer than Minnesota.

Margarine’s origins dated back to 1867, when a French chemist named Hippolyte Mège-Mouriès—seeking a prize offered by Emperor Napoleon III — developed a process for turning beef tallow and milk into a spread that tasted like butter. Mège-Mouriès called his product oleomargarine. (It later became widely known simply as oleo and margarine.) In 1873, Mège-Mouriès’s oleomargarine manufacturing process received a U.S. patent. American oleo manufacturing began in earnest a few years later.

Margarine’s arrival in the United States coincided with the country’s shift from an agricultural to an industrial economy. Many farmers worried that products made in laboratories and factories would replace traditional agricultural goods. Oleomargarine, with its similarities to butter, seemed like a particularly ominous threat. Dairy organizations throughout the country began lobbying Congress and state legislatures to pass protective anti-margarine laws.

In 1885, Minnesota became one of the first states in the nation to prohibit the production and sale of oleo. Two years later, Governor Lucius Hubbard announced that sales of “oleomargarine and its kindred abominations” had virtually stopped in Minnesota. But a new federal law, enacted in 1886, recognized margarine as a legal product subject to taxes and regulation. Minnesota’s anti-oleo law was no longer valid. The battle over margarine entered a new, back-and-forth phase focusing on regulation and taxation.

In 1891, dairy organizations in the state helped convince the legislature to pass what was known as a “pink law.” Under the new law, oleo could now be legally manufactured and sold in Minnesota, but it had to be colored pink. Since few consumers relished the idea of slathering a pink, butter-like spread on their toast, the pink law effectively halted all sales of oleo in the state in the 1890s. But in 1898, the U.S. Supreme Court declared pink laws unconstitutional. Oleo was now legal in Minnesota. The skirmishes over how available it would be to consumers, however, were far from over.

The margarine debate in Minnesota and across the country began focusing on the distinctions between colored and uncolored oleo. Dairy producers argued that margarine in its natural state was an unappealing white, and that margarine producers should be prevented from artificially coloring their product a butter-like yellow. According to this view, yellow margarine was a fraud meant to trick consumers into thinking they were buying and eating butter. Makers of oleo countered that the manufacturing process often produced a yellow-tinted product. Strict labeling laws, they argued, made deception impossible.

Dairy producers scored a major victory in 1902, when the federal government enacted a new law imposing much higher taxes on yellow margarine than on white margarine. Three years later, Minnesota further strengthened the dairy industry’s position in the state by enacting one of the toughest anti-oleo laws in the nation: a prohibition on the manufacture and sale of any margarine “made or colored to imitate yellow butter.”

Consumer demand for oleo continued to grow, despite the many restrictions on its production and distribution. As a result, increasing numbers of Minnesotans began running afoul of the state’s anti-margarine laws. In 1908, the Hammond Packing Company of Minneapolis was found guilty of manufacturing illegal yellow oleo. The Minnesota Supreme Court later overturned its conviction. A few years later, a grocer named Ole Hanson was charged with illegally selling yellow margarine at his store in Mankato. He was acquitted when the Minnesota Supreme Court ruled that the state’s ban on yellow oleo was unconstitutional.

Repeated court setbacks failed to dissuade Minnesota’s anti-margarine crusaders. State legislators continued to tinker with the law in hopes of crafting restrictions that would stand up to judicial scrutiny. In 1913, they approved a revision that stated all oleo manufactured and sold in the state must be “fifty-five percent of white according to the methods and measurements used by the Bureau of Standards.” The fifty-five percent standard was, for all practical purposes, a creative way to re-impose the ban on yellow margarine without directly defying the state’s supreme court. The revised anti-margarine law remained on the books largely unchanged for the next several decades.

Undeterred, oleo producers continued to look for ways to move their product legally to market and increase consumer demand. During the 1910s, they started packaging white margarine with packets of artificial food coloring so that consumers could knead it in by hand. They also began experimenting with new ingredients to improve taste. Oleo mixed with a small percentage of dairy butter — often called “butterine” — became increasingly common and popular. And price, as always, worked in margarine’s favor. In 1916, the price of a pound of high-grade oleo averaged twenty-six cents in Minneapolis and St. Paul. The average price of a pound of high-grade butter was forty cents. Minnesotans responded by buying 1.5 million pounds of margarine a year.

Anti-margarine forces continued to hold sway in Minnesota for several decades after the battles of the late 1800s and early 1900s finally cooled down. Arguments that restrictions on oleo hurt budget-conscious Minnesotans failed to make much difference. If anything, the restrictions only grew tighter. In 1933, the state imposed a new ten-cent tax on white oleo, while maintaining the effective ban on yellow margarine. In 1945, it extended that tax to newer types of oleo made with vegetable oils.

In 1950, the federal government repealed its long-standing tax on margarine. With much of the margarine sold in the United States now being made with vegetable oil produced by American farmers, agriculture’s united front against oleo began to crumble. States started reassessing their anti-margarine laws. One by one, the state laws disappeared. Most states were quicker to drop their bans on yellow margarine than they were to give up the revenue produced by margarine taxes.

Minnesota, however, took its time. It wasn’t until 1963 that the state legislature finally voted to legalize yellow margarine. And even then, the opponents of oleo did not concede gracefully. A few weeks before the final vote on legalization, state inspectors engaged in a final crackdown on illicit margarine. Among the unlucky scofflaws was the owner of a Scandinavian restaurant in Minneapolis who was caught serving lutefisk with an illegal mixture of melted yellow oleo and butter.

Minnesota continued to tax oleo for another twelve years. By that time, it and North Dakota were the only states doing so. The oleo taxes in both states expired on the same day — July 1, 1975.

For more information on this topic, check out the original entry on MNopedia.

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Elected heads of state have shorter lives than their losing rivals, study suggests

If elected to the presidency, Donald Trump will be “unequivocally … the healthiest individual ever” to have that job, according to a statement released by his personal physician on Monday.

If that’s, ahem, true (Trump’s physician, New York gastroenterologist Dr. Harold Bornstein, didn’t say what historical data he used to come to that conclusion), Trump, 69, may want to reconsider running for the presidency — if he wants to live as long as possible, that is.

For a new study has found that people who win elections to head their governments — whether in the United States or in 16 other democracies around the world — live almost three years less, on average, than their losing opponents. 

“Our findings suggest that elected leaders may indeed age more quickly,” the authors of the study conclude.

The study was published Monday in the BMJ’s Christmas issue, which focuses each year on topics that the journal’s editors say are “quirky and fun,” but still scientifically sound (and peer-reviewed).

An ongoing debate

Whether American presidents age at a faster-than-normal rate is a somewhat controversial topic. Conventional wisdom (and some research) says yes, but a 2011 study says no. That study found that American presidents actually tend to live longer than their peers.

But it compared the life expectancy of presidents to that of the general U.S. population — a comparison that may be misleading, say the authors of the BMJ study.

“Given their higher socioeconomic status, one might expect presidents to live longer than the general population on the basis of known inverse associations between social class and mortality,” they write. “The fact that presidents do not live longer may suggest accelerated mortality compared with others of similar socioeconomic status.”

That’s why they decided to conduct a study that would compare the longevity of elected heads of state with runner-up candidates who never served in those highest posts.

Three centuries of data

The researchers — from the Harvard Medical School and Case Western Reserve University School of Medicine — gathered data on 540 elected and runner-up candidates for president or prime minister in 17 countries (U.S., Canada, Australia, New Zealand and 13 European countries). The elections went back to the U.K. parliamentary election of 1722.

After crunching the data, the researchers found that “without adjustment for life expectancy at time of last election, elected leaders lived 4.4 fewer years than their runners-up. However, elected leaders were also on average 3.8 years older in the year of their last election compared with runners-up.”

So the researchers adjusted for life expectancy. The data then revealed that the elected leaders lived, on average, 2.7 fewer years than their runners-up.

The study doesn’t attempt to explain why elected heads of states may have shortened lives. In the case of U.S. presidents, people often point to prolonged stress (accompanied by sleep deprivation) as a key factor. But there’s no direct evidence to support that theory.

Caveats

Like all studies, this one comes with caveats. S. Jay Olshansky, the human longevity expert who conducted the 2011 study that found U.S. presidents tend to live longer than other American men, pointed out one major limitation to Washington Post reporter Carolyn Johnson: The BMJ study couldn’t really determine whether winning leaders were aging faster than losing ones because the study didn’t exclude presidents and prime ministers who died of non-aging-related causes, such as accidents or assassinations.

“I say [presidential candidates] don’t have anything to fear from this study,” Olshansky told Johnson. “You’re part of the one-tenth of the top one percent of the wealthiest, most highly-educated people who have access to the best health care. You’ll do just fine.”

I’m sure Trump agrees.

You can read the BMJ study in full on the journal’s website.

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Event video: ‘Preparing for the Silver Tsunami’

A MinnPost panel discussion entitled “Preparing for the ‘Silver Tsunami’  drew more than 120 people to the Northrops Best Buy Theater at the University of Minnesota last week. Five experts in health care and aging took on the question “How do we better care for Minnesota seniors without breaking the bank?” in the context of the upcoming shift in demographics as baby boomers reach their retirement years.

The discussion was moderated by Susan Albright, MinnPost’s managing editor, and featured the following guest panelists:

Below are some video highlights from the event, which was sponsored by UCare, as well as a recording of the full 80-minute discussion.


Gayle Kvenvold: “Boomers are unprepared and unaware” when it comes to eldercare issues.


Mary Jo George: By some measures, Minnesota is No. 1 state for seniors, but it could be much better.


Dr. Thomas Klemond on the negative aspects of a “fighting culture, and the medical community’s current approach to eldercare.


State Sen. Tony Lourey on the challenge of balancing public resources and personal decisions.


Dawn Simonson on the need to provide support for low-income seniors, who are not poor but could easily be thrust into poverty.


Dr. Thomas Klemond, Susan Albright, and Mary Jo George mention recent innovations in eldercare with the potential to improve life for Minnesota seniors.


And here is a recording of the entire 80-minute discussion:

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Upcoming wave of aging Minnesotans will need better-coordinated, smarter supports, panel says

While seniors in Minnesotans enjoy a comparatively good health-care system, it is expensive, fragmented and complicated, panelists said during an event designed to explore how Minnesota can better care for its aging population. And it reflects doctors, patients’ and families’ inclination to take all possible measures at the very end of life, spending enormous sums of money when death is likely near.

The panel discussion, entitled “Preparing for the ‘Silver Tsunami,’ ” drew more than 120 people to the Northrop’s Best Buy Theater on the University of Minnesota campus. 

The panelists, five leaders from various sectors in the state’s health and aging-services community, tackled where the Minnesota health-care system stands now in comparison to other states — and what should be done to prepare for the approaching retirement of the baby-boom generation. Mary Jo George of AARP, state Sen. Tony Lourey, Gayle Kvenvold of LeadingAge Minnesota, Dawn Simonson of Metropolitan Area Agency on Aging and Dr. Thomas Klemond of Park Nicollet Health Services also put forward ideas to educate consumers in navigating the system, to encourage an affordable model of person-centered care and to advance relationships between doctors and families.

Organized by MinnPost, the event was sponsored by UCare and moderated by Susan Albright, the managing editor of MinnPost. 

“Minnesotans — through state, community and individual actions — must get ready for what we know is going to be a gigantic wave of elders,” Albright said in her opening remarks before she asked the panelists to assess how Minnesotans are doing in preparing for the demographic change.

“We’re not doing all that bad if you look at some of the data,” George said. Citing a study, she added that Minnesota has in fact the best health-care system in the nation: “It’s impressive that Minnesota, over all, is No. 1. And I think we have to be proud of that.”

A need for livable communities

A closer reading of the study, however, shows some troubling concerns about the long-term health-care system, George said. Many older people with low care needs live in nursing homes and others are unnecessarily hospitalized.

“Our system is way too fragmented, way too expensive and way too complicated for consumers to navigate,” George told the audience. “We have to create the livable communities so that we have the supports so that people can live in their homes, because that’s what people want to do.”

Lourey said that he’s concerned about the future of Minnesota’s health-care system, especially since more and more people are retiring and fewer people are replacing them in the work force. Kvenvold echoed the sentiment: “I’ve been traveling the state for the last couple of weeks, and we have pretty deep shortages of caregivers in regions of our state — and that’s the flipside of what we call the ‘silver tsunami.’ ”

Mary Jo George, Tony Lourey and Gayle Kvenvold

MinnPost photo by Andrew Wallmeyer
Panelists included AARP Associate State Director – Advocacy Mary Jo George, state Sen. Tony Lourey, and LeadingAge Minnesota President/CEO Gayle Kvenvold.

And when Minnesota loses workers, Lourey added, the consequence is that taxpayers won’t be able to sustain the system that’s currently in place. “About two-thirds of the long-term care falls on the public support system,” he said. “And that becomes unsustainable as people age and need the supports.” 

Lourey encouraged more engagement with communities and aging individuals to improve the system. “It’s a system that we all have to take ownership of and do our best to move away from,” he said.

‘We are a fighting culture’

Panelists also discussed end-of-life care planning, with some of them encouraging the public to consider engaging in more such conversations.

Lourey said people are fearful of the conversation and of getting old. “The words that we use are very important. And when we start talking about choices about how we die, you know, you’re going to say, “No, no, no. I’m not going to go there.”

He added: “It’s more about choices about how we live as we age. And that’s some of the things we’re really trying to deliver through the legislature.”

Lourey shared a story with the audience about his grandmother, who “didn’t have much time left” and whose physical and mental health had dwindled. One day, Lourey said, his grandmother fell and broke a hip.

Three days after the hip was replaced, she died. “This was a complete misuse of the health-care system and not one that she would have chosen,” Lourey said.

Dr. Klemond, who chairs the Palliative Medicine and Community Care Department at Park Nicollet, expressed both hopefulness and worry about the current care system.  “We’re a fighting culture,” he said. “We are a culture that responds to challenges. And that’s what gives me hope, as I look at all the good work that has been done already.” 

“But the fighter culture is also a bit of an enemy to us, especially in a world where everyone does die ultimately,” he added. “And we have this sort of phenomenon of the unwritten rule that you must do what you can to live or else you’ll be perceived as weak or a failure. And we’ve set up our system with that in mind. Our system is a product of our culture and product of our values. So there’s often no honor in a choice not to continue treatment. And there’s a lot of fear.” 

Ibrahim Hirsi can be reached at ihirsi@minnpost.com. Follow him on Twitter at @IHirsi.

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