narrator: pregnancy is usually a 38-week procs. healthwise, there's much a woman needs to do and learn during that nine months. barbara korsch: i think that, you know, usually people don't make a conscious effort to prepare for that. they are in the state of mind, and let's hope they have someone who's going to father the child whom they respect and whose values they like. i like to say that a pregnancy begins when two people who are in love with each other decide that they're going to become pregnant and raise a child till that child is 20 to 30 years of age, not before. j.p. garamone: we've been married 13 years. we pretty much put the decision off till later on. we really thought that we would, you know, travel and do a lot of things together, etc., etc., and then when the time was right, we'd figure, you know, we'd talk about it then. and then one day, it was like, is this going to be a nursery or is this going to be a guest room? tracey garamone: and i went for my annual doctor's appointment and said we're thinking about it and next thing you know, the next month, it happened. well, there's no question that if we take from the very beginning, planning a pregnancy is far more likely to yield a good outcome than an unplanned pregnancy for a variety of reasons. not every woman is perfectly healthy. doctor: tracey? not ever woman understands that, for example, you can reduce the chance of having a neural tube defect by taking folic acid in the pre-conceptual and the early conceptual period. if you wait until you're pregnant, it's often too late, to, in fact, impact any change on the outcomes. tracey garamone: well, i was in fairly good physical shape. i take vitamins that are equal to, if not better than prenatals, so i was set up for that. the most important thing is the folic acid so that was in place. caffeine i had already cut out of my system a couple years ago so that was easy. but alcohol, definitely, you know, came to a halt, because we are social drinkers and we do love wine tasting and things of that nature. so... it'll come back. overindulgence is not going to work, whether we eat too much red meat, even though it's good for iron, if we eat too much of anything, it's not going to be good for us. so again, use logic in deciding how you handle your pregnancy. i needn't tell you, i needn't tell anybody that alcohol's not going to be good in pregnancy. i needn't tell anyone that using illicit drugs is not going to be healthy for your pregnancy. because ultimately that baby, if the mom uses regularly enough and in high enough quantity, the baby will become dependent on the drug in the same way that an adult would. in the wall of the lining of the uterus, there's a hormone that plays a very important role in the developing brain. so this is a signal from the mother that plays a role in how the baby's brain develops. so clearly speaking, we're talking about a drug, alcohol, that affects the mother's metabolism, where that signal doesn't get delivered to the fetus to allow normal brain development. in the last five to seven years, the rates have started to climb back up again in terms of women drinking while they're pregnant. it's the more highly educated, the more high income, typically white women who appear to be escalating their alcohol use. i think, in part, folks feel very comfortable that this problem was addressed and successfully licked back in the 80's and that it's something we can move on away from at this point. and that is absolutely not the case. smoking also increases the risk of premature delivery and low birth weight. in fact, babies whose mothers smoke are at greater risk for sudden infant death syndrome. calvin john hobel: sometimes it's hard to look at just the effect of smoking by itself, because smoking women have other habits that compound the effect of smoking. for example, nutrition. women who smoke tend to have poor nutrition. they may also be the person who's not taking their vitamins so they have a folic acid deficiency. so when you combine poor nutrition and not taking adequate vitamins, then in combination, that can lead to more serious problems. women often become more health conscious when they become pregnant. and that often translates into a more healthy diet. women aren't "eating for two," as the old saying goes. they only need a few more calories. but they do need to eat well. undernourished pregnant women have a higher risk of miscarrying, having premature or underweight infants and delivering babies with birth defects. i gained weight pretty rapidly, which i was surprised, because i was exercising very regularly and eating-- i eat very well balanced. so it just-- my body was getting ready on its own and my doctor said not to be concerned about that. i've done a lot of reading. i've read about every book i can get my hands on, and they all said the same thing, you know, 25-35 pounds. j.p. garamone: we've been eating basically the same way for years and years and years, so it's not too much of an effort here for us. you know, the pickles and ice cream really weren't an issue. fasting during pregnancy is not good. normally for a non-pregnant person, you can fast for 24 hours without having a metabolic effect, but during pregnancy that time is shortened. so women who fast for 12 to 13 hours have a significant increased risk of having a low birth weight baby, or a baby who delivers pre-term. if a woman has dinner in the evening, let's say at 6:00, and then doesn't have a snack at bedtime and then gets up at 8:00 or 7:00 the next morning, doesn't have breakfast, and then maybe has a late breakfast or lunch, that's way more than 13 hours. so, in our studies so far, we found that about 40% of women have periods of fasting for more than 13 hours. so i think fasting is prevalent in pregnant women. all these health guidelines-- it's enough to make a woman's head spin-- not a good idea, since she may be nauseous already. but her medical practitioner and her own common sense can give her all the tools she needs for a healthy pregnancy. barbara korsch: from a physical health point-of-view, anything that is good for the mother's health is good for her during pregnancy. you know, the mothers go to extremes nowadays. i mean, they may read greek poetry to their belly, you know, in the hope that the child will be exposed to something beautiful and this will improve his mind, and... classical music, even in utero, not only after birth, which was highly touted recently and so on. so they would do many things. now as far as i'm concerned, there's no evidence that this has a direct impact on the baby's brain. but if you think logically, if the mother relaxes when she listens to mozart and her pulse rate slows down and her entire circulatory system and body is less stressed, this can only be healthy for the baby. doctor: the baby's heartbeat sounds great. it sounds calm right now. there's data now to show that women who have stress have a greater risk of having a baby that has an anomaly of either the heart or the central nervous system, like spina bifida, heart abnormalities that are more likely to occur in a woman who has stress. and then also there's been a study showing that women who have stress are more likely to have a miscarriage. so this really focuses us toward the early part of pregnancy. researchers are also studying how acute stressors like domestic violence and natural disasters affect pregnancy. calvin john hobel: recently our team showed a relationship between the northridge earthquake that occurred here in the l.a. basin and those women who experienced the earthquake during the early part of pregnancy. it had a significant effect on their gestational length meaning that they were more likely to deliver early and in some cases, you know, pre-term delivery. there are many factors associated with premature births. some, such as smoking and poor nutrition, are risks women can avoid. others, such as stress, may be more difficult to control. but often premature labor is beyond anyone's control. whatever the cause, it creates serious problems. pre-term birth is the second leading cause of infant morbidity and mortality. the leading cause, is, you know, congenital anomalies and so the two are sort of close to each other but actually pre-term birth is second. and so there's immediate problems with the delivery of a pre-term baby, and it's related to gestational age. babies who are born before 32 weeks, or 31 weeks, we call very low birth weight babies. about 8% are born prematurely and they weigh less than five pounds, five pounds or less. and of those, of all the deliveries, about 1.5%, one and one half percent, are born with extremely low birth weight. it's what we now call "the micro prematures" because they are very tiny. they are less than three pounds. they have pulmonary problems, problems with breathing. they can have bleeding into their brain and these events really increase the risk of these babies having, you know, mental retardation, cerebral palsy, learning difficulties later on in life. so the maternal fetal medicine specialists, the obstetricians that specialize in this, as soon as they suspect premature labor, they try to prolong this because we know that five, seven days, a little bit over a week makes a big difference. several years ago we've shown that to be born at 24 weeks is much worse than being born at 25 weeks, even though medically we say 24 to 26 weeks. it's very different. because of medical advances in the last 20 years, many more premature babies are not only surviving, but surviving with fewer physical problems. augusto sola: i think everyone can understand that this baby born premature, let's say 10 weeks early, was not supposed to be breathing outside of the womb, so they don't have these all well developed. the treatment starts actively in the delivery room of these babies. and what we do there is we insure that enough oxygen is being delivered to the baby's heart, brain, lungs, kidneys. we also make sure that their temperature doesn't drop. and we move the baby usually to the intensive care unit because these premature babies need treatment for several days, weeks-- or even the tiniest ones, for months-- to insure that they make it, you know, uneventfully. the baby, as a member of that family, has special needs. but the parents, they also have special needs to reach. i actually had a perception one day, and then i believe it very clearly, but actually babies-- just like parents are asking us, "please take care of my baby--" babies are asking, "please take care of our parents." medical advances have helped prolong pregnancies and saved premature babies. advances have also given physicians ways to see how a pregnancy is progressing. a commonly used technique is ultrasound scanning. this procedure uses high-frequency sound waves to visualize the fetus. lawrence d. platt: well, i personally believe a woman should be offered an ultrasound in every pregnancy because i personally will tell you i know of no test that can offer us as much information in a shorter time as ultrasound, provided it's being performed with someone that understands and is well-trained and has the proper credentials and accreditation of ultrasound. using an ultrasound, a health care provider can detect structural abnormalities, estimate the age of the fetus, see if there is more than just one fetus, and confirm fetal position. i had no idea that it would be that clear and that you could actually count the fingers and almost see the fingernails and the profile of the baby. it's pretty intense. you know, a large part of my research in ultrasound is in fetal assessment, not only identifying the patient with a chromosomal abnormality, but how is the baby doing? you know, that fetus is my patient, and so we do what's called a fetal biophysical profile-- something that we reported on over 20 years ago that's still used as a test of fetal condition-- combining it with heart-rate monitoring and looking at how is the baby doing. another diagnostic tool is amniocentesis. it involves removing some of the amniotic fluid that surrounds the fetus. geneticists observe cells from the fluid to see whether or not the fetus will be born with a genetic abnormality or other conditions, such as neural tube defects. tracey garamone: the needle is about the size of a blood-taking needle, which they've done a lot of that. i was lucky i did not have any of the adverse affects. some people do have cramping, bleeding etc. and i did not. it just was another day. you know, at this point, i don't remember exactly how long we had to wait for the results, but yes, until we got them and knew everything was perfect, you know, there was a little bit of worry. sometimes it's not just the outcomes of the pregnancy itself that you're looking for measures. there is how you manage the patient. it may be easier for the clinician to manage the patient knowing that there's a singleton pregnancy and not twin pregnancy. it's nicer to know that you don't believe that there's an abnormality. all these become better means of assessing the condition of the baby, and that they're providing you the optimal care of your fetus. tracey garamone: my husband and i decided not to find out the sex of the baby, because we feel there aren't enough surprises in life and felt that would be one of the biggest ones that we will experience together and well as i've been kind of stating that it'll make it worth the work-- that surprise in the end, that reward. really, right now, it's just i'm hoping for a healthy baby. that's really the main concern right now. the first part of labor is cervical dilation-- rhythmic contractions of the uterine muscles that cause the cervix to dilate and to efface. when contractions are only minutes apart, it's time to get to the hospital. tracey garamone: well, about 5:00 on saturday ternoon is when i started feeling the preliminary contractions i would say, because they were very dull. but i noticed that there was repetition, so i made dinner and carried on as normal. and then about 7:00 i took it easy and had jay start to time the contractions. and again, they were at a mild stage and they were about seven minutes apart. so i called dr. galitz and asked him the protocol and he said to go to the hospital when they're at five minutes apart. so by 10:00 the five minute mark hit, and we waited for about an hour to an hour and a half to make sure it was consistent, and it wasn't, what's called the braxton hicks, which are inconsistent. and it was, they were very consistent every five minutes. so i went to the hospital, got hooked up on the fetal monitor and the contraction monitor, and was examined and was told that i wasn't dilated. and that that's known as prodromal labor, meaning that the water hadn't broken. and there was no dilation, my cervix was 70% % effaced, so it wasn't real labor. so they had me walk around for about a half an hour, to see if there would be any change. there wasn't, so they sent me home. try not to lift or carry any heavy objects over the next couple of days. got to keep drinking a lot of fluids-- eight to ten of glasses of water or juice a day. shower only. if you feel decreased fetal movement... the next morning, you know, they just progressively started getting worse and worse, and i noticed some bleeding so i called, they said, "come back", so, ironically, it was about the same time, about 11:30-- heed back to the hospital, 12 hours later. same protocol. on the monitors... exam, still no dilation. still they're telling me i am not in labor. and at this point i am feeling pain and not knowing what labor would feel like otherwise. so again we got sent home because there was no progression. we'll try again another day. j. p. garamone: it was a little frustrating driving back and forth a few times to the hospital, you know. that i didn't really anticipate. - you okay? - yeah. - a little disappointed. - disappointed? yeah. the baby's not cooperating. when the cervix is fully dilated, the second stage of labor begins. the infant descends into the birth canal, normally head first. with each contraction the mother pushes, helping the baby along. but in some cases there are complications. by early evening i was having very severe body shakes, so i called and they said, "come on back." and they said, worst case if i was not dilated, they would try to give me a shot of something like demerol so i could at least sleep through the night, because i was unable to sleep since friday night basically. and now, we're at sunday. so went back to the hospital and i had dilated to one. so was given the opportunity to take the demerol or the doctor had given an okay for an epidural due to the pain thus far and for the time of it, and that's what i opted to do. and that was the savior. love the epidural. tracey came into labor and delivery at west hills in early labor. the examination was a cervix that was about two centimeters dilated, which is very early. tracey unfortunately, is about a week overdue. and in that situation very often there's decreased amniotic fluid. the amniotic fluid inside the uterus acts as a cushion to protect the baby during the course of labor when the uterus is contracting and putting pressure on the baby and the umbilical cord. with decreased amniotic fluid, there's less capability to protect the baby and more often they develop distress which is what tracey's baby started to do. d th when we h thproble the problem of the heartbeat dropping and that got pretty intense and pretty scary. and as a result of that, with the early stage of her labor, we decided that the baby wouldn't tolerate labor well for the rest of the course of labor which would be eight or nine hours. so the decision was made to do an emergency "c" section that evening. j.p. garamone: you could see that everybody was under control, all the doctors were there, etc. that was really, i think, the saving grace, that they were under control, because i was pretty nervous at that point. doctor: what i'm going to do now is just touch you on your belly. left, center, right. low and low. - anything you feel? - no. perfect. good epidural. oh, my god. - you okay, tracey? - yeah. okay. we're doing fine. hello, kiddo. oh, you are a big one, aren't you? - where's the cord? - not much fluid. around the baby's right leg. j. p. garamone: and, you know, i was a little disappointed that she didn't get to see the baby right away because it was a "c" section. other than that i think things went smoothly, so i was happy. tracey garamone: obviously most mothers want a natural delivery but at that point i wanted at was best for the baby. and i had anticipated that bding part of the natural delivery-- they let you have the baby for an hour before they do any of the cleaning and the tests, etc. so i did miss that. i missed not being completely coherent during the delivery just due to the drugs, but the lack of pain i didn't miss, that was fine. so it's all worked out and the baby's healthy and that's really the bottom line and what matters. barbara korsch: it's not absolutely that if you don't have the chance for this early bonding experience there will be mayhem but it is certainly a positive thing and in many instances now, the birthing process has been adapted a little bit to facilitate this early interaction between mother and child. and, for instance, we used to rip the baby away from the mother and put it in the nursery and then nobody could see it except through a window and with masks and gowns so that those early weeks would be very sterile. and now we try to do quite e opposite as a matter for this attachment process. the attachment between mother and son may have been delayed, but only for a matter of hours. linda hanna: in the last 10 years there's been a tremendous energy put on breast-feeding and the health of the infant, and the desire of women to be connecting with their babies at a very primitive, very natural type of level and so feeding-- breast-feeding in that venue has actually become extremely popular. it's so easy now that almost anybody can breast-feed. the food that's produced by the mother is made specifically for her individual baby. although women can donate milk for other babies, her milk is designed specifically to meet the needs of that baby at that gestational age. and so as the baby is developing in the uterus and growing, it's being fed appropriately by the placenta and by the mother. the same thing holds true for the baby after it's delivered. in addition to that, as the baby grows over time, in the year, second year, third year, the milk changes to meet that particular baby's growing needs. the carbohydrate and protein balance is perfect. there's amino acids and carbohydrates that help fuel the baby's brain and continue to help them grow on a continuum that's set, and actually quite adaptable for each individual baby. four days after the delivery, matthew is having his final check-up before release from west hills hospital. if you have any questions that you want to ask me, i'd be happy to answer. i understand he had a circumcision yesterday. now if he urinates or, you know, poops, does that effect the circumcision at all? because i noticed when he did urinate you know, he kind of started crying more so than he ever had, and then i changed him and he was fine. do you think it's sensitive? the area is unquestionably sensitive at this point. but it's-- almost all the babies urinate and defecate over that area and we don't see any significant problem from that. tracey garamone: since he was born we're always listening for any kind of congenital cardiac abnormality. and at this point, what's the heart rate, you know, now that he's out? typically 120, 160. like it was in the womb? yes, and gradually over time, usually over the first two months or so, there'll be a very slow reduction in heart rate. he's very active, and all of his behavior is very appropriate. all of the rooting responses are really excellent. he's doing beautifully. good. if it's in the middle of the night and you're not sure whether what you're worried about is significant or not, you can call the nurses here in the newborn nursery, because they're doing shift work around the clock. if you express a concern to them and they're worried, if it doesn't sound right to them, they'll tell you to call the pediatrician. and of course, we're available 24 hours a day. call us if you're worried about anything. tracey's discharge interview is relatively brief. just you know, be sensible and things like that. and that's about it. how about stairs? i think going up and down stairs shouldn't be a problem. we didn't cut muscles or anything like that. if you feel tired or fatigued after doing that, try to limit the number of times a day you do that. - okay. - but otherwise you can pretty much do what you want. - take it easy. - sounds good. - see you back in two weeks. - thank you. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: and accompanying materials, call: our kids have the mos to deal with today... isn't violence. it isn't drugs. it's unhealthy food. too many of our kids are overweight. they're headed for diabetes, heart problems, or worse. they need to eat healthy things. like vegetables, fruits, high-fiber vegetarian foods. as our kids grow, the right foods can help protect them from obesity, heart problems, diabetes, and even cancer. to find out more, call for a free booklet. or visit our web site -- kidsgethealthy.org. narrator: a century ago, the potential for surviving childhood was not as promising as it is today. there was a higher childhood mortality. it wasn't uncommon to have a family where a sibling or two or three died during childhood. today, of course, that's very uncommon. raising healthy children may not be the challenge it was a century ago, but it's far from automatic. the risks of diphtheria or scarlet fever have given way to accidents. every household, every environment offers different challenges. but there e some fundamentals that come into play. catherine parrish: i thinking limiting your exposure to germs and a balanced diet are the most important things i teach them about keeping their baby healthy... and then coming for shots. the immunizations we provide certainly make a huge difference. diseases that killed hundreds of thousands of people don't even exist in this country anymore. although some concern has been expressed about the possible side effects of vaccines, physicians firmly believe that the benefits far outweigh any risks. vaccines have eliminated polio, and all but wiped out measles, mumps and rubella. i think the reason why we're not seeing a lot of those illnesses is just because of that. not because we're necessarily a healthier population, but because we've taken steps to try and eradicate those diseases that we could eradicate. we have a tremendous number of vaccines we didn't have even when i started practicing, for instance, the h-flu vaccine which came out in the late 80s and we started giving it before the age of 2 in the 90s. when i started practicing, my very first week in practice, i almost lost a child to h-flu meningitis. carried them in the back of my car to the emergency room, ran them in... thankfully they did well. but that's a disease we don't even see anymore because of the h-flu type b vaccine. what we see most commonly now is respiratory infections, especially otitis media. we see a tremendous number of children with ear infections. other respiratory infections are very common-- coughs, cold, sinus and cause us a lot of visits. catherine parrish: and that's because kids aren't at home. they're in day care from six weeks of age. when we were all growing up, we grew up at home and were only exposed to our siblings and cousins, and so we weren't as sick at an early age. now moms go to work at six weeks or eight weeks of age for the child, and so kids get a lot more ear infections, a lot more colds. it may be impossible to avoid runny noses, but experts agree on some easy, yet important ways to give children a good start. catherine parrish: i think i start by telling them to enjoy their baby and love their baby. and then, in the very beginning, like in the first two months of life, to try exposing the baby to as few strangers as possible, to bring as few germs into the house as possible, nurture the baby, feed the baby regularly, not take the baby to the mall... not take the baby to the movies, because i have some very young moms in my practice who want to get back to the mall as soon as possible. and so, you know, i try and limit the baby's exposure to pathogens that might make it sick. well, i certainly think that the perception on the part of many mothers is that the baby's very delicate, very fragile. they hold them le a breakable object, you know, and don't dare really act natural with them. and in general, of course, the baby-- a newborn can't hold his head so the head has to be supported but other than that, they are really quite tough little creatures. you don't have to be afraid of touching all the time because the baby actually needs to be touched. what's important is that their parents are picking them up, touching them, loving them, giving them stimulation, reading to them, talking to them. this is really critical in the early formative years. without any stimulation, infants do very badly. i admitted an infant to the hospital a couple of months ago who had-- came from a really grossly deprived background. and at first, i was sure this baby was going to be very, very delayed and had something wrong with his brain. but after a few weeks of very intense attention the whole staff was so moved by this infant's plight, we never saw him in his crib. i'd come to examine him and he was always in somebody's arms, you know. but anyway, once we fed him and gave him lots of attention and talked to him, and held him, and now put him in a foster home, he's actually a normal baby. and it's one of the most extreme i ever saw-- of what total deprivation can do. stimulate your kids. read to your kids. we know that reading, is one of the best things that we can do for our children. again, i think it's this stimulation of the developing brain, making those nerve connections early and optimally for those kids. so the data's very clear. you need to read to your children. catherine parrish: the idea for a reach out and read program came from some very bright pediatricians in boston, who decided that we do just about everything else for the young child. we're their most constant contact outside of their parents. we talk to them about car safety, home safety, nutrition, what to wear, where to go for good entertainment, why not talk to them about books? let's put these right here. which book would you like? i think we selected one. michael bryant: now we do that as early as six months for those kids, because while they can't read at that age, certainly exposing them to pictures and figures and colors and all of those things early on, i think really does enhance the foundation that they will build on ultimately. yolanda brown-willie: we read every day, maybe three or four times a day, in between me coming from school and going to work. and then my oldest two daughters also read to him at night. so it's very important because he's getting ready to start kindergarten next year, so he really needs to know what he's doing. catherine parrish: it's very exciting thg who never owned a book before gave them one. i have moms who haven't learned to read themselves, who've gone to literacy programs after i started giving their children books. i have moms who have come back after three and four years in this program with their young toddler going to kindergarten reading, so excited that their children can read already. and it's just a very, very positive and rewarding thing and it's something we can do to give kids a step ahead in this urban community. but health professionals caution that the idea is to stimulate baes for normal development-- not to hurry them along. now, throw it to me. ck it up. throw it to me... throw it. ( chuckling ) throw it. can you throw it with your hands? this whole, you know, business again of wanting the fastest baby is very, very noxious, because, you know, they want to have the fastest car, and they want to have the fastest baby and they think you can control that. one of the most exciting things about working with children is this tremendous developmental drive. whatever they know how to do, they want to do all the time. th don't want to just walk, they want to run. they try to climb everything. so you don't need to teach them any of those things and trying to do that is counterproductive. now, of course, they have to have the stimulation. it's always a balance. so for most of the developmental milestones, if given some stimulation, some freedom, some interaction around it, they will learn it as fast as they can. and because young children are busy exploring their world keeping them safe is one of the most pressing health needs. michael bryant: talking about toddlers... probably the thing we worry about most is accidents, because kids at two, three, four years of age are so prone to injuries and accidents, and these are things that obviously are non-intentional. and so prevention begins to be the key. and looking for those, what i like to call, hidden dangers in your home that kids can get into. i mean, kids do things that we would never imagine that they would venture into, simply because of their curiosity and so most of my advice for parents would be around injury and accident prevention. catherine parrish: everywhere from the child's home where there could be exposure to normal things that you have to make safe for the young toddler, like light sockets or stairs and using gates, and i think those are the things people are used to hearing about. and for instance, baby walkers which are very dangerous-- and we try to keep parents from using them. we saw horrible accidents with them all the time. michael bryant: there are parents who have a lot of confidence in the floaties. the floaties are the things that you put on kids arms that allow them to stay afloat in water. and they are very cumbersome, they get in the way, they impede their ability to flail and move their hands and so they remove them. they don't have the knowledge that that's what keeping them afloat. and so it's things like that for the young kids. as children get older, they may still resist wearing protective devices. barbara korsch: then there are certain recreational things children use which are dangerous-- skateboards, roller blades, very dangerous. and we counsel a lot about helmets, elbow guards and all that because many of the children who engage in high-risk athletics don't wear the necessary protective gear. unfortunately, many children live with other risks as well. barbara korsch: causes of injury-- sadly, violence is still at the top of the list even in childhood. i, in my own practice, have had several children who were killed from gun accidents, and i ask every family in my practice whether there are any guns in the home. do you keep it unloaded? do you keep it locked? do you keep it where your children can't reach it? so gun safety is a big thing that i didn't think i was going to have to talk about when i started practicing that i talk about all the time now. we've lost two children to guns in this practice, both teenagers. one was caught in a gun exchange over drug money. another was shot because she was dating someone's boyfriend at 12. it's a scary world out there. there's so much to talk about in terms of safefety. and actually in medicine it's hard to do in the time we're given to pick and choose which topics are the most important for each family and each child. and, of course, there are other topics which are important to a child's health. barbara korsch: we used to worry about malnutrition. now our biggest, biggest problem, big in every sense of the word, is obesity at all ages. i see parents using food as rewards all the time, and generally it's food of low nutrient density. it's like candies, cookies, lollipops, the usual sorts of things. tyler was sort of nice... and she's saying please... and basically when you use a food as reward, you're holding up that food as something special. when you think about it, it doesn't quite make sense. it's like, "you're a good boy, here's a lollipop that will cause you to have tooth decay, and has almost nothing in it for your health and well-being." how much sense does that make? that's a big problem that we have, in particular, in overweight children, where grandma's way of rewarding you is a trip to the local fast food chain. i won't impugn any one chain, they're all there-- you know, and fries and a burger are the way to your heart. we have to change that myth. fries and a burger should not be the way to your heart. it's the way to atherosclerosis. david faxon: in a recent study on autopsies of children and young adults, in the teenager range, a very high percentage had plaques, had hardening of the arteries evident before the age of ten. and by the age 20, the majority had plaques. an estimated 15% of american children are seriously overweight-- twice as many as two decades ago. twenty-five percent are at risk for obesity and many already show biochemical changes such as elevated cholesterol and blood pressure. and as a consequence of that, in certain populations, particularly in certain hispanic communities and in african american communities, we are seeing associated with that obesity the onset of frank-- what we call type ii diabetes where these children actually need medications to control glucose. although genetics plays a role in obesity, for many children, it's their environment that determines whether they will gain unneeded pounds. children's diets today are high in sugar and fat-- invitations to health problems. are you guys hungry? yeah. yeah. want some lunch? nancy anderson: setting an example is the most important thing that an adult can do to help your children learn healthy habits, whether it be diet or exercise. the other thing is to teach them, again, what is moderation. every kid's going to love french fries if you give it to them, but if you teach them that this is a sometimes food and that there are everyday foods that you want to eat every day, and sometimes foods are okay once in a while. i think it gives them a healthy look at moderation and so that hopefully you prevent extremes in either direction. joanne ikeda: young children are naturally neophobic. they have a distrust and a dislike of new foods. you put a new food in front of a toddler, and they generally don't go, "oh, whoopee, a new taste sensation!" it's more like, "what's that? i haven't seen that before. i don't think i'm going to like that." can you try me some strawberries, please? you know there's strawberries in your juice. you know there are strawberries in this juice? and you love this juice so much. try just a little bit of strawberries? you ch it all up? can you try a little bit for me? how about carrots? you want to try carrots today? can we try to eat the carrot? parents say to me, "oh, my child won't eat vegetables, but that's because they've given up too easily. they need to keep serving them, and they also need to model enjoying them. look, i'll try to eat some if you'll eat some? look, see? mmm. that's very good. it's really, really good, buddy. with repeated exposure, you can break down this neophobia and actually get to a point of acceptance. just a little bite for daddy? realize when kids start eating, they have a very clean slate. you know, they develop the tastes that we have acquired over years and years of experience. and so to the extent that you introduce foods that are healthy, then you kind of tailor their palate to enjoy those kinds of foods. if you introduce those kinds of foods that you and i like because they're sweet, because they're tasty, then you are also tailoring the palate of the child. but you have this clean slate to work with, if you start with nutritional foods then you're going to create a child who looks to have those kinds of things. but it's more than just bad food choice that is a factor in obesity. inactivity is also a culprit. children aren't getting as much exercise as they should. one reason is they spend too much time in front of the television set. television watching is the single thing that has been consistently associated with obesity and there have even been some really interesting studies that if a child is just watching television, where they tend to sit very passive, they're usually also snacking, you know. that their metabolism actually goes down. it's a little bit like hibernation. it's sort of not the television, it's what the parents are doing. it's like you could blame television because parents are saying, "i don't want to be bothered," or, "i'm not going to create the environment for you to be physically active in, so watch tv." and when you do the study, it looks like, "well, oh, it's tv that's to blame," you know, when in fact, it's not necessarily tv to blame. researchers have found that when television viewing is limited, children fill their time with more active pursuits. some children find it easier to be "active" than others. catherine parrish: county kids grow up in an environment where they can ride their bikes, they can play ball outside and it's safe. they're in good after school programs, or schools that have after school sports and so county kids exercise. city kids don't, for the most part. there have been interesting studies, for example, done comparing physical activity levels in inner city kids compared with suburban kids and one of the things you find is that... inner city kids may do very well on things like push-ups, sit-ups and less well in running and aerobic type of activities. and the investigators discovered that the reason that that had happened was because in this particular study which had been done in a large city that coaches didn't let the kids during p.e., that they had, they didn't let them go out on the playground because the playground was dangerous. p.e. was inside and so the activities that they did was a lot of calisthenics, sit-ups, push-ups, things like that. catherine parrish: i hear lots of stories when i see these kids for check-ups, and many of them are overweight, about how, "i'd like to play a sport but my school doesn't have that." "i can't get to the program. it's on the other side of town." "it's not safe to ride a bike in my neighborhood." "i can't... my bike got stolen. i haven't been able to ride one since that." "my mom won't let me play basketball at the schoolyard because it's not safe." there's going to be a lot of what we as a society, as parents, as individuals, construct for our children, and the kinds of environments that we create for kids to be physically active, despite that fact that there's going to be a great deal of genetic difference from child to child. a few of them are going to become great athletes-- most won't. but many will benefit from what we can identify as optimal patterns of exercise during childhood. ifood nutrition and exercise become a habit, there's a better chance children will grow into healthier adults. but scheduling too much activity isn't a good idea, either. kerry syed: i think that children, in general, are very little impressionable people. and as we go through childhood, you know, our parents make us do certain things-- "you need to be in soccer. you need to be in ballet. you need to do this," but they never think about, "does my child like this?" they think, "i just want you to be active." jennie trotter: most parents are working and then you have after school or then you have other obligations that the kids have, so what we're trying to let parents know, first of all, is to be able to say no. first of all understanding that your kids' agenda and schedule that you may have to say, "that's too much." we stress them in more ways than you can imagine. many kids start their day at before-school care at 7:00 in the morning. then school till 2:30 or 3:00, then after-school care till thefinally get home between 5:00 and 7:00 in the evening and eat dinner and have that one hour that they're supposed to cram a whole day in with mom or dad, and then go to bed and do it again. in the more suburban community, the stress is running from school to soccer, to violin to dinner to fitting in homework to going to bed. and so i think, you know, we've gotten away from letting kids be kids. kids need time to kick their shoes off and do nothing and be in their house, with their things, with their family. and the kids who don't get enough of that... come to see me. and what do i hear? i hear... "he's having headaches all the time. he's having stomachaches all the time." we weren't meant to run at that pace as youngsters. i don't know if we were meant to run at that pace as adults. jennie trotter: sometimes you just practice some relaxations whether it's, you know, listening to music or exercising together. there's some great slow moving, deep breathing exercise that say, you know as a rule, or having family meetings because there's so much going on to talk about who's doing what. for some families, the concept of family meetings, or even just time together, may be difficult to achieve. the family unit is din in very different terms these days. we have single parent families, we have parents where both parents have to work in order just to make ends meet. catherine parrish: i see many children who are latchkey children, who get very little one-on-one time with their mom or dad, who have nintendo, sega, four pairs of sneakers. spending time with your mother or father is probably the most precious gift you can give your children. not so much the quantity but the quality of that time, and that that child recognizes that as a special time for him to share with his mom or his dad or both, or whomever the caregiver is. as children get older, the value of time together, and communication with trusted adults may be even more important. catherine parrish: i've been right here in baltimore city the whole time i've practiced, and as kids grow up, they feel that they need to trust someone. and you know, it's hard to trust your mom or dad when you're a teenager. i think we've all been there. it's not because mom or dad does anything wrong, it's just you're trying to find yourself at that age and maybe, mom or dad doesn't know what that is and you haven't figured out you can trust them. and so i become the person they can trust. and many kids come to me between the ages of 12 and 18 to tell me about experimenting with sex or drugs and to hear what i have to say about that. and if i say the right thing, many of them don't continue to experiment that way. they do trust my opinion. a recent study found that nearly 1/2 of teenagers received no counseling during their doctor's visit, and only 3% received information on issues such as smoking, sexually transmitted diseases and weight control. but those are precisely the areas in which teens make poor choices and put their health at risk. catherine parrish: i think probably the biggest problem we have in the urban environment is that young children, both girls and boys-- i was going to say girls, but it's definitely both-- become sexually active at way too young an age. it's heavily accepted in the city to have a child before you're 15 or 16 years old, to have sexual relations with multiple partners before the age of 15 or 16, to have venereal disease before the age of 15 or 16. there's nothing right about having sex when you're 10-- or 12, or 14. and i take a very strong stand on that in my practice. but i'm one voice in a very large community and when six of your friends have had babies by the time they're 15, it's a very hard message to fight. a lot of it has to do with peer pressure, and then they get so much from the media. and then you have a whole lot of kids right now that do not have that kind of parent monitoring. because a lot of parents are out making money and trying to support a better way of living in their new age. and then you have so much drugs that are out that you didn't have before, as well as, you know, alcohol. edward mccabe: we know from the studies, kids who take drugs, kids who are involved in gangs, are more likely to be involved in violent acts. we tend to sometimes not be as sensitiveo these issues. we can't predict every violent act, but when there are signs ahead of time, we need to recognize that maybe we need to try and get some help for those individuals. the adolescent physicians are very good at talking to those kids and helping to identify which kids are at higher risk than others. so that i think that we need to use the appropriate health professionals to try and help us do a better job. parents face a wide range of health issues as their child matures. the baby with the runny nose, grows into a teenager who rarely has a bad cold, but is confronted with health issues such as smoking and alcohol. as they grow, children learn about health by what they see around them. kids learn better by example. we can say as much but the first two best role models are the-- you know, the people or the parents that are in the home. "the human condition" is a 26-part series about health and wellness. for more information on this program and accompanying materials, call: or, visit us online at: and accompanying materials, call: annenberg media ♪ by: narrador: bienvenidos al episodio 27 de destinos. en este episodio, vamos a repasar un poco la historia del largo viaje de raquel rodríguez. ijaime! ( sin sonido ) iarturo! ieso es estupendo!
health is not a single state of being. it is a combination of factors which, over time, shape and mold the life of a human being. we have various definitions of health which certainly, in modern times, we think of as not just the absence of disease but... a positive health status, you know-- a well being and ability to be active and productive in one's life. in its simplest form, being healthy is feeling that there are few physical or emotional impediments to your doing the kinds of things with your life that you'd like to. it's not so much a biological state as it is a state of mind. there are many people who are suffering chronic illnesses who are supremely healthy because they are able to maintain their creativity, and their vivacity in the face of a condition that, to other people, just sends them for a loop. being healthy is, healthy first with the mind, having a sense of balance in life. also, i would say, health for me would be eating well, being able to exercise, and being able to be fully active in life. working is a part of health, i think, for many americans, and having a job that's productive and fulfilling is quite important in this perspective. the world health organization describes health as a state of social, physical, and economic well being. i mean, they take in everything, and they're quite right, that if you don't have economic strength and the necessary wherewithal, you'll probably not do well in the world. you'll probably suffer in various ways. i think certainly people that are the highest risk of poor health are those with poor resources, poor financial resources, poor educational resources, because they may not make good judgments or have access to health care when it's very essential, or when it's crucial in prevention of progression of an illness. david bennett: but for many people in the world, their demands in terms of health are mu more modest. the people who face hunger, who face the thrt of disease constantly, for them, survival is really health. to see the very quiet, subtle way in which communities can pull together is really quite remarkable. if we have that very broad definition, then everything becomes health. if we look only at certain narrowly defined diseases, we miss somehow the whole interaction that makes up the human being. the whole interaction that makes up the health of a human being begins with a genetic map. dean hamer: dna is like a blueprint that determines not t only our physical bodie, but also, at least in part, our brains. and our brains, of course, are what control our behavior, and so, although it surprises some people, our genes also play a role in the way we think about things, the way we feel about things, and the things that we do. so we have 100,000 genes, and all of us have to have two copies of each gene, one from each parent. each time they're being transmitted from parent to offspring, the genes have to be copied. and the copying system isn't perfect, so little mistakes are made, or changes, and most of them are irrelevant. but over time, we have in the population for any given gene, variance. in fact, my dna, and your dna, and somebody else's dna is 99.9% the same. but there's about one base out of 1000 that's different. so michael jackson's dna might read "a," and michael jordan's dna might read "g," and michelangelo's dna might read "c," and so on and so forth. and surprisingly those very few differences, that one out of 1000, is enough to make all the differences in the way we look, blue eyes or green eyes, our skin color, our height, as well as in some of our behavioral traits. sometimes people are surprised that such a tiny bit of difference-- .1% can make such a big difference in who we are. but remember that our dna and chimpanzee dna is only 1% different, and obviously we're a lot different than chimps. genes are not all that matter in terms of human health. they offer possibilities and predictions, but not certainty. paul mchugh: genes are just dna. they aren't destiny. some aspect of our life experience, what we choose and what we do, how we form our character given our constitution, is what ultimately makes us the kinds of people we are. the idea that somehow or another we're destined because of genes to be a particular kind of person is not only not true in human life, but it's also, of course, not true in anything in life. the phenotype that's expressed in any organism is in part what their genetic nature is, but it's also a part of what kind of an environment and life they live-- the nurture they have. so you can be genetically susceptible, but never exposed. but i think there's a public perception that the environment-- i mean smog, pesticides, water pollution, hair spray, you name it-- that these things are important causes of disease, and the reality is, they're not. there are a few biggies. there's cigarette smoke; there's asbestos... which is pretty much a problem of the past. and then, it's a pretty short list. the rest of the causes of disease are-- if they're not infectious-- are inside us. but often, the conditions in which one lives play a critical role in the ability to maintain good health, clearly, in most communities a level of development which has benefited many people, but left others behind. so one sees large slum areas of marginalized people, with people living under very poor conditions around the big cities. i saw it in china when i went there with my family in 1982. the farther away from beijing we went, the more "third world" china was. it looked like uganda, almost. you can find it in skid row in this city. i set up a free clinic in skid row with the los angeles catholic workers. we saw a lot of people coming in from mexico, recent immigrants with their children, who had some of the same disease problems. and their challenge is really to get the type of health care, preventive care, and treatment for illness that can be relatively difficult to get, and can be relatively expensive. peter clarke: and these people are caught in a vise-- where rising rents, the high cost of good food, the need for medications and health care for children or themselves-- these are crushing factors. and the first thing that gets sacrificed in that trio is good eating, because it's the thing that you can sort of get along without as long as you have enough calories. marc shiffman: the indigent population faces day to day challenges that are formidable, from the moment they wake up, until the moment they go to bed. and so what we-- you and i-- may take for granted in our day to day running errands and doing this and that, and getting here and there, and going to appointments, and meals and taking care of family, and whatever other responsibilities most of which we may consider mundane-- these are all the issues that impact adversely on their health, because they can't all be sorted out properly. and so in every way, shape and form, the lifestyle impacts adversely on their health. the effects of poverty on health appear to strike hardest at those who are at either end of the age continuum-- the very young and the very old. michael bryant: the concept of primary and preventative health care maintenance-- that is what we should be about, because if we can intervene early, then we are able to... to try and prevent some of the untoward effects that kids will realize as they grow older, as they become adults. you know, as we look to-- and there's been lots of rhetoric, political rhetoric, about universal healthcare, and who should get that... should that be extended to the entire population? i think a good place to start is with the children. my god, we should be trying to take care of our children. you know, the issues about adults are very complex, and, you know-- many adults-- the reasons they're unhealthy are because of things they do themselves or do to themselves. but kids are incredibly vulnerable, and i would think it would have to be a priority of ours to try and protect and ensure their health. marc shiffman: there are too many people out there... who are senior citizens-- fixed low income. medicare is their only insurance, and as they get older, as they get sicker, as they need more medications, they are having to make difficult choices. - hi. how are you doing today? - hello, mrs. phillips. - how are you? - it's good to see you. my social worker spends some time almost every day calling up drug companies, filling out forms to get special dispensations for medications. people break pills in half to stretch them, or they just go without because they've got a food bill, they've got an electrical bill, they've got a mortgage to pay, a rent-- whatever it is. they make choices. this happens more in senior citizens. the young, poor population, and this probably is more single mothers that we see, trying to raise children-- some working, some not working, also are faced with choices. and oftentimes because their lives are so hectic, raising the kids and perhaps working, whatever else they're doing, they do come in to see us late. the health of any nation is closely linked to the health of its people, the productivity of its workforce, the health of future generations-- its survival depends on it. most countries have ministers of health, or public health services whose challenge is to protect the health of society as a whole. looking at all of the factors that influence health in entire populations: a commitment to really put primacy on prevention rather than cure; a commitment to social justice, and to looking at all societal factors and environmental factors that influence health, behavioral factors, as well as factors relating to the healthcare system. in the united states, the concern we have about the public health system is that we have the adequate infrastructure and support for the government aspects of public health that protect us, keep our water supplies safe, that protect us against outbreaks of new infections or new diseases, that assure that we have the best policies to protect the public health at the state and local level as well as the federal level, that we pay enough attention to that infrastructure that we can protect ourselves as a society. but for public health officials, health is no longer just a local or national concern, it has global dimensions. james curran: well, you know, certainly during my lifetime, the world has shrunken. i guess it's the same size as it's always been, but the airplanes take us as well as microbes and organisms and animals rapidly between countries and between continents. this is not the "guns, germs, and steel" environment of-- represented in the book, but rather it's an environment where there's very rapid transmission of ideas, of concepts, and of risks. for example, if it's true that aids first arose somewhere in central africa, it would have been-- the world would have been a lot better off if that part of africa had had a better surveillance system and could have discovered this problem a year or more earlier than they did. that's just one example. this inter-relatedness of the world community was instrumental to the formation of the pan american health organization... even though the year was 1902. the intention was to provide a forum in which the countries could tell each other about what diseases were a problem, and agree on approaches that would allow for the control of the diseases-- these diseases-- without impeding trade. in those times, of course, was largely by ship. in 1948, the concept expanded with the formation of the world health organization, and six regional offices that included paho. some of its efforts are focused toward the eradication of single diseases like polio, using the salk d . david bennett: with these tools, particularly the oral vaccine which is very-- relatively easy to use, and very effective, we felt we could undertake eradication of polio from the americas, embarked upon that, and then by 1991, had seen the last case of wild polio virus in peru-- the last case for the entire americas. in 1988... i think as a result of some pressure from the americas, the world health assembly agreed that the world would take on the effort to eradicate polio. we still have polio in the indian subcontinent, in parts of the middle east, and across much of central and eastern africa, so the challenge is pretty big. we are making headway; the immunization levels are going up. national immunization days-- polio days are being held around the world. it is very, very important, particularly for people in the united states and other relatively wealthy countries to understand, that this is one small boat. and we may be in the more affluent part of the boat, but we're still in the same boat, and it's in our interest to help everybody understand their health and deal with their health problems, especially the infectious disease problems. how do public health experts measure the health of a group of people? the two statistics most often cited are life expectancy, and infant mortality. life expectancy is how long we think we're going to live. life span is how long we're actually able to live, and that's a species specific kind of thing. so, for humans, the maximum amount of time we can live is about 120 years. if you live a good smoke-free life, keep your normal weight, exercise, your chances of living longer and living healthier are so much greater now than they were for our counterparts 100 years ago. the average life expectancy of an american in 1900 was just over 40 years. now it's close to 80. this has been a tremendous public health achievement. and if you look, most of those years of gain that have occurred over this century haven't necessarily occurred because of very technologic medical advances. they've occurred because of very, very simple public health measures, whether it's sanitation, or whether it's refrigeration, or whether it's handwashing and the availability of soap, or whether it's vaccines, those are, by and large, what have driven the improvements in life expectancy over this century. and in particular, in the area of infectious diseases. we have to realize in 1900 that tuberculosis was the single leading cause of death in the unitedtates, and, at the close of this century, the total number of deaths from tuberculosis in this country are under 1500, probably closer to 1000 people a year. we have a really brilliant saying in geriatrics, which is, "the longer you live, the longer you live." and what that means is, as you age, your life expectancy actually increases. so if you've made it past childhood, you can expect to live to young adulthood, and if you make it past young adulthood, you can expect to live into old age. and as you live into old age, you can expect to live longer. if you're a healthy 85-year-old, you can easily expect to live another seven years. the gains in life expectancy that have been achieved in the industrialized world are only partially replicated in developing countries. certainly there have been major gains in latin america, major gains in china, but there are a lot of threats to the developing world-- threats of continued infectious disease, threats of aids, threats caused by the incursion of smoking in the developing world where smoking-related illnesses in the next few decades will become the leading cause of death in the world, and threats from overpopulation and the incursions upon the environment. most of the deaths that occur, occur in children under the age of 5 years. if you look at what the leading causes of infectious disease deaths are in developing countries, they're things like acute respiratory diseases, particularly pneumonia in children. measles is still a major killer. tuberculosis is clearly a major killer. malaria-- we have the vaccines, we have the antibiotics, we have the oral rehydration therapy. the problem is that we simply don't get these technologies to where they're needed. in looking at the two principal measures that are used to evaluate public health, how does the united states rank in comparison to other nations? the united states is in the bottom quartile, in the bottom 25% in most of these indicators compared to the other industrialized countries. and it's relative ranking over the last 30 years has declined, so we have gotten worse relative to the other countries. we're improving-- everybody's improving. we're just improving at a slower rate than these other countries. the difficulty is... that most of what we do... now, affects quality of life, not length of life, and we spend a lot of our money on that particular thing. if you have a patient with angina, with severe chest pain every time they take a couple of steps because of coronary disease, and you can put that person back on the street, so to speak, functioning normally and working, that doesn't show up in the statistics. most of the people who have an angioplasty have a kind of lesion in which repair of the abnormality does not extend life, but it relieves symptoms. and so with many of the things that we do, say for vision-- something as simple as cataracts, and the implantation of artificial lenses-- that's revolutionized the lives of older people who were virtually blind because of cataracts. what's that worth? that's worth a lot, and it doesn't extend life expectancy, or at least if it does, to a very minimum degree, so i think it's quite unfair to judge a system on the basis solely of length of life and infant mortality. those are reasonable criteria... but you have to weigh in quality of life in a major, major way. but other factors also seem to influence the statistical profile of health in the united states. life expectancy has gone up, but infant mortality doesn't come down. and part of that is due to the fact that people are living under circumstances that don't favor healthy pregnancies and healthy early childhood, and where they don't get the type of health care that they need because they can't afford it. and in rural communities, it's not available. gerard anderson: of the industrialized countries, we and mexico and turkey are the three countries that have large numbers of uninsured. and so you know that those people are in serious trouble when they get sick, and they are responsible not due to their own fault, but they are the cause for a lot of our higher infant mortality rates, our low life expectancy, and whatever. every person in america needs to have access to excellent health care and health services. and there are several barriers from that happening. some are financial, and some are system-wide, and these seem to be increasing rather than decreasing at a time when our nation has more wealth and more prosperity than ever. that's deeply disturbing. as a physician, i see... the system beginning to blame itself, and blame each other. today, the hmo's are the problem. tomorrow the government will be the problem. the next day, maybe it'll be the doctors, or it'll be the patients themselves for failing to interpret and navigate the system. this is a dangerous trend. the second thing is we have more discrepancy in high incomes and low incomes in the united states as compared to most of the other countries. they have a much better income support. peter clarke: every indicator... of mortality and morbidity, shows a straight line income function. the lower your income, the quicker your death, and the more serious the burdens you're carrying for chronic conditions. clearly, there are steps that governments can take to improve the health of their citizens. but even more immediate, and more controllable on a personal level, are those steps we can take for ourselves. the key understanding is that what i do affects my health at least as much, maybe more, than anything that can be done to me in a hospital, etc., and that i need to start taking care of my health right from a very young age, as soon as i can have that understanding. i think that is a key message, and there the challenge becomes, with young people, who tend to think they're immortal, etc., haven't had some of these life experiences, just to get them to understand that some of the decisions they're making-- young or not-- are key, and they're going to affect them for the rest of their lives. marc shiffman: our number one overriding societal impact on health is still drugs and substance abuse. illicit drugs, alcohol... are one and two. and obviously those spawn a violent culture, whether it's domestic abuse, whether it's street violence, but it all goes back to the substance abuse. there's no getting around that. that is, without a doubt, the single most important impact on what we see. i think wh people think of behaviors, they think more along the lines of chronic diseases, whether it's exercise, or whether it's smoking, or whether it's alcohol, i think people readily recognize that there's a significant behavioral aspect to who the risk groups are for chronic diseases. i don't think that there's as great a perception that behavior also plays a very important role in infectious diseases, whether it's sexual behavior and its relationship to hiv, whether or not it's the foods you eat and how you cook them, whether it's behavior surrounding antibiotic seeking and taking antibiotics, or whether or not it's the types of activities and whether or not you want to use insect repellents when you decide to go out for a hike on a nice summer day. behaviors are critical to not only chronic diseases, but also to infectious diseases. to be healthy, people need to know about health. you need to be your own consumer. you need to read about health, and how to stay healthy. you need to learn about it, and then you need to abide by certain principles. don't smoke. absolutely don't smoke. maintain your ideal weight... get plenty of exercise... have a trusted healthcare provider who's knowledgeable, and know a lot yourself. ask questions. don't distrust the medical system, but be a consumer who is well informed. "the human condition" is a 26 part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: a group of french doctors working for the red cross sought permission to provide aid to the 100,000 refugees in biafra who were suffering from famine and disease. but because these refugees were on the "wrong" side of the government a civil war, the red cross said "no." the doctors resigned their post and started what was to become "doctors without borders," an organization committed to serving all populations in need, regardless of politics or national borders. at the same time, a hemisphere and continent away, the people of venice, california were demanding health care for those who could not afford to pay for it. a group of concerned citizens, working with two local doctors, secured the loan of a dental office at night, and started a volunteer clinic. from these humble beginnings emerged the venice family clinic, the largest free clinic in the united states. this is the story of two organizations and the people they serve... in the name of health, and humanity. suraj achar had only recently opened his family practice when he left for six months to help somali refugees who were entering kenya ne the border with somalia and ethiopia. suraj achar: when we landed our plane on the dirt field, you couldn't see anything green for tens of miles all around and, unfortunately, when i landed, i recognized the suffering the people were encountering there. the children were severely malnourished. i could see it from their faces and their bellies, and the animals were dying actually in front of me. some of the animals were laying on the ground suffering because they had nothing to eat, and no water. teams of volunteers from 45 nations serve with "doctors without borders," wherever and whenever the need arises. i was the only doctor in the team because we're a nutrition-based team. we had up to four nurses. we had logisticians who came from diverse backgrounds: we had a computer engineer from spain, a stockbroker who worked in the trading houses in toronto; a fireman from france; and everybody had bs to do. and they were trained with "doctors without borders," or at least debriefed, before they came onto the mission and trained with people who were leaving the mission. the somalis did not instantly accept or trust the new team. suraj achar: to survive in the desert, with the wars, and the famines and the tastrophes that somali people have survived, makes them a little tough skinned. and it was difficult for us, the whole team-- not just mysel- to earn their respect and achieve their trust. fortunately we were there for such a long time, and we were doing such intensive work with them on a day to day basis-- especially with the children and the mothers who were most hit by severe malnutrition-- that they grew to trust us over time, and would ing us their most severe cases. the incidence of malnutrition, particular among the childr, was alarming. and with severe malnutrition, the mortality of this disease, depending on the variation of protein energy malnutrition that we see, can be as high as 30 to 50%. usually the children die from routine infections like diarrhea or pneumonia. in fact, pneumonia is the most common cause of death. children who are severely malnourished appear anorexic. they do not want to eat. they're often very depressed. their heads are low. they stop talking. they stop walking, and they're severely dehydrated and suffering from inftious diseases. perhaps the most extme case omalnuttion the team witnessed was annis-- a tiny wisp of a girl, two and a half years old. annis is just skin and bones and a head. and i looked at her, and i looked at the weight, and i asked the mother how old she is and the mother told me. and i said, "it's not possible." so i took annis myself back to weigh. i saw the scale, it said 4.2 kilos, took annis off, measured her height, put her back on the scale. i still couldn't believe it. it was amazing to me that annis was still alive. the highest mortality for children so severely malnourished occurs in the first few days. if you overfeed these kids they will die from electrolyte changes in their body. so you have to be very careful. we immediately started her on a rehydration program as well as high energy milk and antibiotics for her infections. and as she started getting better, we started her on soya bean protein mix. and i would come by daily to check on annis'roes what he discovered was that annis' mother was feeding her daughter's food to her other children, and even eating some of it herself. and the food was very basic. it included high energy protein shakes that were like milk, plus a soya bean porridge. and we used this, and it had a variety of nutrients in it-- full range of amino acids which are e buildi blocksfor . i would have to go and get more food to give to annis myself, and i would individually feed annis. and i asked mother why would she not give any food for annis. and mother said she had already given up on annis, that there was no chance that annis was going to survive and that her older children were very important to her and shwanted to help theme that anas much as she could.ive and over time, in our program, annis' mother began to trust us. and as we were feeding annis, annis' mother would also feed annis. it was amazing when she would raise her head, and look up and smile eventually, and eventually even almost start trying to walk. i would carry her arou on rounds, and to see her thrive and suive when her mother was so sure th she would never do so, was probably one of the more beautiful experiences that i had there. but as well as the program seemed to be progressing, the challenges were just beginning. about six weeks into my stay i was called to come to the intensivcare feedingente at 4:45 or:0in the morning, very early. and we rushed over there in the dark in our four-wheel-drive car, we found in the tent where we keep our children with tuberculosis, was one of the mothers lying prostrate on the floor in a pool of diarrhea and vomitus. we assessed her quickly and found she had almost no pulse that we could palpate. we could barely detect a blood pressure, and she was almost comatose. she would barely respond to pain. we then immediately started her on iv fluids. within 15 minutes we'd given her seven liters of fluid to replace some of the losses, just some of the losses that she had encountered over the night when she had started her diarrhea. and we noted the water that was coming out-- the stool quality was very different than usual. it looks almost like rice and water mixed together. and we were astounded by this because we knew that this probably meant cholera. samples were sent to nairobi for analysis, and within a few days the diagnosis was confirmed. it was indeed cholera. at that point, the lives of the "doctors without borders" team and their mission, changed dramatically. iv bags of fluid, antibiotics, and chemicals to purify the water and prevent the spread of cholera were airlifted to the site. one of the most devastating problems with cholera is it can go quickly amongst patients who are immuno-suppressed, like our children with mautrition, and it can cause high, high mortality in this population. so we quickly had to isolate the kids and adults who had cholera. we built a center with beds and iv bags hanging from the roof for the patients who were suffering that were adults. we removed the children with tuberculosis from our isolation tent, and put our children with cholera in this tent. then we built a chlorine bath all around. we burned all their clothes-- anything that potentially could have cholera, we burned it. we built a special latrine for their waste. and we tried to isolate them as much as possible while, at the same time, providing very intensive care for their dehydration, which is the critical problem in cholera. it's a disease that comes on within a few days of incubation, and may only last a few days. but within those three days, you can lose halfour weight in diarrhea, and critically need support. iv fluids, oral rehydration fluids-- all of that plus the antibiotics that the cholera would be sensitive to. before the cholera outbreak, only a small percentage of the children with severe malnutrition died. once the cholera hit, that figure rose. it's very difficult to fight cholera. and these children would have as many as 50 episodes of diarrhea in a 12 hour period. losing so much water, it's very hard to keep up. often times i would go to lunch and come back and a new child would just fall ill during e lunchtime with diarrhea, and would pass away within hours. children were brought to us and would just pass away within five minutes of arriving at our center. so we had some very rapid demises. and it was very difficult as a physician. for a while, my nurses, the local staff, were wondering, am i really a doctor?-- because we were having so many deaths. the epidemic lasted about a month, infecting between 500 and 1000 adults and children. others probably were asymptomatic and carried the bacteria as well. the total number of deaths in the children was probably in the teens. but still, for us, it was devastating to watch a child expire. the death of a child generated a whole new set of challenges. the somali people are moslem, and they're very particular about their ceremonies and their burial ceremonies. but unfortunately, the remains of the children were very infectious and we had to isolate them. so we came up with a compromise. we would clean the child after the child expired and then put them in a body bag. and we'd hand them to the families and they would bury them in the body bag which was somewhat of a protection for the community. at times, the situatio was frustrating for d, knowing that they really couldn't do everything they were trained to do. when the children became the most severely ill and we didn't have a way to manage them, to measure their electrolytes, to measure their fluid balance in their body most accurately, to culture their infecous diseases most accurately, to measure their blood count to see how anemic they were and to potentially get the medicines that weren't available, or diagnostic tests that weren't available, and then to watch these children- some of these children pass away... that's probably the most difficult experience for any physician from the west to work in-- the situation like we had in africa. but as the cholera epidemic waned, and attention once again focused on the malnutrition scourge they were sent to attack, the good they were doing came full circle. i remember doing an evaluation on two children-- one who was four, two girls, and one was six. coming from a town in ethiopia, very nearby, they would walk 10 to 15 kilometers every day with no shoes on through the desert. the temperature was about 110 to 120 in the shade during their walk. they would come, and they would get their nutrition in the morning, and then they would stay sitting outside in the sun for the feeding that would happen in the afternoon. and then they would go home and... on saturdays we would give them a packet of food for sunday. well, after evaluating them and finding out that they had no medical complications that would necessitate medical care, i was about to discharge them, and i asked them, "what is it like on sunday for you?" and these two girls said to me that their food is distributed amongst the family. and because the family doesn't eat during the week, the family eats the food that they bring home on sunday. but they were very happy coming on the other days where they would get the soybean porridge. and i asked the older child if i were to discharge them from our program, would there be a way for them to get food in ethiopia? and she looked at me and said, "probably not," through a translator-- that there was no option for them outside of our program. after hearing the story, of course i found some medical excuse to keep them in our program and continue them there. but being able to help children like that who have nowhere else to turn, was just a great privilege, just a beautiful experience. the health needs of people who live in venice, california may seem a far cry from the health needs of somali refugees. but there is a common denominator: people in need, without adequate resources to maintain their health. it's a few minutes before 9:00, and already, activity at the venice family clinic is in high gear. elizabeth benson forer: our mission is to provide comprehensive primary healthcare that's affordable, accessible and compassionate for people who have no other access to care. we truly are unique in that we're not seeking business with money attached. we're seeking people with no health insurance and low incomes. anzeledón friendly: the majority of our patients are hispanic, and many of them monolingual, so all of our staff members are bilingual in english and spanish. and they're able to provide the services, also in a culturally sensitive manner. and we do have also a large immigrant population from russia. susan fleischman: most of them are older people in their 50s and 60s, but they seem older than that. they've come to this country mostly as economic refugees. most of them have almost no english skills, and they are very, very sick. they have terrible hypertension, lots and lots of heart disease and cardiovascular disease and terrible depression, as well. and they have a very difficult time assimilating to life here. the clinic also serves several thousand homeless people. ana zeledón friendly: we have a special program where our homeless are able to walk in on a daily basis, and we have slot available for them so we can see them right away. susan fleischman: i think most patients are nervous the first time they come here. they clearly don't know what to expect. i don't know how they've heard about us, maybe from a friend, from a family member. i think they're nervous about the quality of care. i think they're nervous language-wise... "will there be someone there who speaks and understands lmy language?".. they're worried about whether we're going to call immigration. they're worried about whether coming here will affect their children's ability to become u.s. citizens, so there's a whole host of worries. elizabeth benson forer: we try to make it so that it's easy for them to get care. it's as simple as really writing down their name. 's a self-dlation someone can say, "i'm jose, and this is how much i earn. i earn $14,000 a year," and that's it. some of our patients want to show us and want to provide proof. but, for the most part, they just have to sign a form with their name, and that's it. it's really wonderful to sort of watch them take a big breath and relax during the course of the visit because i think what they find as they're here is that we do meet their needs. they get the tests done that they need. they get the medications that they need. they can't believe they're not going to have to go to a pharmacy and somehow come up with $60 or $100. it's interesting that many people try to use the clinic as an urgent care center. we have had exames of a man who was having a heart attack who drove by many major hospitals and did not stop, and was coming to us because he knew that we knew him very well. he's been here with us for many years and that he trusts us, and that we could help him. and so what we're able to do is stabilize our patients if there's a case of emergency, and we call paramedics and then refer them to the hospitals for their care. last year, the clinic recorded more than 80,000 patient visits and filled more than 65,000 free prescriptions. no one paid a cent for the care they so badly needed. they frequently haven't had care in a long time. they've delayed going to the doctor. they've neglected themselves. they've put other things first like housing and feeding their children. and so they're quite sick, frequently, by the time we come here. and unfortunately that hasn't changed. we see a lot of people who are immigrants, and that has not really changed. and unfortunely we still see lots of people who are homeless. i think all that's really happened is that the numbers of people in need have increased. elizabeth benson forer: when i was here very early on i met a patient and i asked her, "tell me, how did you come to the clinic?" and she said she had been a headhunter for a medical headhunting firm and she had decided to switch jobs. within her first month of work, her daughter fell at school, and broke her arm. she didn't have health insurance at the time. the daughter had a severe break and needed to be hospitalized. while she was doing her new job from the hospital room of her daughter, she was fired. so she went from making about $50,000 a year to nothing in seconds. at the point i met her, they were on the verge of being homeless, and she had developed some type of back problem and was having problems walking. she was delighted to come here because she said it was the first time she felt that someone really looked at her and said, "this is a person we can hel" it's things like that that make you realize, this can be anybody in our society. people used to live in extended families, and when one person in a family had rough times, the rest of the family helped. the one thing i've noticed over all these years is the difference between someone being homeless and not homeless is usually that the homeless person doesn't have any family to catch them when they fall, or they've burnt all their bridges with family, or their family's in a position where they can't help them. and then they end up utterly and totally alone. the clinic provides basic care, but not specialized care. for that they rely on the generosity of "volunteers." we have about 175 staff members, but the wonderful thing about this agency is that we've been able to secure a lot of volunteers. we have 2,600 volunteers working with us in a year, and 600 of them alone are doctors that are providing about 35,000 patient visits in a year. part of our comprehensiveness, and part of it is serendipity, and that's good and bad. you know, when we see a need, we try to fill it. but because we frequently fill it with a volunteer, it's not always dependable. when i have a nephrologist who's volunteering, then we run nephrology clinic once a month. if the nephrologist moves out of town, we don't have nephrology clinic available here anymore. so then we will go out and look for someone to replace that physician. but for the patient's sake i wish we weren't so dependent on luck and serendipity and charity. i mean, i wish it was just a given that if they needed to see the nephrologist, they would get to see one. as the demand for their services is exploding, the staff is attempting to retain the personal service for which they are known. our fear is that we've lost that feeling of family-- the family clinic where everyone knew everyone, and we've gotten a little bit more anonymous. and we want patients to feel comfortable here. we want them to know their physician. so our solutn to that is to move to a team approach, that's sort of breaking down a large company, a lge clinic, into multiple small clinics so that the patients interact with the same nurse every time, and they see one of three physicians instead one of 10, anth interacwith the same case manager. so f, i think eryone les it. for many patients, the case manager is the key to healthcare at the clinic itself, and points beyond. for your medications, make a left at the second window. the pharmacist will give you the instructions - on your medications, sir. - okay. thank you for waiting. susan fleischman: case managers e ally the glue to the ce at we give her besides the fact that they sit and work with patients one-on-one sometimes for 15, 20, 30 minutes, they're the people thatllow us to use all of the in-kind services that we use so if the patient has multiple needs, you can imagine that they're going to go see two or three different doctors in the community. they may have their blood sent to three different laboratories, anthey may have radiologic studies at two different facilities. that's overwhelming, even if you have a car and a map. but if you don't have transportation, it's really overwhelming. the case managers actually make it happen. as we are talking about the medicines that they need to take or they need to go to a hospital for special tests, we're also asking them, "do you need food?" "do you need shelter?" the quality of care at the venice family clinic is often compared to that which a patient would receive in the private sector. susan fleischman: we may actually be a little slower here than physicians who are working in a capitated environment. our motivation is not so much to see a lot of patients because of the income, but we're sort of driven by the need. there's this constant sense that we're turning patients away, that if we went a little faster, we could see more people that day. so that tends to drive you to go a little faster. on the other hand, the patients here are quite needy. so a five minute in-and-out really doesn't touch the surface. so we take as long as we need, you know, on the other hand, i'm sort of watching the clock and thinking, "who's outside who can't get seen if i go too slowly?" so the dynamics are a little bit different. the pride in the work they do is tempered by the fact that such a facility is needed at all. susan fleischman, m.d.: i so much wish that we didn't need to exist. so i'm always ambivalent about "oh, isn't it wonderful that we've grown, and isn't it wonderful that we offer the services that we do?" but it's really just a marker for the need in the community. and so it's actually very sad that we've had to grow to the extent that we have. and i wish people just got healthcare, as part of what you get when you live here in the united states, like you get public education. my long term vision would be to see a day when anybody could go to a doctor and just get care, and the question wouldn't be, "what insurance do you have? what form do you have? how are you going to pay for this?" that there is a basic knowledge. i lived in england for a little bit. i got sick there. i went to the doctor. it cost me ten cents, and the ten cents was for the bottle for my medication. that was it. i know that england has a problem with their system, and they're working on it, but i think we need to really come up with something that works for everybody that's living in the country. and it's not a question of who's american and who's not. i was in england. i wasn't a citizen. it's a question of caring for people because they're here and they're here now, and they have a need. you never know why someone touches you more than someone else, but it does happen. and several months ago i saw an older homeless gentleman, and it was his first visit to the clinic. he was a very quiet man, well kempt, well dressed. we started to chat a little bit. and he had been sent here from a local hospital where he'd been seen in the emergency room for atrial fibrillation, which is a fast heartbeat which can be life threatening. had been admitted to the hospital for several days, was discharged, and they suggested to him that he follow-up here. this gentleman was about 63, 64, was brand new to the streets. he was absolutely, utterly homeless which is unusual. most of the homeless patients we see are younger than that. so i asked him to tell me what his story was. he h lived and worked for the last 30 years in a bookstore. and as a favor, he slept upstairs. so he was kind of a quiet gentleman. he had no family, he didn't have a lot of friends, and the bookstore went bankrupt. he had no savings, so as soon as the bookstore closed its shop, he was out on the street. he was on the street for about 48 hours, and i suspect on a stress-related basis, went into this horrible heart rhythm, had chest pain, couldn't breathe, fell down in the street, and someone called 911. he was taken to the hospital which is how he ended up here. so we helped him with his medical needs, but the bigger issue for this gentleman was you know, how was he-- brand new homeless, completely vulnerable, older, going to survive on the street? and he was not very many months away from collecting social security income and receiving medicare. and i remember i sort of jovially said, "well, the good news is, you're close to 65. those things will be available to you in a number of months." and he looked at me and he said, "i'll die before then." "the human condition" is a 26 part series about health and wellness. for more information on this program and additional materials, call: or, visit us online at: and additional materials, call: annenberg media ♪
and also crazy since it's the other day he acts as the protests is to find a new leadership in kiev class with a flat already have many of whom i can support. i had my say on our team to match the american doll makers of seeking to slap sanctions on venezuela owned by ongoing protests that have left twenty eight people deeds the british crime is that they be counted as on some of the seven facial media result into painful wall lights on faith. fan. i am. what welcomed see if it does to me this the nineteenth nationally life hamas to you it's me time on my tree russia is standing for the main issue for full time year's upcoming referendum on a wet bed to break away from ukraine. the chevron has ruled out the possibility of russian machine to mention in the country. actually squealed like a has been fighting his last days talks with the us secretary of state in london. to say i wasn't walking around the gardens of the us ambassador's residence that has predictably been no major breakthroughs here in london the us the uk and russia. he looks at currumbin days and hezbollah said a map of john kerry i'd it's like he wasn't budging one bits from the usa east kazakhstan who said that sanctions will work among the up line in process continues to support the referendum and find me at last that russian foreign minister cui to racing that moscow will respect the will of the crimean people to determine that he said in a referendum on sunday and said that russia has no parents rebates just in ukraine the new ticket to the russian federation does not and cannot have any plans to invade east and southern ukraine. we strongly believe that the rights of russians just like the rights of hungarian poet of karen's or post the rights of ukrainians it must be shown to protect us at the top off was asked about the recent referendum is that taking place around the glazing he said that back in two thousand and eight it's cos of it was a special case in clay meera is a very special case and said they claim the extra one k is more important in the hopes and ideas are to the uk and to think about the principle of self determination of what's gone is the claim that a referendum on the amount you are a few is the people's right to self determination has never been counted. this is one of the main points of view and charts. and there are many cases with it's right next to scientists go on that site said self determination is something that has become. vettel in the run up to this referendum on sunday and some western governments have in the not too distant hospital. the tns appointee. still it's fun to see how the us and that weston pond is the tiniest thing to make referendums and secessionist states the refereum o self determination. i tried to speak airline would be reckoned as more nations around the world shaker date in line determine their own future must take place. like when costs of and takes it to copy itself ounce of sebi act in two thousand and eight this is what the birth of the nation looks like the euro. you read it. in fact us. costa's independence two days before the un judge did was legal and in doing says set precedents. then knelt early on in the bloody conflict ensued on my friends and still haunt the country breakaway in two thousand and eleven to create the world's new extra treat to see don the realization of this historic day is a testament to tyler's efforts of the people of south sudan and a search for peace. the ussr its embassy in the cap to achieve at the very same day just nostalgia the case to the canteen at it even at the oakland items that it didn't feel well may need to remain with tips. he is david cameron is selling the argentinian president of the race specifically with the option of president. it's a simple little pays attention to this referendum something the right thing to do. and in britain as the three hundred years of union control and can set you back. being an attitude that on with its heat the union the prime minister says it's up to scott's to decide if you chat. yet both a tool to south contamination tiny as referendum has been denounced as illegal by the team's second clip of the welts biggest economies. the us has sent one to jack's place to question to putting them in peyton's in lithuania. it's also preparing sanctions along with bikini to comes to self determination for territorial integrity. your guess is as good as anybody he said predicting which way it's a natural talents will sign it. the biggest need is whether if it's happening in tests when evil intent on to london. while the use of siding with the usl with threats of sanctions against russia. the rocket science and eighty cents mention skin that high on here. the first of march and a team of coffee trade and industry is warning that denied the nation cannot fall to teach me some fun the phrase is the one billion yuan state of the solution to russia is at stake. european commie kids meanwhile could use baby gets mocked it. he is applied as to the eu with the threat since. add to the end the constant gets eighty percent of its annual gas from russia and to london that huge sums to bed to ferry into the city from plunging property sales from russians would be at risk and last but not least for its revenue to supple with nineteen million on a russian is a byzantine countries in the european country in the form of sinn fein is pecan slaying of combat phase of compromise is the totally out of the sand. houdini obey and accede to a new european union accepted kosovo but it's against the referendum in ukraine the situation in ukraine. seriously this is just an antagonistic way but presented to the absolutely different versions of what's happening. seems a european countries aren't even trying to find a compromise from both sides in this conflict the facts are being falsified. they don't want to accept that groups came to power in the ukraine. they say they're democrats. it's all russian propaganda german chancellor has dismissed the parallels being drawn between the referendum in crimea and the unilateral declaration of independence impossible. the michaels statement to get chris's of within the german parliament to with blackhawks team and is lashing out at me it's one thing off the price. i could get in and of course the movie opened a pandora's on the books aloud for kosovo we should also allow for others that i've told you that you haven't listened to me. winning the cold war has eclipsed everything you feel about everything else it is the posture ousting why companies make that choice whether they want to stay with us plainly. it's definitely interesting. why come they decide they don't belong to him. of course people living in crime in the mosque in the same thing i think the crimea breaking away to cry he's just the same also. i knew who she would use the r and d on the go or at stake. once this led to tensions in creamy and decreed that all is that guy is really coming into politics and power. i actively involved in the event in korea the members of the fascist consistency and someone is gone. i'm very smoothly. and the well times last in america has also want a rucksack. ah but that can damage the massive damage she calls it that if he continues to support the referendum in crimea the sun does not have the backing of the german as rt has been finding out. it goes on this good position so that by themselves. in june initiatives in bold. i think it is thanks to new. i think the sanctions against threshold be like the berlin wall between the east and west along for good and i'm against that but it was in the sitting there thinking what doesn't so i think sanctions will harm both russia and europe. maybe the two discuss and behind the curtain first give diplomacy a chance before slamming the door that way it is obvious that ukraine belongs to europe just like the western part of russia allies territory leading europe and that has nothing to do with the eu or nato those of different things chad says activists say so i don't think sanctions are a good idea that they should see down at table and talk it down to see it. anything you claim political differences at spiel about causing street violence in the city of the onion two days writing in support of both knew the ship and get cash would prove russian context is a one man was fatally stabbed as the result. the russian foreign ministry has released a statement accusing from wright himself attacking peaceful demonstrators and indeed all fanatical self defense. lots of things to chaos and sixty wednesday that he can't. did you hear he derided the hero and publication when pro russian activists were forced to respond to the violets director. on the eve of the rally there were calls for action to be taken against them. tokyo based company by its organizers called for the ultra nationalist stance of local football club to come to the protest was peaceful paths and firing rockets police were getting orders in kiev just don't understand the people of demands on the inch. we are so upset with the key of how much the nationalists fighters were welcomed to power given weapons put into the government. and now all that has come to work towards people are if you read. all the trees spotlights upon scenes of blood that which now controls several government ministries has been put on the wanted list in brush and prosecutors in moscow ike using the next seat we bought the fight scene on the side of catchment areas in the mid nineties. the sad he's received two seats no encouragement from some of the world's top diplomat including catherine ashton added present in the eu and the toe at newlands on the us that says five to seek a new box of controversial costs and that the neo rhetoric of his car. apple custard into the deep divisions within ukrainian society. ah website and i t dot com with the state while the docket in crimea rejects the self appointed his youth. i eye the peel way to administer you can comment to sixteen self sacrificing the bar which was a concept and profits. i have decided not to face a tough stance on she'll get fighting. this infuriated the accidents have all that surprising often the shoveling. off the eye ukraine's state is in the balance of regime leading candidate is of dubious legitimacy in the upcoming vote in the crimea in all likelihood puts the country's sovereignty and to question the ukraine. parked the car the new ukrainian fashion should come to our land. it's a threat to russian troops when it is a small republic and russia is a huge country to send us. walking ten and went to a small cocktail was thrown into a chinese custom they are defending the law and what do we do it again gregory has never strayed into it and it never will. is yes. he is a welcome to you future attacks. the rebels and syria have admitted to kidnapping multiple people all women and children going to be an ally plan our team you abducted in all the sons of radicals want the exchange them for two thousand opposing find just what kind the kind thoughts not be analyzed consider themselves moderate shiites and tammy got twelve percent of the population. syria's president to have been stacked on the sides and add the olives to the group which is why it matters on being targeted by the rebels in the series of scientific human rights as out of the four two thousand and one of them killed since the war began nice of them soldiers and pro admonition and jonathan steele who has written extensively about syria for the audience as minorities face a grim future if the sun is remains from power. this has become. daddy and me. nestle will in some cases as well. any money rizzo accusing the government establishment and operation sleeping with the cartoon devil. not just something wrong with them on his way to even get into the temple may have a difficult time uses the system is to remain stable sunni fundamentalists to this. who says you need to finish the city who impressed by the alliance needs and wants him to give up. also if anyone did it. just another license and christians and to the armenian listened to some parents may have a difficult time to clean. he said. sunni muslims. on line see you in prayer palestinian setting at the top of things to smile for you. this can get behind a body con on these rainy days to find out how that works and the hot seat. the un men's us aerial strikes come under the label scrutiny the pentagon is not racing for fun is all i want to try some more details on how much the spending. you find one on online sites right from the sea the interesting picture the importers twitter. just to wear. the animal. the move on. the road. it's me her keys. when that problem was that fit on the appeal site night at the traffic light thingy. it really helped me to do with them. prime minister has under which he become a sensation on which to battle the end of the game includes the fun of himself running sliding off into the rough about what the situation in ukraine now the image when clara was selected teams including pet treats to attend the pics den he come up with that in pennies. all of the camera and amy teaches to actually express the unison especially ukraine in crisis with the pm and that's not the only key ups on this backfired on him in the posse days as i see separate report. we were fourth in the conservative caucus just dissipate in the face with appetite thing for the finest is at page illustrates that in a bid to generate clicks. i likes on his face that page the things that when comments are all about reports that i'm keen to cut the results it seems that at the same deal of time and place as any team lacking just a month the gate and the plaintiffs this page was about twenty thousand the likes of mind to keep the finding is that he likes things that page. now he's laugh in front again with more than a hunch it affects the thousands who likes to play wii tennis team the consensus was that i hate the advertising to get more lights on faith that what we think about that. good thing bad thing. it sucks the distributors. i didn't use it for some people like you mean it's interesting isn't it like that it's not gonna take a peek. at the taiping which generates like the looks of it ready the singers of the woods it's not giving this comes across as kind of liked. it's dismissed leaving it sounded like his book about that love to see the pace of the reference offered up anything you think daddy is a kind of bull. let's say it when i lived on the button at the cake thank you very much that's a good thing or bad thing. love to give reasons to deal with the side's most of you who do these days that we would get fast results. it has to be liked or facebook you know. it's a full third term and that the social media puppy i'd see it that much tv this is a necessary reflected in the polling results and once the finest necessity has his head that it's a film media gas in the pas than expected site would probably have a few more to come in the feature one or the parts he needed to read it and will come twenty fifty but they say show me your likes and he translate it into but it's sad that i see london. the us congress is urging president obama to impose economic sanctions on venezuela. the comes amid andreas has left twenty people dead in the south american country. washington condemning the crackdown on anti government protests correct answer is defending the actions of the security stopped in the face of the year was that the attacks scores of an islet and protests a second shot saved by unidentified gunmen who present a month to assist with father michael bryant is working with support from washington. julian box and he has been upset of the sexes in the country for the twenty eight says the us is fully explain a bullet in the emirates the concern is that motions in the states on the opposition great seats been offering technical support logistical support soon they might not have a direct us saint vincent and tyrrell escape the argument that the government says that this is being a micro see what she is standing in a difficult situation the economy is in american studies he said. but the key way for now is the dialogue and train stations and supports been stressed but not so reasonable and analysts said the organization ranked sites of fortune in the mind and your position he seems to do that but dialogue is the only way forward. the problem is that in the presidential elections and wash it nicholas might go to the current president's anyone bought one point eight cents. and that is the speech against the opposition is likely about this is an entry point into the stop testing and stubborn to do just moisten the government says is not an hour in the charts has been a real weakness but having said that the government's increased by ten percent since that's what elections in december. rising has found its geological it's a show it's age. it was accepted at the beach and release he returned to his instructions together the run up dolls one else is happening upon the world the princess and scuffles have played out in jordan's capital. that is meaningful that got sucked into a two d and cats. these women seeking the official tried to grab the fire a rifle from sylvia while crossing the border the mine had been climbing on the government to acknowledge his agreement with israel and to deport the country's ambassador thousands of riot police officers are trying to prevent the protesters attacking these are the antics. it sits in gaza have fired rockets into israel during its flights in retaliation. as of this by the trees called by the palestinian group islamic last three days of cross border attacks have been the most intensive since november twenty twelve on wednesday a barrage of sixteen lock it away by its by islamic in retaliation for israel killing three of its contents. well then responded with a slight scent and five targeting minutes and hideouts in science does i kissed on the eighth least nineteen people have been killed in a series of bomb attacks in busy areas of content echelon. a suicide bomb up in himself out in that market. what was supposed to get meaningful prius and other assaults and expensive dates and bicycle was enough outside to a colleague's this comes despite government interesting piece by piece sons come in time. in peaceful. thousands taking to the streets of sao paolo to protest the gaze of this spending on the upcoming football world cup demonstrate to save billions of dollars have been wasted on stadiums meeting in future budgets of all that's impacting the services including how the patient that follows numerous protests in brazil's main street scenes with the constant months most of its cost is free the chilled as industry has been given a boost in the eu and the european parliament as they did for mowbray has rules and all in and gets its duration. the left front came out of the cgt not the links in the tin then put a screw up my itching to take me as a way to deal with energy costs comes with major risks in taking toxic needs into soil and ground quartet and the neo con see you and pete john then and that's it says it's a mom she said of blind eye to this dentist unfortunately agreement between flemish to get from carmen with dom member state governments. leaves out the compulsory element is still very much up to the end of the two member states how they can't do that. we think that that's the real ira environmental impact assessments of necessary to settle debts so that you really get on tokyo one of the two go to the circumstances. what do you think that the potential outcomes and that you really give the new lights that before anything goes ahead and so we think that in the revision of the legislation we've got this week. we haven't really gone far enough of this week of the greatest skillt of scrua thanks to ike and russia in the us reach a compromise over ukraine. the company based in costs are down ninety two ay ay ay ay ay ay i am. sure pill cause quite a stir at least twenty fourteen conservative political action conference at her now famous infamous quote about how to deal with russia is flying all over the area at the book's years and years she said. he only needs to be a guy with good looking guy with the deal. to be fair people are taking a school a bit out of context using that in terms of her fears that obama is disarming the country's nuclear arsenal will part we've seen having a big batch and it sure keeps the interventions of the country. boxer believes obama is disarming the us is madness there's actually no evidence that obama has even put a dent in the military industrial complex also use the term bad guys is an singer backcountry such bad people in them or just looking at things. this is the level intellectual discourse of a kindergarten class you would choose to pan her childlike you will also lead to violence because she talked about it being pressed a potent took the streets even mean drawn to war with russia nuclear war. peel and grate is the worst type of chicken hawk garbage and what is even worse is that there are millions of people out there who buy into the simplistic more i like that stupid bad ice more war rhetoric but that's just my opinion. i him. in a day. he is the only enduring. last time. isn't this a very open space. the chinese. system reviews and acupuncture points to the bell so that she always goes back to thousands of years. it is the chinese. to be very useful and children. there are a little broader. there are chinese medicine over to japan in small six inch a japanese them destitute. it's their own on style. feeling so then. it also has a maximum two hundred years this century. and on the gentleman who made it resuming on was named an encore she and the people known as the first time the disco christian school in nineteen twenty five. aah his system when what he calls got two was based on that impressed. what is one of his students must not the last sentence yes two which includes more striking than it is more than just the pressure comes with just twenty four. the thought of the united states and europe with very popular and on. in america especially of east and west calls just two years on. ever changing. it's also based on the same. same principles of chinese medicine but it can vary. we can always feel you know it's it's just you know this many styles. what i do is call there's a chance to us yes which is more emphasis on using your feet. on the exams yet to. yes humans. different shots. basically based on the senate yesterday was fun but also that and thus far but now coaching. the i am so was done in berlin. eric kelly welcomed additional years of coming up in the next half hour. no common ground on ukraine last ditch negotiations between the united states and russia raised an hour after hour of our ports. going to jail only to those assigned to a president that's as he will serve her sentence the search for the missing malaysian airlines. the plane is extended to the indian ocean as the mystery of its disappearance
the environment is a crucial factor in the health of each of us. if the environment is not healthy, there is no way we can truly call ourselves healthy. persistent efforts and regulation over the last few decades have greatly reduced environmental pollution. ib: our rivers don't catch on fire anymore. persistent efforts and regulation over the last few decades we don't have big, black plumes in most communities in america. we don't see slicks going down the great lakes. so people believe, because they don't see it, that, somehow, we're in a better state now than we ever were before, and the truth is, that all we've done is cosmetic surgery. we have scraped off the surface and made that look pretty, but beneath it are the invisible chemicals that are getting into our food supply, our water supply and our air each and every day, and poisoning us. not gross poisoning, but subtle poisoning, day after day after day. we are not exposed to individual toxicants in the environment. we're exposed to hundreds and thousands of chemicals in our food, air and water, many of these natural, many of them human-made. so the question is, what happens when we have all of these added together, in varying amounts? many of these chemicals are difficult to escape. they reside in the atmosphere that surrounds us. john peters: for years, there's been a well known set of responses that people get when they breathe southern california-type air pollution. eye irritation, you know, irritation in the chest, cough, things of this sort-- but the real question that i think some of us have been interested in is what does this repeated kind of experience result in, as far as permanent, chronic damage to the lung, or anything else? health officials suspect that air pollution may be a factor in diseases such as emphysema, chronic bronchitis, and lung cancer. it can also intensify the breathing difficulties people with asthma experience. john peters: if you divide the population into asthmatics and non-asthmatics, there's a striking relationship within the asthmatics as to air pollution level, and frequency of cough and phlegm-- it's twice as much in the more polluted communities than the less polluted communities. nine years ago, the california air resources board initiated a study to determine the long-term effects of air pollution on health. their subjects? 5,000 school-aged children living in 12 southern california communities, from atascadero to alpine. john peters: we decided to look at children primarily because we can find them more easily. we can go to schools, and if they're young enough, they don't smoke yet. they don't have hazardous occupations, so that there are some things about them that are amenable to study, maybe not the least of which is-- at least thought by some-- that the growing lung in a young person is more susceptible to the effects of air pollution as well. plus the fact that children spend more time outdoors and they exercise more so that they would be breathing more of the ambient air and when they're exercising, even more. children in the study are periodically tested to determine if there are any long-term effects from air pollution. researchers measure each child's lung development and function in relation to the air quality at home and in school, as well as the outside environment. so if we see an effect, we'll be trying to isolate whether it's caused by particles in the air, or ozone in the air, or a combination of the two, or nitrogen dioxide, or some other pollutant. thus far, three results seem clear. first, children who live in areas with high amounts of air pollution exhibit slower rates of lung growth. second, children with asthma and other respiratory illnesses are affected more by the pollution than other children. and third, school absences related to respiratory illnesses in the communities studied, are not linked to ozone pollution, as first thought. what we've seen so far makes it look like particles and no2 or nox are more important than ozone as far as the chronic effects. health problems related to air quality tend to emerge over time. illness related to contaminated water is much more direct. david bennett: the diarrheal diseases are usually transmitted through contaminated fd d water. so with poor sanation systems the comnities, poor hygiene in the household, lack of running water, water that has to be stored and can be easily contaminated, lack of refrigeration for keeping foods-- these are all factors that contribute very heavily to the occurrence of diarrheal disease. for the past decade and a half, the carter center has led a worldwide campaign to eradicate two water related diseases: river blindness-- caused by the bite of a blackfly which breeds in rivers and streams, and guinea worm disease. donald hopkins: this is a parasitic infection that people get when they drink contaminated water from open ponds. a year later, worms that are two or three feet long come out of their body. the threadlike worm emerges slowly through a painful blister in the skin. if the worm breaks during its exit from the body, it causes a severe infection. donald hopkins: people are incapacitated, usually temporarily, for periods averaging six to eight weeks. during that time, children can't go to school, farmers can't farm, parents can't take care of their young toddlers. many victims immerse the affected area in water to soothe the burning pain. when the female worm touches the water, she releases tens of thousands of larvae that begin the cycle again. although guinea worm disease cannot be cured once the larvae is ingested, the disease can be stopped if the one-year life cycle is broken. donald hopkins: it can be prevented completely by teaching people not to go into water when they have worms coming out of their body, because that's how the infant worms get back into the water. teach people to boil their water, if they can afford to do that. teach them to filter their water through a finely woven cloth. there's a chemical abate which you can put in the water that kills these parasites, but leaves the water safe for people to drink. it also doesn't kill fish or plants in the water. but the best way of preventing this infection is by helping people to get safe underground sources of water, such as from a bore-hole well. that improves-- it gets rid of guinea worm, but it also reduces the amount of diarrhea and other kinds of water-borne problems that people suffer. water quality is often perceived as a local or regional issue, as is the case of the guinea worm. but the very fact that water circulates around the globe and through the soil, means that contamination in one area eventually spreads. rebecca goldberg: the ocean has historically been treated as so vast that we can do anything to it and it doesn't matter. cities have pumped vast quantities of untreated sewage into the ocean. new york city has dumped garbage in the ocean. ships have thrown their wastes overboard or discharged their sewage directly overboard without treatment. the beaches of imperial beach, california, a seaside community south of san diego, are closed during much of the year because high levels of pollution pose a danger to swimmers and surfers. two miles to the south is the city of tijuana, mexico. almost half of the homes and businesses in this rapidly growing ban area are not connected to a sewer system. ababout half a mile short of that two miles is the mouth of the tijuana river, where a million acre watershed pours water and unconnected sewage from homes that are unsewered in mexico down into the watershed, and that's out the mouth of the river where the sewage flows north or south, depending on ocean currents. the rapid growth of industry along the border has also created severe pollution problems. most mexican factories do not treat their wastes before dumping them in the ocean. carolyn powers: you don't see toxics in the waters so the beauty that you see behind me is very deceptive in that you don't see the chloroforms, you don't see the lead, you don't see the arsenic, you don't see the toxins discharged from the maquiladoras in mexico that come down the tijuana river untreated and actually pollute the marine mammal fisheries, and as well as the recreational users here in imperial beach. the unseen risks have resulted in very real health problems for anyone venturing into these waters. gary sirota: i remember, i used to go into the ocean when i had a cut and i'd heal myself. and now when i go into the ocean i almost always have to come out-- peroxide my cuts to make sure that i don't get an infection. i can't even point to how many times that i've gotten gastroenteritis, diarrhea, nasal infections, ear infections in the last ten years from surfing the local coastal waters. the heavily populated city of san diego, a few miles north of imperial beach adds to the pollution problems. kathy stone: when it rains in urbanized areas such as san diego, we're going to get a lot of run-off coming in from all the asphalt-- it comes into the ocean and that's going to be highly polluted with chemicals, fertilizers, high bacteria levels that can potentially make people sick. so what the county does is we advise the swimmers and surfers that please don't go in the water near lagoons, rivers, creeks and storm drain outlets. marco gonzales: i can go out three, four days after a storm, after they've pulled down all the signs and coming in, get a gulp of water or something, and my throat starts burning almost immediately. you know, 24 hours later, i'm completely sick, laid up with the flu. it doesn't take a large stretch of the imagination to attribute that to the polluted water. air pollution and contamination of the water supply, are not the only purveyors of toxic risk. for many people, especially in decades past, the most dangerous environment may be associated with a paycheck... the workplace. the women who were using their tongues to make the point on the brush to make the fine letters on the dials luminous and were, you know, getting a lot of radium into their body and winding up with cancer of the jawbones. and then, there are lots of stories of, you know, coke oven workers developing cancer, coalminers developing lung disease from inhaling coal dust and silica miners being exposed to silica and developing serio respiratory illnesses. at the hawk's nest tunnel, but in the 1930s, mostly black miners who were driving the tunnels through in west virginia, they ran into a mountain of virtually pure silica and they contracted these diseases in days and weeks, because of the high intensity of their exposure to it. fortunately, we don't have that kind of exposure now but we do have and continue to have silicosis as a problem among miners and among workers generally. workers who are sandblasting tunnels or bridges, workers in factory settings that use abrasives to clean, elements to clean machinery, those frequently contain sand and silica and those workers then have exposure. hello. my name's richard, and i'm with the state osha program. and i'd like to see the person here with the highest authority, please. today, it is the job of osha-- the occupational safety and health administration, to keep workers free from health hazards by regulating their exposure to different hazards. jim, you have richard from osha in the front office. please come to the front office. all of our inspections are really a surprise to the employer. we cannot give advance notice to any of the employers. my name is richard, i'm with the state osha program. - and i'm here to do an inspection. - okay. some inspections are prompted by a violation or complaint reported by an employee; others are routine. ray barkley: they'll explain why we're out there, and then they'll ask to look at specific programs. well, let's just start and walk around the shop. and then they'll start their walk around, which is the inspection. this is interesting. tim, could you come here and-- ? yeah? this device shows whether an electrical circuit is grounded or not. and i'm showing no ground here, but i am showing that it's grounded here. i don't understand what the problem is. so could you kind of peek in there and tell me, without sticking your fingers in it? looks like the grounding wire is not hooked up to the face plate. so, there's no grounding wire on this particular plug, and that's a very dangerous situation. again, that will result in a citation... ray barkley: our whole job here is to try and make the job safe or the place of employment safe. to avoid liabilities, industries with potential workplace hazards will often hire medical personnel and industrial hygienists to monitor employee health and safety. teresa howe: we fabricate a number of parts for the various launch vehicles here, so, employees could be exposed to a number of different chemical substances, fibers, vapors, gases, various liquids, corrosive-type materials. tracy schile: the goal of the industrial hygienist is to undertake preventive measures that keep our workers from being exposed to chemical, physical, and biological hazards. okay, so the time i started you is 10:05. and then this is to get the short-term exposure limit, so i'm gonna wave at you to get you to stop what you're doing. at 15 minutes, i'm gonna change out that cassette. okay. tracy schilf: we're looking for the results of what the fume exposure is gonna be for his welding process. he's using a... what's called the "rod 4-10," a stainless steel rod, it has some chromium in it, so that's what's gonna be our biggest concern. teresa howe: engineering controls are the primary tactic that we would like to use in occupational health and safety to keep exposures away from the employees. those are methods that we use, or perhaps devices that we use, to actually control the exposure at the point of generation, perhaps; isolate or separate the employee from the exposure; engineer the release of the hazardous material. for example, engineer that out of the process, so that we just don't have the exposures. for many reasons, howe considers personal protective equipment the least desirable line of defense. howe: we reallhate to have to rely on these devices. they can be, you know, they can fail. they can come from the manufacturer with holes in them. a glove with a... maybe a small pinhole leak that the employee might not notice, and they're relying on this for chemical protection to keep that material off of their skin. with respirators, for example, there can be breakthrough in the cartridges where the filter material becomes unable to filter out anymore of the solvent or dust or something like that, and the employee then can be exposed. or the respirator might not fit properly on the person's face, again resulting in possible leakage and the contaminants getting in there. other hazards that we typically have in... well, in a number of our production areas, is noise. we've got machine shops, for example. we need to get these people in the hearing conservation program, make sure they have earplugs; make sure we check their hearing every year to ensure that there's no degradation of their hearing. the one place most people feel free of environmental hazards is their home, and yet it's estimated that there are anywhere from 50 to 75,000 chemicals concealed in the products we commonly use and wear. the body interacts with these according to the way our biochemistry is programmed, according to nature. in general, i like to think about all of these other chemicals in three ways. they are either nutrients which our body can use for energy or for building tissue; they are inert, which means we don't use them at all and they just pass through; or they're toxicants-- they have the ability to alter the biochemistry within our body. good shot! parents of toddlers and small children must be paicularly careful about protecting young ones from toxic substances-- the cleaning compounds and plants, cosmetics and drug products familiar to most households. michael bryant: and so prevention begins to be the key, and looking for those, what i like to call, "hidden dangers" in your home that kids can get into, and trying to be proactive in terms of educating yourself and them about those dangers. and they exist in some of the most unlikely places. i mean, kids do things that we would never imagine that they would venture into, simply because of their curiosity. other health hazards may be less obvious, when an enterprising pest control service started using a chemical designed for agricultural use to destroy their household pests. milton clark methon isrgano-osphatpestide. it has been in use as an agricultural product for probably four decades, and it's a chemical that has significant toxicity and also short life in the environment, which has made it a chemical of choice in agricultural use. the trouble was, mr. brown, the unlicensed pest exterminator, did not use methyl parathion for agricultural purposes, as instructed. he used it inside people's homes. the roaches was real, real bad in my house. real bad. so he came and sprayed. when he sprayed, they stayed gone about a year. "o ths no pbl withhiuf there's no worry about it. you just have to air it out, and it'll dissipate." "o ths no pbl withhiuf bradenning: when it's used indoors, you don't have the wat or the bteri or the sunlight to break it down. it can stay inside a house for two to three years beforet breaks down, and that was the big problem here-- is this was all sprayed indoors. it was not breaking down, and it was still a threat to everybody that was living in these homes. an exposure to a chemical occurs when... through one of the routes: oral, respiratory, or dermal, we come in contact with a chemical in an environmental medium, such as air, water, soil... whatever. the effects may be either local or systemic. local efcts occur near the se ofe. craigmill: a systemic toxic effect can only occur if the chemical penetrates our skin. when parathion gets onto the skin, it is absorbed slowly into the bloodstream and causes an inhibition of an enzyme in our body. this inhibition causes widespread generalized toxicity, which results in headache, nausea, vomiting, diarrhea, and difficulty breathing. when we went intoeople's homes, we found that there were often the pesticide product in fruit jars, in milk jars, in honey containers... and the products looks like milk, actually, when it's diluted with water. obviously, we had great concern about children or others picking up these bottles, which were drink bottles, and consuming the methyl parathion in high concentrations. that would have been a very big problem. it turns out that these containers had a high enough percentage that the ingestion of between one and two teaspoons of the product by an infant, and let's say this would be 20 pounds and under, would be capable of killing the child. and a dose slightly greater than that, spilled on the skin without washing it off, would also kill a child. letters were sent to residents whose homes had been sprayed informing them of the potential danger of the pesticide. letters- monica fan? residents whose homes hahibeen sprayed hi, nica. my name is rosa. i'm with the department ofubc th spoke with you elier this morning, regardin thmeth pathion. evans: we relied heavily on the public health nurses who provided information he residents initially, who collected the urine samples, and who followed up with the residents about the outcome of the urine testing. how soon will you pick up these results? tomorrow morning. if you like, i can be here... somewhere between 10:00 and 11:00. okay, that's fine. we took a lot of time to ask questions about what kinds of habits and behaviors that people in the homes practiced, so that we would learn more about which kinds of behaviors resulted in high levels of exposure. now i need to know... during the spraying, right after the spraying, maybe a couple of hours after when you came back into the house, or when you were in the house, was anybody, you know, complaining of any sickness, headaches, anything? yes, my husband was. he was nauseous. he had headaches. he just didn't feel right. and that was how soon after the spraying? well, he had stayed here while the gentleman was spraying, and so afterwards, within an hour, he felt sick. when i think about it now, some of us were getting sick. because i had headaches all the time, and the kids would vomit, have diarrhea, you know, or complain about headaches all the time too, but we thought it was the flu or something. we didn't know it was coming from the spray. one of the questions that is often asked is, "if the product is so acutely toxic, why didn't we have hundreds of people going to emergency room?" often the pesticide symptoms that do result mimic many other types of symptoms, such as flu, frankly. e.p.a. officials were not just concerned abt the immediat health eexposue methyl parathion. we, however, have also been concerned about, and the scientific literature is incomplete and inconclusive on this, is whether or not we can be exposed to a pesticide in less than an acute fashion, just below an acute level, and end up having chronic health effects later. we were concerned that children might have subtle neurobehavioral effects that you would be able to observe years down the road, but the parent might not necessarily notice at the time of the exposure. in their assessment, children and pets were at greatest risk because of their smaller body weights and more frequent contact with contaminated surfaces such as the floor. aonce methyl parathion,ct or a pticide, has been sprayed to wood or anyurface such th's rous,or. it soaks in, and you rely can't cln it. it basicly has to be remov to ban efftive dcon. so, thwe w.. they were taking out drywall, baseboards, flooring... at some point, yeah, some of the houses were brought right down to the studs, and then totally rebuilt. christine scott: we got rid of all of the toys and stuff. we couldn't have the toys... but the furniture... this is some of the furniture. uh-huh, but the toys... all of that, the games-- we had to get rid of that. we couldn't keep that. dolls, and, you know, teddy bears-- because it had the stuff on real bad. and if there's any one single message that u.s. e.p.a. would like to get out to people is make sure that the people they're dealing with is reputable, that they show them what is actually being sprayed, put out on piece of paper what is being sprayed, and certify that, and also will show them the license that people have to allow this to be done. if you don't do all of those three things, then you may be in a vulnerable situation. despite the hazards we live with, people who have been working to improve the environment are optimistic. and part of that optimism is just looking at what's happening out there. it's not a matter of how many sites are being cleaned up, or how many smokestacks are being shutown. that's onmeasurement, but think the real measurement is, how many peoe e concerd about what they're eating today? how many people are buying organic food? how many pple are looking at the labs of food products? how many people are looking at labels of clothg? once we changehe marketplace and edate nsumers, then we begin to make changes in this country that are really solid, rooted changes. so, i think the fact that the american public has become more educated and are taking their own steps, is very, very optimistic for me, and i think that we can win. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: and accompanying materials, call: our kids have the mos to deal with today... isn't violence. it isn't drugs. it's unhealthy food. too many of our kids are overweight. they're headed for diabetes, heart problems, or worse. they need to eat healthy things. like vegetables, fruits, high-fiber vegetarian foods. as our kids grow, the right foods can help protect them from obesity, heart problems, diabetes, and even cancer. to find out more, call for a free booklet. or visit our web site -- kidsgethealthy.org. narrator: once upon a time, before we started ordering chicken without the skin, or cappuccino with non-fat milk, we simply ate what tasted good, and filled our stomachs without worrying about whether or not we were clogging our arteries or adding extra calories. today, eating seems like a daily struggle-- a constant battle between pleasure and health. it would seem that the abundance of food, and the wide variety of choices we have in the united states would almost guarantee proper and adequate nutrition for everyone. however, that is not always the case. peter clarke: there are a lot of people in this country-- tens of millions of people in this country-- who eat enough calories per day and even grow overweight but are malnourished. they are not getting the vitamins and minerals that they need. they're not getting antioxidants that they need. they're not controlling obesity which has so many health consequences and so malnutrition is a serious epidemic problem in this country, invisible to most people. the latest research on diet and nutrition confirms that what we eat does indeed play a role in maintaining overall health and well-being. what has changed through the years is the concept of just what a healthy diet is. joanne ikeda: when i first started as a nutritionist, we told people that it didn't make a difference whether you ate white bread or whole wheat bread. now we say the exact opposite. at one time, we actually put polyunsaturated oil in a cup and gave it to patients in hospitals because of "the health benefits" of polyunsaturates. now we know that total fat in the diet makes a tremendous difference and we would never do that again. so, over time, a lot of what we used to do has changed dramatically. however, a few nutritional facts remain constant. our bodies need the nutrients found in foods to function-- to power muscular movements and cell activities, repair tissues, and maintain body temperature. to carry out these metabolic activities, cells need the energy stored in three nutrients: carbohydrates, proteins, and fats. linda gigliotti: the body prefers to get energycarbydrate, and carbohydrate we may refer to as sugars or starches, but we get carbohydrates from grain products, fruits and vegetables primarily. joanne ikeda: carbohydrates are really a great source of energy for the body, particularly complex carbohydrates because it takes a while for the body to digest them, to absorb them, and then it gives a fairly constant elevation to blood glucose levels. and that's what we want because that's where we're getting our energy from. dietary fiber is another important health benefit of complex carbohydrates. the typical american consumes about 10 grams of fiber a day. medical experts recommend doubling that amount-- adding more fiber-rich fruits, vegetables, beans, and whole grain cereal products to the diet. protis used initially in the body to maintn scle mass, to build cells, antibodies, hormones, etc. and generally, that need for protein will be met if we take in 12 to no more than 20% of our calories from protein. any additional protein that we take in will be used for energy. calories will be broken down and burned for calories. and of course, a lot of those proteins are found in animal products such as milk, cheese, eggs, poultry, fish, lamb, beef, although it's quite possible to also get them by combining plant foods and legumes and things like that. linda gigliotti: we will really get enough protein from taking in about five to six ounces of meaper day. now three ounces of meat is about the size of a deck of playing cards. so you can kind of imagine a day's intake, that if i have a couple ounces maybe at breakfast or lunch, three ounces, that deck of playing cards on my plate at night would really give me enough protein, assuming i'm eating the other foods in the guideline as well. but as americans we don't eat the deck of playing cards. we eat the paperback book, you know, a very large paperback book, as our portion size. for health conscious people who have worked hard to minimize or eliminate fat from their diets, it may come as a surprise to learn that a healthy body actually needs fat to function. the body uses dietary fat to make tissue and hormones, and to provide a protective layer over vital organs. but in fact, it's these fatty acids that run the heart and other vital organs in the body, just a major food substrate, glucose being another food substrate. so they're a very vital part of our bodies and very important in function. but, in high levels, and probably certain types, can also be dangerous to the arterial wall. whether a fat or oil is considered dangerous or healthy depends on the type of fatty acid involved. is it largely polyunsaturated, monounsaturated, or saturated? when you're cooking, in general, choose monounsaturates and polyunsaturates. peanut oil, olive oil, canola oils are all excellent choices. butter tends to be more saturated. they are solid fats. beef fat, pork fat, chicken fat, lard-- they're all solid fats. linda gigliotti: the saturated fatty acids have a higher link to cardiovascular disease and probably cancer. there is increasing evidence that there's a value to having monounsaturated fatty acids up to about 10%-- about 10% of our total calorie intake from monounsaturated fats. so a balanced diet needs to provide all three of those nutrients in a healthful proportion. generally speaking, because fat is associated with cardiovascular disease and cancer, we recommend keeping the total amount of calories from fat less than 30% of the diet. protein is going to build those muscles and body cells, but you can do that if you get 12 to 15 or so percent of your calories from protein. so the balance of the calories are going to come from carbohydrate, and that generally puts us in the range of 50 to 60% of total calories coming from carbohydrate. now, if we're working with a diabetic, we may want to keep the percentage of calories from carbohydrate closer to that 50 to 55% but other people are going to do just fine with 60%. if absolutely necessary, we could live weeks without eating anything. our bodies would get nutrients by digesting its own muscle and fat. however, if we were to go without water, we would die within days. the human body is made up of 50 to 70% water, which makes bodily processes such as digestion and regulation of body temperature possible. joanne ikeda: people can die very quickly after becoming dehydrated. so it's really important to drink six to eight glasses of fluid a day. now, one can take that in as fruit juice, as low fat milk products, those kinds of things. as you buy fruit juices or processed foods, my rule of thumb is, when a new product comes into the market, look at the list of ingredients. if you can recognize 10 of those words, then you are ready to take that first sip. for any new beverage, look at all the chemicals that go into some of the processed foods. do they really belong in your body? can you live without them or can you do moderation? the body also needs vitamins and minerals to function. vitamins occur naturally in all living things- cows, carrots, trees and humans. each vitamin and mineral plays a key role in keeping the body functioning. joanne ikeda: well, i always think particularly of calcium and iron because those are the ones that we're commonly concerned about in this day and age. calcium, because of the high incidence of osteoporosis. women don't realize that they achieve peak bone density by their mid-twenties, and if they don't get enough calcium, they are going to end up with weak bones that will become even weaker over time. iron is very important because it is critical to carrying oxygen to every cell in the body. that's why when we don't get enough iron, we feel tired and lethargic. it's because our cells aren't receiving the oxygen that they need. the question is, how much of any one nutrient is enough? many countries have established dietary guidelines-- recommended dietary allowances, to help people answer this question. joanne ikeda: the very first guideline is eat a variety of foods because, again, nutrition scientists know that in order to get those 50 nutrients that are needed for human growth, health and well-being, you need to eat a wide variety. priya venkatesan: in 2005, the united states department of agriculture launched the dietary guidelines for americans. because dynamics have changed. people are eating differently, we're shopping differently, our lifestyles have changed too. no one has any time for exercise anymore, without pang attention to the quality and the quantity of foods we cannot ensure that we have longevity. so to prevent disease and to maintain health, we have to keep up with what the new standards are and change them. because people are different, their nutritional needs are also different. priya venkatesan: there's no one size that fits all. we're all different. so it becomes necessary to make it more individual, personalize it, as though you have a personal consultant. all you have to do is to log on to www.mypyramid.gov, and it will take you to the main page. if you want to have introductory information about what is this "my pyramid," you can learn. the toolbars are very easy, very simple, and honesty is the rule here. you cannot go with your driver's license from about 15 years ago and say, "i am that height and that weight." you have to weigh yourself you have to measure yourself again, because this is about you, this is about your body. lying or cheating is only going to make you go backwards instead of forward. i would ask you for your age, or you would type it in yourself. you would enter your gender. you would enter your activity level. now, that's another area that a lot of people either exaggerate or underestimate. if i ask anybody, "do you exercise?" they will say "moderate." what is moderate? does moderate mean parking your car five steps from your door? or is it parking a mile and a half from your door? everything is defined. just sitting in front of a couch and moving from the couch to turn the tv on-- is that moderate? the new "my pyramid" says, you could be sedentary. you could be in the category where we will give you a slightly lower caloric allowance. if you're not planning to move, please don't give the body any more calories. that's only going to result in undue weight gain and over a period of time with diabetes and cancer or cardiovascular disease that you can completely prevent. it's going to give you an accurate amount of calories that you can use to plan your daily caloric needs. no single food group provides all the nutrients people nee priya venkatesan: one of the most common features between the food guide pyramid and "my pyramid" is they are recommending predominantly vegetable-based foods. wholesome grains, fiber-rich fruits and vegetables are still the norm. whether you talk about what we do today, or whether you think about what was probably the way that foods were eaten hundreds and even thousands of years ago, grains were always available. society after society is-- has been oriented towards an agrarian lifestyle, with hunting and gathering as kind of a hit and miss sort of thing. so meat-eating is episodic, but grains and fruits and vegetables are there all the time. the labels on processed foods also cater to the needs ofealtconscioucoers. each package or can list nutrition facts-- thcari arits ntnein each ng seg of the product. anyone trying to limit calories or fat, or maximize the intake of vitamins, minerals and fiber, can check the label to see just what they're getting. nancy anderson: i look at how many fat grams are in a serving, and try and figure out how that fits into the overall recommendation for a day's intake. the other thing i look at is how much saturated fat is in a product. saturated fat is very responsible for raising blood cholesterol levels, so that's something that a lot of people need to pay attention to. for many people, sodium is an important thing to look at. if they have high blood pressure or congestive heart failure or certain conditions that warrant a low sodium diet, we would look at sodium. and something that is often overlooked is fiber. i look at the fiber content because many times you can get a comparable product that has more fiber just by incorporating whole grains into it. with all of this information, and the wide range of nutritious foods available, why would anyone need to take dietary supplements... like multi-purpose vitamins? joanne ikeda: pills are not a substitute for good nutrition because many of the essential nutrients cannot be isated, synthesized and put into a pill. we can get 100% or more of the usrda, the recommended dietary allowance from a variety of foods, but are we taking in that variety of foods on a daily basis in order to provide the nutrients? and then other items like the calcium is a bit tougher to get. so supplements may be indicated for some individuals. joanne ikeda: certainly pregnant women who have increased nutrient needs. certainly to someone who is sick and is not able to consume the amount of food they need. in those cases, yes we do recommend supplements. in general, wide variety of fresh fruits and vegetables, either frozen or canned, staying away from the artificial processed foods will supplement and take care of your needs on a daily basis. but again, if you are in certain stages of life, if you're pregnant, if you have certain deficiencies, then we have to address them. at this point, there's no consensus. vegetarians may also need to exercise caution in terms of their nutrient intake, despite the healthy aspects of their diet. once one starts eliminating a lot of foods from the diet, and just restricting what one is consuming to a very narrow range of foods, then you're at greater and greater risk of not meeting your nutrient needs. vegetarians, there's a concern about protein, of course, because all of the essential amino acids are generally found in animal foods. and if you don't eat any animal foods, you have to make sure to combine plant foods in the correct way so that an amino acid that's low in one food is combined with another plant food where the amino acid is there in a plentiful amount. linda gigliotti: the non-meat sources of protein could come from beans, legumes, pinto beans, kidney beans, black beans, lentils, etc. tofu. some from seeds and nuts although those are higher fat sources of protein as well. also iron is another problem because meat is an excellent source of iron. when you eliminate lean meats from the diet, you're eliminating a very good source of iron. not that you can't be well nourished. you can as a vegetarian. it's just that people need to pay some attention. they need to choose foods more carefully. disease prevention through nutrition is a relatively new area of research that explores the link between certain foods and the nutrients in them and their ability to prevent or minimize a long list of medical conditions including heart disease, high blood pressure, and cancer. for example, researchers have found a correlation between foods which contain phytochemicals and antioxidants and the slowing of normal wear and tear of the body. joanne ikeda: phytochemicals and antioxidants reduce oxidation, oxidative damage to cellular tissue. and that's involved not only in the aging process but also in carcinogenesis where cells become weak. they, of course become-- they mutate, and you get cancer cells. these substances are found primarily in fruits and vegetables. linda gigliotti: a lot of the research lately has really supported the intake of vegetables and fruits. whether it's the cruciferous vegetables or certain ones that contain vitamin c or beta-carotene or fiber. in research trials with heart patients, results, thus far, are mixed. howard hodis: it's our belief that it's possible that once a disease process is established to the point that you already manifest the symptoms or had a heart attack or a stroke, that the antioxidants or the vitamins may be too late. can't use them as treatment. their role may be in preventing that from occurring. so early on, you want to start the antioxidants and see of you can reduce the amount of atherosclerosis or the amount of disease-- heart disease that develops. is a diet filled with antioxidants an anti-cancer diet? evidence is inconclusive. however, there is evidence that an antioxidant diet low in saturated fats can lower cholesterol levels and help prevent heart disease. in laboratory work and in animal work antioxidants such as vitamin e have been shown to perhaps slow the atherosclerotic process, the disease process and it's felt that that's done by inhibiting these oxidative changes to cholesterol. dietary manipulations ought to be aimed at the prevention of heart disease for a little while longer because we understand how that works. heart disease is a more common disease than cancer and it makes more sense to focus your diet there. probably when the dust settles, those diets are going to be the ones that turn out to lower cancer risks as well. they'll probably be pretty smart cancer diets but we just are way behind the cardiologists at figuring out the diet part of this whole thing. adapting and maintaining healthier eating habits is not always as easy as it sounds. it takes work and long-term commitment. so a physician says, "well, just stop eating that." well, you can't just stop eating that high fat food that you've been eating for 40 years. it takes time to adjust and find ways to moderate it, and/or dilute it or whatever needs to be done so you lose the urge to taste that food and you can then eat lower fat or other types of foods. going cold turkey never really works and one has to adapt and moderate slowly over time. people are hard on themselves. so i often like to point out, "well, how many years were you doing it another way? you've just given yourself six months practice. why are you beating up on yourself because you didn't do it right or perfectly this time?" howard hodis: i was brought up by european parents who ate meat and potatoes. liver was a big item every week for that iron. that was my taste for many years... high fat milks and cheeses and things like this. when we learned to ride a bicycle, or when we learned to tie shoes, or type on a keyboard, we made mistakes. so i think we have to allow ourselves to make mistakes as we are learning new food behaviors. and slowly over time using tricks, diluting the milk, for example, eventually going down to non-fat milk, i cannot even remember the taste of high fat, cream milks anymore, and if i was even exposed to it, i would be sickened by it. and so it's a matter of changing your tastes slowly over time. the local supermarket may be a place to begin... walkg down the aisles, making choices, with a nutritionist aching you each sp of the way. linda gigliotti: so if i were walking dow the aisle in the grocery store with you what i would look for would , well, what are we putting in the grocery cart? are yogog to be able to get enough wholesome, fairly unprocessed simple foods to be the foundation of your diet? and then, how might you use some other food items? to start with, nutrient packed fruits and vegetables provide a nutritious foundation. linda gigliotti: now fresh would be great but you may tell me you don't have time to cook and prepar or cook those. so we could go over and look for some frozen items that werprepared without added fat, sauces or sugar in the case of frozen fruits. frozen or pre-packag items are health convenient sources of food that may help deter a quick stop at the fast food restaurant on the way home from work. ndgiglioi: we would look at our grain odts. ouk ereal aisle or through the bakery department. we would look for the ount of fiber that you're getting from that cereal or bread, not just the color of the bread product but how many grams of fiber on that label. i would want to make sure that the relative amount of fat in those items was probably less than about 30% of the total calories in those items. and then i would also ask you to buy a bag of frozen vegetables that you could mix in with that to increase the fiber and the overall nutrient content of what you were taking in. we would go along the back of the store where the dairy section frequently is some low fat or non fat milk or yogurts to make sure you were getting some calcium. and we would look at the fat content in those particular foods. and finally, the shopping cart should contain low fat sources of protein such as turkey, chicken and seafood, or bns and other legumes another key to maintaining a healthy diet is by eating regularly and not skipping meals. marc shiffman: i constantly hear from people, "i don't have time to eat breakfast." you do have time. i have time. if i have time, you have time. you have to know how to have the right food available. whether it's a bowl of cereal, whether it's muffins that you can grab out of the refrigerator, whether it is taking time on a weekend to whip up a batch of things you can pop into the toaster, there are healthy choices that you can make that are better than mcdonald's or burger king or any of these other fast morning stops that are also more expensive. and the same with lunch. you can-- low fat yogurt or sandwiches with whole grain bread is always a much better start, coupled with a piece of fruit, than going out to any kind of a fast food place. it's cheaper. it's healthier. and again, with working people, i hear this same excuse all the time. "i don't have time. i don't have time." if you have a little time on the weekend, you sit down and make a salad, spend an extra 10 minutes and make enough salad for six portions. grill chicken on the weekend. don't grill one or two chicken breasts; grill 10 of them. once you start doing it for a short while, it becomes second nature. it'll save you money and you'll feel healthier. linda gigliotti: the point that helps a lot of people is "well what's doable in my daily route that i can have readily available? how can i set up the environment in my work day to help me keep on target with what i really want to do versus being led astray-- the candy on the desk or the donuts and muffins being brought in, fast food meals being brought in or any kind of food being brought in for a luncheon meeting?" so my point is take control. set up your environment so that you have there the items that are going to help you stay on target. and that's the bottom line... in terms of food consumption or any other goal related to healthy living. take control and stay on target. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call... or visit us online at... and accompanying materials, call... annenberg media ♪ by: narrador: bienvenidos al episodio 36 de destinos: an introduction to spanish la mayor parte de este episodio es un repaso de lo que ha pasado desde que raquel y angela salieron de puerto rico. vamos a ver lala historia desde varios puntos de vista: el de raquel... el de arturo... yo sí. realmente estaba muy preocupado. ¿hay algún mensaje para mí? ah, sí. le llamó la señorita rodríguez.
despite the fact that americans are more and more conscious about their weight, despite the fact that we have more and more so-called low fat foods and sugar substitutes, obesity is increasing constantly in the united states. i think it's fair to say we have an epidemic of obesity in the united states. today there are more than 100 million americans who are either overweight or obese. this is a disease and a condition which causes a whole host of important medical complications, so i think we have a very serious public health problem on our hands that we need to address as a nation. narrator: poor food choices, combined with increasingly sedentary lifestyles, are blamed for the dramatic increase in obesity over the last several decades. close to 35% of women and 31% of men over the age of 20 are now considered obese. ralph cygan: obesity is defined by excess body fat. a normal body fat for a male is somewhere in the 20% range. for a woman it's 25 to 30% range. unfortately it's not easy to measure body fat. it's not something that could be done easily in a physician's office or at home, so over the last few decades another measure of body fat and obesity has been developed, and that's the bmi or body mass index. bmi is calculated by dividing a person's weight in pounds by their height in inches squared. the answer is then multiplied by 705. a bmi that is associated with good health is in the 19 to 25 range. to put these figures in perspective, supermodels run bmi's of about 16 or 17. sumo wrestlers, on the other hand, are in the 43 to 45 range. you are considered overweight if you have a bmi between 25 and 29; obese if it's 30 or above. all of the very serious causes of early morbidity and mortality are strongly associated with obesity. for example, cardiovascular disease, high blood pressure, high cholesterol, low good cholesterol or low hdl cholesterol, diabetes mellitus, very important risk factor for heart disease and very closely correlated with increasing degrees of obesity. obesity can damage a person's joints and affect their ability to move. the large, weight bearing joints in the lower extremities-- the hips, knees, ankles, etc. those joints have a much higher likelihood of developing severe and premature degeneration because of the extra stress associated with obesity. mary pat anderson: i have very bad knees, had knee surgery about 15 years ago, and found myself sitting in my classroom and sending students to get books and papers and so forth, and just hardly moving at all, which just continues the cycle of gaining. even if i wasn't eating as much as i used to, i wouldn't lose because i wasn't moving at all. obesit also linked to certain types of cancer. older women have a higher risk of breast cancer if they're very heavy. they have a higher risk of endometrial cancer and their obesity may be, in some way, related to colon cancer, as well, and for men, to prostate cancer. why have so many people lost the battle to achieve and maintain a healthy weight? dean hamer: some people think that it's all a matter of metabolism, that some people have a slow metabolism and that makes them fat. well it turns out that the same genes that control metabolism also control appetite-- these are genes coding for hormones and receptors that are released in response to how much a person eats and how fat their cells are, in essence. it turns out the same hormones and receptors control how hungry you are. so when people eat a big meal, the hormone is produced. the hormone tells the body, "burn off the fat and use it as fuel," and it also tells the brain, "you're full, stop eating." if a person has a problem or different variety of these hormone and receptor genes, then their body doesn't burn off the fat so well and they want to continue eating. so often people will say, "well, he has a metabolic problem, but she doesn't have enough willpower." actually both of those are at least, in part, affected by a person's genes. one theory is that these genes are leftover survival mechanisms from thousands of years ago, when humans lived from one meal to the next-- or one feast to the next famine. joanne ikeda, r.d.: if, when they found a lot, they ate a lot and deposited fat in the body, then when the lean times cam when there were times of famine, there was a survival advantage for those people who deposited fat. they were the ones who got through the famine and survived. now we come into a modern age where we don't have to go out and hunt. we don't have to go out and fish. we don't go out and plow the fields and harvest food. we have now created an envonment so that this predisposion towards depositing fat in the body is no longer an advantage. it's a disadvantage. genes also play a role in how fat is distributed. the riskiest fat distribution is the male or android or apple shaped distribution where most of the fat is in the intra-abdominal cavity. there are many more metabolic consequences and many more medical problems associated with that fat distribution-- for example, high blood pressure, high cholesterol, diabetes mellitus. now that's opposed to the gynoid or female distribution, or pear distribution, where the excess weight is in the hips and the buttocks. now, for some reason, that obesity is much less likely toto contribute to the metaboc and health consequences. obesity is no longer confined to those who are middle aged or older. increasingly, the patterns associated with obesity are found in the very young. barbara korsch: many people believe a fat baby's a healthy baby, but from a health point of view, more obese babies go on to be fat adults. stopping the progression of obesity in childhood can be a challenge, as dr. korsch and a team of specialists learned. and we had a really hard time getting good results, as has everybody. and one trouble was, the nutritionist would earnestly say, "don't eat between meals," and all that. a lot of those families didn't even have meals. they don't sit down together either at breakfast or lunch or dinner and eat a meal with the children involved, so that it's gotten quite chaotic, and whatever is quick and available and tastes good. and the media, dr. korsch contends, just compound the problem. barbara korsch: television watching is the single thing that has been consistently associated with obesity. and there have even been some really interesting studies that if a child is just just watching television, where they tend to sit very passively, usually also snacking, that their metabolism actually goes down. it's a little bit like hibernation. in recent years, the health risks of obesity and the cultural obsession with slimness, have developed into a $33 billion industry. weight loss pills, fad diets, and dietary supplements promise miraculous results. joanne ikeda: there's nothing over-the-counter that you can buy that is going to melt the fat off your body. yet, day in and day out, you open women's magazines, you open newspapers, you go to the shopping mall, and they're selling products that claim to do this. i recently went to the supermarket, picked up a couple of popular magazines and a couple of supermarket tabloids, just to see what was being advertised. some of my favorites were the "new fat fighters-- slimming capsules that soak up fat." another diet guaranteed weight loss without diet or exercise, astounding to me. several others tout the ability to lose 30 pounds in one month, or your money back. another one says you can make money while you do this if you sell this product to your neighbor. many of these miracle products are either useless or produce only temporary results. some are even dangerous. joanne ikeda: all of the magic potions have had side effects. we look at the fiasco with respect to the phen-fen combination-- the fenfluramine-phentermine-- that was so popular and ended up being withdrawn because it caused heart valve damage in women. ralph cygan: there are a number of stimulants on the market: ephedra, which is an epinephrine or sympathamimetic drug which is a strong metabolic stimulant that will probably suppress appetite for a few days or a few weeks, but longterm, can be extremely dangerous, and taken in doses higher than is recommended, can also cause potential cardiovascular problems, arrhythmias, chest pains, high blood pressure, etc. fad diets that limit or promote excessive intake of certain nutrients can also be dangerous. take high-protein diets, for example. protein is used, initially, in the body to maintain muscle mass, to build cells, antibodies, hormones, etc. generally, that need for protein will be met if we take in 12 to no more than 20% of our calories from protein. any additional protein that we take in will be broken down and burned for calories. however, protein is a rather inefficient source of calories in the body because it first has to be metabolized through the liver, some components of the protein structure removed. those components of the protein structure then are waste products, and they're excreted through the kidneys. so, if a person is taking in a very high level of protein, and protein is contributing significantly to the calorie level for that person, we then are taxing the liver and we're taxing the kidneys. an individual may not be aware of having any kind of liver or kidney problem, but may be pushed over the edge because they're not being medically supervised. ralph cygan: the biggest consequence of diets like this is that it perpetuate the yo-yo cycle of dieting. many of these diets, the patients will lose a few pounds-- they'll lose some water weight perhaps, but then quickly, they'll become very frustrated because there's nothing fundamentally different about their eating behavior, their exercise behavior. it may be that this dieting may be contributing to increased obesity, because in my work, for example, a study i did with african-american women, three generations-- look at the number of times these women have dieted and regained weight. and the more often they have dieted and regained, the higher their weight is. penny weismuller: i would lose weight, but i couldn't learn how to keep it off. and i would gain more weight, and i just got into that cycle that you read about you know somebody loses 10 pounds, they gain 20. they lose 20 pounds, they gain 30. so by the time i was 29, i was... i'm going to say 60 to 65 pounds overweight. mary pat anderson: i was in "tops." it's called "take off pounds sensibly," and there's no specific diet. it's just a group of people that get together for support. that worked very well for a while. i tried nutrisystem twice and lost a considerable amount of weight both times, but was never able to keep it off. it's very difficult, and i think the more that people yo-yo the more desperate they become for something that's a magic pill or a magic bullet. so it's very difficult psychologically to convince them that there is nothing like that, that it is slow, sustained behavior change that works best. good morning, uci weight management program. may i help you? that is the goal of the uc irvine weight management program: encouraging and supporting behavior changes that will result in sustained weight loss. wonderful... well, we have a couple of program options. do you have an idea about how much weight you're interested in losing? linda gigliotti: when people inquire about our program, we invite them to come in for an information session where we can have an opportunity to explore a little bit of their goals and history in terms of weight loss, and management of that loss, but also so we can explore program options. there's not one strategy that works for everybody in terms of losing weight. now, you've tried losing weight before? i have, but it's been kind of a roller coaster for me. okay, so we want to stop the roller coaster then. ralph cygan: when patients come to you for weight loss, many have a shortterm orientation. they want to go on a program and then resume their prior lifestyle. clearly you're not doing these patients a favor if you don't try to disavow them of this short-term mentality. obesity, i think, needs to be looked at as a chronic, lifelong condition, and i think we have treatments that can be used effectively, but they need to be applied for the longterm. there are no quick fixes for obesity. penny weismuller: i called and i spoke to linda on the phone and made an appointment, came in to talk to her. i was really interested in how well people could maintain a weight loss, because i didn't want to... i didn't want to lose weight and not keep it off. linda gigliotti: when a patient comes in, we will ask them, "well, what do you see your goal weight being? what goal do you have in mind?" because we need to know where that person is coming from. ralph cygan: many patients come to a weight loss program with extremely unrealistic ideas about what their goal weight should be. i think they're either motivated by what they see on fashion magazines, or perhaps think about the old height/weight tables they're used to seeing from insurance companies, and have really unrealistic goals. i was having pain in my heel, and i was feeling pretty desperate. i was thinking about having the weight loss surgery, but i was afraid of complications. so i thought i would call here as one last chance. i only wanted to lose 20 pounds. i wanted to fix the heel pain. if i could just keep that 20 pounds off, that's all i wanted to do. weight loss programs are individualized, depending on the severity of the problem. linda gigliotti: if an individual has 10 pounds to lose, it's not appropriate to use a very, very intensive approach as a quick fix. so in that case, the patient would be guided into a more moderate, reduced calorie food plan, allowing for gradual weight loss in the range of one to maybe two pounds per week. come on back let's get your height and weight. but when people are suffering from health problems as a result of their obesity, and need to lose weight quickly, a medically supervised fast that includes proper nutritional supplements can be an effective way to begin the process. linda gigliotti: the calorie intake on that regimen is going to be somewhere between usually 500 to 1000 calories per day, coming exclusively from a liquid nutritional supplement as their sole source of intake. penny weismuller: once you start on the fast, hunger's primarily not an issue if you're using the protein supplement fairly regularly, throughout the day. linda gigliotti: i do have to emphasize that it's not a magic potion. it's a way to get the ball rolling, a way, perhaps, for that patient to reduce rather urgent medical problems, to be able to increase their physical activity so they can begin to burn more calories, in terms of calorie output, and then move eventually into the maintenance phase of the program. it is in the maintance phase th the patient begins to build new and healthy eating habits. linda gigliotti: in maintenance, we emphasize using fruits and vegetables as the bottom of their food guide pyramid, if you will, consuming an absolute minimum of five servings of fruits and vegetables a day. because they are low calorie density, high water containing, but a lot of other nutrients in terms of vitamins and minerals coming from the fruits and vegetables. i knew that maybe maintaining was going to be a whole heck of a lot harder. we spent a lot of time talking about just how many calories' difference you have to change in your lifestyle and, for me, to maintain a 100 pound loss, it's you know a 1,000 calories a day difference, either eating less or exercising more, and that's a lot of change. changing food habits and being consistent requires planning and preparation. the key is to make healthy eating a priority... at home, at the office, en at a restaurant. i think you have to be your own sleuth and ask questions. don't just assume that even if it has a heart by it, or some kind of emblem, that it's going to be healthy, or as healthy as you might think it's going to be. do you know what you'd like? the yellowfin tuna-- how is that prepared? linda gigliotti: i like to view the menu as a list of suggestions, not a list of dictates. the menu tells me what they have in the kitchen. now how can i creatively ask for something if i don't see it presented on the menu? mary pat anderson: the other thing that you really need to pay attention to is portion size. most restaurants give you very, very large portions and because we're paying for it, we feel entitled, and that we have to eat it all. so, if you could take some of it home with you or share it with another person, that would be better. changing the way you eat is the first step in losing weight. the second step is changing the way you move. linda gigliotti: i think it's really important to emphasize that small changes make a difference. let's take physical activity, for example. we don't need to come up with a whole lot of rules about going after a certain length of time, or even being at a heart rate level for it to count. just moving will make a difference. so even without the exercise at first, just on the fast and with the support of the doctors and the health educators here, i lost very consistently four pounds a week. and it just sort of rolled off, and then i started to get brave and attempt exercise. penny weismuller: because of the heel pain early on, i needed to look for a low impact thing to do, and i got an air glider, and i would do 10 minutes a day on the air glider. ten minutes equaled like 75 calories of physical activity, and that was just one more thing to help build it up. the bottom line for weight management is calories in versus calories out. of course, we need to consider one's nutritional intake. i could consume my maintenance calories in ice cream or chocolate, but that doesn't mean that even though i could, theoretically, maintain my weight, it doesn't mean that's going to be the healthiest way to do it. but there is room, in a day's intake, in a week's intake, in a month's intake, for most any food as long as the calories net out it's hard when you swim laps in a pool to figure out how much exercise you're actually doing. how many calories you're burning. so one night when nobody was around, i took my yardstick to the pool and actually measured the length of the pool, figured out how many fractions of a mile i was swimming, and actually worked out a program where i swam a half a mile a night. and that's what helped me develop the exercise. maintaing weight, in the long run, a constant series of tradeoffs. gigliotti: if i'm going to have this muffin, which is about 600 calories, then i have to say, "well, that's in my case, about 40% of my day's maintenance budget." if it's worth it to me, one choice might be, "okay, i can walk six miles because that would burn off the equivalent," or "i'm going to adjust my food intake at other times of the day to accommodate for the calories with this muffin." but it's not forbidden, and i think that freedom allows me to decide whether or not i choose. when weight loss attempts continue to fail, and health problems continue to mount, extreme measures are sometimes initiated. one such measure is gastric bypass surgery-- a procedure which diverts food from the stomach directly to the small intestine. ralph cygan: now, you have to be very careful about which patients you would refer for such a procedure. usually these patients need to be so-called "morbidly obese," which means their bmi is over 40, which is at least 100 pounds overweight. these patients have to have other complications associated with obesity, so many of them would have cardiovascular disease or other complications. and these patients would also have tried and failed usually several attempts at more conventional types of weight loss. some success is also being achieved with pharmacologic approaches, prescribed and monitored by a physician. one such product works by regulating neurotransmitters. namely noradrenaline and serotonin, which are both neurotransmitters which affect appetite. and by increasing the level of these neurotransmitters in the brain, the appetite can be effectively suppressed. patients on this program have been able to lose about five to 10% of their total body weight, and maintain it. ralph cygan: we know now that losing modest amounts of weight-- for most patients, about 10% of total body weight-- can have a profoundly positive effect on health risks of obesity. so from the medical perspective, modest weight loss and maintenance is really the goal that we try to get our patients in tune with. by studying people who have lost weight, and maintained that loss for five years or more, researchers are beginning to document factors that promote success. ralph cygan: we've learned a couple of, i think, very good lessons from this study. first and foremost, the patients accept responsibility. they don't blame anybody else. it's their job and their responsibility to get their weight off and keep it off, and they work hard at it. most of the patients eat a very low fat diet. the majority of pients exercise, and theyim f 20 to 3000 calories of exercise per week. in addition to that, they monitor their weight carefully. they usually weigh at least weekly, and they're able to catch small slips. and last, but not least, they have a social support network that allows them to succeed. if you're in an environment that's toxic-- that's always tempting you, that's putting food in front of you, that doesn't support your longterm weight loss goals, you're going to fail. penny weismuller: i still eat candy, and i have dessert once in whe. but primarily, i look at the stuff and i say, "you know, i like the energy and the clear thinking that healthy food choice allows." it's still my mantra. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: [♪...] >> female announcer: some dreams are universal... dreams that inspire us. multiple sclerosis is a devastating disease that changes lives forever. the national ms society does more for people with ms than any organization in the world... but we can't do it alone. to get involved, visit us online at nationalmssociety.org or call 1-800-fight ms. this is why we're here... because nobody dreams of having multiple sclerosis. narrator: people who exercise regularly have a 43% lower risk of premature death compared to those who are sedentary. are you physically fit? can your body respond to the demands that are placed on it? technology has made life easier, but it has also made us less active. nearly 1/4 of american adults are sedentary. another 1/3 aren't physically active enough to be considered fit. "physically fit" is being able to do whatever you want to do without restriction, either with your body or with endurance. to reach that level of fitness, we need more than just a walk from the parking lot to the mall. we need exercise. thomas mirich: the need for regular exercise transcends not just the need to be able to participate in sports activities, but it really covers the whole gamut from youth 'til 80s, 90-year age group. it's been shown that people that participate in a regular exercise program, meaning at least three or four days a week, have better health overall, whether it's better heart condition, lung condition, lower risk of osteoporosis, they have better balance. so that when you are 75 and 80 years old, your bones are stronger, your balance is better. so you're not falling and breaking your hip or breaking your wrist, and your function is overall better. study after study confirms that exercise is vital to good health. it contributes to cardiovascular fitness as well as the control of excess body fat. it may even play a role in reducing the risk of certain cancers. leslie bernstein: exercise definitely reduces your risk of colon cancer. we see it in studies of men. we see it in studies of women. i've spent a lot of time studying exercise and breast cancer and in the studies that i have conducted, we have shown that women who exercise substantially over their lifetimes have a lower risk of breast cancer. not everybody believes this yet. the results of all the studies aren't consistent. but i still firmly believe that, you know, exercise has the potential to reduce breast cancer risk. and then, of course, exercise is healthy for a whole slew of other diseases. loren lipson: it gives you a sense of well-being. people who have various psychologic illness find that exercise actually gives them endorphins and they feel good. exercise and fitness have a number of different components. leading the list is aerobics. kerry syed: and that is to do three to five times per week, 20 to 60 minutes of continued using-large-muscle-group exercise. so it's a big exercise-- running, walking, biking. but there are other kinds of exercise which also contribute to physical fitness. syed: there's a muscular strength component and a muscular endurance component. how much weight can you lift in one time is your strength. how much of a percentage of that weight you can lift several times is your endurance-- how many sit-ups can i do? and the last component, always forgotten, is the flexibility. every joint and muscle in the body has an intended range of motion. flexible joints perform a variety of movements-- bending, rotating, twisting. as we get older, muscles tend to tighten, especially in the backs of the legs, the lower back and the shoulders. our range of motion decreases, and we develop aches and pains that weren't there before. i think you have to take a look at what body parts aren't moving very much during the day, and then you can assume from that, those are the ones that are gonna be tight, and you need to do some things to maintain your flexibility. if you're not actively doing something to maintain or improve your flexibility, then you're probably going to be tightening up. syed: and what happens is, as we age, that's one of those things that goes downhill real fast, among so many others... but that we don't want to end up as this stooped-over, old person. most of the time, it's not osteoporosis, it's the lack of flexibility and the ability to stretch yourself into the position of upright. so i really encourage stretching, you know, like two to three times a week, when you get up, sometime during the day, that you take time to do eight to 12 stretches. the technique that is recommended is "static stretching--" increasing the flexibility of the muscles that control the joints by stretching them gently, then holding the position for 10 to 20 seconds. olsen: a lot of people just go to where they feel a little pain and then they let off the tension. and in order to increase flexibility, you have to hold that stretch for a long enough time to allow the fibers to assume a new length, so that takes longer than most people realize. five second stretch is not going to... you're not going to gain any range of motion through that. most fitness experts caution against stretching with bouncing movements, or trying to stretch a joint beyond its natural range of motion. olsen: there are things that you can do to maintain your flexibility and there's things that you can do to improve your flexibility, no matter how tight you are. there is hope. things can change. rigor mortis only starts after you're dead. my right arm's stronger from carrying my briefcase. it's also never too late to improve muscular strength, that aspect of fitness that helps us get through daily activities more easily. strong muscles prevent jot and mule injuries, improve posture, and even contribute to weight loss. mirich: what happens is, when we build up our muscle mass, we've exchanged weight in terms of fat for good weight, which is muscle mass. now that muscle mass is lean mass. there is more muscle-- it's like having a bigger car engine... it burns more gas. so, now we burn weight more efficiently, so it further helps with weight reduction. lastly, that weight training adds a balance factor, or a proprioception factor, that improves people's quickness, agility and balance to the equation, all of which are extremely beneficial at lowering injury potential. if you were talking about lifting weights, we'd have to have a goal in mind. if the goal is just to stay toned, then, you know, we would probably use lighter weights and do a lot more repetitions. if your goal is to be an arnold schwarzenegger lookalike, then you're going to have to use heavier weights. strength training also builds muscular endurance, the ability to contract a muscle repeatedly. it's muscular endurance that keeps our arms and legs moving during aerobic exercise. aerobic exercise, in turn, builds cardiovascular endurance. mirich: it's been well documented that we need to perform an aerobic activity to get our heart rate to our appropriate target value for at least 30 minutes, and ideally on a daily basis, at a minimum of three to four days a week. and the simplest of that is pure walking. the reason for that is that it has a very low injury risk and a high benefit risk in both cardiovascular, bone, osteoporosis, weight reduction, lower risk of diabetes because you're not overweight and obese. other activities such as bicycling and swimming or aqua aerobics or water exercise programs, when performed appropriately, have the same low impact aerobic types of benefit. what we're looking at is aerobic exercise, so moving arms and legs, all four limbs together. and it's important that, you know, taking the dog out is good, but you need that 30 minutes of concerted exercise where you're trying to keep your heart rate up and steady. syed: the thing that i believe is to do at least three times a week up to seven, for at least 20 minutes up to an hour. i mean, past an hour, you're not gonna do anything good, and really at 45 minutes, personally, i'm pooping out. i'm saying, "i have done this way too long." i'm tired. i'm bored. i've been on a machine if i've been in the gym. now, if you're outside and you're doing something you love, you might be able to do it for over an hour. it's something that is individual for each person, but what you're committed to is really gonna make the difference. hodis: especially if you're a patient who has heart disease, but of course, any patient, any individual, the heart's a muscle. the stronger that muscle is... if it becomes damaged or further damaged, you're going to do much better, clinically, than you would if you just had a floppy, sick heart. so you want to keep muscle tone, not just in your arms and legs but your heart also. the heart of a physically fit person is more efficient. each minute, it can pump the same amount of blood with fewer heartbeats than the heart of an unfit person. a person in good shape may have a heart that actually lasts longer. olsen: i think the trick is trying to find the right cardiovascular exercise for you and for your body. we naturally assume that all of our bodies are built the same way and are structured the same way, but in fact, even though we might have the same parts, how they're put together is so much different. and so running might be a great activity for one person and it could be a source of multiple injuries for another person. choosing the wrong exercise, or going overboard with it, can cause problems, no matter how good our intentions. mirich: the biggest causes or reasons for people coming in and seeing me can be summarized in, i guess, a phrase used by our runners-- "too far, too fast, too soon," meaning people have gone out and done too much when they weren't ready for it. and that can apply to all age groups. in america, we're very impatient. we don't want to spend the time to achieve that goal. people go into the gym and they may see a person who's... has an excellent body, huge biceps, curling 300 pounds weight, and they say, "well, boy, this skinny guy like me can do that." they stack on those weights. they try to do that. they lift incorrectly. it's too much weight and then they injure themselves. it can be things like running. "well, boy, i can go out and run five miles." well, if i tried to do that today i would probably be in here seeing my therapist tomorrow. we have to realize that, as we age, our bodies are always changing. and sometimes our minds can feel as young and vigorous as we were when we were teenagers, so we tend to think that our bodies are the same. our bones are changing and our joints are changing, and so if we haven't been consistent with a flexibility program or a strengthening program, and we'ot dng i on regular basis, it's highly likely that somhing h changed over the years and/or over the months. and when you go to do an exercise or an activity suddenly, you know, you might find out the hard way that something has happened, and usually that's through pain. before you just wake up saturday morning and say, "boy, i'm not fit. i'm gonna start exercising," you know, you want to see your doctor, especially if you're middle-aged or beyond. make sure your heart and lungs are in good condition. maybe see a physical therapist or a personal trainer to be put on an appropriate training program, both in terms of stretching, flexibility, aerobic and weight-lifting capacities. those who are in good physical shape still need to be careful to avoid doing too much of a good thing. mirich: the problem that we run into is where, again, if 30 mites is good or jogging three miles is good, well, running a 10k race is even better. what happens is with that increased time and intensity of participation, that's when we start seeing more of the overuse injuries coming in. our swimmers are all rotator cuff, the back part of the shoulder kind of stuff, and that has to do with a lot of... they're extending their times right now. the baseball... same thing, shoulder stuff. whereas when we go on to football season, it's knees and shoulders again. during the winter, which is amazing, we see a ton of girl soccer players with bad knees-- intercruciate ligaments-- which isn't good. this'll help to work on the edema, the swelling... i play soccer, and i injured it in practice one day. i was just running, and then, all of a sudden, my knee just gave out. give yourself a good effort, laura. kick, pull... so i tore my anterior crucial ligament, which is really popular in females, and then they told me that i'd be okay if i strengthened my muscles and gave me a big brace to wear. and then they decided i needed surgery. mirich: in the last 20 years, the biggest advancement has been the use of arthroscopy, which is small incision surgery, or minimally invasive surgery. and what that's allowed us to do is treat the injured athlete through a small incision with a more rapid return to activities. and that's one of the goals of treatment in sports medicine, is to return the athlete to their activity as safely and as quickly as possible. we're teaching the kids that it's an athletic event, but it's also a lifetime sport. we want them to be able to last, and the lasting thing is that they're going to know how to take care of themselves. but not all injuries are related to sports. "overdoing" can apply to daily activities, as well. olsen: well, we see a lot of low back injuries, and that comes from either home or work injuries. people getting out gardening for the first time in the spring and they... we all tend to want to finish the job that we start, and so if that particular job requires you to be in a bent-over position for a long period of time, certainly that will have an effect on your low back. people who don't know how to lift properly where they... constantly bending and twisting and doing that at a bad angle will produce those types of injuries. so, moderation, if i had one word of advice, is really the important key. appropriate regimented type of exercise or training program is very important to prevent the excesses or to prevent from doing too little, and th being the couch poto and going out and participating on the weekend and not being physically fit to participate in that activity. the risk of injury during any activity can be lowered by warming up and cooling down. olsen: you know, you can start out kind of slow if you're stiff, and i think a lot of people think that stretching muscles out before they begin their activity is a good way to do things but oftentimes if you're cold, muscles don't stretch very well. so if you really want them to elongate, it's better to increase the temperature of those muscles first. you can warm up anywhere from five to ten minutes, slowly walking, then you're going to do a brisk walk, into a jog. at that point, you can sttch. you can stretch then, or you can stretch afterwards. i prefer afterwards just because i'm so warm and i feel really loose and i can stretch better. it's been shown that if you don't warm up before the exercise and cool down after the exercise then you're putting undue stresses on your heart. so it is very important, say, after your aerobic exercise, to maybe do a cooldown where you're walking slowly or riding that bicycle just without resistance at the end for a little while just to allow your heart rate to settle down to a normal rate of speed. while on that walk or bike ride, parents often include their children. they need exercise just as much as adults, and childhood is the perfect time to key in on the enjoyment of healthy physical activity. it's not hard to encourage small children-- they rarely sit still anyway. daniel cooper: the work that has been done in children and in other mammalian species, if left alone, almost, the younger members of the species are more physically active. they want to be. now, why they want to be, i don't know... whether it's endorphins released in the brain more readily, i don't know. it's a fascinating question. but they want to be in more physical activity. but as children get older, their involvement in physical activity tends to change. cooper: in almost every sector of this society, parents don't do what they perhaps did in my generation, which was say to a child, "go and play," and then, "i'll see you at such and such an hour." so we now have an environment which, for physical activity, which is a natural phenomenon in children, being much, much, much more controlled by parents, and this raises a lot of issues. parents want their children, instinctively, to be physically active so we have, certainly in the suburban and certain urban areas, this explosion of interest in organized sports at very young ages, like soccer. michael bryant: i think those things build esprit de corps, build a sense of teamwork, teach kids how to share, how to work together to achieve a common goal. but one of the things you really must do, even for those little, very, very flexible bodies, is make sure you warm them up adequately. and even though those parents are well intentioned, there are a lot of those parents who are the coaches who don't have a lot of experience in what you need to do in order to prevent injuries in kids. and part of that is adequate warm-up, adequate stretching. even with those young bodies, you still need to do that in order to prevent them from injuring themselves. mirich: in dance and ballet, we have six and seven-year-old girls, nine-year-old girls who want to look like that professional 22-year-old ballerina. their muscles aren't ready, their ligaments aren't ready, and one of the worst training errors is to have them try to emulate that mature dancer when their bodies are not ready for it. they don't have the strength, they don't have the flexibility, they don't have the skeletal development to allow them to do that. olsen: because i have three daughters and they're involved in fast-pitch softball, i'm seeing at a very early age parents pushing kids to play all year round in order to get that scholarship down the road, and these are kids that are eight years old, you know. and by the time they get into their teenage years, they're having major surgeries on their shoulders. mirich: and a lot of that is misinformation from coaches who push too hard... okay, let's stay tough! we got a big game. - let's win it! let's go! - yeah! and pushing too hard can actually create permanent damage to ligaments and tendons and growth plates that can hamper or ruin a person's chances of participating up to expectations as a teenager or mature adult. cooper: you know, if you're just looking for the talented athlete you've got your one or two percent, or your five percent, but what about the rest of these kids? and one of the worries to me is that the emphasis on sport per se, can for many children, make physical activity almost a negative experience. they tried to go out for the team. the coach told them ey weren't good enough. "that wasn't fun. i don't want to do this anymore." i'm working with children now, in yoga. i never thought that yoga could be for anybody else but adults and people that wanted to meditate. and yoga can be for kids. they want to act like... they want to look like an eagle. they want to look like a turtle. they want to look like a snake. they want to move like that. and if you put it in that kind of context for them, if you talk about it in the right way, kids are very receptive to being active little individuals because they got more energy than we could ever imagine having, as adults. we're gonna go straight up about halfway... about there, and then come down slowly. olsen: rather than having them do the same thing all year long, i think it's important to develop the muscles in different ways. strengthening muscle is very important, but resting is part of that strengthening process, as well. nutrition and all those things are important, but i think we forget the resting part and so i think the rest, and the cross-training-- doing something different, exercising the muscles indirectly, the same muscles, but doing them in a different way. come on! good job! come on, angie! while it is great to encourage an athlete, the real goal is to encourage children to have fun being active. a habit that starts at a young age is easier to maintain through the years. syed: we're a very inactive society and i do think that as role models now, you can be a role model now for those people in your life that you can exercise at any age, and being just healthy and active, i mean, is not just about rigorous exercise planned every day. it's about, "i took the stairs instead of the elevator." now, depending on what kind of commitment i have to my life, then i can make that decision and say, "you know, i really am committed to having a very physically fit life," and that's gonna help me in my future. and then you can really achieve that goal. the goal of being physally f is portan i rered in '74, and then i started walking up the mountain. exercise is extremely important, i cannot stress enough, for seniors. many of my seniors, the only exercise they get is coming to and from the clinic, and it's unfortunate. stacy: well, i'll be 90 in may. i'loly, and the views fr the top are wonderf. and to wch the s come up every rning something. so i just automatically wa up, get dressed and come out. seniors, in particular, need to pick an exercise program that matches their physical abilities. if you have someone who has coronary artery disease, you have them run the marathon, it'll be their last act. if you have someone who has arthritis of the hips, riding a bicycle may just not work. so you have to be very thoughtful in planning exercise that it's not too strenuous, that it's easy to remember, and it's healthy. and that's why walking fits in most of these categories. mirich: in the older population, the parts are starting to wear out. people are starting to get arthritis in their joints, in their back, in their neck... and they have a lot of sore areas. having that age group participate in a low impact aerobic exercise program has again been found to be very beneficial from a whole host of reasons-- cardiovascular fitness, osteoporosis prevention, balancd fall prevention, lessening injuries, plus the actual improvement in those functions lessens pain in the joints. gen ogata: i'85 years o, and i bike about... on the average, abouten miles a day. sundays, i have a son-in-law... we have a son-in-law who is... he's only 40 years old, and he's got a lot more energy than i have. and so, on sundays, we go up to mt. rubideaux, but of course, he's way, way ahead of me. mirich: their body adjusts to that higher activity level, cardiovascular fitness, strength, flexibility, and then they'll find that, "boy, i have more energy. i am less stiff when i need to go out and mow the lawn or go shopping or to visit the grandkids. i'm sleeping better. i'm requiring less blood pressure medications. my diabetes is better controlled. i'm now able to get off my insulin and go on to an oral pill to control my diabetes." so the health benefits of a moderate exercise program is enormous even in the older population. olsen: they're very motivated. they're easier to work with, i think, in some respects because they've reached a point in their life where they know that things don't happen quickly all the time, and they're very disciplined, usually. the elements of becoming physically fit apply to all ages: develop an exercise program you like; make sure it fits your physical ability; perform it correctly, and remember that it takes time and discipline to achieve your goals. syed: you have to say, "what do i really want? do i want to be healthy and live a long life?" you can be thin, you can have muscles, you can be strong, but you have to commit to a lifestyle. ogata: i try to go everyday. it's such a habit that... if i don't go, i feel like something is amiss. been: it means everything to me. it's a release for me when i'm upset. it energizes me. it's where all my friends have come from. it's everything. it's, like, my life. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: patty: hello? cathy: patty! i've decided to follow your lead and file for social security benefits online. patty: but cath, aren't you back in zanzibar? cathy: i just got on my laptop and went to socialsecurity.gov. it took less than 15 minutes! patty: wow! you are a miracle worker. cathy: well, cheers, patty. i'm off to film a baby rhino. ♪ when cousins are two of a kind! ♪ patty: a baby rhino. annenberg media ♪ by: narrador: bienvenidos al episodio 41 de destinos: an introduction to spanish. primero vamos a ver algunas escenas de este episodio. raquel, es mejor que entres sola primero y hables con él. de acuerdo. se va a poner muy feliz. sí, claro. carlos: la verdad es que... gloria juega. ¿quieres decir, por dinero? pero, ¿qué necesidad hay de vender el apartamento? nos criamos en ese apartamento. en este episodio, vamos a aprender un poco
narrator: pregnancy is usually a 38-week procs. healthwise, there's much a woman needs to do and learn during that nine months. barbara korsch: i think that, you know, usually people don't make a conscious effort to prepare for that. they are in the state of mind, and let's hope they have someone who's going to father the child whom they respect and whose values they like. i like to say that a pregnancy begins when two people who are in love with each other decide that they're going to become pregnant and raise a child till that child is 20 to 30 years of age, not before. j.p. garamone: we've been married 13 years. we pretty much put the decision off till later on. we really thought that we would, you know, travel and do a lot of things together, etc., etc., and then when the time was right, we'd figure, you know, we'd talk about it then. and then one day, it was like, is this going to be a nursery or is this going to be a guest room? tracey garamone: and i went for my annual doctor's appointment and said we're thinking about it and next thing you know, the next month, it happened. well, there's no question that if we take from the very beginning, planning a pregnancy is far more likely to yield a good outcome than an unplanned pregnancy for a variety of reasons. not every woman is perfectly healthy. doctor: tracey? not ever woman understands that, for example, you can reduce the chance of having a neural tube defect by taking folic acid in the pre-conceptual and the early conceptual period. if you wait until you're pregnant, it's often too late, to, in fact, impact any change on the outcomes. tracey garamone: well, i was in fairly good physical shape. i take vamins that are equal to, if not better than prenatals, so i was set up for that. the most important thing is the folic acid so that was in place. caffeine i had already cut out of my system a couple years ago so that was easy. but alcohol, definitely, you know, came to a halt, because we are social drinkers and we do love wine tasting and things of that nature. so... it'll come back. overindulgence is not going to work, whether we eat too much red meat, even though it's good for iron, if we eat too much of anything, it's not going to be good for us. so again, use logic in deciding how you handle your pregnancy. i needn't tell you, i needn't tell anybody that alcohol's not going to be good in pregnancy. i needn't tell anyone that using illicit drugs is not going to be healthy for your pregnancy. because ultimately that baby, if the mom uses regularly enough and in high enough quantity, the baby will become dependent on the drug in the same way that an adult would. in the wall of the lining of the uterus, there's a hormone that plays a very important role in the developing brain. so this is a signal from the mother that plays a role in how the baby's brain develops. so clearly speaking, we're talking about a drug, alcohol, that affects the mother's metabolism, where that signal doesn't get delivered to the fetus to allow normal brain development. in the last five to seven years, the rates have started to climb back up again in terms of women drinking while they're pregnant. it's the more highly educated, the more high income, typically white women who appear to be escalating their alcohol use. i think, in part, folks feel very comfortable that this problem was addressed and successfully licked back in the 80's and that it's something we can move on away from at this point. and that is absolutely not the case. smoking also increases the risk of premature delivery and low birth weight. in fact, babies whose mothers smoke are at greater risk for sudden infant death syndrome. calvin john hobel: sometimes it's hard to look at just the effect of smoking by itself, because smoking women have other habits that compound the effect of smoking. for example, nutrition. women who smoke tend to have poor nutrition. they may also be the person who's not taking their vitamins so they have a folic acid deficiency. so when you combine poor nutrition and not taking adequate vitamins, then in combination, that can lead to more serious problems. women often become more health conscious when they become pregnant. and that often translates into a more healthy diet. women aren't "eating for two," as the old saying goes. they only need a few more calories. but they do need to eat well. undernourished pregnant women have a higher risk of miscarrying, having premature or underweight infants and delivering babies with birth defects. i gained weight pretty rapidly, which i was surprised, because i was exercising very regularly and eating-- i eat very well balanced. so it just-- my body was getting ready on its own and my doctor said not to be concerned about that. i've done a lot of reading. i've read about every book i can get my hands on, and they all said the same thing, you know, 25-35 pounds. j.p. garamone: we've been eating basically the same way for years and years and years, so it's not too much of an effort here for us. you know, the pickles and ice cream really weren't an issue. fasting during pregnancy is not good. normally for a non-pregnant person, you can fast for 24 hours without having a metabolic effect, but during pregnancy that time is shortened. so women who fast for 12 to 13 hours have a significant increased risk of having a low birth weight baby, or a baby who delivers pre-term. if a woman has dinner in the evening, let's say at 6:00, and then doesn't have a snack at bedtime and then gets up at 8:00 or 7:00 the next morning, doesn't have breakfast, and then maybe has a late breakfast or lunch, that's way more than 13 hours. so, in our studies so far, we found that about 40% of women have periods of fasting for more than 13 hours. so i think fasting is prevalent in pregnant women. all these health guidelines-- it's enough to make a woman's head spin-- not a good idea, since she may be nauseous already. but her medical practitioner and her own common sense can give her all the tools she needs for a healthy pregnancy. barbara korsch: from a physical health point-of-view, anything that is good for the mother's health is good for her during pregnancy. you know, the mothers go to extremes nowadays. i mean, they may read greek poetry to their belly, you know, in the hope that the child will be exposed to something beautiful and this will improve his mind, and... classical music, even in utero, not only after birth, which was highly touted recently and so on. so they would do many things. now as far as i'm concerned, there's no evidence that this has a direct impact on the baby's brain. but if you think logically, if the mother relaxes when she listens to mozart and her pulse rate slows down and her entire circulatory system and body is less stressed, this can only be healthy for the baby. doctor: the baby's heartbeat sounds great. it sounds calm right now. there's data now to show that women who have stress have a greater risk of having a baby that has an anomaly of either the heart or the central nervous system, like spina bifida, heart abnormalities that are more likely to occur in a woman who has stress. and then also there's been a study showing that women who have stress are more likely to have a miscarriage. so this really focuses us toward the early part of pregnancy. researchers are also studying how acute stressors like domestic violence and natural disasters affect pregnancy. calvin john hobel: recently our team showed a relationship between the northridge earthquake that occurred here in the l.a. basin and those women who experienced the earthquake during the early part of pregnancy. it had a significant effect on their gestational length meaning that they were more likely to deliver early and in some cases, you know, pre-term delivery. there are many factors associated with premature births. some, such as smoking and poor nutrition, are risks women can avoid. others, such as stress, may be more difficult to control. but often premature labor is beyond anyone's control. whatever the cause, it creates serious problems. pre-term birth is the second leading cause of infant morbidity and mortality. the leading cause, is, you know, congenital anomalies and so the two are sort of close to each other but actually pre-term birth is second. and so there's immediate problems with the delivery of a pre-term baby, and it's related to gestational age. babies who are born before 32 weeks, or 31 weeks, we call very low birth weight babies. about 8% are born prematurely and they weigh less than five pounds, five pounds or less. and of those, of all the deliveries, about 1.5%, one and one half percent, are born with extremely low birth weight. it's what we now call "the micro prematures" because they are very tiny. they are less than three pounds. they have pulmonary problems, problems with breathing. they can have bleeding into their brain and these events really increase the risk of these babies having, you know, mental retardation, cerebral palsy, learning difficulties later on in life. so the maternal fetal medicine specialists, the obstetricians that specialize in this, as soon as they suspect premature labor, they try to prolong this because we know that five, seven days, a little bit over a week makes a big difference. several years ago we've shown that to be born at 24 weeks is much worse than being born at 25 weeks, even though medically we say 24 to 26 weeks. it's very different. because of medical advances in the last 20 years, many more premature babies are not only surviving, but surviving with fewer physical problems. augusto sola: i think everyone can understand that this baby born premature, let's say 10 weeks early, was not supposed to be breathing outside of the womb, so they don't have these all well developed. the treatment starts actively in the delivery room of these babies. and what we do there is we insure that enough oxygen is being delivered to the baby's heart, brain, lungs, kidneys. we also make sure that their temperature doesn't drop. and we move the baby usually to the intensive care unit because these premature babies need treatment for several days, weeks-- or even the tiniest ones, for months-- to insure that they make it, you know, uneventfully. the baby, as a member of that family, has special needs. but the parents, they also have special needs to reach. i actually had a perception one day, and then i believe it very clearly, but actually babies-- just like parents are asking us, "please take care of my baby--" babies are asking, "please take care of our parents." medical advances have helped prolong pregnancies and saved premature babies. advances have also given physicians ways to see how a pregnancy is progressing. a commonly used technique is ultrasound scanning. this procedure uses high-frequency sound waves to visualize the fetus. lawrence d. platt: well, i personally believe a woman should be offered an ultrasound in every pregnancy because i personally will tell you i know of no test that can offer us as much information in a shorter time as ultrasound, provided it's being performed with someone that understands and is well-trained and has the proper credentials and accreditation of ultrasound. using an ultrasound, a health care provider can detect structural abnormalities, estimate the age of the fetus, see if there is more than just one fetus, and confirm fetal position. i had no idea that it would be that clear and that you could actually count the fingers and almost see the fingernails and the profile of the baby. it's pretty intense. you know, a large part of my research in ultrasound is in fetal assessment, not only identifying the patient with a chromosomal abnormality, but how is the baby doing? you know, that fetus is my patient, and so we do what's called a fetal biophysical profile-- something that we reported on over 20 years ago that's still used as a test of fetal condition-- combining it with heart-rate monitoring and looking at how is the baby doing. another diagnostic tool is amniocentesis. it involves removing some of the amniotic fluid that surrounds the fetus. geneticists observe cells from the fluid to see whether or not the fetus will be born with a genetic abnormality or other conditions, such as neural tube defects. tracey garamone: the needle is about the size of a blood-taking needle, which they've done a lot of that. i was lucky i did not have any of the adverse affects. some people do have cramping, bleeding etc. and i did not. it just was another day. you know, at this point, i don't remember exactly how long we had to wait for the results, but yes, until we got them and knew everything was perfect, you know, there was a little bit of worry. sometimes it's not just the outcomes of the pregnancy itself that you're looking for measures. there is how you manage the patient. it may be easier for the clinician to manage the patient knowing that there's a singleton pregnancy and not twin pregnancy. it's nicer to know that you don't believe that there's an abnormality. all these become better means of assessing the condition of the baby, and that they're providing you the optimal care of your fetus. tracey garamone: my husband and i decided not to find out the sex of the baby, because we feel there aren't enough surprises in life and felt that would be one of the biggest ones that we will experience together and well as i've been kind of stating that it'll make it worth the work-- that surprise in the end, that reward. really, right now, it's just i'm hoping for a healthy baby. that's really the main concern right now. the first part of labor is cervical dilation-- rhythmic contractions of the uterine muscles that cause the cervix to dilate and to efface. when contractions are only minutes apart, it's time to get to the hospital. tracey garamone: well, about 5:00 on saturday ternoon is when i started feeling the preliminary contractions i would say, because they were very dull. but i noticed that there was repetition, so i made dinner and carried on as normal. and then about 7:00 i took it easy and had jay start to time the contractions. and again, they were at a mild stage and they were about seven minutes apart. so i called dr. galitz and asked him the protocol and he said to go to the hospital when they're at five minutes apart. so by 10:00 the five minute mark hit, and we waited for about an hour to an hour and a half to make sure it was consistent, and it wasn't, what's called the braxton hicks, which are inconsistent. and it was, they were very consistent every five minutes. so i went to the hospital, got hooked up on the fetal monitor and the contraction monitor, and was examined and was told that i wasn't dilated. and that that's known as prodromal labor, meaning that the water hadn't broken. and there was no dilation, my cervix was 70% % effaced, so it wasn't real labor. so they had me walk around for about a half an hour, to see if there would be any change. there wasn't, so they sent me home. try not to lift or carry any heavy objects over the next couple of days. got to keep drinking a lot of fluids-- eight to ten of glasses of water or juice a day. shower only. if you feel decreased fetal movement... the next morning, you know, they just progressively started getting worse and worse, and i noticed some bleeding so i called, they said, "come back", so, ironically, it was about the same time, about 11:30-- heed back to the hospital, 12 hours later. same protocol. on the monitors... exam, still no dilation. still they're telling me i am not in labor. and at this point i am feeling pain and not knowing what labor would feel like otherwise. so again we got sent home because there was no progression. we'll try again another day. j. p. garamone: it was a little frustrating driving back and forth a few times to the hospital, you know. that i didn't really anticipate. - you okay? - yeah. - a little disappointed. - disappointed? yeah. the baby's not cooperating. when the cervix is fully dilated, the second stage of labor begins. the infant descends into the birth canal, normally head first. with each contraction the mother pushes, helping the baby along. but in some cases there are complications. by early evening i was having very severe body shakes, so i called and they said, "come on back." and they said, worst case if i was not dilated, they would try to give me a shot of something like demerol so i could at least sleep through the night, because i was unable to sleep since friday night basically. and now, we're at sunday. so went back to the hospital and i had dilated to one. so was given the opportunity to take the demerol or the doctor had given an okay for an epidural due to the pain thus far and for the time of it, and that's what i opted to do. and that was the savior. love the epidural. tracey came into labor and delivery at west hills in early labor. the examination was a cervix that was about two centimeters dilated, which is very early. tracey unfortunately, is about a week overdue. and in that situation very often there's decreased amniotic fluid. the amniotic fluid inside the uterus acts as a cushion to protect the baby during the course of labor when the uterus is contracting and putting pressure on the baby and the umbilical cord. with decreased amniotic fluid, there's less capability to protect the baby and more often they develop distress which is what tracey's baby started to do. d th when we h thproble the problem of the heartbeat dropping and that got pretty intense and pretty scary. and as a result of that, with the early stage of her labor, we decided that the baby wouldn't tolerate labor well for the rest of the course of labor which would be eight or nine hours. so the decision was made to do an emergency "c" section that evening. j.p. garamone: you could see that everybody was under control, all the doctors were there, etc. that was really, i think, the saving grace, that they were under control, because i was pretty nervous at that point. doctor: what i'm going to do now is just touch you on your belly. left, center, right. low and low. - anything you feel? - no. perfect. good epidural. oh, my god. - you okay, tracey? - yeah. okay. we're doing fine. hello, kiddo. oh, you are a big one, aren't you? - where's the cord? - not much fluid. around the baby's right leg. j. p. garamone: and, you know, i was a little disappointed that she didn't get to see the baby right away because it was a "c" section. other than that i think things went smoothly, so i was happy. tracey garamone: obviously most mothers want a natural delivery but at that point i wanted what was best for the baby. and i had anticipated that bding part of the natural delivery-- they let you have the baby for an hour before they do any of the cleaning and the tests, etc. so i did miss that. i missed not being completely coherent during the delivery just due to the drugs, but the lack of pain i didn't miss, that was fine. so it's all worked out and the baby's healthy and that's really the bottom line and what matters. barbara korsch: it's not absolutely that if you don't have the chance for this early bonding experience there will be mayhem but it is certainly a positive thing and in many instances now, the birthing process has been adapted a little bit to facilitate this early interaction between mother and child. and, for instance, we used to rip the baby away from the mother and put it in the nursery and then nobody could see it except through a window and with masks and gowns so that those early weeks would be very sterile. and now we try to do quite e opposite as a matter for this attachment process. the attachment between mother and son may have been delayed, but only for a matter of hours. linda hanna: in the last 10 years there's been a tremendous energy put on breast-feeding and the health of the infant, and the desire of women to be connecting with their babies at a very primitive, very natural type of level and so feeding-- breast-feeding in that venue has actually become extremely popular. it's so easy now that almost anybody can breast-feed. the food that's produced by the mother is made specifically for her individual baby. although women can donate milk for other babies, her milk is designed specifically to meet the needs of that baby at that gestational age. and so as the baby is developing in the uterus and growing, it's being fed appropriately by the placenta and by the mother. the same thing holds true for the baby after it's delivered. in addition to that, as the baby grows over time, in the year, second year, third year, the milk changes to meet that particular baby's growing needs. the carbohydrate and protein balance is perfect. there's amino acids and carbohydrates that help fuel the baby's brain and continue to help them grow on a continuum that's set, and actually quite adaptable for each individual baby. four days after the delivery, matthew is having his final check-up before release from west hills hospital. if you have any questions that you want to ask me, i'd be happy to answer. i understand he had a circumcision yesterday. now if he urinates or, you know, poops, does that effect the circumcision at all? because i noticed when he did urinate you know, he kind of started crying more so than he ever had, and then i changed him and he was fine. do you think it's sensitive? the area is unquestionably sensitive at this point. but it's-- almost all the babies urinate and defecate over that area and we don't see any significant problem from that. tracey garamone: since he was born we're always listening for any kind of congenital cardiac abnormality. and at this point, what's the heart rate, you know, now that he's out? typically 120, 160. like it was in the womb? yes, and gradually over time, usually over the first two months or so, there'll be a very slow reduction in heart rate. he's very active, and all of his behavior is very appropriate. all of the rooting responses are really excellent. he's doing beautifully. good. if it's in the middle of the night and you're not sure whether what you're worried about is significant or not, you can call the nurses here in the newborn nursery, because they're doing shift work around the clock. if you express a concern to them and they're worried, if it doesn't sound right to them, they'll tell you to call the pediatrician. and of course, we're available 24 hours a day. call us if you're worried about anything. tracey's discharge interview is relatively brief. just you know, be sensible and things like that. and that's about it. how about stairs? i think going up and down stairs shouldn't be a problem. we didn't cut muscles or anything like that. if you feel tired or fatigued after doing that, try to limit the number of times a day you do that. - okay. - but otherwise you can pretty much do what you want. - take it easy. - sounds good. - see you back in two weeks. - thank you. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: narrator: a century ago, the potential for surviving childhood was not as promising as it is today. there was a higher childhood mortality. it wasn't uncommon to have a family where a sibling or two or three died during childhood. today, of course, that's very uncommon. raising healthy children may not be the challenge it was a century ago, but it's far from automatic. the risks of diphtheria or scarlet fever have given way to accidents. every household, every environment offers different challenges. but there are some fundamentals that come into play. catherine parrish: i thinking limiting your exposure to germs and a balanced diet are the most important things i teach them about keeping their baby healthy... and then coming for shots. the immunizations we provide certainly make a huge difference. diseases that killed hundreds of thousands of people don't even exist in this country anymore. although some concern has been expressed about the possible side effects of vaccines, physicians firmly believe that the benefits far outweigh any risks. vaccines have eliminated polio, and all but wiped out measles, mumps and rubella. i think the reason why we're not seeing a lot of those illnesses is just because of that. not because we're necessarily a healthier population, but because we've taken steps to try and eradicate those diseases that we could eradicate. we have a tremendous number of vaccines we didn't have even when i started practicing, for instance, the h-flu vaccine which came out in the late 80s and we started giving it before the age of 2 in the 90s. when i started practicing, my very first week in practice, i almost lost a child to h-flu meningitis. carried them in the back of my car to the emergency room, ran them in... thankfully they did well. but that's a disease we don't even see anymore because of the h-flu type b vaccine. what we see most commonly now is respiratory infections, especially otitis media. we see a tremendous number of children with ear infections. other respiratory infections are very common-- coughs, cold, sinus and cause us a lot of visits. catherine parrish: and that's because kids aren't at home. they're in day care from six weeks of age. when we were all growing up, we grew up at home and were only exposed to our siblings and cousins, and so we weren't as sick at an early age. now moms go to work at six weeks or eight weeks of age for the child, and so kids get a lot more ear infections, a lot more colds. it may be impossible to avoid runny noses, but experts agree on some easy, yet important ways to give children a good start. catherine parrish: i think i start by telling them to enjoy their baby and love their baby. and then, in the very beginning, like in the first two months of life, to try exposing the baby to as few strangers as possible, to bring as few germs into the house as possible, nurture the baby, feed the baby regularly, not take the baby to the mall... not take the baby to the movies, because i have some very young moms in my practice who want to get back to the mall as soon as possible. and so, you know, i try and limit the baby's exposure to pathogens that might make it sick. well, i certainly think that the perception on the part of many mothers is that the baby's very delicate, very fragile. they hold them like a breakable object, you know, and don't dare really act natural with them. and in general, of course, the baby-- a newborn can't hold his head so the head has to be supported but other than that, they are really quite tough little creatures. you don't have to be afraid of touching all the time because the baby actually needs to be touched. what's important is that their parents are picking them up, touching them, loving them, giving them stimulation, reading to them, talking to them. this is really critical in the early formative years. without any stimulation, infants do very badly. i admitted an infant to the hospital a couple of months ago who had-- came from a really grossly deprived background. and at first, i was sure this baby was going to be very, very delayed and had something wrong with his brain. but after a few weeks of very intense attention the whole staff was so moved by this infant's plight, we never saw him in his crib. i'd come to examine him and he was always in somebody's arms, you know. but anyway, once we fed him and gave him lots of attention and talked to him, and held him, and now put him in a foster home, he's actually a normal baby. and it's one of the most extreme i ever saw-- of what total deprivation can do. stimulate your kids. read to your kids. we know that reading, is one of the best things that we can do for our children. again, i think it's this stimulation of the developing brain, making those nerve connections early and optimally for those kids. so the data's very clear. you need to read to your children. catherine parrish: the idea for a reach out and read program came from some very bright pediatricians in boston, who decided that we do just about everything else for the young child. we're their most constant contact outside of their parents. we talk to them about car safety, home safety, nutrition, what to wear, where to go for good entertainment, why not talk to them about books? let's put these right here. which book would you like? i think we selected one. michael bryant: now we do that as early as six months for those kids, because while they can't read at that age, certainly exposing them to pictures and figures and colors and all of those things early on, i think really does enhance the foundation that they will build on ultimately. yolanda brown-willie: we read every day, maybe three or four times a day, in between me coming from school and going to work. and then my oldest two daughters also read to him at night. so it's very important because he's getting ready to start kindergarten next year, so he really needs to know what he's doing. catherine parrish: it's a ry exciting thg and i ha many, many young families who never owned a book before gave them one. i have moms who haven't learned to read themselves, who've gone to literacy programs after i started giving their children books. i have moms who have come back after three and four years in this program with their young toddler going to kindergarten reading, so excited that their children can read already. and it's just a very, very positive and rewarding thing and it's something we can do to give kids a step ahead in this urban community. but health professionals caution that the idea is to stimulate babies for normal development-- not to hurry them along. now, throw it to me. ck it up. throw it to me... throw it. ( chuckling ) throw it. can you throw it with your hands? this whole, you know, business again of wanting the fastest baby is very, very noxious, because, you know, they want to have the fastest car, and they want to have the fastest baby and they think you can control that. one of the most exciting things about working with children is this tremendous developmental drive. whatever they know how to do, they want to do all the time. they don't want to just walk, they want to run. they try to climb everything. so you don't need to teach them any of those things and trying to do that is counterproductive. now, of course, they have to have the stimulation. it's always a balance. so for most of the developmental milestones, if given some stimulation, some freedom, some interaction around it, they will learn it as fast as they can. and because young children are busy exploring their world keeping them safe is one of the most pressing health needs. michael bryant: talking about toddlers... probably the thing we worry about most is accidents, because kids at two, three, four years of age are so prone to injuries and accidents, and these are things that obviously are non-intentional. and so prevention begins to be the key. and looking for those, what i like to call, hidden dangers in your home that kids can get into. i mean, kids do things that we would never imagine that they would venture into, simply because of their curiosity and so most of my advice for parents would be around injury and accident prevention. catherine parrish: everywhere from the child's home where there could be exposure to normal things that you have to make safe for the young toddler, like light sockets or stairs and using gates, and i think those are the things people are used to hearing about. and for instance, baby walkers which are very dangerous-- and we try to keep parents from using them. we saw horrible accidents with them all the time. michael bryant: there are parents who have a lot of confidence in the floaties. the floaties are the things that you put on kids arms that allow them to stay afloat in water. and they are very cumbersome, they get in the way, they impede their ability to flail and move their hands and so they remove them. they don't have the knowledge that that's what keeping them afloat. and so it's things like that for the young kids. as children get older, they may still resist wearing protective devices. barbara korsch: then there are certain recreational things children use which are dangerous-- skateboards, roller blades, very dangerous. and we counsel a lot about helmets, elbow guards and all that because many of the children who engage in high-risk athletics don't wear the necessary protective gear. unfortunately, many children live with other risks as well. barbara korsch: causes of injury-- sadly, violence is still at the top of the list even in childhood. i, in my own practice, have had several children who were killed from gun accidents, and i ask every family in my practice whether there are any guns in the home. do you keep it unloaded? do you keep it locked? do you keep it where your children can't reach it? so gun safety is a big thing that i didn't think i was going to have to talk about when i started practicing that i talk about all the time now. we've lost two children to guns in this practice, both teenagers. one was caught in a gun exchange over drug money. another was shot because she was dating someone's boyfriend at 12. it's a scary world out there. there's so much to talk about in terms of safefety. and actually in medicine it's hard to do in the time we're given to pick and choose which topics are the most important for each family and each child. and, of course, there are other topics which are important to a child's health. barbara korsch: we used to worry about malnutrition. now our biggest, biggest problem, big in every sense of the word, is obesity at all ages. i see parents using food as rewards all the time, and generally it's food of low nutrient density. it's like candies, cookies, lollipops, the usual sorts of things. tyler was sort of nice... and she's saying please... and basically when you use a food as reward, you're holding up that food as something special. when you think about it, it doesn't quite make sense. it's like, "you're a good boy, here's a lollipop that will cause you to have tooth decay, and has almost nothing in it for your health and well-being." how much sense does that make? that's a big problem that we have, in particular, in overweight children, where grandma's way of rewarding you is a trip to the local fast food chain. i won't impugn any one chain, they're all there-- you know, and fries and a burger are the way to your heart. we have to change that myth. fries and a burger should not be the way to your heart. it's the way to atherosclerosis. david faxon: in a recent study on autopsies of children and young adults, in the teenager range, a very high percentage had plaques, had hardening of the arteries evident before the age of ten. and by the age 20, the majority had plaques. an estimated 15% of american children are seriously overweight-- twice as many as two decades ago. twenty-five percent are at risk for obesity and many already show biochemical changes such as elevated cholesterol and blood pressure. and as a consequence of that, in certain populations, particularly in certain hispanic communities and in african american communities, we are seeing associated with that obesity the onset of frank-- what we call type ii diabetes where these children actually need medications to control glucose. although genetics plays a role in obesity, for many children, it's their environment that determines whether they will gain unneeded pounds. children's diets today are high in sugar and fat-- invitations to health problems. are you guys hungry? yeah. yeah. want some lunch? nancy anderson: setting an example is the most important thing that an adult can do to help your children learn healthy habits, whether it be diet or exercise. the other thing is to teach them, again, what is moderation. every kid's going to love french fries if you give it to them, but if you teach them that this is a sometimes food and that there are everyday foods that you want to eat every day, and sometimes foods are okay once in a while. i think it gives them a healthy look at moderation and so that hopefully you prevent extremes in either direction. joanne ikeda: young children are naturally neophobic. they have a distrust and a dislike of new foods. you put a new food in front of a toddler, and they generally don't go, "oh, whoopee, a new taste sensation!" it's more like, "what's that? i haven't seen that before. i don't think i'm going to like that." can you try me some strawberries, please? you know there's strawberries in your juice. you know there are strawberries in this juice? and you love this juice so much. try just a little bit of strawberries? you ch it l up? can you try a little bit for me? how about carrots? you want to try carrots today? can we try to eat the carrot? parents say to me, "oh, my child won't eat vegetables, but that's because they've given up too easily. they need to keep serving them, and they also need to model enjoying them. look, i'll try to eat some if you'll eat some? look, see? mmm. that's very good. it's really, really good, buddy. with repeated exposure, you can break down this neophobia and actually get to a point of acceptance. just a little bite for daddy? realize when kids start eating, they have a very clean slate. you know, they develop the tastes that we have acquired over years and years of experience. and so to the extent that you introduce foods that are healthy, then you kind of tailor their palate to enjoy those kinds of foods. if you introduce those kinds of foods that you and i like because they're sweet, because they're tasty, then you are also tailoring the palate of the child. but you have this clean slate to work with, if you start with nutritional foods then you're going to create a child who looks to have those kinds of things. but it's more than just bad food choice that is a factor in obesity. inactivity is also a culprit. children aren't getting as much exercise as they should. one reason is they spend too much time in front of the television set. television watching is the single thing that has been consistently associated with obesity and there have even been some really interesting studies that if a child is just watching television, where they tend to sit very passive, they're usually also snacking, you know. that their metabolism actually goes down. it's a little bit like hibernation. it's sort of not the television, it's what the parents are doing. it's like you could blame television because parents are saying, "i don't want to be bothered," or, "i'm not going to create the environment for you to be physically active in, so watch tv." and when you do the study, it looks like, "well, oh, it's tv that's to blame," you know, when in fact, it's not necessarily tv to blame. researchers have found that when television vwing is limited, children fill their time with more active pursuits. some children find it easier to be "active" than others. catherine parrish: county kids grow up in an environment where they can ride their bikes, they can play ball outside and it's safe. they're in good after school programs, or schools that have after school sports and so county kids exercise. city kids don't, for the most part. there have been interesting studies, for example, done comparing physical activity levels in inner city kids compared with suburban kids and one of the things you find is that... inner city kids may do very well on things like push-ups, sit-ups and less well in running and aerobic type of activities. and the investigators discovered that the reason that that had happened was because in this particular study which had been done in a large city that coaches didn't let the kids during p.e., that they had, they didn't let them go out on the playground because the playground was dangerous. p.e. was inside and so the activities that they did was a lot of calisthenics, sit-ups, push-ups, things like that. catherine parrish: i hear lots of stories when i see these kids for check-ups, and many of them are overweight, about how, "i'd like to play a sport but my school doesn't have that." "i can't get to the program. it's on the other side of town." "it's not safe to ride a bike in my neighborhood." "i can't... my bike got stolen. i haven't been able to ride one since that." "my mom won't let me play basketball at the schoolyard because it's not safe." there's going to be a lot of what we as a society, as parents, as individuals, construct for our children, and the kinds of environments that we create for kids to be physically active, despite that fact that there's going to be a great deal of genetic difference from child to child. a few of them are going to become great athletes-- most won't. but many will benefit from what we can identify as optimal patterns of exercise during childhood. if good nutrition and exercise become a habit, there's a better chance children will grow into healthier adults. but scheduling too much activity isn't a good idea, either. kerry syed: i think that children, in general, are very little impressionable people. and as we go through childhood, you know, our parents make us do certain things-- "you need to be in soccer. you need to be in ballet. you need to do this," but they never think about, "does my child like this?" they think, "i just want you to be active." jennie trotter: most parents are working and then you have after school or then you have other obligations that the kids have, so what we're trying to let parents know, first of all, is to be able to say no. first of all understanding that your kids' agenda and schedule that you may have to say, "that's too much." we stress them in more ways than you can imagine. many kids start their day at before-school care at 7:00 in the morning. then school till 2:30 or 3:00, then after-school care till they finally get home between 5:00 and 7:00 in the evening and eat dinner and have that one hour that they're supposed to cram a whole day in with mom or dad, and then go to bed and do it again. in the more suburban community, the stress is running from school to soccer, to violin to dinner to fitting in homework to going to bed. and so i think, you know, we've gotten away from letting kids be kids. kids need time to kick their shoes off and do nothing and be in their house, with their things, with their family. and the kids who don't get enough of that... come to see me. and what do i hear? i hear... "he's having headaches all the time. he's having stomachaches all the time." we weren't meant to run at that pace as youngsters. i don't know if we were meant to run at that pace as adults. jennie trotter: sometimes you just practice some relaxations whether it's, you know, listening to music or exercising together. there's some great slow moving, deep breathing exercise that say, you know as a rule, or having family meetings because there's so much going on to talk about who's doing what. for some families, the concept of family meetings, or even just time together, may be difficult to achieve. the family uniis din in very different terms these days. we have single parent families, we have parents where both parents have to work in order just to make ends meet. catherine parrish: i see many children who are latchkey children, who get very little one-on-one time with their mom or dad, who have nintendo, sega, four pairs of sneakers. spending time with your mother or father is probably the most precious gift you can give your children. not so much the quantity but the quality of that time, and that that child recognizes that as a special time for him to share with his mom or his dad or both, or whomever the caregiver is. as children get older, the value of time together, and communication with trusted adults may be even more important. catherine parrish: i've been right here in baltimore city the whole time i've practiced, and as kids grow up, they feel that they need to trust someone. and you know, it's hard to trust your mom or dad when you're a teenager. i think we've all been there. it's not because mom or dad does anything wrong, it's just you're trying to find yourself at that age and maybe, mom or dad doesn't know what that is and you haven't figured out you can trust them. and so i become the person they can trust. and many kids come to me between the ages of 12 and 18 to tell me about experimenting with sex or drugs and to hear what i have to say about that. and if i say the right thing, many of them don't continue to experiment that way. they do trust my opinion. a recent study found that nearly 1/2 of teenagers received no counseling during their doctor's visit, and only 3% received information on issues such as smoking, sexually transmitted diseases and weight control. but those are precisely the areas in which teens make poor choices and put their health at risk. catherine parrish: i think probably the biggest problem we have in the urban environment is that young children, both girls and boys-- i was going to say girls, but it's definitely both-- become sexually active at way too young an age. it's heavily accepted in the city to have a child before you're 15 or 16 years old, to have sexual relations with multiple partners before the age of 15 or 16, to have venereal disease before the age of 15 or 16. there's nothing right about having sex when you're 10-- or 12, or 14. and i take a very strong stand on that in my practice. but i'm one voice in a very large community and when six of your friends have had babies by the time they're 15, it's a very hard message to fight. a lot of it has to do with peer pressure, and then they get so much from the media. and then you have a whole lot of kids right now that do not have that kind of parent monitoring. because a lot of parents are out making money and trying to support a better way of living in their new age. and then you have so much drugs that are out that you didn't have before, as well as, you know, alcohol. edward mccabe: we know from the studies, kids who take drugs, kids who are involved in gangs, are more likely to be involved in violent acts. we tend to sometimes not be as sensitive to these issues. we can't predict every violent act, but when there are signs ahead of time, we need to recognize that maybe we need to try and get some help for those individuals. the adolescent physicians are very good at talking to those kids and helping to identify which kids are at higher risk than others. so that i think that we need to use the appropriate health professionals to try and help us do a better job. parents face a wide range of health issues as their child matures. the baby with the runny nose, grows into a teenager who rarely has a bad cold, but is confronted with health issues such as smoking and alcohol. as they grow, children learn about health by what they see around them. kids learn better by example. we can say as much but the first two best role models are the-- you know, the people or the parents that are in the home. "the human condition" is a 26-part series about health and wellness. for more information on this program and accompanying materials, call: or, visit us online at: and accompanying materials, call: annenberg media ♪ provided by: narrador: bienvenidos al episodio 43 de destinos: an introduction to spanish.
the environment is a crucial factor in the health of each of us. if the environment is not healthy, there is no way we can truly call ourselves healthy. persistent efforts and regulation over the last few decades have greatly reduced environmental pollution. ib: our rivers don't catch on fire anymore. persistent efforts and regulation over the last few decades we don't have big, black plumes in most communities in america. we don't see slicks going down the great lakes. so people believe, because they don't see it, that, somehow, we're in a better state now than we ever were before, and the truth is, that all we've done is cosmetic surgery. we have scraped off the surface and made that look pretty, but beneath it are the invisible chemicals that are getting into our food supply, our water supply and our air each and every day, and poisoning us. not gross poisoning, but subtle poisoning, day after day after day. we are not exposed to individual toxicants in the environment. we're exposed to hundreds and thousands of chemicals in our food, air and water, many of these natural, many of them human-made. so the question is, what happens when we have all of these added together, in varying amounts? many of these chemicals are difficult to escape. they reside in the atmosphere that surrounds us. john peters: for years, there's been a well known set of responses that people get when they breathe southern california-type air pollution. eye irritation, you know, irritation in the chest, cough, things of this sort-- but the real question that i think some of us have been interested in is what does this repeated kind of experience result in, as far as permanent, chronic damage to the lung, or anything else? health officials suspect that air pollution may be a factor in diseases such as emphysema, chronic bronchitis, and lung cancer. it can also intensify the breathing difficulties people with asthma experience. john peters: if you divide the population into asthmatics and non-asthmatics, there's a striking relationship within the asthmatics as to air pollution level, and frequency of cough and phlegm-- it's twice as much in the more polluted communities than the less polluted communities. nine years ago, the california air resources board initiated a study to determine the long-term effects of air pollution on health. their subjects? 5,000 school-aged children living in 12 southern california communities, from atascadero to alpine. john peters: we decided to look at children primarily because we can find them more easily. we can go to schools, and if they're young enough, they don't smoke yet. they don't have hazardous occupations, so that there are some things about them that are amenable to study, maybe not the least of which is-- at least thought by some-- that the growing lung in a young person is more susceptible to the effects of air pollution as well. plus the fact that children spend more time outdoors and they exercise more so that they would be breathing more of the ambient air and when they're exercising, even more. children in the study are periodically tested to determine if there are any long-term effects from air pollution. researchers measure each child's lung development and function in relation to the air quality at home and in school, as well as the outside environment. so if we see an effect, we'll be trying to isolate whether it's caused by particles in the air, or ozone in the air, or a combination of the two, or nitrogen dioxide, or some other pollutant. thus far, three results seem clear. first, children who live in areas with high amounts of air pollution exhibit slower rates of lung growth. second, children with asthma and other respiratory illnesses are affected more by the pollution than other children. and third, school absences related to respiratory illnesses in the communities studied, are not linked to ozone pollution, as first thought. what we've seen so far makes it look like particles and no2 or nox are more important than ozone as far as the chronic effects. health problems related to air quality tend to emerge over time. illness related to contaminated water is much more direct. david bennett: the diarrheal diseas are usually trsmitted through contaminated food d water. so with poor sanation systems the comnities, poor hygiene in the household, lack of running water, water that has to be stored and can be easily contaminated, lack of refrigeration for keeping foods-- these are all factors that contribute very heavily to the occurrence of diarrheal disease. for the past decade and a half, the carter center has led a worldwide campaign to eradicate two water related diseases: river blindness-- caused by the bite of a blackfly which breeds in rivers and streams, and guinea worm disease. donald hopkins: this is a parasitic infection that people get when they drink contaminated water from open ponds. a year later, worms that are two or three feet long come out of their body. the threadlike worm emerges slowly through a painful blister in the skin. if the worm breaks during its exit from the body, it causes a severe infection. donald hopkins: people are incapacitated, usually temporarily, for periods averaging six to eight weeks. during that time, children can't go to school, farmers can't farm, parents can't take care of their young toddlers. many victims immerse the affected area in water to soothe the burning pain. when the female worm touches the water, she releases tens of thousands of larvae that begin the cycle again. although guinea worm disease cannot be cured once the larvae is ingested, the disease can be stopped if the one-year life cycle is broken. donald hopkins: it can be prevented completely by teaching people not to go into water when they have worms coming out of their body, because that's how the infant worms get back into the water. teach people to boil their water, if they can afford to do that. teach them to filter their water through a finely woven cloth. there's a chemical abate which you can put in the water that kills these parasites, but leaves the water safe for people to drink. it also doesn't kill fish or plants in the water. but the best way of preventing this infection is by helping people to get safe underground sources of water, such as from a bore-hole well. that improves-- it gets rid of guinea worm, but it also reduces the amount of diarrhea and other kinds of water-borne problems that people suffer. water quality is often perceived as a local or regional issue, as is the case of the guinea worm. but the very fact that water circulates around the globe and through the soil, means that contamination in one area eventually spreads. rebecca goldberg: the ocean has historically been treated as so vast that we can do anything to it and it doesn't matter. cities have pumped vast quantities of untreated sewage into the ocean. new york city has dumped garbage in the ocean. ships have thrown their wastes overboard or discharged their sewage directly overboard without treatment. the beaches of imperial beach, california, a seaside community south of san diego, are closed during much of the year because high levels of pollution pose a danger to swimmers and surfers. two miles to the south is the city of tijuana, mexico. almost half of the homes and businesses in this rapidly growing ban area are not connected to a sewer system. ababout half a mile short of that two miles is the mouth of the tijuana river, where a million acre watershed pours water and unconnected sewage from homes that are unsewered in mexico down into the watershed, and that's out the mouth of the river where the sewage flows north or south, depending on ocean currents. the rapid growth of industry along the border has also created severe pollution problems. most mexican factories do not treat their wastes before dumping them in the ocean. carolyn powers: you don't see toxics in the waters so the beauty that you see behind me is very deceptive in that you don't see the chloroforms, you don't see the lead, you don't see the arsenic, you don't see the toxins discharged from the maquiladoras in mexico that come down the tijuana river untreated and actually pollute the marine mammal fisheries, and as well as the recreational users here in imperial beach. the unseen risks have resulted in very real health problems for anyone venturing into these waters. gary sirota: i remember, i used to go into the ocean when i had a cut and i'd heal myself. and now when i go into the ocean i almost always have to come out-- peroxide my cuts to make sure that i don't get an infection. i can't even point to how many times that i've gotten gastroenteritis, diarrhea, nasal infections, ear infections in the last ten years from surfing the local coastal waters. the heavily populated city of san diego, a few miles north of imperial beach adds to the pollution problems. kathy stone: when it rains in urbanized areas such as san diego, we're going to get a lot of run-off coming in from all the asphalt-- it comes into the ocean and that's going to be highly polluted with chemicals, fertilizers, high bacteria levels that can potentially make people sick. so what the county does is we advise the swimmers and surfers that please don't go in the water near lagoons, rivers, creeks and storm drain outlets. marco gonzales: i can go out three, four days after a storm, after they've pulled down all the signs and coming in, get a gulp of water or something, and my throat starts burning almost immediately. you know, 24 hours later, i'm completely sick, laid up with the flu. it doesn't take a large stretch of the imagination to attribute that to the polluted water. air pollution and contamination of the water supply, are not the only purveyors of toxic risk. for many people, especially in decades past, the most dangerous environment may be associated with a paycheck... the workplace. the women who were using their tongues to make the point on the brush to make the fine letters on the dials luminous and were, you know, getting a lot of radium into their body and winding up with cancer of the jawbones. and then, there are lots of stories of, you know, coke oven workers developing cancer, coalminers developing lung disease from inhaling coal dust and silica miners being exposed to silica and developing serious respiratory illnesses. at the hawk's nest tunnel, built in the 1930s, mostly black miners who were driving the tunnels through in west virginia, they ran into a mountain of virtually pure silica and they contracted these diseases in days and weeks, because of the high intensity of their exposure to it. fortunately, we don't have that kind of exposure now but we do have and continue to have silicosis as a problem among miners and among workers generally. workers who are sandblasting tunnels or bridges, workers in factory settings that use abrasives to clean, elements to clean machinery, those frequently contain sand and silica and those workers then have exposure. hello. my name's richard, and i'm with the state osha program. and i'd like to see the person here with the highest authority, please. today, it is the job of osha-- the occupational safety and health administration, to keep workers free from health hazards by regulating their exposure to different hazards. jim, you have richard from osha in the front office. please come to the front office. all of our inspections are really a surprise to the employer. we cannot give advance notice to any of the employers. my name is richard, i'm with the state osha program. - and i'm here to do an inspection. - okay. some inspections are prompted by a violation or complaint reported by an employee; others are routine. ray barkley: they'll explain why we're out there, and then they'll ask to look at specific programs. well, let's just start and walk around the shop. and then they'll start their walk around, which is the inspection. this is interesting. tim, could y come here and-- ? yeah? this device shows whether an electrical circuit is grounded or not. and i'm showing no ground here, but i am showing that it's grounded here. i don't understand what the problem is. so could you kind of peek in there and tell me, without sticking your fingers in it? looks like the grounding wire is not hooked up to the face plate. so, there's no grounding wire on this particular plug, and that's a very dangerous situation. again, that will result in a citation... ray barkley: our whole job here is to try and make the job safe or the place of employment safe. to avoid liabilities, industries with potential workplace hazards will often hire medical personnel and industrial hygienists to monitor employee health and safety. teresa howe: we fabricate a number of parts for the various launch vehicles here, so, employees could be exposed to a number of different chemical substances, fibers, vapors, gases, various liquids, corrosive-type materials. tracy schile: the goal of the industrial hygienist is to undertake preventive measures that keep our workers from being exposed to chemical, physical, and biological hazards. okay, so the time i started you is 10:05. and then this is to get the short-term exposure limit, so i'm gonna wave at you to get you to stop what you're doing. at 15 minutes, i'm gonna change out that cassette. okay. tracy schilf: we're looking for the results of what the fume exposure is gonna be for his welding process. he's using a... what's called the "rod 4-10," a stainless steel rod, it has some chromium in it, so that's what's gonna be our biggest concern. teresa howe: engineering controls are the primary tactic that we would like to use in occupational health and safety to keep exposures away from the employees. those are methods that we use, or perhaps devices that we use, to actually control the exposure at the point of generation, perhaps; isolate or separate the employee from the exposure; engineer the release of the hazardous material. for example, engineer that out of the process, so that we just don't have the exposures. for many reasons, howe considers personal protective equipment the least desirable line of defense. howe: we reallhate to have to rely on these devices. they can be, you know, they can fail. they can come from the manufacturer with holes in them. a glove with a... maybe a small pinhole leak that the employee might not notice, and they're relying on this for chemical protection to keep that material off of their skin. with respirators, for example, there can be breakthrough in the cartridges where the filter material becomes unable to filter out anymore of the solvent or dust or something like that, and the employee then can be exposed. or the respirator might not fit properly on the person's face, again resulting in possible leakage and the contaminants getting in there. so other hazards that we typicay have in... well, in a number of our production areas, is noise. we've got machine shops, for example. we need to get these people in the hearing conservation program, make sure they have earplugs; make sure we check their hearing every year to ensure that there's no degradation of their hearing. the one place most people feel free of environmental hazards is their home, and yet it's estimated that there are anywhere from 50 to 75,000 chemicals concealed in the products we commonly use and wear. the body interacts with these according to the way our biochemistry is programmed, according to nature. in general, i like to think about all of these other chemicals in three ways. they are either nutrients which our body can use for energy or for building tissue; they are inert, which means we don't use them at all and they just pass through; or they're toxicants-- they have the ability to alter the biochemistry within our body. good shot! parents of toddlers and small children must be particularly careful about protecting young ones from toxic substances-- the cleaning compounds and plants, cosmetics and drug products familiar to most households. michael bryant: and so prevention begins to be the key, and looking for those, what i like to call, "hidden dangers" in your home that kids can get into, and trying to be proactive in terms of educating yourself and them about those dangers. and they exist in some of the most unlikely places. i mean, kids do things that we would never imagine that they would venture into, simply because of their curiosity. other health hazards may be less obvious, as a number of families this chicago nehborod lened, when an enterprising pest control service started using a chemical designed for agricultural use to destroy their household pests. milton clark methylonsrgano-phatstide. it has been in use as an agricultural product for probably four decades, and it's a chemical that has significant toxicity and also short life in the environment, which has made it a chemical of choice in agricultural use. the trouble was, mr. brown, the unlicensed pest exterminator, did not use methyl parathion for agricultural purposes, as instructed. he used it inside people's homes. the roaches was real, real bad in my house. real bad. so he came and sprayed. when he sprayed, they stayed gone about a year. there's no worry about it. you just have to air it out, and it'll dissipate." brad menning: when it's used indoors, you don't have the wat or the bacteria or the sunlight to break it down. it can stay inside a house for two to three years before it breaks down, and that was the big problem here-- is this was all sprayed indoors. it was not breaking down, and it was still a threat to everybody that was living in these homes. an exposure to a chemical occurs when... through one of the routes: oral, respiratory, or dermal, we come in contact with a chemical in an environmental medium, such as air, water, soil... whatever. the effects may be either local or systemic. local efcts occur near the se ofe. craigmill: a systemic toxic effect can only occur if the chemical penetrates our skin. when parathion gets onto the skin, it is absorbed slowly into the bloodstream and causes an inhibition of an enzyme in our body. this inhibition causes widespread generalized toxicity, which results in headache, nausea, vomiting, diarrhea, and difficulty breathing. when we went into people's homes, we found that there were often the pesticide product in fruit jars, in milk jars, in honey containers... and the products looks like milk, actually, when it's diluted with water. obviously, we had great concern about children or others picking up these bottles, which were drink bottles, and consuming the methyl parathion in high concentrations. that would have been a very big problem. it turns out that these containers had a high enough percentage that the ingestion of between one and two teaspoons of the product by an infant, and let's say this would be 20 pounds and under, would be capable of killing the child. and a dose slightly greater than that, spilled on the skin without washing it off, would also kill a child. letters were sent to residents whose homes had been sprayed informing them of the potential danger of the pesticide. letter- monica fan?o residents whose homes hahibeen sprayed hi, nica. my name is rosa. i'm with the department of pubc th spoke with you elier this morning, regardinthmeth po. evs: we relied heavily on the public health nurses who provided information the residents initially, who collected the urine samples, and who followed up with the residents about the outcome of the urine testing. how soon will you pick up these results? tomorrow morning. if you like, i can be here... somewhere between 10:00 and 11:00. okay, that's fine. we took a lot of time to ask questions about what kinds of habits and behaviors that people in the homes practiced, so that we would learn more about which kinds of behaviors resulted in high levels of exposure. now i need to know... during the spraying, right after the spraying, maybe a couple of hours after when you came back into the house, or when you were in the house, was anybody, you know, complaining of any sickness, headaches, anything? yes, my husband was. he was nauseous. he had headaches. he just didn't feel right. and that was how soon after the spraying? well, he had stayed here while the gentleman was spraying, and so afterwards, within an hour, he felt sick. when i think about it now, some of us were getting sick. cause i had headaches all the time, and the kids would vomit, have diarrhea, you know, or complain about headaches all the time too, but we thought it was the flu or something. we didn't know it was coming from the spray. one of the questions that is often asked is, "if the product is so acutely toxic, why didn't we have hundreds of people going to emergency room?" often the pesticide symptoms that do result mimic many other types of symptoms, such as flu, frankly. e.p.a. officials were not just concerned abt the immediat health eexposue methyl parathion. we, however, have also been concerned about, and the scientific literature is incomplete and inconclusive on this, is whether or not we can be exposed to a pesticide in less than an acute fashion, just below an acute level, and end up having chronic health effects later. we were concerned that children might have subtle neurobehavioral effects that you would be able to observe years down the road, but the parent might not necessarily notice at the time of the exposure. in their assessment, children and pets were at greatest risk because of their smaller body weights and more frequent contact with contaminated surfac, such as the floor. aonce methyl parathion,ct or a pesticide, has been sprayed it soaks in, and you rely can't cln it. it bicly has to be remov to b efftive dcon. so, the we w.. they were taking out drywall, baseboards, flooring... at some point, yeah, some of the houses re brought right down to the studs, and then totally rebuilt. christine scott: we got rid of all of the toys and stuff. we couldn't have the toys... but the furniture... this is some of the furniture. uh-huh, but the toys... all of that, the games-- we had to get rid of that. we couldn't keep that. dolls, and, you know, teddy bears-- because it had the stuff on real bad. and if there's any one single message that u.s. e.p.a. would like to get out to people is make sure that the people they're dealing with is reputable, that they show them what is actually being sprayed, put out on piece of paper what is being sprayed, and certify that, and also will show them the license that people have to allow this to be done. if you don't do all of those three things, then you may be in a vulnerable situation. despite the hazards we live with, people who have been working to improve the environment are optimistic. and part of that optimism is just looking at what's happening out there. it's not a matter of how many sites are being cleaned up, or how many smokestacks are being shut down. that's one measurement, but i think the real measurement is, how many people are concerned about what they're eating today? how many people are buying organic food? how many people are looking at the labels of food products? how many people are looking at labels of clothing? once we change the marketplace and educate consumers, then we begin to make changes in this country that are really solid, rooted changes. so, i think the fact that the american public has become more educated and are taking their own steps, is very, very optimistic for me, and i think that we can win. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: and accompanying materials, call: announcer: the bare necessities of living healthy are easy. just eat right, be active, and have fun. yeah! go to mypyramid.gov to find out more. narrator: once upon a time, before we started ordering chicken without the skin, or cappuccino with non-fat milk, we simply ate what tasted good, and filled our stomachs without worrying about whether or not we were clogging our arteries or adding extra calories. today, eating seems like a daily struggle-- a constant battle between pleasure and health. it would seem that the abundance of food, and the wide variety of choices we have in the united states would almost guarantee proper and adequate nutrition for everyone. however, that is not always the case. peter clarke: there are a lot of people in this country-- tens of millions of people in this country-- who eat enough calories per day and even grow overweight but are malnourished. they are not getting the vitamins and minerals that they need. they're not getting antioxidants that they need. they're not controlling obesity which has so many health consequences and so malnutrition is a serious epidemic problem in this country, invisible to most people. the latest research on diet and nutrition confirms that what we eat does indeed play a role in maintaining overall health and well-being. what has changed through the years is the concept of just what a healthy diet is. joanne ikeda: when i first started as a nutritionist, we told people that it didn't make a difference whether you ate white bread or whole wheat bread. now we say the exact opposite. at one time, we actually put polyunsaturated oil in a cup and gave it to patients in hospitals because of "the health benefits" of polyunsaturates. now we know that total fat in the diet makes a tremendous difference and we would never do that again. so, over time, a lot of what we used to do has changed dramatically. however, a few nutritional facts remain constant. our bodies need the nutrients found in foods to function-- to power muscular movements and cell activities, repair tissues, and maintain body temperature. to carry out these metabolic activities, cells need the energy stored in three nutrients: carbohydrates, proteins, and fats. linda gigliotti: the body prefers to get energycarbydrate, and carbohydrate we may refer to as sugars or starches, but we get carbohydrates from grain products, fruits and vegetables primarily. joanne ikeda: carbohydrates are really a great source of energy for the body, particularly complex carbohydrates because it takes a while for the body to digest them, to absorb them, and then it gives a fairly constant elevation to blood glucose levels. and that's what we want because that's where we're getting our energy from. dietary fiber is another important health benefit of complex carbohydrates. the typical american consumes about 10 grams of fiber a day. medical experts recommend doubling that amount-- adding more fiber-rich fruits, vegetables, beans, and whole grain cereal products to the diet. protis used initially in the body to maintn scle mass, to build cells, antibodies, hormones, etc. and generally, that need for protein will be met if we take in 12 to no more than 20% of our calories from protein. any additional protein that we take in will be used for energy. calories will be broken down and burned for calories. and of course, a lot of those proteins are found in animal products such as milk, cheese, eggs, poultry, fish, lamb, beef, although it's quite possible to also get them by combining plant foods and legumes and things like that. linda gigliotti: we will really get enough protein from taking in about five to six ounces of meat per day. now three ounces of meat is about the size of a deck of playing cards. so you can kind of imagine a day's intake, that if i have a couple ounces maybe at breakfast or lunch, three ounces, that deck of playing cards on my plate at night would really give me enough protein, assuming i'm eating the other foods in the guideline as well. but as americans we don't eat the deck of playing cards. we eat the paperback book, you know, a very large paperback book, as our portion size. for health conscious people who have worked hard to minimize or eliminate fat from their diets, it may come as a surprise to learn that a healthy body actually needs fat to function. the body uses dietary fat to make tissue and hormones, and to provide a protective layer over vital organs. but in fact, it's these fatty acids that run the heart and other vital organs in the body, just a major food substrate, glucose being another food substrate. so they're a very vital part of our bodies and very important in function. but, in high levels, and probably certain types, can also be dangerous to the arterial wall. whether a fat or oil is considered dangerous or healthy depends on the type of fatty acid involved. is it largely polyunsaturated, monounsaturated, or saturated? when you're cooking, in general, choose monounsaturates and polyunsaturates. peanut oil, olive oil, canola oils are all excellent choices. butter tends to be more saturated. they are solid fats. beef fat, pork fat, chicken fat, lard-- they're all solid fats. linda gigliotti: the saturated fatty acids have a higher link to cardiovascular disease and probably cancer. there is increasing evidence that there's a value to having monounsaturated fatty acids up to about 10%-- about 10% of our total calorie intake from monounsaturated fats. so a balanced diet needs to provide all three of those nutrients in a healthful proportion. generally speaking, because fat is associated with cardiovascular disease and cancer, we recommend keeping the total amount of calories from fat less than 30% of the diet. protein is going to build those muscles and body cells, but you can do that if you get 12 to 15 or so percent of your calories from protein. so the balance of the calories are going to come from carbohydrate, and that generally puts us in the range of 50 to 60% of total calories coming from carbohydrate. now, if we're working with a diabetic, we may want to keep the percentage of calories from carbohydrate closer to that 50 to 55% but other people are going to do just fine with 60%. if absolutely necessary, we could live weeks without eating anything. our bodies would get nutrients by digesting its own muscle and fat. however, if we were to go without water, we would die within days. the human body is made up of 50 to 70% water, which makes bodily processes such as digestion and regulation of body temperature possible. joanne ikeda: people can die very quickly after becoming dehydrated. so it's really important to drink six to eight glasses of fluid a day. now, one can take that in as fruit juice, as low fat milk products, those kinds of things. as you buy fruit juices or processed foods, my rule of thumb is, when a new product comes into the market, look at the list of ingredients. if you can recognize 10 of those words, then you are ready to take that first sip. for any new beverage, look at all the chemicals that go into some of the processed foods. do they really belong in your body? can you live without them or can you do moderation? the body also needs vitamins and minerals to function. vitamins occur naturally in all living things- cows, carrots, trees and humans. each vitamin and mineral plays a key role in keeping the body functioning. joanne ikeda: well, i always think particularly of calcium and iron because those are the ones that we're commonly concerned about in this day and age. calcium, because of the high incidence of osteoporosis. women don't realize that they achieve peak bone density by their mid-twenties, and if they don't get enough calcium, they are going to end up with weak bones that will become even weaker over time. iron is very important because it is critical to carrying oxygen to every cell in the body. that's why when we don't get enough iron, we feel tired and lethargic. it's because our cells aren't receiving the oxygen that they need. the question is, how much of any one nutrient is enough? many countries have established dietary guidelines-- recommended dietary allowances, to help people answer this question. joanne ikeda: the very first guideline is eat a variety of foods because, again, nutrition scientists know that in order to get those 50 nutrients that are needed for human growth, health and well-being, you need to eat a wide variety. priya venkatesan: in 2005, the united states department of agriculture launched the dietary guidelines for americans. because dynamics have changed. people are eating differently, we're shopping differently, our lifestyles have changed too. no one has any time for exercise anymore, without pang attention to the quality and the quantity of foods we cannot ensure that we have longevity. so to prevent disease and to maintain health, we have to keep up with what the new standards are and change them. because people are different, their nutritional needs are also different. priya venkatesan: there's no one size that fits all. we're all different. so it becomes necessary to make it more individual, personalize it, as though you have a personal consultant. all you have to do is to log on to www.mypyramid.gov, and it will take you to the main page. if you want to have introductory information about what is this "my pyramid," you can learn. the toolbars are very easy, very simple, and honesty is the rule here. you cannot go with your driver's license from about 15 years ago and say, "i am that height and that weight." you have to weigh yourself you have to measure yourself again, because this is about you, this is about your body. lying or cheating is only going to make you go backwards instead of forward. i would ask you for your age, or you would type it in yourself. you would enter your gender. you would enter your activity level. now, that's another area that a lot of people either exaggerate or underestimate. if i ask anybody, "do you exercise?" they will say "moderate." what is moderate? does moderate mean parking your car five steps from your door? or is it parking a mile and a half from your door? everything is defined. just sitting in front of a couch and moving from the couch to turn the tv on-- is that moderate? the new "my pyramid" says, you could be sedentary. you could be in the category where we will give you a slightly lower caloric allowance. if you're not planning to move, please don't give the body any more calories. that's only going to result in undue weight gain and over a period of time with diabetes and cancer or cardiovascular disease that you can completely prevent. it's going to give you an accurate amount of calories that you can use to plan your daily caloric needs. no single food group provides all the nutrients people need. priya venkatesan: one of the most common features between the food guide pyramid and "my pyramid" is they are recommending predominantly vegetable-based foods. wholesome grains, fiber-rich fruits and vegetables are still the norm. whether you talk about what we do today, or whether you think about what was probably the way that foods were eaten hundreds and even thousands of years ago, grains were always available. society after society is-- has been oriented towards an agrarian lifestyle, with hunting and gathering as kind of a hit and miss sort of thing. so meat-eating is episodic, but grains and fruits and vegetables are there all the time. the labels on processed foods also cater to the needs of heah-cocioucoums. each package or can list nutrition facts-- e calori a nrits ainein each ng seg of the proct. anyone trying to limit calories or fat, or maximize the intake of vitamins, minerals and fiber, can check the label to see just what they're getting. nancy anderson: i look at how many fat grams are in a serving, and try and figure out how that fits into the overall recommendation for a day's intake. the other thing i look at is how much saturated fat is in a product. saturated fat is very responsible for raising blood cholesterol levels, so that's something that a lot of people need to pay attention to. for many people, sodium is an important thing to look at. if they have high blood pressure or congestive heart failure or certain conditions that warrant a low sodium diet, we would look at sodium. and something that is often overlooked is fiber. i look at the fiber content because many times you can get a comparable product that has more fiber just by incorporating whole grains into it. with all of this information, and the wide range of nutritious foods available, why would anyone need to take dietary supplements... like multi-purpose vitamins? joanne ikeda: pills are not a substitute for good nutrition because many of the essential nutrients cannot be isated, synthesized and put into a pill. we can get 100% or more of the usrda, the recommended dietary allowance from a variety of foods, but are we taking in that variety of foods on a daily basis in order to provide the nutrients? and then other items like the calcium is a bit tougher to get. so supplements may be indicated for some individuals. joanne ikeda: certainly pregnant women who have increased nutrient needs. certainly to someone who is sick and is not able to consume the amount of food they need. in those cases, yes we do recommend supplements. in general, wide variety of fresh fruits and vegetables, either frozen or canned, staying away from the artificial processed foods will supplement and take care of your needs on a daily basis. but again, if you are in certain stages of life, if you're pregnant, if you have certain deficiencies, then we have to address them. at this point, there's no consensus. vegetarians may also need to exercise caution in terms of their nutrient intake, despite the healthy aspects of their diet. once one starts eliminating a lot of foods from the diet, and just restricting what one is consuming to a very narrow range of foods, then you're at greater and greater risk of not meeting your nutrient needs. vegetarians, there's a concern about protein, of course, because all of the essential amino acids are generally found in animal foods. and if you don't eat any animal foods, you have to make sure to combine plant foods in the correct way so that an amino acid that's low in one food is combined with another plant food where the amino acid is there in a plentiful amount. linda gigliotti: the non-meat sources of protein could come from beans, legumes, pinto beans, kidney beans, black beans, lentils, etc. tofu. some from seeds and nuts although those are higher fat sources of protein as well. also iron is another problem because meat is an excellent source of iron. when you eliminate lean meats from the diet, you're eliminating a very good source of iron. not that you can't be well nourished. you can as a vegetarian. it's just that people need to pay some attention. they need to choose foods more carefully. disease prevention through nutrition is a relatively new area of research that explores the link between certain foods and the nutrients in them and their ability to prevent or minimize a long list of medical conditions including heart disease, high blood pressure, and cancer. for example, researchers have found a correlation between foods which contain phytochemicals and antioxidants and the slowing of normal wear and tear of the body. joanne ikeda: phytochemicals and antioxidants reduce oxidation, oxidative damage to cellular tissue. and that's involved not only in the aging process but also in carcinogenesis where cells become weak. they, of course become-- they mutate, and you get cancer cells. these substances are found primarily in fruits and vegetables. linda gigliotti: a lot of the research lately has really supported the intake of vegetables and fruits. whether it's the cruciferous vegetables or certain ones that contain vitamin c or beta-carotene or fiber. in research trials with heart patients, results, thus far, are mixed. howard hodis: it's our belief that it's possible that once a disease process is established to the point that you already manifest the symptoms or had a heart attack or a stroke, that the antioxidants or the vitamins may be too late. can't use them as treatment. their role may be in preventing that from occurring. so early on, you want to start the antioxidants and see of you can reduce the amount of atherosclerosis or the amount of disease-- heart disease that develops. is a diet filled with antioxidants an anti-cancer diet? evidence is inconclusive. however, there is evidence that an antioxidant diet low in saturated fats can lower cholesterol levels and help prevent heart disease. in laboratory work and in animal work antioxidants such as vitamin e have been shown to perhaps slow the atherosclerotic process, the disease process and it's felt that that's done by inhibiting these oxidative changes to cholesterol. dietary manipulations ought to be aimed at the prevention of heart disease for a little while longer because we understand how that works. heart disease is a more common disease than cancer and it makes more sense to focus your diet there. probably when the dust settles, those diets are going to be the ones that turn out to lower cancer risks as well. they'll probably be pretty smart cancer diets but we just are way behind the cardiologists at figuring out the diet part of this whole thing. adapting and maintaining healthier eating habits is not always as easy as it sounds. it takes work and long-term commitment. so a physician says, "well, just stop eating that." well, you can't just stop eating that high fat food that you've been eating for 40 years. it takes time to adjust and find ways to moderate it, and/or dilute it or whatever needs to be done so you lose the urge to taste that food and you can then eat lower fat or other types of foods. going cold turkey never really works and one has to adapt and moderate slowly over time. people are hard on themselves. so i often like to point out, "well, how many years were you doing it another way? you've just given yourself six months practice. why are you beating up on yourself because you didn't do it right or perfectly this time?" howard hodis: i was brought up by european parents who ate meat and potatoes. liver was a big item every week for that iron. that was my taste for many years... high fat milks and cheeses and things like this. when we learned to ride a bicycle, or when we learned to tie shoes, or type on a keyboard, we made mistakes. so i think we have to allow ourselves to make mistakes as we are learning new food behaviors. and slowly over time using tricks, diluting the milk, for example, eventually going down to non-fat milk, i cannot even remember the taste of high fat, cream milks anymore, and if i was even exposed to it, i would be sickened by it. and so it's a matter of changing your tastes slowly over time. the local supermarket may be a place to begin... walkg down the aisles, making choices, with a nutritionist aching you each step of the way. linda gigliotti: so if i were walking down the aisle in the grocery store with you what i would look for would be, well, what are we putting in the grocery cart? are yogog to be able to get enough wholesome, fairly unprocessed simple foods to be the foundation of your diet? and then, how might you use some other food items? to start with, nutrient packed fruits and vegetables provide a nutritious foundation. linda gigliotti: now fresh would be great but you may tell me you don't have time to cook and prepare or cook those. so we could go over and look for some frozen items that were prepared without added fat, sauces or sugar in the case of frozen fruits. frozen or prpackag items are healthy, convenient sources of food that may help deter a quick stop at the fast food restaurant on the way home from work. ligiglioi: we would look at our grain products. ou walk cerl aisle or through the bakery department. we wouldook for the ount of fer that you're getting from that cereal or bread, not just the color of the bread product but how many grams of fiber on that label. i would want to make sure that the relative amount of fat in those items was probably less than about 30% of the total calories in those items. and then i would also ask you to buy a bag of frozen vegetables that you could mix in with that to increase the fiber and the overall nutrient content of what you were taking in. we would go along the back of the store where the dairy section frequently is weould make re that youere inin some low fat or non fat milk or yogurts to make sure you were getting some calcium. and we would look at the fat content in those particular foods. and finally, the shopping cart should contain low fat sources of protein such as turkey, chicken and seafood, or bns and other legumes another key to maintaining a healthy diet is by eating regularly and not skipping meals. marc shiffman: i constantly hear from people, "i don't have time to eat breakfast." you do have time. i have time. if i have time, you have time. you have to know how to have the right food available. whether it's a bowl of cereal, whether it's muffins that you can grab out of the refrigerator, whether it is taking time on a weekend to whip up a batch of things you can pop into the toaster, there are healthy choices that you can make that are better than mcdonald's or burger king or any of these other fast morning stops that are also more expensive. and the same with lunch. you can-- low fat yogurt or sandwiches with whole grain bread is always a much better start, coupled with a piece of fruit, than going out to any kind of a fast food place. it's cheaper. it's healthier. and again, with working people, i hear this same excuse all the time. "i don't have time. i don't have time." if you have a little time on the weekend, you sit down and make a salad, spend an extra 10 minutes and make enough salad for six portions. grill chicken on the weekend. don't grill one or two chicken breasts; grill 10 of them. once you start doing it for a short while, it becomes second nature. it'll save you money and you'll feel healthier. linda gigliotti: the point that helps a lot of people is "well what's doable in my daily routine that i can have readily available? how can i set up the environment in my work day to help me keep on target with what i really want to do versus being led astray-- the candy on the desk or the donuts and muffins being brought in, fast food meals being brought in or any kind of food being brought in for a luncheon meeting?" so my point is take control. set up your environment so that you have there the items that are going to help you stay on target. and that's the bottom line... in terms of food consumption or any other goal related to healthy living. take control and stay on target. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call... or visit us online at... annenberg media ♪ by: narrator: welcome todeinos: an introduction to spanish. destinos is a 52-episode spanish language telecourse. deme seis naranjas. it will introducyou to the richness and variety of the language and culture take you on a journey through the spanish-speaking world and intrigue you with the search for a missing person. rosario... perdóname... perdóname.
despite the fact that americans are more and more conscious about their weight, despite the fact that we have more and more so-called low fat foods and sugar substitutes, obesity is increasing constantly in the united states. i think it's fair to say we have an epidemic of obesity in the united states. today there are more than 100 million americans who are either overweight or obese. this is a disease and a condition which causes a whole host of important medical complications, so i think we have a very serious public health problem on our hands that we need to address as a nation. narrator: poor food choices, combined with increasingly sedentary lifestyles, are blamed for the dramatic increase in obesity over the last several decades. close to 35% of women and 31% of men over the age of 20 are now considered obese. ralph cygan: obesity is defined by excess body fat. a normal body fat for a male is somewhere in the 20% range. for a woman it's 25 to 30% range. unfortunately it's not easy to measure body fat. it's not something that could be done easily in a physician's office or at home, so over the last few decades another measure of body fat and obesity has been developed, and that's the bmi or body mass index. bmi is calculated by dividing a person's weight in pounds by their height in inches squared. the answer is then multiplied by 705. a bmi that is associated with good health is in the 19 to 25 range. to put these figures in perspective, supermodels run bmi's of about 16 or 17. sumo wrestlers, on the other hand, are in the 43 to 45 range. you are considered overweight if you have a bmi between 25 and 29; obese if it's 30 or above. all of the very serious causes of early morbidity and mortality are strongly associated with obesity. for example, cardiovascular disease, high blood pressure, high cholesterol, low good cholesterol or low hdl cholesterol, diabetes mellitus, very important risk factor for heart disease and very closely correlated with increasing degrees of obesity. obesity can damage a person's joints and affect their ability to move. the large, weight bearing joints in the lower extremities-- the hips, knees, ankles, etc. those joints have a much higher likelihood of developing severe and premature degeneration because of the extra stress associated with obesity. mary pat anderson: i have very bad knees, had knee surgery about 15 years ago, and found myself sitting in my classroom and sending students to get books and papers and so forth, and just hardly moving at all, which just continues the cycle of gaining. even if i wasn't eating as much as i used to, i wouldn't lose because i wasn't moving at all. obesit ao linked to certain types of cancer. older women have a higher risk of breast cancer if they're very heavy. they have a higher risk of endometrial cancer and their obesity may be, in some way, related to colon cancer, as well, and for men, to prostate cancer. why have so many people lost the battle to achieve and maintain a healthy weight? dean hamer: some people think that it's all a matter of metabolism, that some people have a slow metabolism and that makes them fat. well it turns out that the same genes that control metabolism also control appetite-- these are genes coding for hormones and receptors that are released in response to how much a person eats and how fat their cells are, in essence. it turns out the same hormones and receptors control how hungry you are. so when people eat a big meal, the hormone is produced. the hormone tells the body, "burn off the fat and use it as fuel," and it also tells the brain, "you're full, stop eating." if a person has a problem or different variety of these hormone and receptor genes, then their body doesn't burn off the fat so well and they want to continue eating. so often people will say, "well, he has a metabolic problem, but she doesn't have enough willpower." actually both of those are at least, in part, affected by a person's genes. one theory is that these genes are leftover survival mechanisms from thousands of years ago, when humans lived from one meal to the next-- or one feast to the next famine. joanne ikeda, r.d.: if, when they found a lot, they ate a lot and deposited fat in the body, then when the lean times came, when thereere times of famine, there was a survival advantage for those people who deposited fat. they were the ones who got through the famine and survived. now we come into a modern age where we don't have to go out and hunt. we don't have to go out and fish. we don't go out and plow the fields and harvest food. we have now created an environment so that this predisposion towards depositing fat in the body is no longer an advantage. it's a disadvantage. genes also play a role in how fat is distributed. the riskiest fat distribution is the male or android or apple shaped distribution where most of the fat is in the intra-abdominal cavity. there are many more metabolic consequences and many more medical problems associated with that fat distribution-- for example, high blood pressure, high cholesterol, diabetes mellitus. now that's opposed to the gynoid or female distribution, or pear distribution, where the excess weight is in the hips and the buttocks. now, for some reason, that obesity is much less likely toto contribute to the metaboc and health consequences. obesity is no longer confined to those who are middle aged or older. increasingly, the patterns associated with obesity are found in the very young. barbara korsch: many people believe a fat baby's a healthy baby, but from a health point of view, more obese babies go on to be fat adults. stopping the progression of obesity in childhood can be a challenge, as dr. korsch and a team of specialists learned. and we had a really hard time getting good results, as has everybody. and one trouble was, the nutritionist would earnestly say, "don't eat between meals," and all that. a lot of those families didn't even have meals. they don't sit down together either at breakfast or lunch or dinner and eat a meal with the children involved, so that it's gotten quite chaotic, and whatever is quick and available and tastes good. and the media, dr. korsch contends, just compound the problem. barbara korsch: television watching is the single thing that has been consistently associated with obesity. and there have even been some really interesting studies that if a child is just just watching television, where they tend to sit very passively, usually also snacking, that their metabolism actually goes down. it's a little bit like hibernation. in recent years, the health risks of obesity and the cultural obsession with slimness, have developed into a $33 billion industry. weight loss pills, fad diets, and dietary supplements promise miraculous results. joanne ikeda: there's nothing over-the-counter that you can buy that is going to melt the fat off your body. yet, day in and day out, you open women's magazines, you open newspapers, you go to the shopping mall, and they're selling products that claim to do this. i recently went to the supermarket, picked up a couple of popular magazines and a couple of supermarket tabloids, just to see what was being advertised. some of my favorites were the "new fat fighters-- slimming capsules that soak up fat." another diet guaranteed weight loss without diet or exercise, astounding to me. several others tout the ability to lose 30 pounds in one month, or your money back. another one says you can make money while you do this if you sell this product to your neighbor. many of these miracle products are either useless or produce only temporary results. some are even dangerous. joanne ikeda: all of the magic potions have had side effects. we look at the fiasco with respect to the phen-fen combination-- the fenfluramine-phentermine-- that was so popular and ended up being withdrawn because it caused heart valve damage in women. ralph cygan: there are a number of stimulants on the market: ephedra, which is an epinephrine or sympathamimetic drug which is a strong metabolic stimulant that will probably suppress appetite for a few days or a few weeks, but longterm, can be extremely dangerous, and taken in doses higher than is recommended, can also cause potential cardiovascular problems, arrhythmias, chest pains, high blood pressure, etc. fad diets that limit or promote excessive intake of certain nutrients can also be dangerous. take high-protein diets, for example. protein is used, initially, in the body to maintain muscle mass, to build cells, antibodies, hormones, etc. generally, that need for protein will be met if we take in 12 to no more than 20% of our calories from protein. any additional protein that we take in will be broken down and burned for calories. however, protein is a rather inefficient source of calories in the body because it first has to be metabolized through the liver, some components of the protein structure removed. those components of the protein structure then are waste products, and they're excreted through the kidneys. so, if a person is taking in a very high level of protein, and protein is contributing significantly to the calorie level for that person, we then are taxing the liver and we're taxing the kidneys. an individual may not be aware of having any kind of liver or kidney problem, but may be pushed over the edge because they're not being medically supervised. ralph cygan: the biggest consequence of diets like this is that it perpetuate the yo-yo cycle of dieting. many of these diets, the patients will lose a few pounds-- they'll lose some water weight perhaps, but then quickly, they'll become very frustrated because there's nothing fundamentally different about their eating behavior, their exercise behavior. it may be that this dieting may be contributing to increased obesity, because in my work, for example, a study i did with african-american women, three generations-- look at the number of times these women have dieted and regained weight. and the more often they have dieted and regained, the higher their weight is. penny weismuller: i would lose weight, but i couldn't learn how to keep it off. and i would gain more weight, and i just got into that cycle that you read about you know somebody loses 10 pounds, they gain 20. they lose 20 pounds, they gain 30. so by the time i was 29, i was... i'm going to say 60 to 65 pounds overweight. mary pat anderson: i was in "tops." it's called "take off pounds sensibly," and there's no specific diet. it's just a group of people that get together for support. that worked very well for a while. i tried nutrisystem twice and lost a considerable amount of weight both times, but was never able to keep it off. it's very difficult, and i think the more that people yo-yo the more desperate they become for something that's a magic pill or a magic bullet. so it's very difficult psychologically to convince them that there is nothing like that, that it is slow, sustained behavior change that works best. good morning, uci weight management program. may i help you? that is the goal of the uc irvine weight management program: encouraging and supporting behavior changes that will result in sustained weight loss. wonderful... well, we have a couple of program options. do you have an idea about how much weight you're interested in losing? linda gigliotti: when people inquire about our program, we invite them to come in for an information session where we can have an opportunity to explore a little bit of their goals and history in terms of weight loss, and management of that loss, but also so we can explore program options. there's not one strategy that works for everybody in terms of losing weight. now, you've tried losing weight before? i have, but it's been kind of a roller coaster for me. okay, so we want to stop the roller coaster then. ralph cygan: when patients come to you for weight loss, many have a shortterm orientation. they want to go on a program and then resume their prior lifestyle. clearly you're not doing these patients a favor if you don't try to disavow them of this short-term mentality. obesity, i think, needs to be looked at as a chronic, lifelong condition, and i think we have treatments that can be used effectively, but they need to be applied for the longterm. there are no quick fixes for obesity. penny weismuller: i called and i spoke to linda on the phone and made an appointment, came in to talk to her. i was really interested in how well people could maintain a weight loss, because i didn't want to... i didn't want to lose weight and not keep it off. linda gigliotti: when a patient comes in, we will ask them, "well, what do you see your goal weight being? what goal do you have in mind?" because we need to know where that person is coming from. ralph cygan: many patients come to a weight loss program with extremely unrealistic ideas about what their goal weight should be. i think they're either motivated by what they see on fashion magazines, or perhaps think about the old height/weight tables they're used to seeing from insurance companies, and have really unrealistic goals. i was having pain in my heel, and i was feeling pretty desperate. i was thinking about having the weight loss surgery, but i was afraid of complications. so i thought i would call here as one last chance. i only wanted to lose 20 pounds. i wanted to fix the heel pain. if i could just keep that 20 pounds off, that's all i wanted to do. weight loss programs are individualized, depending on the severity of the problem. linda gigliotti: if an individual has 10 pounds to lose, it's not appropriate to use a very, very intensive approach as a quick fix. so in that case, the patient would be guided into a more moderate, reduced calorie food plan, allowing for gradual weight loss in the range of one to maybe two pounds per week. come on back let's get your height and weight. but when people are suffering from health problems as a result of their obesity, and need to lose weight quickly, a medically supervised fast that includes proper nutritional supplements can be an effective way to begin the process. linda gigliotti: the calorie intake on that regimen is going to be somewhere between usually 500 to 1000 calories per day, coming exclusively from a liquid nutritional supplement as their sole source of intake. penny weismuller: once you start on the fast, hunger's primarily not an issue if you're using the protein supplement fairly regularly, throughout the day. linda gigliotti: i do have to emphasize that it's not a magic potion. it's a way to get the ball rolling, a way, perhaps, for that patient to reduce rather urgent medical problems, to be able to increase their physical activity so they can begin to burn more calories, in terms of calorie output, and then move eventually into the maintenance phase of the program. it is in the maintance phase that the patient begins to build new and healthy eating habits. linda gigliotti: in maintenance, we emphasize using fruits and vegetables as the bottom of their food guide pyramid, if you will, consuming an absolute minimum of five servings of fruits and vegetables a day. we put a very strong emphasis on the fruit and vegetablintake because they are low calorie density, high water containing, but a lot of other nutrients in terms of vitamins and minerals coming from the fruits and vegetables. i knew that maybe maintaining was going to be a whole heck of a lot harder. we spent a lot of time talking about just how many calories' difference you have to change in your lifestyle and, for me, to maintain a 100 pound loss, it's you know a 1,000 calories a day difference, either eating less or exercising more, and that's a lot of change. changing food habits and being consistent requires planning and preparation. the key is to make healthy eating a priority... at home, at the office, even at a restaurant. i think you have to be your own sleuth and ask questions. don't just assume that even if it has a heart by it, or some kind of emblem, that it's going to be healthy, or as healthy as you might think it's going to be. do you know what you'd like? the yellowfin tuna-- how is that prepared? linda gigliotti: i like to view the menu as a list of suggestions, not a list of dictates. the menu tells me what they have in the kitchen. now how can i creatively ask for something if i don't see it presented on the menu? mary pat anderson: the other thing that you really need to pay attention to is portion size. most restaurants give you very, very large portions and because we're paying for it, we feel entitled, and that we have to eat it all. so, if you could take some of it home with you or share it with another person, that would be better. changing the way you eat is the first step in losing weight. the second step is changing the way you move. linda gigliotti: i think it's really important to emphasize that small changes make a difference. let's take physical activity, for example. we don't need to come up with a whole lot of rules about going after a certain length of time, or even being at a heart rate level for it to count. just moving will make a difference. so even without the exercise at first, just on the fast and with the support of the doctors and the health educators here, i lost very consistently four pounds a week. and it just sort of rolled off, and then i started to get brave and attempt exercise. penny weismuller: because of the heel pain early on, i needed to look for a low impact thing to do, and i got an air glider, and i would do 10 minutes a day on the air glider. ten minutes equaled like 75 calories of physical activity, and that was just one more thing to help build it up. the bottom line for weight management is calories in versus calories out. of course, we need to consider one's nutritional intake. i could consume my maintenance calories in ice cream or chocolate, but that doesn't mean that even though i could, theoretically, maintain my weight, it doesn't mean that's going to be the healthiest way to do it. but there is room, in a day's intake, in a week's intake, in a month's intake, for most any food as long as the calories net out it's hard when you swim laps in a pool to figure out how much exercise you're actually doing. how many calories you're burning. so one night when nobody was around, i took my yardstick to the pool and actually measured the length of the pool, figured out how many fractions of a mile i was swimming, and actually worked out a program where i swam a half a mile a night. and that's what helped me develop the exercise. maintaing weight, in the lonrun, a constant series of tradeoffs. gigliotti: if i'm going to have this muffin, which is about 600 calories, then i have to say, "well, that's in my case, about 40% of my day's maintenance budget." if it's worth it to me, one choice might be, "okay, i can walk six miles because that would burn off the equivalent," or "i'm going to adjust my food intake at other times of the day to accommodate for the calories with this muffin." but it's not forbidden, and i think that freedom allows me to decide whether or not i choose. when weight loss attempts continue to fail, and health problems continue to mount, extreme measures are sometimes initiated. one such measure is gastric bypass surgery-- a procedure which diverts food from the stomach directly to the small intestine. ralph cygan: now, you have to be very careful about which patients you would refer for such a procedure. usually these patients need to be so-called "morbidly obese," which means their bmi is over 40, which is at least 100 pounds overweight. these patients have to have other complications associated with obesity, so many of them would have cardiovascular disease or other complications. and these patients would also have tried and failed usually several attempts at more conventional types of weight loss. some success is also being achieved with pharmacologic approaches, prescribed and monitored by a physician. one such product works by regulating neurotransmitters. namely noradrenaline and serotonin, which are both neurotransmitters which affect appetite. and by increasing the level of these neurotransmitters in the brain, the appetite can be effectively suppressed. patients on this program have been able to lose about five to 10% of their total body weight, and maintain it. ralph cygan: we know now that losing modest amounts of weight-- for most patients, about 10% of total body weight-- can have a profoundly positive effect on health risks of obesity. so from the medical perspective, modest weight loss and maintenance is really the goal that we try to get our patients in tune with. by studying people who have lost weight, and maintained that loss for five years or more, researchers are beginning to document factors that promote success. ralph cygan: we've learned a couple of, i think, very good lessons from this study. first and foremost, the patients accept responsibility. they don't blame anybody else. it's their job and their responsibility to get their weight off and keep it off, and they work hard at it. most of the patients eat a very low fat diet. the majority of pients exercise, and they aim f 2000 to 3000 calories of exercise per week. in addition to that, they monitor their weight carefully. they usually weigh at least weekly, and they're able to catch small slips. and last, but not least, they have a social support network that allows them to succeed. if you're in an environment that's toxic-- that's always tempting you, that's putting food in front of you, that doesn't support your longterm weight loss goals, you're going to fail. penny weismuller: i still eat candy, and i have dessert once in a while. but primarily, i look at the stuff and i say, "you know, i like the energy and the clear thinking that healthy food choice allows." it's still my mantra. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: narrator: people who exercise regularly have a 43% lower risk of premature death compared to those who are sedentary. are you physically fit? can your body respond to the demands that are placed on it? technology has made life easier, but it has also made us less active. nearly 1/4 of american adults are sedentary. another 1/3 aren't physically active enough to be considered fit. "physically fit" is being able to do whatever you want to do without restriction, either with your body or with endurance. to reach that level of fitness, we need more than just a walk from the parking lot to the mall. we need exercise. thomas mirich: the need for regular exercise transcends not just the need to be able to participate in sports activities, but it really covers the whole gamut from youth 'til 80s, 90-year age group. it's been shown that people that participate in a regular exercise program, meaning at least three or four days a week, have better health overall, whether it's better heart condition, lung condition, lower risk of osteoporosis, they have better balance. so that when you are 75 and 80 years old, your bones are stronger, your balance is better. so you're not falling and breaking your hip or breaking your wrist, and your function is overall better. study after study confirms that exercise is vital to good health. it contributes to cardiovascular fitness as well as the control of excess body fat. it may even play a role in reducing the risk of certain cancers. leslie bernstein: exercise definitely reduces your risk of colon cancer. we see it in studies of men. we see it in studies of women. i've spent a lot of time studying exercise and breast cancer and in the studies that i have conducted, we have shown that women who exercise substantially over their lifetimes have a lower risk of breast cancer. not everybody believes this yet. the results of all the studies aren't consistent. but i still firmly believe that, you know, exercise has the potential to reduce breast cancer risk. and then, of course, exercise is healthy for a whole slew of other diseases. loren lipson: it gives you a sense of well-being. people who have various psychologic illness find that exercise actually gives them endorphins and they feel good. exercise and fitness have a number of different components. leading the list is aerobics. kerry syed: and that is to do three to five times per week, 20 to 60 minutes of continued using-large-muscle-group exercise. so it's a big exercise-- running, walking, biking. but there are other kinds of exercise which also contribute to physical fitness. syed: there's a muscular strength component and a muscular endurance component. how much weight can you lift in one time is your strength. how much of a percentage of that weight you can lift several times is your endurance-- how many sit-ups can i do? and the last component, always forgotten, is the flexibility. every joint and muscle in the body has an intended range of motion. flexible joints perform a variety of movements-- bending, rotating, twisting. as we get older, muscles tend to tighten, especially in the backs of the legs, the lower back and the shoulders. our range of motion decreases, and we develop aches and pains that weren't there before. i think you have to take a look at what body parts aren't moving very much during the day, and then you can assume from that, those are the ones that are gonna be tight, and you need to do some things to maintain your flexibility. if you're not actively doing something to maintain or improve your flexibility, then you're probably going to be tightening up. syed: and what happens is, as we age, that's one of those things that goes downhill real fast, among so many others... but that we don't want to end up as this stooped-over, old person. most of the time, it's not osteoporosis, it's the lack of flexibility and the ability to stretch yourself into the position of upright. so i really encourage stretching, you know, like two to three times a week, when you get up, sometime during the day, that you take time to do eight to 12 stretches. the technique that is recommended is "static stretching--" increasing the flexibility of the muscles that control the joints by stretching them gently, then holding the position for 10 to 20 seconds. olsen: a lot of people just go to where they feel a little pain and then they let off the tension. and in order to increase flexibility, you have to hold that stretch for a long enough time to allow the fibers to assume a new length, so that takes longer than most people realize. five second stretch is not going to... you're not going to gain any range of motion through that. most fitness experts caution against stretching with bouncing movements, or trying to stretch a joint beyond its natural range of motion. olsen: there are things that you can do to maintain your flexibility and there's things that you can do to improve your flexibility, no matter how tight you are. there is hope. things can change. rigor mortis only starts after you're dead. my right arm's stronger from carrying my briefcase. it's also never too late to improve muscular strength, that aspect of fitness that helps us get through daily tivities more easily. strong muscles prevent jot and mule injuries, improve posture, and even contribute to weight loss. mirich: what happens is, when we build up our muscle mass, we've exchanged weight in terms of fat for good weight, which is muscle mass. now that muscle mass is lean mass. there is more muscle-- it's like having a bigger car engine... it burns more gas. so, now we burn weight more efficiently, so it further helps with weight reduction. lastly, that weight training adds a balance factor, or a proprioception factor, that improves people's quickness, agility and balance to the equation, all of which are extremely beneficial at lowering injury potential. if you were talking about lifting weights, we'd have to have a goal in mind. if the goal is just to stay toned, then, you know, we would probably use lighter weights and do a lot more repetitions. if your goal is to be an arnold schwarzenegger lookalike, then you're going to have to use heavier weights. strength training also builds muscular endurance, the ability to contract a muscle repeatedly. it's muscular endurance that keeps our arms and legs moving during aerobic exercise. aerobic exercise, in turn, builds cardiovascular endurance. mirich: it's been well documented that we need to perform an aerobic activity to get our heart rate to our appropriate target value for at least 30 minutes, and ideally on a daily basis, at a minimum of three to four days a week. and the simplest of that is pure walking. the reason for that is that it has a very low injury risk and a high benefit risk in both cardiovascular, bone, osteoporosis, weight reduction, lower risk of diabetes because you're not overweight and obese. other activities such as bicycling and swimming or aqua aerobics or water exercise programs, when performed appropriately, have the same low impact aerobic types of benefit. what we're looking at is aerobic exercise, so moving arms and legs, all four limbs together. and it's important that, you know, taking the dog out is good, but you need that 30 minutes of concerted exercise where you're trying to keep your heart rate up and steady. syed: the thing that i believe is to do at least three times a week up to sen, for at least 20 minutes up to an hour. i mean, past an hour, you're not gonna do anything good, and really at 45 minutes, personally, i'm pooping out. i'm saying, "i have done this way too long." i'm tired. i'm bored. i've been on a machine if i've been in the gym. now, if you're outside and you're doing something you love, you might be able to do it for over an hour. it's something that is individual for each person, but what you're committed to is really gonna make the difference. hodis: especially if you're a patient who has heart disease, but of course, any patient, any individual, the heart's a muscle. the stronger that muscle is... if it becomes damaged or further damaged, you're going to do much better, clinically, than you would if you just had a floppy, sick heart. so you want to keep muscle tone, not just in your arms and legs but your heart also. the heart of a physically fit person is more efficient. each minute, it can pump the same amount of blood with fewer heartbeats than the heart of an unfit person. a person in good shape may have a heart that actually lasts longer. olsen: i think the trick is trying to find the right cardiovascular exercise for you and for your body. we naturally assume that all of our bodies are built the same way and are structured the same way, but in fact, even though we might have the same parts, how they're put together is so much different. and so running might be a great activity for one person and it could be a source of multiple injuries for another person. choosing the wrong exercise, or going overboard with it, can cause problems, no matter how good our intentions. mirich: the biggest causes or reasons for people coming in and seeing me can be summarized in, i guess, a phrase used by our runners-- "too far, too fast, too soon," meaning people have gone out and done too much when they weren't ready for it. and that can apply to all age groups. in america, we're very impatient. we don't want to spend the time to achieve that goal. people go into the gym and they may see a person who's... has an excellent body, huge biceps, curling 300 pounds weight, and they say, "well, boy, this skinny guy like me can do that." they stack on those weights. they try to do that. they lift incorrectly. it's too much weight and then they injure themselves. it can be things like running. "well, boy, i can go out and run five miles." well, if i tried to do that today i would probably be in here seeing my therapist tomorrow. we have to realize that, as we age, our bodies are always changing. and sometimes our minds can feel as young and vigorous as we were when we were teenagers, so we tend to think that our bodies are the same. our bones are changing and our joints are changing, and so if we haven't been consistent with a flexibility program or a strengthening program, anand we'ot dng in't on regular basis,ent it's highly likely that somhing has changed over the years and/or over the months. and when you go to do an exercise or an activity suddenly, you know, you might find out the hard way that something has happened, and usually that's through pain. before you just wake up saturday morning and say, "boy, i'm not fit. i'm gonna start exercising," you know, you want to see your doctor, especially if you're middle-aged or beyond. make sure your heart and lungs are in good condition. maybe see a physical therapist or a personal trainer to be put on an appropriate training program, both in terms of stretching, flexibility, aerobic and weight-lifting capacities. those who are in good physical shape still need to be careful to avoid doing too much of a good thing. mirich: the problem that we run into is where, again, if 30 mites is good or jogging three miles is good, well, running a 10k race is even better. what happens is with that increased time and intensitof participation, that's when we starseeing more of the overuse injuries coming in. our swimmers are all rotator cuff, the back part of the shoulder kind of stuff, and that has to do with a lot of... they're extending their times right now. the baseball... same thing, shoulder stuff. whereas when we go on to football season, it's knees d shoulders again. during the winter, which is amazing, we see a ton of girl soccer players with bad knees-- intercruciate ligaments-- which isn't good. this'll help to work on the edema, the swelling... i play soccer, and i injured it in practice one day. i was just running, and then, all of a sudden, my knee just gave out. give yourself a good effort, laura. kick, pull... so i tore my anterior crucial ligament, which is really popular in females, and then they told me that i'd be okay if i strengthened my muscles and gave me a big brace to wear. and then they decided i needed surgery. mirich: in the last 20 years, the biggest advancement has been the use of arthroscopy, which is small incision surgery, or minimally invasive surgery. and what that's allowed us to do is treat the injured athlete through a small incision with a more rapid return to activities. and that's one of the goals of treatment in sports medicine, is to return the athlete to their activity as safely and as quickly as possible. we're teaching the kids that it's an athletic event, but it's also a lifetime sport. we want them to be able to last, and the lasting thing is that they're going to know how to take care of themselves. but not all injuries are related to sports. "overdoing" can apply to daily activities, as well. olsen: well, we see a lot of low back injuries, and that comes from either home or work injuries. people getting out gardening for the first time in the spring and they... we all tend to want to finish the job that we start, and so if that particular job requires you to be in a bent-over position for a long period of time, certainly that will have an effect on your low back. people who don't know how to lift properly where they... constantly bending and twisting and doing that at a bad angle will produce those types of injuries. so, moderation, if i had one word of advice, is really the important key. appropriate regimented type of exercise or training program is very important to prevent the excesses or to prevent from doing too little, and th being the couch potato and going out and participating on the weekend and not being physically fit to participate in that activity. the risk of injury during any activity can be lowered by warming up and cooling down. olsen: you know, you can start out kind of slow if you're stiff, and i think a lot of people think that stretching muscles out before they begin their activity is a good way to do things but oftentimes if you're cold, muscles don't stretch very well. so if you really want them to elongate, it's better to increase the temperature of those muscles first. you can warm up anywhere from five to ten minutes, slowly walking, then you're going to do a brisk walk, into a jog. at that point, you can stretch. you can stretch then, or you can stretch afterwards. i prefer afterwards just because i'm so warm and i feel really loose and i can stretch better. it's been shown that if you don't warm up before the exercise and cool down after the exercise then you're putting undue stresses on your heart. so it is very important, say, after your aerobic exercise, to maybe do a cooldown where you're walking slowly or riding that bicycle just without resistance at the end for a little while just to allow your heart rate to settle down to a normal rate of speed. while on that walk or bike ride, parents often include their children. they need exercise just as much as adults, and childhood is the perfect time to key in on the enjoyment of healthy physical activity. it's not hard to encourage small children-- they rarely sit still anyway. daniel cooper: the work that has been done in children and in other mammalian species, if left alone, almost, the younger members of the species are more physically active. they want to be. now, why they want to be, i don't know... whether it's endorphins released in the brain more readily, i don't know. it's a fascinating question. but they want to be in more physical activity. but as children get older, their involvement in physical activity tends to change. cooper: in almost every sector of this society, parents don't do what they perhaps did in my generation, which was say to a child, "go and play," and then, "i'll see you at such and such an hour." so we now have an environment which, for physical activity, which is a natural phenomenon in children, being much, much, much more controlled by parents, and this raises a lot of issues. parents want their children, instinctively, to be physically active so we have, certainly in the suburban and certain urban areas, this explosion of interest in organized sports at very young ages, like soccer. michael bryant: i think those things build esprit de corps, build a sense of teamwork, teach kids how to share, how to work together to achieve a common goal. but one of the things you really must do, even for those little, very, very flexible bodies, is make sure you warm them up adequately. and even though those parents are well intentioned, there are a lot of those parents who are the coaches who don't have a lot of experience in what you need to do in order to prevent injuries in kids. and part of that is adequate warm-up, adequate stretching. even with those young bodies, you still need to do that in order to prevent them from injuring themselves. mirich: in dance and ballet, we have six and seven-year-old girls, nine-year-old girls who want to look like that professional 22-year-old ballerina. their muscles aren't ready, their ligaments aren't ready, and one of the worst training errors is to have them try to emulate that mature dancer when their bodies are not ready for it. they don't have the strength, they don't have the flexibility, they don't have the skeletal development to allow them to do that. olsen: because i have three daughters and they're involved in fast-pitch softball, i'm seeing at a very early age parents pushing kids to play all year round in order to get that scholarship down the road, and these are kids that are eight years old, you know. and by the time they get into their teenage years, they're having major surgeries on their shoulders. mirich: and a lot of that is misinformation from coaches who push too hard... okay, let's stay tough! we got a big game. - let's win it! let's go! - yeah! and pushing too hard can actually create permanent damage to ligaments and tendons and growth plates that can hamper or ruin a person's chances of participating up to expectations as a teenager or mature adult. cooper: you know, if you're just looking for the talented athlete you've got your one or two percent, or your five percent, but what about the rest of these kids? and one of the worries to me is that the emphasis on sport per se, can for many children, make physical activity almost a negative experience. they tried to go out for the team. the coach told them they weren't good enough. "that wasn't fun. i don't want to do this anymore." i'm working with children now, in yoga. i never thought that yoga could be for anybody else but adults and people that wanted to meditate. and yoga can be for kids. they want to act like... they want to look like an eagle. they want to look like a turtle. they want to look like a snake. they want to move like that. and if you put it in that kind of context for them, if you talk about it in the right way, kids are very receptive to being active little individuals because they got more energy than we could ever imagine having, as adults. we're gonna go straight up about halfway... about there, and then come down slowly. olsen: rather than having them do the same thing all year long, i think it's important to develop the muscles in different ways. strengthening muscle is very important, but resting is part of that strengthening process, as well. nutrition and all those things are important, but i think we forget the resting part and so i think the rest, and the cross-training-- doing something different, exercising the muscles indirectly, the same muscles, but doing them in a different way. come on! good job! come on, angie! while it is great to encourage an athlete, the real goal is to encourage children to have fun being active. a habit that starts at a young age is easier to maintain through the years. syed: we're a very inactive society and i do think that as role models now, you can be a role model now for those people in your life that you can exercise at any age, and being just healthy and active, i mean, is not just about rigorous exercise planned every day. it's about, "i took the stairs instead of the elevator." now, depending on what kind of commitment i have to my life, then i can make that decision and say, "you know, i really am committed to having a very physically fit life," and that's gonna help me in my future. and then you can really achieve that goal. the goal of being physally f is portan i rered in '74, and then i started walking up the mountain. exercise is extremely important, i cannot stress enough, for seniors. many of my seniors, the only exercise they get is coming to and from the clinic, and it's unfortunate. stacy: well, i'll be 90 in may. i'loly, and the views fr the top are wonderf. and to wch the s comup every rning something. so i just automatically wa up, get dressed and come out. seniors, in particular, need to pick an exercise program that matches their physical abilities. if you have someone who has coronary artery disease, you have them run the marathon, it'll be their last act. if you have someone who has arthritis of the hips, riding a bicycle may just not work. so you have to be very thoughtful in planning exercise that it's not too strenuous, that it's easy to remember, and it's healthy. and that's why walking fits in most of these categories. mirich: in the older population, the parts are starting to wear out. people are starting to get arthritis in their joints, in their back, in their neck... and they have a lot of sore areas. having that age group participate in a low impact aerobic exercise program has again been found to be very beneficial from a whole host of reasons-- cardiovascular fitness, osteoporosis prevention, balancd fall prevention, lessening injuries, plus the actual improvement in those functions lessens painn the joints. gen ogata: i'85 years o, and i bike about... on the average, abouten miles a day. ndays, i have a son-in-law... we have a son-in-law who is... he's only 40 years old, and he's got a lot more energy than i have. and so, on sundays, we go up to mt. rubideaux, but of course, he's way, way ahead of me. mirich: their body adjusts to that higher activity level, cardiovascular fitness, strength, flexibility, and then they'll find that, "boy, i have more energy. i am less stiff when i need to go out and mow the lawn or go shopping or to visit the grandkids. i'm sleeping better. i'm requiring less blood pressure medications. my diabetes is better controlled. i'm now able to get off my insulin and go on to an oral pill to control my diabetes." so the health benefits of a moderate exercise program is enormous even in the older population. olsen: they're very motivated. they're easier to work with, i think, in some respects because they've reached a point in their life where they know that things don't happen quickly all the time, and they're very disciplined, usually. the elements of becoming physically fit apply to all ages: develop an exercise program you like; make sure it fits your physical ability; perform it correctly, and remember that it takes time and discipline to achieve your goals. syed: you have to say, "what do i really want? do i want to be healthy and live a long life?" you can be thin, you can have muscles, you can be strong, but you have to commit to a lifestyle. ogata: i try to go everyday. it's such a habit that... if i don't go, i feel like something is amiss. been: it means everything to me. it's a release for me when i'm upset. it energizes me. it's where all my friends have come from. it's everything. it's, like, my life. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: [♪...] >> female announcer: some dreams are universal... dreams that inspire us. multiple sclerosis is a devastating disease that changes lives forever. the national ms society does more for people with ms than any organization in the world... but we can't do it alone. to get involved, visit us online at nationalmssociety.org or call 1-800-fight ms. this is why we're here... because nobody dreams of having multiple sclerosis. annenberg media ♪ by: narrator: welcome to episodio seis of destinos: an introduction to spanish. most of what you will hear and see in this episode will be familiar to you as raquel reviews her notes on what happened in sevilla. ¿ud. sabe dónde está la calle pureza? as before, you will not understand every word but your experience with previous episodes will help you understand raquel's review. as raquel reviews what has happened to her in sevilla you will notice that she is using past tenses.
health is not a single state of being. it is a combination of factors which, over time, shape and mold the life of a human being. we have various definitions of health which certainly, in modern times, we think of as not just the absence of disease but... a positive health atus, you know-- a well being and ability to be active and productive in one's life. in its simplest form, being healthy is feeling that there are few physical or emotional impediments to your doing the kinds of things with your life that you'd like to. it's not so much a biological state as it is a state of mind. there are many people who are suffering chronic illnesses who are supremely healthy because they are able to maintain their creativity, and their vivacity in the face of a condition that, to other people, just sends them for a loop. being healthy is, healthy first with the mind, having a sense of balance in life. also, i would say, health for me would be eating well, being able to exercise, and being able to be fully active in life. working is a part of health, i think, for many americans, and having a job that's productive and fulfilling is quite important in this perspective. the world health organization describes health as a state of social, physical, and economic well being. i mean, they take in everything, and they're quite right, that if you don't have economic strength and the necessary wherewithal, you'll probably not do well in the world. you'll probably suffer in various ways. i think certainly people that are the highest risk of poor health are those with poor resources, poor financial resources, poor educational resources, because they may not make good judgments or have access to health care when it's very essential, or when it's crucial in prevention of progression of an illness. david bennett: but for ny people in the world, their demands in terms of health are mu more modest. the people who face hunger, who face the threat of disease constantly, for them, survival is really health. to see the very quiet, subtle way in which communitiescan puly quite remarkable. if we have that very broad definition, then everything becomes health. if we look only at certain narrowly defined diseases, we miss somehow the whole interaction that makes up the human being. the whole interaction that makes up the health of a human being begins with a genetic map. dean hamer: dna is like a blueprint that determines not t only our physical bodie, but also, at least in part, our brains. and our brains, of course, are what control our behavior, and so, although it surprises some people, our genes also play a role in the way we think about things, the way we feel about things, and the things that we do. so we have 100,000 genes, and all of us have to have two copies of each gene, one from each parent. each time they're being transmitted from parent to offspring, the genes have to be copied. and the copying system isn't perfect, so little mistakes are made, or changes, and most of them are irrelevant. but over time, we have in the population for any given gene, variance. in fact, my dna, and your dna, and somebody else's dna is 99.9% the same. but there's about one base out of 1000 that's different. so michael jackson's dna might read "a," and michael jordan's dna might read "g," and michelangelo's dna might read "c," and so on and so forth. and surprisingly those very few differences, that one out of 1000, is enough to make all the differences in the way we look, blue eyes or green eyes, our skin color, our height, as well as in some of our behavioral traits. sometimes people are surprised that such a tiny bit of difference-- .1% can make such a big difference in who we are. but remember that our dna and chimpanzee dna is only 1% different, and obviously we're a lot different than chimps. genes are not all that matter in terms of human health. they offer possibilities and predictions, but not certainty. paul mchugh: genes are just dna. they aren't destiny. some aspect of our life experience, what we choose and what we do, how we form our character given our constitution, is what ultimately makes us the kinds of people we are. the idea that somehow or another we're destined because of genes to be a particular kind of person is not only not true in human life, but it's also, of course, not true in anything in life. the phenotype that's expressed in any organism is in part what their genetic nature is, but it's also a part of what kind of an environment and life they live-- the nurture they have. so you can be genetically susceptible, but never exposed. but i think there's a public perception that the environment-- i mean smog, pesticides, water pollution, hair spray, you name it-- that these things are important causes of disease, and the reality is, they're not. there are a few biggies. there's cigarette smoke; there's asbestos... which is pretty much a problem of the past. and then, it's a pretty short list. the rest of the causes of disease are-- if they're not infectious-- are inside us. but often, the conditions in which one les play a critical role in the ability to maintain good health, clearly, in most communities a level of development which has benefited many people, but left others behind. so one sees large slum areas of marginalized people, with people living under very poor conditions around the big cities. i saw it in china when i went there with my family in 1982. the farther away from beijing we went, the more "third world" china was. it looked like uganda, almost. you can find it in skid row in this city. i set up a free clinic in skid row with the los angeles catholic workers. we saw a lot of people coming in from mexico, recent immigrants with the children, who had some of the same disease problems. and their challenge is really to get the type of health care, preventive care, and treatment for illness that can be relatively difficult to get, and can be relatively expensive. peter clarke: and these people are caught in a vise-- where rising rents, the high cost of good food, the need for medications and health care for children or themselves-- these are crushing factors. and the first thing that gets sacrificed in that trio is good eating, because it's the thing that you can sort of get along without as long as you have enough calories. marc shiffman: the indigent population faces day to day challenges that are formidable, from the moment they wake up, until the moment they go to bed. and so what we-- you and i-- may take for granted in our day to day running errands and doing this and that, and getting here and there, and going to appointments, and meals and taking care of family, and whatever other responsibilities most of which we may consider mundane-- these are all the issues that impact adversely on their health, because they can't all be sorted out properly. and so in every way, shape and form, the lifestyle impacts adversely on their health. the effects of poverty on health appear to strike hardest at those who are at either end of the age continuum-- the very young and the very old. michael bryant: the concept of primary and preventative health care maintenance-- that is what we should be about, because if we can intervene early, then we are able to... to try and prevent some of the untoward effects that kids will realize as they grow older, as they become adults. you know, as we look to-- and there's been lots of rhetoric, political rhetoric, about universal healthcare, and who should get that... should that be extended to the entire population? i think a good place to start is with the children. my god, we should be trying to take care of our children. you know, the issues about adults are very complex, and, you know-- many adults-- the reasons they're unhealthy are because of things they do themselves or do to themselves. but kids are incredibly vulnerable, and i would think it would have to be a priority of ours to try and protect and ensure their health. marc shiffman: there are too many people out there... who are senior citizens-- fixed low income. medicare is their only insurance, and as they get older, as they get sicker, as they need more medications, they are having to make difficult choices. - hi. how are you doing today? - hello, mrs. phillips. - how are you? - it's good to see you. my social worker spends some time almost every day calling up drug companies, filling out forms to get special dispensations for medications. people break pills in half to stretch them, or they just go without because they've got a food bill, they've got an electrical bill, they've got a mortgage to pay, a rent-- whatever it is. they make choices. this happens more in senior citizens. the young, poor population, and this probably is more single mothers that we see, trying to raise children-- some working, some not working, also are faced with choices. and oftentimes because their lives are so hectic, raising the kids and perhaps working, whatever else they're doing, they do come in to see us late. the health of any nation is closely linked to the health of its people, the productivity of its workforce, the health of future generations-- its survival depends on it. most countries have ministers of health, or public health services whose challenge is to protect the health of society as a whole. looking at all of the factors that influence health in entire populations: a commitment to really put primacy on prevention rather than cure; a commitment to social justice, and to looking at all societal factors and environmental factors that influence health, behavioral factors, as well as factors relating to the healthcare system. in the united states, the concern we have about the public health system is that we have the adequate infrastructure and support for the government aspects of public health that protect us, keep our water supplies safe, that protect us against outbreaks of new infections or new diseases, that assure that we have the best policies to protect the public health at the state and local level as well as the federal level, that we pay enough attention to that infrastructure that we can protect ourselves as a society. but for public health officials, health is no longer just a local or national concern, it has global dimensions. james curran: well, you know, certainly during my lifetime, the world has shrunken. i guess it's the same size as it's always been, but the airplanes take us as well as microbes and organisms and animals rapidly between countries and between continents. this is not the "guns, germs, and steel" environment of-- represented in the book, but rather it's an environment where there's very rapid transmission of ideas, of concepts, and of risks. for example, if it's true that aids first arose somewhere in central africa, it would have been-- the world would have been a lot better off if that part of africa had had a better surveillance system and could have discovered this problem a year or more earlier than they did. that's just one example. this inter-relatedness of the world community was instrumental to the formation of the pan american health organization... even though the year was 1902. the intention was to provide a forum in which the countries could tell each other about what diseases were a problem, and agree on approaches that would allow for the control of the diseases-- these diseases-- without impeding trade. in those times, of course, was largely by ship. in 1948, the concept expanded with the formation of the world health organization, and six regional offices that included paho. some of its efforts are focused toward the eradication of single diseases like polio, using the salk d . david bennett: with these tools, particularly the oral vaccine which is very-- relatively easy to use, and very effective, we felt we could undertake eradication of polio from the americas, embarked upon that, and then by 1991, had seen the last case of wild polio virus in peru-- the last case for the entire americas. in 1988... i think as a result of some pressure from the americas, the world health assembly agreed that the world would take on the effort to eradicate polio. we still have polio in the indian subcontinent, in parts of the middle east, and across much of central and eastern africa, so the challenge is pretty big. we are making headway; the immunization levels are going up. national immunization days-- polio days are being held around the world. it is very, very important, particularly for people in the united states and other relatively wealthy countries to understand, that this is one small boat. and we may be in the more affluent part of the boat, but we're still in the same boat, and it's in our interest to help everybody understand their health and deal with their health problems, especially the infectious disease problems. how do public health experts measure the health of a group of people? the two statistics most often cited are life expectancy, and infant mortality. life expectancy is how long we think we're going to live. life span is how long we're actually able to live, and that's a species specific kind of thing. so, for humans, the maximum amount of time we can live is about 120 years. if you live a good smoke-free life, keep your normal weight, exercise, your chances of living longer and living healthier are so much greater now than they were for our counterparts 100 years ago. the average life expectancy of an american in 1900 was just over 40 years. now it's close to 80. this has been a tremendous public health achievement. and if you look, most of those years of gain that have occurred over this century haven't necessarily occurred because of very technologic medical advances. they've occurred because of very, very simple public health measures, whether it's sanitation, or whether it's refrigeration, or whether it's handwashing and the availability of soap, or whether it's vaccines, those are, by and large, what have driven the improvements in life expectancy over this century. and in particular, in the area of infectious diseases. we have to realize in 1900 that tuberculosis was the single leading cause of death in the unitedtates, and, at the close of this century, the total number of deaths from tuberculosis in this country are under 1500, probably closer to 1000 people a year. we have a really brilliant saying in geriatrics, which is, "the longer you live, the longer you live." and what that means is, as you age, your life expectancy actually increases. so if you've made it past childhood, you can expect to live to young adulthood, and if you make it past young adulthood, you can expect to live into old age. and as you live into old age, you can expect to live longer. if you're a healthy 85-year-old, you can easily expect to live another seven years. the gains in life expectancy that have been achieved in the industrialized world are only partially replicated in developing countries. certainly there have been major gains in latin america, major gains in china, but there are a lot of threats to the developing world-- threats of continued infectious disease, threats of aids, threats caused by the incursion of smoking in the developing world where smoking-related illnesses in the next few decades will become the leading cause of death in the world, and threats from overpopulation and the incursions upon the environment. most of the deaths that occur, occur in children under the age of 5 years. if you look at what the leading causes of infectious disease deaths are in developing countries, they're things like acute respiratory diseases, particularly pneumonia in children. measles is still a major killer. tuberculosis is clearly a major killer. malaria-- we have the vaccines, we have the antibiotics, we have the oral rehydration therapy. the problem is that we simply don't get these technologies to where they're needed. in looking at the two principal measures that are used to evaluate public health, how does the united states rank in comparison to other nations? the united states is in the bottom quartile, in the bottom 25% in most of these indicators compared to the other industrialized countries. and it's relative ranking over the last 30 years has declined, so we have gotten worse relative to the other countries. we're improving-- everybody's improving. we're just improving at a slower rate than these other countries. the difficulty is... that most of what we do... now, affects quality of life, not length of life, and we spend a lot of our money on that particular thing. if you have a patient with angina, with severe chest pain every time they take a couple of steps because of coronary disease, and you can put that person back on the street, so to speak, functioning normally and working, that doesn't show up in the statistics. most of the people who have an angioplasty have a kind of lesion in which repair of the abnormality does not extend life, but it relieves symptoms. and so with many of the things that we do, say for vision-- something as simple as cataracts, and the implantation of artificial lenses-- that's revolutionized the lives of older people who were virtually blind because of cataracts. what's that worth? that's worth a lot, and it doesn't extend life expectancy, or at least if it does, to a very minimum degree, so i think it's quite unfair to judge a system on the basis solely of length of life and infant mortality. those are reasonable criteria... but you have to weigh in quality of life in a major, major way. but other factors also seem to influence the statistical profile of health in the united states. life expectancy has gone up, but infant mortality doesn't come down. and part of that is due to the fact that people are living under circumstances that don't favor healthy pregnancies and healthy early childhood, and where they don't get the type of health care that they need because they can't afford it. and in rural communities, it's not available. gerard anderson: of the industrialized countries, we and mexico and turkey are the three countries that have large numbers of uninsured. and so you know th those people are in serious trouble when they get sick, and they are responsible not due to their own fault, but they are the cause for a lot of our higher infant mortality rates, our low life expectancy, and whatever. every person in america needs to have access to excellent health care and health services. and there are several barriers from that happening. some are financial, and some are system-wide, and these seem to be increasing rather than decreasing at a time when our nation has more wealth and more prosperity than ever. that's deeply disturbing. as a physician, i see... the system beginning to blame itself, and blame each other. today, the hmo's are the problem. tomorrow the government will be the problem. the next day, maybe it'll be the doctors, or it'll be the patients themselves for failing to interpret and navigate the system. this is a dangerous trend. the second thing is we have more discrepancy in high incomes and low incomes in the united states as compared to most of the other countries. they have a much better income support. peter clarke: every indicator... of mortality and morbidity, shows a straight line income function. the lower your income, the quicker your death, and the more serious the burdens you're carrying for chronic conditions. clearly, there are steps that governments can take to improve the health of their citizens. but even more immediate, and more controllable on a personal level, are those steps we can take for ourselves. the key understanding is that what i do affects my health at least as much, maybe more, than anything that can be done to me in a hospital, etc., and that i need to start taking care of my health right from a very young age, as soon as i can have that understanding. i think that is a key message, and there the challenge becomes, with young people, who tend to think they're immortal, etc., haven't had some of these life experiences, just to get them to understand that some of the decisions they're making-- young or not-- are key, and they're going to affect them for the rest of their lives. marc shiffman: our number one overriding societal impact on health is still drugs and substance abuse. illicit drugs, alcohol... are one and two. and obviously those spawn a violent culture, whether it's domestic abuse, whether it's street violence, but it all goes back to the substance abuse. there's no getting around that. that is, without a doubt, the single most important impact on what we see. i think when people think of behaviors, they think more along the lines of chronic diseases, whether it's exercise, or whether it's smoking, or whether it's alcohol, i think people readily recognize that there's a significant behavioral aspect to who the risk groups are for chronic diseases. i don't think that there's as great a perception that behavior also plays a very important role in infectious diseases, whether it's sexual behavior and its relationship to hiv, whether or not it's the foods you eat and how you cook them, whether it's behavior surrounding antibiotic seeking and taking antibiotics, or whether or not it's the types of activities and whether or not you want to use insect repellents when you decide to go out for a hike on a nice summer day. behaviors are critical to not only chronic diseases, but also to infectious diseases. to be healthy, people need to know about health. you need to be your own consumer. you need to read about health, and how to stay healthy. you need to learn about it, and then you need to abide by certain principles. don't smoke. absolutely don't smoke. maintain your ideal weight... get plenty of exercise... have a trusted healthcare provider who's knowledgeable, and know a lot yourself. ask questions. don't distrust the medical system, but be a consumer who is well informed. "the human condition" is a 26 part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: a group of french doctors working for the red cross sought permission to provide aid to the 100,000 refugees in biafra who were suffering from famine and disease. but because these refugees were on the "wrong" side of the government in a civil war, the red cross said "no." the doctors resigned their post and started what was to become "doctors without borders," an organization committed to serving all populations in need, regardless of politics or national borders. at the same time, a hemisphere and continent away, the people of venice, california were demanding health care for those who could not afford to pay for it. a group of concerned citizens, working with two local doctors, secured the loan of a dental office at night, and started a volunteer clinic. from these humble beginnings emerged the venice family clinic, the largt free clinic in the united states. this is the story of two organizations and the people they serve... in the name of health, and humanity. suraj achar had only recently opened his family practice when he left for six months to help somali refugees who were entering kenya near the border with somalia and ethiopia. suraj achar: when we landed our plane on the dirt field, you couldn't see anything green for tens of miles all around and, unfortunately, when i landed, i recognized theuffering the people were encountering there. the children were severely malnourished. i could see it from their faces and their bellies, and the animals were dying actually in front of me. some of the animals were laying on the ground suffering because they had nothing to eat, and no water. teams of volunteers from 45 nations serve with "doctors without borders," wherever and whenever the need arises. i was the only doctor in the team because we're a nutrition-based team. we had up to four nurses. we had logisticians who came from diverse backgrounds: we had a computer engineer from spain, a stockbroker who worked in the trading houses in toronto; a fireman from france; and everybody had jobs to do. and they were trained with "doctors without borders," or at least debriefed, before they came onto the mission and trained with people who were leaving the mission. the somalis did not instantly accept or trust the new team. suraj achar: to survive in the desert, with the wars, and the famines and the catastrophes that somali people have survived, makes them a little tough skinned. and it was difficult for us, the whole team-- not just myself-- to earn their respect and achieve their trust. fortunately we were there for such a long time, and we were doing such intensive work with them on a day to day basis-- especially with the children and the mothers who were most hit by severe malnutrition-- that they grew to trust us over time, and would bring us their most severe cases. the incidence of malnutrition, particularly among the children, was alarming. and with severe malnutrition, the mortality of this disease, depending on the variation of protein energy malnutrition that we see, can be as high as 30 to 50%. usually the children die from routine infections like diarrhea or pneumonia. in fact, pneumonia is the most common cause of death. children who are severely malnourished appear anorexic. they do not want to eat. they're often very depressed. their heads are low. they stop talking. they stop walking, and they're severely dehydrated and suffering from infectious diseases. perhaps the most extreme case of malnutrition the team witnessed was annis-- a tiny wisp of a girl, two and a half years old. annis is just skin and bones and a head. and i looked at her, and i looked at the weight, and i asked the mother how old she is and the mother told me. and i said, "it's not possible." so i took annis myself back to weigh. i saw the scale, it said 4.2 kilos, took annis off, measured her height, put her back on the scale. i still couldn't believe it. it was amazing to me that annis was still alive. the highest mortality for children so severely malnourished occurs in the first few days. if you overfeed these kids they will die from electrolyte changes in their body. so you have to be very careful. we immediately started her on a rehydration program as well as high energy milk and antibiotics for her infections. and as she started getting better, we started her on soya bean protein mix. and i would come by daily to check on annis' progress. what he discovered was that annis' mother was feeding her daughter's food to her other children, and even eating some of it herself. and the food was very basic. it included high energy protein shakes that were like milk, plus a soya bean porridge. and we used this, and it had a variety of nutrients in it-- full range of amino acids which are the building blocks for our proteins in our body. i would have to go and get more food to give to annis myself, and i would individually feed annis. and i asked mother why would she not give any food for annis. and mother said she had already given up on annis, that there was no chance that annis was going to survive and that her older children were very important to her and she wanted to help them as much as she could. and over time, in our program, annis' mother began to trust us. and as we were feeding annis, annis' mother would also feed annis. it was amazing when she would raise her head, and look up and smile eventually, and eventually even almost start trying to walk. i would carry her around on rounds, and to see her thrive and survive when her mother was so sure that she would never do so, was probably one of the more beautiful experiences that i had there. but as well as the program seemed to be progressing, the challenges were just beginning. about six weeks into my stay i was called to come to the intensive care feeding center where we keep our most critical cases... at 4:45 or 5:00 in the morning, very early. and we rushed over there in the dark in our four-wheel-drive car, we found in the tent where we keep our children with tuberculosis, was one of the mothers lying prostrate on the floor in a pool of diarrhea and vomitus. we assessed her quickly and found she had almost no pulse that we could palpate. we could barely detect a blood pressure, and she was almost comatose. she would barely respond to pain. we then immediately started her on iv fluids. within 15 minutes we'd given her seven liters of fluid to replace some of the losses, just some of the losses that she had encountered over the night when she had started her diarrhea. and we noted the water that was coming out-- the stool quality was very different than usual. it looks almost like rice and water mixed together. and we were astounded by this because we knew that this probably meant cholera. samples were sent to nairobi for analysis, and within a few days the diagnosis was confirmed. it was indeed cholera. at that point, the lives of the "doctors without borders" team and their mission, changed dramatically. iv bags of fluid, antibiotics, and chemicals to purify the water and prevent the spread of cholera were airlifted to the site. one of the most devastating problems with cholera is it can go quickly amongst patients who are immuno-suppressed, like our children with malnutrition, and it can cause high, high mortality in this population. so we quickly had to isolate the kids and adults who had cholera. we built a center with beds and iv bags hanging from the roof for the patients who were suffering that were adults. we removed the children with tuberculosis from our isolation tent, and put our children with cholera in this tent. then we built a chlorine bath all around. we burned all their clothes-- anything that potentially could have cholera, we burned it. we built a special latrine for their waste. and we tried to isolate them as much as possible while, at the same time, providing very intensive care for their dehydration, which is the critical problem in cholera. it's a disease that comes on within a few days of incubation, and may only last a few days. but within those three days, you can lose half your weight in diarrhea, and critically need support. iv fluids, oral rehydration fluids-- all of that plus the antibiotics that the cholera would be sensitive to. before the cholera outbreak, only a small percentage of the children with severe malnutrition died. once the cholera hit, that figure rose. it's very difficult to fight cholera. and these children would have as many as 50 episodes of diarrhea in a 12 hour period. losing so much water, it's ve hard to keep up. often times i would go to lunch and come back and a new child would just fall ill during the lunchtime with diarrhea, and would pass away within hours. children were brought to us and would just pass away within five minutes of arriving at our center. so we had some very rapid demises. and it was very difficult as a physician. for a while, my nurses, the local staff, were wondering, am i really a doctor?-- because we were having so many deaths. the epidemic lasted about a month, infecting between 500 and 1000 adults and children. others probably were asymptomatic and carried the bacteria as well. the total number of deaths in the children was probably in the teens. but still, for us, it was devastating to watch a child expire. the death of a child generated a whole new set of challenges. the somali people are moslem, and they're very particular about their ceremonies and their burial ceremonies. but unfortunately, the remains of the children were very infectious and we had to isolate them. so we came up with a compromise. we would clean the child after the child expired and then put them in a body bag. and we'd hand them to the families and they would bury them in the body bag which was somewhat of a protection for the community. at times, the situation was frustrating for dr. achar and his team, knowing that they really couldn't do everything they were trained to do. when the children became the most severely ill and we didn't have a way to manage them, to measure their electrolytes, to measure their fluid balance in their body most accurately, to culture their infectious diseases most accurately, to measure their blood count to see how anemic they were and to potentially get the medicines that weren't available, or diagnostic tests that weren't available, and then to watch these children- some of these children pass away... that's probably the most difficult experience for any physician from the west to work in-- the situation like we had in africa. but as the cholera epidemic waned, and attention once again focused on the malnutrition scourge they were sent to attack, the good they were doing came full circle. i remember doing an evaluation on two children-- one who was four, two girls, and one was six. coming from a town in ethiopia, very nearby, they would walk 10 to 15 kilometers every day with no shoes on through the desert. the temperature was about 110 to 120 in the shade during their walk. they would come, and they would get their nutrition in the morning, and then they would stay sitting outside in the sun for the feeding that would happen in the afternoon. and then they would go home and... on saturdays we would give them a packet of food for sunday. well, after evaluating them and finding out that they had no medical complications that would necessitate medical care, i was about to discharge them, and i asked them, "what is it like on sunday for you?" and these two girls said to me that their food is distributed amongst the family. and because the family doesn't eat during the week, the family eats the food that they bring home on sunday. but they were very happy coming on the other days where they would get the soybean porridge. and i asked the older child if i were to discharge them from our program, would there be a way for them to get food in ethiopia? and she looked at me and said, "probably not," through a translator-- that there was no option for them outside of our program. after hearing the story, of course i found some medical excuse to keep them in our program and continue them there. but being able to help children like that who have nowhere else to turn, was just a great privilege, just a beautiful experience. the health needs of people who live in venice, california may seem a far cry from the health needs of somali refugees. but there is a common denominator: people in need, without adequate resources to maintain their health. it's a few minutes before 9:00, and already, activity at the venice family clinic is in high gear. elizabeth benson forer: our mission is to provide comprehensive primary healthcare that's affordable, accessible and compassionate for people who have no other access to care. we truly are unique in that we're not seeking business with money attached. we're seeking people with no health insurance and low incomes. ana zeledón friendly: the majority of our patients are hispanic, and many of them monolingual, so all of our staff members are bilingual in english and spanish. and they're able to provide the services, also in a culturally sensitive manner. and we do have also a large immigrant population from russia. susan fleischman: most of them are older people in their 50s and 60s, but they seem older than that. they've come to this country mostly as economic refugees. most of them have almost no english skills, and they are very, very sick. they have terrible hypertension, lots and lots of heart disease and cardiovascular disease and terrible depression, as well. and they have a very difficult time assimilating to life here. the clinic also serves several thousand homeless people. ana zeledón friendly: we have a special program where our homeless are able to walk in on a daily basis, and we have slots available for them so we can see them right away. susan fleischman: i think most patients are nervous the first time they come here. they clearly don't know what to expect. i don't know how they've heard about us, maybe from a friend, from a family member. i think they're nervous about the quality of care. i think they're nervous language-wise... "will there be someone there who speaks and understands my language?" they're worried about whether we're going to call immigration. they're worried about whether coming here will affect their children's ability to become u.s. citizens, so there's a whole host of worries. elizabeth benson forer: we try to make it so that it's easy for them to get care. it's as simple as really writing down their name. it's a self-declaration. someone can say, "i'm jose, and this is how much i earn. i earn $14,000 a year," and that's it. some of our patients want to show us and want to provide proof. but, for the most part, they just have to sign a form with their name, and that's it. it's really wonderful to sort of watch them take a big breath and relax during the course of the visit because i think what they find as they're here is that we do meet their needs. they get the tests done that they need. they get the medications that they need. they can't believe they're not going to have to go to a pharmacy and somehow come up with $60 or $100. it's interesting that many people try to use the clinic as an urgent care center. we have had examples of a man who was having a heart attack who drove by many major hospitals and did not stop, and was coming to us because he knew that we knew him very well. he's been here with us for many years and that he trusts us, and that we could help him. and so what we're able to do is stabilize our patients if there's a case of emergency, and we call paramedics and then refer them to the hospitals for their care. last year, the clinic recorded more than 80,000 patient visits and filled more than 65,000 free prescriptions. no one paid a cent for the care they so badly needed. they frequently haven't had care in a long time. they've delayed going to the doctor. they've neglected themselves. they've put other things first like housing and feeding their children. and so they're quite sick, frequently, by the time we come here. and unfortunately that hasn't changed. we see a lot of people who are immigrants, and that has not really changed. and unfortunately we still see lots of people who are homeless. i think all that's really happened is that the numbers of people in need have increased. elizabeth benson forer: when i was here very early on i met a patient and i asked her, "tell me, how did you come to the clinic?" and she said she had been a headhunter for a medical headhunting firm and she had decided to switch jobs. within her first month of work, her daughter fell at school, and broke her arm. she didn't have health insurance at the time. the daughter had a severe break and needed to be hospitalized. while she was doing her new job from the hospital room of her daughter, she was fired. so she went from making about $50,000 a year to nothing in seconds. at the point i met her, they were on the verge of being homeless, and she had developed some type of back problem and was having problems walking. she was delighted to come here because she said it was the first time she felt that someone really looked at her and said, "this is a person we can help." it's things like that that make you realize, this can be anybody in our society. people used to live in extended families, and when one person in a family had rough times, the rest of the family helped. the one thing i've noticed over all these years is the difference between someone being homeless and not homeless is usually that the homeless person doesn't have any family to catch them when they fall, or they've burnt all their bridges with family, or their family's in a position where they can't help them. and then they end up utterly and totally alone. the clinic provides basic care, but not specialized care. for that they rely on the generosity of "volunteers." we have about 175 staff members, but the wonderful thing about this agency is that we've been able to secure a lot of volunteers. we have 2,600 volunteers working with us in a year, and 600 of them alone are doctors that are providing about 35,000 patient visits in a year. part of our comprehensiveness is through intent, and part of it is serendipity, and that's good and bad. you know, when we see a need, we try to fill it. but because we frequently fill it with a volunteer, it's not always dependable. when i have a nephrologist who's volunteering, then we run nephrology clinic once a month. if the nephrologist moves out of town, we don't have nephrology clinic available here anymore. so then we will go out and look for someone to replace that physician. but for the patient's sake i wish we weren't so dependent on luck and serendipity and charity. i mean, i wish it was just a given that if they needed to see the nephrologist, they would get to see one. as the demand for their services is exploding, the staff is attempting to retain the personal service for which they are known. our fear is that we've lost that feeling of family-- the family clinic where everyone knew everyone, and we've gotten a little bit more anonymous. and we want patients to feel comfortable here. we want them to know their physician. so our solution to that is to move to a team approach, that's sort of breaking down a large company, a large clinic, into multiple small clinics so that the patients interact with the same nurse every time, and they see one of three physicians instead one of 10, and they interact with the same case manager. so far, i think everyone likes it. for many patients, the case manager is the key to healthcare at the clinic itself, and points beyond. for your medications, make a left at the second window. the pharmacist will give you the instructions - on your medications, sir. - okay. thank you for waiting. susan fleischman: case managers are really the glue to the care that we give here. besides the fact that they sit and work with patients one-on-one sometimes for 15, 20, 30 minutes, they're the people that allow us to use all of the in-kind services that we use. so if the patient has multiple needs, you can imagine that they're going to go see two or three different doctors in the community. they may have their blood sent to three different laboratories, and they may have radiologic studies at two different facilities. that's overwhelming, even if you have a car and a map. but if you don't have transportation, it's really overwhelming. the case managers actually make it happen. as we are talking about the medicines that they need to take or they need to go to a hospital for special tests, we're also asking them, "do you need food?" "do you need shelter?" the quality of care at the venice family clinic is often compared to that which a patient would receive in the private sector. susan fleischman: we may actually be a little slower here than physicians who are working in a capitated environment. our motivation is not so much to see a lot of patients because of the income, but we're sort of driven by the need. there's this constant sense that we're turning patients away, that if we went a little faster, we could see more people that day. so that tends to drive you to go a little faster. on the other hand, the patients here are quite needy. so a five minute in-and-out really doesn't touch the surface. so we take as long as we need, you know, on the other hand, i'm sort of watching the clock and thinking, "who's outside who can't get seen if i go too slowly?" so the dynamics are a little bit different. the pride in the work they do is tempered by the fact that such a facility is needed at all. susan fleischman, m.d.: i so much wish that we didn't need to exist. so i'm always ambivalent about "oh, isn't it wonderful that we've grown, and isn't it wonderful that we offer the services that we do?" but it's really just a marker for the need in the community. and so it's actually very sad that we've had to grow to the extent that we have. and i wish people just got healthcare, as part of what you get when you live here in the united states, like you get public education. my long term vision would be to see a day when anybody could go to a doctor and just get care, and the question wouldn't be, "what insurance do you have? what form do you have? how are you going to pay for this?" that there is a basic knowledge. i lived in england for a little bit. i got sick there. i went to the doctor. it cost me ten cents, and the ten cents was for the bottle for my medication. that was it. i know that england has a problem with their system, and they're working on it, but i think we need to really come up with something that works for everybody that's living in the country. and it's not a question of who's american and who's not. i was in england. i wasn't a citizen. it's a question of caring for people because they're here and they're here now, and they have a need. you never know why someone touches you more than someone else, but it does happen. and several months ago i saw an older homeless gentleman, and it was his first visit to the clinic. he was a very quiet man, well kempt, well dressed. we started to chat a little bit. and he had been sent here from a local hospital where he'd been seen in the emergency room for atrial fibrillation, which is a fast heartbeat which can be life threatening. had been admitted to the hospital for several days, was discharged, and they suggested to him that he follow-up here. this gentleman was about 63, 64, was brand new to the streets. he was absolutely, utterly homeless which is unusual. most of the homeless patients we see are younger than that. so i asked him to tell me what his story was. he had lived and worked for the last 30 years in a bookstore. and as a favor, he slept upstairs. so he was kind of a quiet gentleman. he had no family, he didn't have a lot of friends, and the bookstore went bankrupt. he had no savings, so as soon as the bookstore closed its shop, he was out on the street. he was on the street for about 48 hours, and i suspect on a stress-related basis, went into this horrible heart rhythm, had chest pain, couldn't breathe, fell down in the street, and someone called 911. he was taken to the hospital which is how he ended up here. so we helped him with his medical needs, but the bigger issue for this gentleman was you know, how was he-- brand new homeless, completely vulnerable, older, going to survive on the street? and he was not very many months away from collecting social security income and receiving medicare. and i remember i sort of jovially said, "well, the good news is, you're close to 65. those things will be available to you in a number of months." and he looked at me and he said, "i'll die before then." "the human condition" is a 26 part series about health and wellness. for more information on this program and additional materials, call: or, visit us online at: and additional materials, call: annenberg media ♪ by: narrador: bienvenidos al episodio 34. en este episodio, llevan a roberto a un hospital en la ciudad de méxico. en camino a la ciudad de méxico raquel y angela hablan de sus relaciones con otras personas. sabes, raquel aunque le he tenido un poco de envidia a roberto
health is not a single state of being. it is a combination of factors which, over time, shape and mold the life of a hum being. we have various definitions of health which certainly, in modern times, we think of as not just the absence of disease but... a positive health atus, you know-- a well ing and ability to be active and productiv in one's life. in its simplest form, being healthy is feeling that there are few physical or emotional impediments to your doing the kinds of things with your life that you'd like to. it's not so much a biological state as it is a state of mind. there are many people who are suffering chronic illnesses who are supremely healthy because they are able to maintain their creativity, and their vivacity in the face of a condition that, to other people, just sends them for a loop. being healthy is, healthy first with the mind, having aense of balanc in life. eating well, being able to exercise, and being able to be fully actitive in life. working is a part of health, i think, for many americans, and having a job that's productive and fulfilling is quite important in this perspective. the world health organization describes health as a state of social, physical, and economic well being. i mean, they take in everything, and they're quite right, that if you don't have economic strength and the necessary wherewithal, you'll probably not do well in the world. you'll probably suffer in various ways. i think certainly people that are the highest risk of poor health are those with poor resources, poor financial resources, poor educational resources, because they may not make good judgments or have access to health care when it's very essential, or when it's crucial in prevention of progression of an illness. david bennett: but for ny people in the world, their demands in terms of health are mu more modest. the people who face hunger, who face the threat of disease constantly, for them, survival is really health. to see the very quiet, subtle way in which communitiescan puly quite remarkable ife have that very broad definition, then everything becomes health. if we look only at certain narrowly defined diseases, we miss somehow the whole interaction that makes up the human being. the whole interaction that makes up the health of a human being begins with a genetic map. dean hamer: dna is like a blueprint that determines not t only our physical bodie, but also, at least in part, our brains. and our brains, of course, are what control our behavior, and so, although it surprises some people, our genes also play a role in the way we think about things, the way we feel about things, and the things that we do. so we have 100,000 genes, and all of us have to have two copies of each gene, one from each parent. each time they're being transmitted from parent to offspring, the genes have to be copied. and the copying system isn't perfect, so little mistakes are made, or changes, and most of them are irrelevant. but over time, we have in the population for any given gene, variance. in fact, my dna, and your dna, and somebody else's dna is 99.9% the same. but there's about one base out of 1000 that's different. so michael jackson's dna might read "a," and michael jordan's dna might read "g," and michelangelo's dna might read "c," and so on and so forth. and surprisingly those very few differences, that one out of 1000, is enough to make all the differences in the way we look, blue eyes or green eyes, our skin color, our height, as well as in some of our behavioral traits. sometimes people are surprised that such a tiny bit of difference-- .1% can make such a big difference in who we are. but remember that our dna and chimpanzee dna is only 1% different, and obviously we're a lot different than chimps. genes are not all that matter in terms of human health. they offer possibilities and predictions, but not certainty. paul mchugh: genes are just dna. they aren't destiny. some aspect of our life experience, what we choose and what we do, how we form our character given our constitution, is what ultimately makes us the kinds of people we are. the idea that somehow or another we're destined because of genes to be a particular kind of person is not only not true in human life, but it's also, of course, not true in anything in life. the phenotype that's expressed in any organism is in part what their genetic nature is, but it's also a part of what kind of an environment and life they live-- the nurture they have. so you can be genetically susceptible, but never exposed. but i think there's a public perception that the environment-- i mean smog, pesticides, water pollution, hair spray, you name it-- that these things are important causes of disease, and the reality is, they're not. there are a few biggies. there's cigarette smoke; there's asbestos... which is pretty much a problem of the past. and then, it's a pretty short list. the rest of the causes of disease are-- if they're not infectious-- are inside us. but often, the conditions in which one lives play a critical role in the ability to maintain good health, clearly, in most communities a level of development which has benefited many people, but left others behind. so one sees large slum areas of marginalized people, with people living under very poor conditions around the big cities. i saw it in china when i went there with my family in 1982. the farther away from beijing we went, the more "third world" china was. it looked like uganda, almost. you can find it in skid row in this city. i set up a free clinic in skid row with the los angeles catholic workers. we saw a lot of people coming in from mexico, recent immigrants with their children, who had some of the same disease problems. and their challenge is really to get the type of health care, preventive care, and treatment for illness that can be relatively difficult to get, and can be relatively expensive. peter clarke: and these people are caught in a vise-- where rising rents, the high cost of good food, the need for medications and health care for children or themselves-- these are crushing factors. and the first thing that gets sacrificed in that trio is good eating, because it's the thing that you can sort of get along without as long as you have enough calories. marc shiffman: the indigent population faces day to day challenges that are formidable, from the moment they wake up, until the moment they go to bed. and so what we-- you and i-- may take for granted in our day to day running errands and doing this and that, and getting here and there, and going to appointments, and meals and taking care of family, and whatever other responsibilities most of which we may consider mundane-- these are all the issues that impact adversely on their health, because they can't all be sorted out properly. and so in every way, shape and form, the lifestyle impacts adversely on their health. the effects of poverty on health appear to strike hardest at those who are at either end of the age continuum-- the very young and the very old. michael bryant: the concept of primary and preventative health care maintenance-- that is what we should be about, because if we can intervene early, then we are able to... to try and prevent some of the untoward effects that kids will realize as they grow older, as they become adults. you know, as we look to-- and there's been lots of rhetoric, political rhetoric, about universal healthcare, and who should get that... should that be extended to the entire population? i think a good place to start is with the children. my god, we should be trying to take care of our children. you know, the issues about adults are very complex, and, you know-- many adults-- the reasons they're unhealthy are because of things they do themselves or do to themselves. but kids are incredibly vulnerable, and i would think it would have to be a priority of ours to try and protect and ensure their health. marc shiffman: there are too many people out there... who are senior citizens-- fixed low income. medicare is their only insurance, and as they get older, as they get sicker, as they need more medications, they are having to make difficult choices. - hi. how are you doing today? - hello, mrs. phillips. - how are you? - it's good to see you. my social worker spends some time almost every day calling up drug companies, filling out forms to get special dispensations for medications. people break pills in half to stretch them, or they just go without because they've got a food bill, they've got an electrical bill, they've got a mortgage to pay, a rent-- whatever it is. they make choices. this happens more in senior citizens. the young, poor population, and this probably is more single mothers that we see, trying to raise children-- some working, some not working, also are faced with choices. and oftentimes because their lives are so hectic, raising the kids and perhaps working, whatever else they're doing, they do come in to see us late. the health of any nation is closely linked to the health of its people, the productivity of its workforce, the health of future generations-- its survival depends on it. most countries have ministers of health, or public health services whose challenge is to protect the health of society as a whole. looking at all of the factors that influence health in entire populations: a commitment to really put primacy on prevention rather than cure; a commitment to social justice, and to looking at all societal factors and environmental factors that influence health, behavioral factors, as well as factors relating to the healthcare system. in the united states, the concern we have about the public health system is that we have the adequate infrastructure and support for the government aspects of public health that protect us, keep our water supplies safe, that protect us against outbreaks of new infections or new diseases, that assure that we have the best policies to protect the public health at the state and local level as well as the federal level, that we pay enough attention to that infrastructure that we can protect ourselves as a society. but for public health officials, health is no longer just a local or national concern, it has global dimensions. james curran: well, you know, certainly during my lifetime, the world has shrunken. i guess it's the same size as it's always been, but the airplanes take us as well as microbes and organisms and animals rapidly between countries and between continents. this is not the "guns, germs, and steel" environment of-- represented in the book, but rather it's an environment where there's very rapid transmission of ideas, of concepts, and of risks. for example, if it's true that aids first arose somewhere in central africa, it would have been-- the world would have been a lot better off if that part of africa had had a better surveillance system and could have discovered this problem a year or more earlier than they did. that's just one example. this inter-relatedness of the world community was instrumental to the formation of the pan american health organization... even though the year was 1902. the intention was to provide a forum in which the countries could tell each other about what diseases were a problem, and agree on approaches that would allow for the control of the diseases-- these diseases-- without impeding trade. in those times, of course, was largely by ship. in 1948, the concept expanded with the formation of the world health organization, and six regional offices that included paho. some of its efforts are focused toward the eradication of single diseases like polio, using the salk d . david bennett: withhese tools, particularly the oral vaccine which is very-- relatively easy to use, and very effective, we felt we could undertake eradication of polio from the americas, embarked upon that, and then by 1991, had seen the last case of wild polio virus in peru-- the last case for the entire americas. in 1988... i think as a result of some pressure from the americas, the world health assembly agreed that the world would take on the effort to eradicate polio. we still have polio in the indian subcontinent, in parts of the middle east, and across much of central and eastern africa, so the challenge is pretty big. we are making headway; the immunization levels are going up. national immunization days-- polio days are being held around the world. it is very, very important, particularly for people in the united states and other relatively wealthy countries to understand, that this is one small boat. and we may be in the more affluent part of the boat, but we're still in the same boat, and it's in our interest to help everybody understand their health and deal with their health problems, especially the infectious disease problems. how do public health experts measure the health of a group of people? the two statistics most often cited are life expectancy, and infant mortality. life expectancy is how long we think we're going to live. life span is how long we're actually able to live, and that's a species specific kind of thing. so, for humans, the maximum amount of time we can live is about 120 years. if you live a good smoke-free life, keep your normal weight, exercise, your chances of living longer and living healthier are so much greater now than they were for our counterparts 100 years ago. the average life expectancy of an american in 1900 was just over 40 years. now it's close to 80. this has been a tremendous public health achievement. and if you look, most of those years of gain that have occurred over this century haven't necessarily occurred because of very technologic medical advances. they've occurred because of very, very simple public health measures, whether it's sanitation, or whether it's refrigeration, or whether it's handwashing and the availability of soap, or whether it's vaccines, those are, by and large, what have driven the improvements in life expectancy over this century. and in particular, in the area of infectious diseases. we have to realize in 1900 that tuberculosis was the single leading cause of death in the unitedtates, and, at the close of this century, the total number of deaths from tuberculosis in this country are under 1500, probably closer to 1000 people a year. we have a really brilliant saying in geriatrics, which is, "the longer you live, the longer you live." and what that means is, as you age, your life expectancy actually increases. so if you've made it past childhood, you can expect to live to young adulthood, and if you make it past young adulthood, you can expect to live into old age. and as you live into old age, you can expect to live longer. if you're a healthy 85-year-old, you can easily expect to live another seven years. the gains in life expectancy that have been achieved in the industrialized world are only partially replicated in developing countries. certainly there have been major gains in latin america, major gains in china, but there are a lot of threats to the developing world-- threats of continued infectious disease, threats of aids, threats caused by the incursion of smoking in the developing world where smoking-related illnesses in the next few decades will become the leading cause of death in the world, and threats from overpopulation and the incursions upon the environment. most of the deaths that occur, occur in children under the age of 5 years. if you look at what the leading causes of infectious disease deaths are in developing countries, they're things like acute respiratory diseases, particularly pneumonia in children. measles is still a major killer. tuberculosis is clearly a major killer. malaria-- we have the vaccines, we have the antibiotics, we have the oral rehydration therapy. the problem is that we simply don't get these technologies to where they're needed. in looking at the two principal measures that are used to evaluate public health, how does the united states rank in comparison to other nations? the united states is in the bottom quartile, in the bottom 25% in most of these indicators compared to the other industrialized countries. and it's relative ranking over the last 30 years has declined, so we have gotten worse relative to the other countries. we're improving-- everybody's improving. we're just improving at a slower rate than these other countries. the difficulty is... that most of what we do... now, affects quality of life, not length of life, and we spend a lot of our money on that particular thing. if you have a patient with angina, with severe chest pain every time they take a couple of steps because of coronary disease, and you can put that person back on the street, so to speak, functioning normally and working, that doesn't show up in the statistics. most of the people who have an angioplasty have a kind of lesion in which repair of the abnormality does not extend life, but it relieves symptoms. and so with many of the things that we do, say for vision-- something as simple as cataracts, and the implantation of artificial lenses-- that's revolutionized the lives of older people who were virtually blind because of cataracts. what's that worth? that's worth a lot, and it doesn't extend life expectancy, or at least if it does, to a very minimum degree, so i think it's quite unfair to judge a system on the basis solely of length of life and infant mortality. those are reasonable criteria... but you have to weigh in quality of life in a major, major way. but other factors also seem to influence the statistical profile of health in the united states. life expectancy has gone up, but infant mortality doesn't come down. and part of that is due to the fact that people are living under circumstances that don't favor healthy pregnancies and healthy early childhood, and where they don't get the type of health care that they need because they can't afford it. and in rural communities, it's not available. gerard anderson: of the industrialized countries, we and mexico and turkey are the three countries that have large numbers of uninsured. and so you know that those people are in serious trouble when they get sick, and they are responsible not due to their own fault, but they are the cause for a lot of our higher infant mortality rates, our low life expectancy, and whatever. every person in america needs to have access to excellent health care and health services. and there are several barriers from that happening. some are financial, and some are system-wide, and these seem to be increasing rather than decreasing at a time when our nation has more wealth and more prosperity than ever. that's deeply disturbing. as a physician, i see... the system beginning to blame itself, and blame each other. today, the hmo's are the problem. tomorrow the government will be the problem. the next day, maybe it'll be the doctors, or it'll be the patients themselves for failing to interpret and navigate the system. this is a dangerous trend. the second thing is we have more discrepancy in high incomes and low incomes in the united states as compared to most of the other countries. they have a much better income support. peter clarke: every indicator... of mortality and morbidity, shows a straight line income function. the lower your income, the quicker your death, and the more serious the burdens you're carrying for chronic conditions. clearly, there are steps that governments can take to improve the health of their citizens. but even more immediate, and more controllable on a personal level, are those steps we can take for ourselves. the key understanding is that what i do affects my health at least as much, maybe more, than anything that can be done to me in a hospital, etc., and that i need to start taking care of my health right from a very young age, as soon as i can have that understanding. i think that is a key message, and there the challenge becomes, with young people, who tend to think they're immortal, etc., haven't had some of these life experiences, just to get them to understand that some of the decisions they're making-- young or not-- are key, and they're going to affect them for the rest of their lives. marc shiffman: our number one overriding societal impact on health is still drugs and substance abuse. illicit drugs, alcohol... are one and two. and obviously those spawn a violent culture, whether it's domestic abuse, whether it's street violence, but it all goes back to the substance abuse. there's no getting around that. that is, without a doubt, the single most important impact on what we see. i think when people think of behaviors, they think more along the lines of chronic diseases, whether it's exercise, or whether it's smoking, or whether it's alcohol, i think people readily recognize that there's a significant behavioral aspect to who the risk groups are for chronic diseases. i don't think that there's as great a perception that behavior also plays a very important role in infectious diseases, whether it's sexual behavior and its relationship to hiv, whether or not it's the foods you eat and how you cook them, whether it's behavior surrounding antibiotic seeking and taking antibiotics, or whether or not it's the types of activities and whether or not you want to use insect repellents when you decide to go out for a hike on a nice summer day. behaviors are critical to not only chronic diseases, but also to infectious diseases. to be healthy, people need to know about health. you need to be your own consumer. you need to read about health, and how to stay healthy. you need to learn about it, and then you need to abide by certain principles. don't smoke. absolutely don't smoke. maintain your ideal weight... get plenty of exercise... have a trusted healthcare provider who's knowledgeable, and know a lot yourself. ask questions. don't distrust the medical system, but be a consumer who is well informed. "the human condition" is a 26 part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: a group of french doctors working for the red cross sought permission to provide aid to the 100,000 refugees in biafra who were suffering from famine and disease. but because these refugees were on the "wrong" side of the government in a civil war, the red cross said "no." the doctors resigned their post and started what was to become "doctors without borders," an organization committed to serving all populations in need, regardless of politics or national borders. at the same time, a hemisphere and continent away, the people of venice, california were demanding health care for those who could not afford to pay for it. a group of concerned citizens, working with two local doctors, secured the loan of a dental office at night, and started a volunteer clinic. from these humble beginnings emerged the venice family clinic, thlargest free clinic in the united states. this is the story of two organizations and the people they serve... in the name of health, and humanity. suraj achar had only recently opened his family practice when he left for six months to help somali refugees who were entering kenya ne the border with somalia and ethiopia. suraj achar: when we landed our plane on the dirt field, you couldn't see anything green for tens of miles all around and, unfortunately, when i landed, i recognized the suffering the people were encountering there. the children were severely malnourished. i could see it from their faces and their bellies, and the animals were dying actually in front of me. some of the animals were laying on the ground suffering because they had nothing to eat, and no water. teams of volunteers from 45 nations serve with "doctors without borders," wherever and whenever the need arises. i was the only doctor in the team because we're a nutrition-based team. we had up to four nurses. we had logisticians who came from diverse backgrounds: we had a computer engineer from spain, a stockbroker who worked in the trading houses in toronto; a fireman from france; and everybody had bs to do. and they were trained with "doctors without borders," or at least debriefed, before they came onto the mission and trained with people who were leaving the mission. the somalis did not instantly accept or trust the new team. suraj achar: to survive in the desert, with the wars, and the famines and the tastrophes that somali people have survived, makes them a little tough skinned. and it was difficult for us, the whole team-- not just myself-- to earn their respect and achieve their trust. fortunately we were there for such a long time, and we were doing such intensive work with them on a day to day basis-- especially with the children and the mothers who were most hit by severe malnutrition-- that they grew to trust us over time, and would bring us their most severe cases. the incidence of malnutrition, particular among the childr, was alarming and th severe malnutrition, the mortality this disease, depending on the variation of protein energy malnutrition that we see, can be as high as 30 to 50%. usually the children die from routine infections like diarrhea or pneumonia. in fact, pneumonia is the most common cause of death. children who are severely malnourished appear anorexic. they do not want to eat. they're often very depressed. their heads are low. they stop talking. they stop walking, and they're severely dehydrated and suffering from inftious diseases perhaps the most extme case omalnuttion the team witnessed was annis-- a tiny wisp of a girl, two and a half years old. annis is just skin and bones and a head. and i looked at her, and i looked at the weight, and i asked the mother how old she is and the mother told me. and i said, "it's not possible." so i took annis myself back to weigh. i saw the scale, it said 4.2 kilos, took annis off, measured her height, put her back on the scale. i still couldn't believe it. it was amazing to me that annis was still alive. the highest mortality for children so severely malnourished occurs in the first few days. if you overfeed these kids they will die from electrolyte changes in their body. so you have to be very careful. we immediately started her on a rehydration program as well as high energy milk and antibiotics for her infections. and as she started getting better, we started her on soya bean protein mix. and i would come by daily to check on annis'roes what he discovered was that annis' mother was feeding her daughter's food to her other children, and even eating some of it herself. and the food was very basic. it included high energy protein shakes that were like milk, plus a soya bean porridge. and we used this, and it had a variety of nutrients in it-- full range of amino acids which are e building blocks for our proteins in our body. i would have to go and get more food to give to annis myself, and i would individually feed annis. and i asked mother why would she not give any food for annis. and mother said she had already given up on annis, that there was no chance that annis was going to survive and that her older children were very important to her and she wanted to help them as much as she could. and over time, in our program, annis' mother began to trust us. and as we were feeding annis, annis' mother would also feed annis. it was amazing when she would raise her head, and look up and smile eventually, and eventually even almost start trying to walk. i would carry her around on rounds, and to see her thrive and survive when her mother was so sure th she would never do so, was probably one of the more beautiful experiences that i had there. but as well as the program seemed to be progressing, the challenges were just beginning. about x weeks into my stay i was lled to come to the inteive ca feeding cente where we keep our st critical cases... at 4:45 or:0in the morning, very early. and we rushed over there in the dark in our four-wheel-drive car, we found in the tent where we keep our children with tuberculosis, was one of the mothers lying prostrate on the floor in a pool of diarrhea and vomitus. we assessed her quickly and found she had almost no pulse that we could palpate. we could barely detect a blood pressure, and she was almost comatose. she would barely respond to pain. we then immediately started her on iv fluids. within 15 minutes we'd given her seven liters of fluid to replace some of the losses, just some of the losses that she had encountered over the night when she had started her diarrhea. and we noted the water that was coming out-- the stool quality was very different than usual. it looks almost like rice and water mixed together. and we were astounded by this because we knew that this probably meant cholera. samples were sent to nairobi for analysis, and within a few days the diagnosis was confirmed. it was indeed cholera. at that point, the lives of the "doctors without borders" team and their mission, changed dramatically. iv bags of fluid, antibiotics, and chemicals to purify the water and prevent the spread of cholera were airlifted to the site. one of the most devastating problems with cholera is it can go quickly amongst patients who are immuno-suppressed, like our children with malnutrition, and it can cause high, high mortality in this population. so we quickly had to isolate the kids and adults who had cholera. we built a center with beds and iv bags hanging from the roof for the patients who were suffering that were adults. we removed the children with tuberculosis from our isolation tent, and put our children with cholera in this tent. then we built a chlorine bath all around. we burned all their clothes-- anything that potentially could have cholera, we burned it. we built a special latrine for their waste. and we tried to isolate them as much as possible while, at the same time, providing very intensive care for their dehydration, which is the critical problem in cholera. it's a disease that comes on within a few days of incubation, and may only last a few days. but within those three days, you can lose half your weight in diarrhea, and critically need support. iv fluids, oral rehydration fluids-- all of that plus the antibiotics that the cholera would be sensitive to. before the cholera outbreak, only a small percentage of the children with severe malnutrition died. once the cholera hit, that figure rose. it's very difficult to fight cholera. and these children would have as many as 50 episodes of diarrhea in a 12 hour period. losing so much water, it's very hard to keep up. often times i would go to lunch and come back and a new child would just fall ill during e lunchtime with diarrhea, and would pass away within hours. children were brought to us and would just pass away within five minutes of arriving at our center. so we had some very rapid demises. and it was very difficult as a physician. for a while, my nurses, the local staff, were wondering, am i really a doctor?-- because we were having so many deaths. the epidemic lasted about a month, infecting between 500 and 1000 adults and children. others probably were asymptomatic and carried the bacteria as well. the total number of deaths in the children was probably in the teens. but still, for us, it was devastating to watch a child expire. the death of a child generated a whole new set of challenges. the somali people are moslem, and they're very particular about their ceremonies and their burial ceremonies. but unfortunately, the remains of the children were very infectious and we had to isolate them. so we came up with a compromise. we would clean the child after the child expired and then put them in a body bag. and we'd hand them to the families and they would bury them in the body bag which was somewhat of a protection for the community. at times, the situatio was ustrating dr. achaand his team, knowing that they really couldn't do everything they were trained to do. when the children became the most severely ill and we didn't have a way to manage them, to measure their electrolytes, to measure their fluid balance in their body most accurately, to culture their infectious diseases most accurately, to measure their blood count to see how anemic they were and to potentially get the medicines that weren't available, or diagnostic tests that weren't available, and then to watch these children- some of these children pass away... that's probably the most difficult experience for any physician from the west to work in-- the situation like we had in africa. but as the cholera epidemic waned, and attention once again focused on the malnutrition scourge they were sent to attack, the good they were doing came full circle. i remember doing an evaluation on two children-- one who was four, two girls, and one was six. coming from a town in ethiopia, very nearby, they would walk 10 to 15 kilometers every day with no shoes on through the desert. the temperature was about 110 to 120 in the shade during their walk. they would come, and they would get their nutrition in the morning, and then they would stay sitting outside in the sun for the feeding that would happen in the afternoon. and then they would go home and... on saturdays we would give them a packet of food for sunday. well, after evaluating them and finding out that they had no medical complications that would necessitate medical care, i was about to discharge them, and i asked them, "what is it like on sunday for you?" and these two girls said to me that their food is distributed amongst the family. and because the family doesn't eat during the week, the family eats the food that they bring home on sunday. but they were very happy coming on the other days where they would get the soybean porridge. and i asked the older child if i were to discharge them from our program, would there be a way for them to get food in ethiopia? and she looked at me and said, "probably not," through a translator-- that there was no option for them outside of our program. after hearing the story, of course i found some medical excuse to keep them in our program and continue them there. but being able to help children like that who have nowhere else to turn, was just a great privilege, just a beautiful experience. the health needs of people who live in venice, california may seem a far cry from the health needs of somali refugees. but there is a common denominator: people in need, without adequate resources to maintain their health. it's a few minutes before 9:00, and already, activity at the venice family clinic is in high gear. elizabeth benson forer: our mission is to provide comprehensive primary healthcare that's affordable, accessible and compassionate for people who have no other access to care. we truly are unique in that we're not seeking business with money attached. we're seeking people with no health insurance and low incomes. anzeledón friendly: the majority of our patients are hispanic, and many of them monolingual, so all of our staff members are bilingual in english and spanish. and they're able to provide the services, also in a culturally sensitive manner. and we do have also a large immigrant population from russia. susan fleischman: most of them are older people in their 50s and 60s, but they seem older than that. they've come to this country mostly as economic refugees. most of them have almost no english skills, and they are very, very sick. they have terrible hypertension, lots and lots of heart disease and cardiovascular disease and terrible depression, as well. and they have a very difficult time assimilating to life here. the clinic also serves several thousand homeless people. ana zeledón friendly: we have a special program where our homeless are able to walk in on a daily basis, and we have slot available for them so we can see them right away. susan fleischman: i think most patients are nervous the first time they come here. they clearly don't know what to expect. i don't know how they've heard about us, maybe from a friend, from a family member. i think they're nervous about the quality of care. i think they're nervous language-wise... "will there be someone there who speaks and understands my language?" they're worried about whether we're going to call immigration. they're worried about whether coming here will affect their children's ability to become u.s. citizens, so there's a whole host of worries. elizabeth benson forer: we try to make it so that it's easy for them to get care. it's as simple as really w. it's a self-declaration. someone can say, "i'm jose, and this is how much i earn. i earn $14,000 a year," and that's it. some of our patients want to show us and want to provide proof. but, for the most part, they just have to sign a form with their name, and that's it. it's really wonderful to sort of watch them take a big breath and relax during the course of the visit because i think what they find as they're here is that we do meet their needs. they get the tests done that they need. they get the medications that they need. they can't believe they're not going to have to go to a pharmacy and somehow come up with $60 or $100. it's interesting that many people try to use the clinic as an urgent care center. we have had exames of a man who was having a heart attack who drove by many major hospitals and did not stop, and was coming to us because he knew that we knew him very well. he's been here with us for many years and that he trusts us, and that we could help him. and so what we're able to do is stabilize our patients if there's a case of emergency, and we call paramedics and then refer them to the hospitals for their care. last year, the clinic recorded more than 80,000 patient visits and filled more than 65,000 free prescriptions. no one paid a cent for the care they so badly needed. they frequently haven't had care in a long time. they've delayed going to the doctor. they've neglected themselves. they've put other things first like housing and feeding their children. and so they're quite sick, frequently, by the time we come here. and unfortunately that hasn't changed. we see a lot of people who are immigrants, and that has not really changed. and unfortunely we still see lots of people who are homeless. i think all that's really happened is that the numbers of people in need have increased. elizabeth benson forer: when i was here very early on i met a patient and i asked her, "tell me, how did you come to the clinic?" and she said she had been a headhunter for a medical headhunting firm and she had decided to switch jobs. within her first month of work, her daughter fell at school, and broke her arm. she didn't have health insurance at the time. the daughter had a severe break and needed to be hospitalized. while she was doing her new job from the hospital room of her daughter, she was fired. so she went from making about $50,000 a year to nothing in seconds. at the point i met her, they were on the verge of being homeless, and she had developed some type of back problem and was having problems walking. she was delighted to come here because she said it was the first time she felt that someone really looked at her and said, "this is a person we can hel" it's things like that that make you realize, this can be anybody in our society. people used to live in extended families, and when one person in a family had rough times, the rest of the family helped. the one thing i've noticed over all these years is the difference between someone being homeless and not homeless is usually that the homeless person doesn't have any family to catch them when they fall, or they've burnt all their bridges with family, or their family's in a position where they can't help them. and then they end up utterly and totally alone. the clinic provides basic care, but not specialized care. for that they rely on the generosity of "volunteers." we have about 175 staff members, but the wonderful thing about this agency is that we've been able to secure a lot of volunteers. we have 2,600 volunteers working with us in a year, and 600 of them alone are doctors that are providing about 35,000 patient visits in a year. part of our comprehensiveness is through intent, and part of it is serendipity, and that's good and bad. you know, when we see a need, we try to fill it. but because we frequently fill it with a volunteer, it's not always dependable. when i have a nephrologist who's volunteering, then we run nephrology clinic once a month. if the nephrologist moves out of town, we don't have nhrology clinic available here anymore. so then we will go out and look for someone to replace that physician. but for the patient's sake i wish we weren't so dependent on luck and serendity and charity. i mean, i wish it was just a given that if they needed to see the nephrologist, they would get to see one. as the demand for their services is exploding, the staff is attempting to retain the personal service for which they are known. our fear is that we've lost that feeling of family-- the family clinic where everyone knew everyone, and we've gotten a little bit more anonymous. and we want patients to feel comfortable here. we want them to know their physician. so our solution to that is to move to a team approach, that's sort of brking down a large company, a large clinic, into multiple small clinics so that the patients interact with the same nurse every time, and they see one of three physicians instead one of 10, anth interact wi so that the patients interact with the same case magery time, so far, i thk everne likes it. for many patients, the case manager is the key to healthcare at the clinic itself, and points beyond. for your medications, make a left at the second window. the pharmacist will give you the instructions - on your medications, sir. - okay. thank you for waiting. susan fleischman: case managers e really the glue to the c at we give her besides the fact that they sit and work with patients one-on-one sometimes for 15, 20, 30 minutes, they're the people thatllow uto use all ofhe in-kind serves that we use so if the patient has multiple needs, you can imagine that they're going to go see two or three different doctors in the community. they may have their blood sent to three different laboratories, and they may have radiologic studies at two different facilities. that's overwhelming, even if you have a car and a map. but if you don't have transportation, it's really overwhelming. the case managers actually make it happen. as we are talking about the medicines that they need to take or they need to go to a hospital for special tests, we're also asking them, "do you need food?" "do you need shelter?" the quality of care at the venice family clinic is often compared to that which a patient would receive in the private sector. susan fleischman: we may actually be a little slower here than physicians who are working in a capitated environment. our motivation is not so much to see a lot of patients because of the income, but we're sort of driven by the need. there's this constant sense that we're turning patients away, that if we went a little faster, we could see more people that day. so that tends to drive you to go a little faster. on the other hand, the patients here are quite needy. so a five minute in-and-out really doesn't touch the surface. so we take as long as we need, you know, on the other hand, i'm sort of watching the clock and thinking, "who's outside who can't get seen if i go too slowly?" so the dynamics are a little bit different. the pride in the work they do is tempered by the fact that such a facility is needed at all. susan fleischman, m.d.: i so much wish that we didn't need to exist. so i'm always ambivalent about "oh, isn't it wonderful that we've grown, and isn't it wonderful that we offer the services that we do?" but it's really just a marker for the need in the community. and so it's actually very sad that we've had to grow to the extent that we have. and i wish people just got healthcare, as part of what you get when you live here in the united states, like you get public education. my long term vision would be to see a day when anybody could go to a doctor and just get care, and the question wouldn't be, "what insurance do you have? what form do you have? how are you going to pay for this?" that there is a basic knowledge. i lived in england for a little bit. i got sick there. i went to the doctor. it cost me ten cents, and the ten cents was for the bottle for my medication. that was it. i know that england has a problem with their system, and they're working on it, but i think we need to really come up with something that works for everybody that's living in the country. and it's not a question of who's american and who's not. i was in england. i wasn't a citizen. it's a question of caring for people because they're here and they're here now, and they have a need. you never know why someone touches you more than someone else, but it does happen. and several months ago i saw an older homeless gentleman, and it was his first visit to the clinic. he was a very quiet man, well kempt, well dressed. we started to chat a little bit. and he had been sent here from a local hospital where he'd been seen in the emergency room for atrial fibrillation, which is a fast heartbeat which can be life threatening. had been admitted to the hospital for several days, was discharged, and they suggested to him that he follow-up here. this gentleman was about 63, 64, was brand new to the streets. he was absolutely, utterly homeless which is unusual. most of the homeless patients we see are younger than that. so i asked him to tell me what his story was. he h lived and worked for the last 30 years in a bookstore. and as a favor, he slept upstairs. so he was kind of a quiet gentleman. he had no family, he didn't have a lot of friends, and the bookstore went bankrupt. he had no savings, so as soon as the bookstore closed its shop, he was out on the street. he was on the street for about 48 hours, and i suspect on a stress-related basis, went into this horrible heart rhythm, had chest pain, couldn't breathe, fell down in the street, and someone called 911. he was taken to the hospital which is how he ended up here. so we helped him with his medical needs, but the bigger issue for this gentleman was you know, how was he-- brand new homeless, completely vulnerable, older, going to survive on the street? and he was not very many months away from collecting social security income and receiving medicare. and i remember i sort of jovially said, "well, the good news is, you're close to 65. those things will be available to you in a number of months." and he looked at me and he said, "i'll die before then." "the human condition" is a 26 part series about health and wellness. for more information on this program and additional materials, call: or, visit us online at: and additional materials, call: new year's eve, 2002. just two years ago. in the sixth grade. july 11, 1994. i was shot by a teenage gang member. my son valentino was killed by a drunk driver. my baby brother joseph was shot. i was sexually assaulted. my wife emma was killed by a drunk driver. my heart was ripped apart. the day this happened to us, our family died. at that time, i had no idea that i needed help or that my family needed help. i didn't know help was there. a detective told us about victims' assistance. we did receive help with the funeral and burial. they informed me of my court dates. they paid for my wheelchair-accessible van. if you're a victim of crime, seek help, because help is there for you. even if you never reported the crime... crime victims' assistance programs are there to help. justice isn't served until crime victims are. annenberg media ♪