*"It doesn't matter if the cat is black or white as long as it catches
mice."*

Deng Hsaio P'ing 1904-1997

This a page for sharing "what works" as seen in the published literature
as well as what is done at sites that care for American Indian/Alaskan
Native children. If you have any suggestions, comments or questions
please contact Steve Holve, MD, Chief Clinical Consultant in Pediatrics
at sholve@tcimc.ihs.gov

IHS Child Health Notes

March 2006

# Quote of the month

*"If you want to see what children can do, you must stop giving them
things"*

Norman Douglas

**Articles of Interest**

Cardiovascular screening of student athletes.\
Am Fam Physician. 2000 Aug 15;62(4):765-74

<http://www.aafp.org/afp/20000815/765.html>

-   Sudden cardiac death occurs in 1/200,00 high school athletes per
    year

-   The majority of sudden deaths are related to undiagnosed congenital
    cardiac anomalies such as hypertrophic cardiomyopathy ( 40%),
    coronary artery anomalies (20%), and increased cardiac mass 910%)

-   Screening is problematic because of the low incidence and low risk
    of death: 200,000 athletes need to be screened to identify 1,000
    with risk for sudden death for the 1 athlete who would die

-   Currently, there is no cost-effective battery of tests to identify
    all, or even most, of the dangerous cardiovascular conditions

-   Current consensus is to follow the 1996 screening guidelines of the
    Sudden Death Committee of the American Heart Association: These
    utilize a combination of personal history, family history and
    cardiac exam

Medical and legal issues in the cardiovascular evaluation of competitive
athletes.\
JAMA. 2005 Dec 21;294(23):3011-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16414949&query_hl=1&itool=pubmed_docsum>

-   Physician screening should adhere to the 1996 recommendations of the
    Sudden Death Committee of the American Heart Association

-   The recommendations state that pre-participation screening by
    history and exam is clinically justified but that routine
    non-invasive testing is not recommended due to the low yield and
    prohibitive cost

-   When cardiovascular abnormalities are identified or suspected, the
    athlete should be referred to a specialist for further evaluation.
    He/she should not be cleared until this evaluation is completed.

-   Court decisions state that athletes can rightfully be disqualified
    from competitive sports if reasonable national guidelines are used.

**Editorial Comment**

Despite a lack of compelling evidence to show that cardiovascular
preparticipation screening is effective, it is recommended based on cost
and medicolegal considerations and is required by nearly all high
schools in the United States. While this method may be imperfect, the
American Heart Association 1996 guidelines are considered the most
practical and best available strategy for screening large populations of
athletes. These guidelines have become the medical and legal standard
for sports examinations in this country. The guidelines are listed in
both articles. The American Family Physician article also has a sample
physical exam and screening questionnaire that has become the standard
form in many states.

One benefit of preparticipation sports exams is that physicians have an
opportunity to evaluate and counsel adolescents who may not otherwise be
seen for medical care. The sports exam is not intended to exclude
athletes from participation but to maintain their health and safety. The
exam should focus on ensuring the safety of the adolescent athlete and,
to the extent possible, be used as an opportunity to counsel young
athletes on the important health issues of adolescence.

**Infectious Disease Updates**.

Rosalyn Singleton, MD, MPH

 **RotaTeq™ (Rotavirus vaccine) newly licensed for infants**

The FDA just licensed a new Rotavirus vaccine, RotaTeq™ (Merck & Co.,
Inc.) to prevent severe gastroenteritis in infants. RotaTeq™ is a live
oral 3 dose vaccine to be given at 2, 4, and 6 months of age. The
Advisory Committee on Immunization Practice is expected to decide on
recommendations later this month.

Rotavirus causes an estimated 2.7 million episodes of gastroenteritis,
250,000 emergency room visits, and up to 55,000 hospitalizations per
year in the United States. The licensure is based on a Phase III REST
efficacy study, which involved 70,000 infants. RotaTeq™ prevented 98% of
severe cases of vaccine-strain rotavirus and 98% of severe cases of any
rotavirus strain. In addition, RotaTeq™ prevented 71% of rotavirus
gastroenteritis of any severity. Unlike the ill-fated RotaShield™
vaccine in 1999, RotaTeq™ was not associated with increased incidence of
intussusception -- there were 13 cases of intussusception in the vaccine
group and 15 cases in placebo group.

**Editors Note:**

Rotateq is already approved for the Vaccine for Children Program that
provides immunizations at no cost to AI/AN. However, as a practical
matter most states will probably not begin purchase of this vaccine
until late summer or Fall.

**Recent literature on American Indian/Alaskan Native Health**

Doug Esposito, MD

**Articles of Interest**

**[Race, Genetics, and the Biologic Versus Social Determinants of Health
and Health Disparities]{.underline}**

The December 2005 issue of the *American Journal of Public Health* is
devoted to exploring the controversial relationship between genes, race,
and health disparities. This hotly debated issue is outlined in a
collection of five articles, well worth study by anyone endeavoring to
understand the basis for measured differences in health status of
racially and ethnically distinct groups. What are the underlying
determinants of health disparities? Are they a function of the inherent
genetic makeup of groups and populations, or are they born out of
socially imposed inequities and injustices in exposure and access to
resources? This timely volume seeks to bring these issues into focus.

In "Bridging the Gaps between Race and Genetics," Michael Fine calls
into question the existence of substantive data supporting the presence
of genetic or biologic determinants of racially derived health
disparities. He contends that an ever increasing body of evidence to the
contrary exists. "Although considerable time and energy have been
devoted to understanding the associations between genes, race, and
health disparities over the past decade, there is currently abundant
evidence that a multitude of other nonbiological, nongenetic factors
contribute to health disparities. These well documented factors include
diminished access to health care, low socioeconomic status, cultural
preferences, low levels of health literacy, racial discrimination, poor
doctor--patient communication, and environmental hazards and exposures.
Despite the progress that has been made in understanding the genetic
makeup of humans, genetics research does not yet have the capacity to
explain or rectify observed racial disparities in health or health care.
Thus, the jury remains out regarding the value of genes and genomics as
tools for understanding and addressing health disparities."

In their editorial "The Role of Race and Genetics in Health Disparities
Research," Fine, Ibrahim, and Thomas investigate the pros and cons of
using a genetic definition of race in medical research. Central to the
argument is whether race is a biologic, or conversely, a socio-cultural
construct. It all boils down to how one uses genetic data and
ethics/social justice to argue the case. Their contention is that
insufficient evidence exists to support a genetic or biologic basis for
race. Therefore, health disparities are more appropriately investigated
and addressed through a thorough understanding of the interplay between
environment, exposure, and access to resources as modulators of
prevalence and outcomes of disease. Furthermore, they contend that there
is no demonstrated role for "race-based genomics to reduce or eliminate
such disparities." On the contrary, they assert that such a view likely
impedes progress toward the elimination of racial and ethnic health
disparities.

In "Racializing Drug Design: Implications of Pharmacogenomics for Health
Disparities" Sandra Soo-Jin Lee, too, suggests the potential negative
consequences of using a genetic/biologic definition of race on achieving
health equity. His arguments are compelling as he points out that
science's continued attempts to strengthen the notion of a biologic
basis for race likely will further strengthen "race as a naturalized,
immutable biologic reality." Or, in my own words, the medical and social
institutionalization and ratification of biologically-based racism.

Thomas, *et al.* present a complex review of the ethical considerations
of genomics in public health in "Genomics and the Public Health Code of
Ethics." Here, they lay out the differences and similarities between
medical ethics and public health ethics. They then go on to define the
ethical issues in genomics from both a medical and public health
perspective. Most developed is a discussion of genomics and ethical
concerns as they relate to the 12 principles of the Public Health Code
of Ethics. A good article, but one I frankly had some trouble digesting!

Finally, Nancy Krieger eloquently argues in favor of considering race as
a random concept born entirely out of historic and non-scientific
fallacy in "Stormy Weather: Race, Gene Expression, and the Science of
Health Disparities." If you only read one of the five listed articles, I
would recommend this one. It is the most interesting, insightful,
articulate, and entertaining of the lot!

So, what is genomics anyway? According to Guttmacher *et al.*, genomics
is "the study of the functions and interactions of all the genes in the
genome, including their interactions with environmental factors."
(Genomic medicine---a primer. *N Engl J* *Med.* 2002;347:1512--1520.
<http://content.nejm.org/cgi/content/extract/347/19/1512>).

In my opinion, it is important to recognize that modern man shares about
99.9% homogeneity in genetic composition, and that most (90-95%) of the
observed genetic heterogeneity lies within, not between, population
groups. Additionally, much of our genetic content appears to be little
more than filler! With so little genetic variance between the "races,"
how then can genomics hope to explain health disparities? I'm not sure
it can. As Krieger points out, "phenotype is not equivalent to
genotype---precisely because observed traits are a function of gene
expression and not simply gene frequency. As any serious engagement with
developmental biology would readily reveal, genetically identical
organisms raised under markedly different conditions exhibit important
differences in stature, appearance, and physiology. To assume that
phenotypic variation among humans is a function solely of inherited
genes is an ideological, not scientific, argument." In fact, "race"
appears to be a purely human designation, born entirely out of the human
psyche.

So, what does this all mean? Again, in the words of Krieger: "The larger
goal is to strengthen development of a more critical, reflexive, and
rigorous science capable of generating evidence useful for
rectifying---rather than perpetuating---social disparities in health."
It is my belief that we should be cautious when it comes to the
"promise" of genomics. We cannot lose track of what we already know,
that health disparities are in their largest part born out of socially
imposed inequities and injustices in exposure and access to resources,
lest we forget what we are really after: the [elimination]{.underline}
of health disparities by the year 2010 (*Healthy People 2010:
Understanding and Improving Health.* 2nd ed. Washington, DC: US Dept of
Health and Human Services; November 2000.
<http://www.healthypeople.gov/>).

**[Articles]{.underline}**

Bridging the Gaps Between Race and Genetics. *Am J Public Health*, Dec
2005; 95: 2124.
<http://www.ajph.org/cgi/search?sortspec=relevance&author1=fine&fulltext=gaps&pubdate_year=&volume=&firstpage>=

The role of race and genetics in health disparities research. *Am J
Public Health*. 2005 Dec;95(12):2125-8.
<http://www.ajph.org/cgi/content/full/95/12/2125>

Racializing drug design: implications of pharmacogenomics for health
disparities. *Am J Public Health*. 2005 Dec;95(12):2133-8.
<http://www.ajph.org/cgi/content/full/95/12/2133>

Genomics and the public health code of ethics. *Am J Public Health*.
2005 Dec;95(12):2139-43.
<http://www.ajph.org/cgi/content/full/95/12/2139>

Stormy weather: race, gene expression, and the science of health
disparities. *Am J Public Health*. 2005 Dec;95(12):2155-60.
<http://www.ajph.org/cgi/content/full/95/12/2155>

Here's an article I came across that is representative of research that,
in my opinion, is irrelevant and should be tempered by the above
discussion.

Genomic Screen for loci associated with tobacco usage in Mission
Indians. *BMC Med Genet*. 2006 Feb 10;7(1):9 \[Epub ahead of print\].
<http://www.biomedcentral.com/1471-2350/7/9>

# Announcements from the AAP Indian Health Special Interest Group 

Sunnah Kim, MS **Locums Tenens and Job Opportunities**

If you have a short or long term opportunity in an IHS, Tribal or Urban
facility that you'd like for us to publicize (i.e. AAP Web site or
complimentary ad on Ped Jobs, the official AAP on-line job board),
please forward the information to <indianhealth@aap.org> or complete the
on-line locum tenens form at <http://www.aap.org/nach/locumtenens.htm>

.