Rural mental health efforts; family doctors' role; lead's threat: Upstate Medical University's HealthLInk on Air for Sunday, May 28, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a psychiatrist shares a method of increasing mental health services in rural areas.

Justin Meyer, MD: ... You really become an integral part of that smaller community in a rural site. That's been a real great thing to see. ...

Host Amber Smith: A doctor explains the role of family medicine in the American health care system.

Sana Zekri, MD: ... We're very good at identifying when something is wrong and doing the first steps to fix it, and sometimes we need to get experts in other specialties involved if we don't feel comfortable addressing it all on our own. ...

Host Amber Smith: And a pediatrician tells why baby food may contain lead and what you can do about it.

Travis Hobart, MD: ... The lead really comes from the environment in which the food was grown or the way that the food was processed. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical Center. I'm your host, Amber Smith.

On this week's show, we'll learn about the specialty of family medicine. Then, a look at the dangers of lead, especially for children. But first, how psychiatrists at Upstate are helping bring more mental health care to rural residents.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

The U.S. census projects a significant shortage of doctors related to population growth, aging and a growing need for medical care. This applies to the field of psychiatry, and especially in rural communities, but psychiatrists at Upstate are working to address the predicted shortages.

And here to tell us about a novel strategy is Dr. Justin Meyer. He's an assistant professor of psychiatry and behavioral sciences at Upstate.

Welcome to "HealthLink on Air," Dr. Meyer.

Justin Meyer, MD: Thanks so much for having me.

Host Amber Smith: Why are rural communities hit harder with these shortages?

Justin Meyer, MD: Well, I think there's a lot that goes into it, needless to say that the amount of people in a rural area is smaller, and so there are fewer physicians that are there in those communities, and there are fewer subspecialists or specialists in those areas as well.

Host Amber Smith: Why do you think that most doctors stay within a hundred miles of where they complete their residency training?

Justin Meyer, MD: So for those that aren't so familiar with residency and medical education in general, you have to get a bachelor's degree first. So that's your college. Then you go to medical school, that's another four years. After that, there's something called residency and that's where you're trained in a specialty, sort of practicing that specific profession, for example, psychiatry, which is what I do.

As you grow older, you're also a human being, so you're going to come into your own, you might get married, you might have kids, you might buy a house. The longer you wait, the more likely these things happen.

So that's a major factor. During residency, it's when people start putting down roots and settling down, and so it's less and less likely as you get older to move out and further away. Additionally, people in their 20s and 30s generally like to live in urban areas. That's just a demographic and population-based issue. And so for that reason, a lot of people wind up settling in urban areas.

Host Amber Smith: What does Medicare have to do with graduate medical education?

Justin Meyer, MD: This is an interesting one to dissect. Believe it or not, Medicare, so the insurance that we pay for in our taxes, pays for almost all of graduate medical education or residency.

So part of that is built into the insurance of Medicare, and historically, in order to get that funding, you have to be an academic facility. Usually this would be a place like Upstate, where there's a medical school, and there are multiple residencies attached. One of the unfortunate consequences has become that these tend to be in urban areas, where there's more people, so that they can train more people.

And so, how do you navigate that when you're looking at rural communities? This is becoming an interesting problem to solve.

Host Amber Smith: Would you say that it's common or unusual for people living in rural America to have access to a mental health provider?

Justin Meyer, MD: I would say it's unfortunately pretty usual to not have access, so the opposite.

In fact, about a quarter of people in cities are able to have access, to have psychiatrists. About 65% of those in rural communities do not have psychiatrists. So again, the majority of people, unfortunately, do not have access to psychiatry in rural areas.

Host Amber Smith: So how does the Rural Academic Partnership Program address this?

Justin Meyer, MD: So back in about 2015, this was prior to me coming to Upstate, some of the innovative people, Dr. Dewan, Dr. Meszaros, Dr. Gregory (Mantosh Dewan, MD, Zsuzsa Meszaros, MD, PhD, and Robert Gregory, MD), these are all psychiatrists, saw this problem on the forefront and wanted to be proactive. And they started partnering with some of the regional, health care systems and hospitals in more rural areas. Think about Oswego. You think about Watertown, there's a lot of them nearby Syracuse.

And the idea was to have those hospitals sponsor a residency spot. Essentially, they pay for a resident to get trained, with the understanding that after they're trained, they can come and work at their hospital.

Host Amber Smith: And so how many rural hospitals so far have funded residency positions like this?

Justin Meyer, MD: It started before I began, but I believe it's on the order of at least 10 or so different sites. So it's a number of different hospitals, and each year we're growing, and there have been more and more sites. This upcoming year, starting in July, we're working with two new sites we haven't worked with and one we previously have.

Host Amber Smith: So do the rural facilities have any obligation to do the selection process? Do they help you choose which resident is going to be placed in at their location?

Justin Meyer, MD: Yeah, they absolutely do. We meet, as a residency, we help figure it, curate that list, and then we bring it forward to them and say, here are the people we think would be great for the program. What do you think? And then they certainly have essentially final say, since they're the ones that are going to be working together for the long haul.

Host Amber Smith: How popular are these residency slots with the new doctors that are looking for residencies?

Justin Meyer, MD: They're increasingly popular. So in the beginning, it was tough, but it's been getting in some ways easier to recruit for them. There's a lot of factors that go into that, and I'm happy to expand if you like.

Host Amber Smith: I do want to get into that. Now just getting a little bit ahead of things, the program's about 7 years old. Does it seem to be working?

Justin Meyer, MD: Yeah, it does. So we've had a number of residents that have graduated, five have graduated so far, and all work in rural areas.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Justin Meyer, an assistant professor of psychiatry and behavioral sciences, about a program designed to increase the number of psychiatrists working in rural areas.

Let's talk about the residency training at Upstate, which is four years, is that right?

Justin Meyer, MD: Yeah, that's right. So within psychiatry, residency typically is four years. If you're interested in doing child psychiatry, you can shorten it to three and then do an additional couple of years for further training.

Host Amber Smith: Now, how does this work with the rural partnership residents? Do they do the same training as the students that are in downtown Syracuse?

Justin Meyer, MD: Pretty much, so about 20% of their time is a little bit different. So we designed it to really be about getting the same academic, city experience, with a little bit, about 20%, of the time, they wind up going to those rural sites.

And why did we settle on 20%? Well, the thought was, this way they can get familiar with the rural site, make sure they're comfortable there, and also they're interested in doing rural psychiatry. They're in it for the long haul. So why would we withhold that completely? At the same time, we wanted to make sure they had a really thorough training at our site, which we know and love and are comfortable with, and so that accounts for 80% of their training.

Host Amber Smith: So do they live typically in Syracuse and commute to the rural area, or do they live in the rural area and come downtown on occasion?

Justin Meyer, MD: I would say that a majority wind up living in Syracuse and then commute to the rural area. But we've had it both ways.

And it's interesting as they get more comfortable with the rural site, so in the second or the third and fourth year of their residency, that's when we start seeing them move closer to the rural sites, knowing that that transition is coming up.

Host Amber Smith: So the transition, after they complete their residency, they stay for what, five years at least? I mean, they could stay permanently, I guess, at the facility, is that right?

Justin Meyer, MD: Yeah, the agreement is basically to pay back the time they've been in residency. So about five years after, they wind up working, at least, at the rural site.

Host Amber Smith: So they're an attending, a staff member, of that hospital or mental health facility?

Justin Meyer, MD: That's correct. Yeah.

Host Amber Smith: Now getting back to the overall shortage of doctors, I understand, nationwide, there continues to be a lot of interest in medical school. Are adequate numbers of students entering medical school with the thought of going into mental health care, becoming psychiatrists?

Justin Meyer, MD: One thing that we've done really great in this country is increasing the number of medical students, and we've done this through a number of different streams, both expanding it from MDs to DOs (doctor of osteopathy) to people from outside the country as well. So we actually have a number of people that are ready for residency.

Unfortunately, there hasn't been a commensurate increase in the number of residency slots, which is part of why we really needed this program.

Amber Smith: So there is interest, but because we don't have enough slots, well, your program kind of addresses that by adding slots, right?

Justin Meyer, MD: That's right. So, historically, these slots have been paid for out of Medicare, and still a vast majority are.

But this, part of what we were excited about with this program and what we wanted to share, was that this was a new way of funding those slots, sort of a combination of public and private funding in order to help pay and educate and ultimately get more doctors into more areas.

Host Amber Smith: What would you say to a person who's interested in the field of psychiatry or mental health?

What is gratifying to you as a provider? Why would someone want to choose this line of work?

Justin Meyer, MD: I thought a lot about this question. I mean, I can't imagine doing anything else, so you're going to get a little bit of a biased stance, but I really love what I do, and if you're interested, I think you should pursue it. You get to see patients that are incredibly ill go from, for example, not being able to eat, drink, take care of themselves, to being back to normal, functioning at very high levels. We're talking about doctors and lawyers that have become so severely depressed, they can't do anything. And you really can see them get much better. And one of the perks of psychiatry is you actually get to be a part of that change and see it happen right before your eyes.

Host Amber Smith: How would you advise a medical school graduate to go about selecting the right residency for them?

Justin Meyer, MD: You've got to know yourself and take it one step at a time and figure out all that. Typically, a lot of students come to me and ask, should I do psychiatry? Should I do emergency medicine?

And there's no one size fits all. One of the best things about medical school, one of the things that I remember enjoying the most, is it's pretty unique. You get to try out all the different specialties and see what one fits, and you'll know when you're in the right one. You'll feel pretty much just at home.

Host Amber Smith: Why would doing a rural residency appeal to someone?

Justin Meyer, MD: Well, I think for a lot of reasons. There's been increasing interest in serving the underserved across this country, and certainly the rural areas are decreasingly served, or more underserved, and so I think there's been a great deal of interest in making sure that we serve these communities that are in need of our help.

Additionally, because of that, you're going to get a lot of grateful clients that you're there and that you're able to help them. So those are a couple of reasons.

Host Amber Smith: Do you ever encounter someone who's a little hesitant about going into a rural area? What do they find appealing once they get there?

Justin Meyer, MD: I think the most common thing that people enjoy when they are there is the access to the outdoors.

I'm originally from New York City myself, Manhattan specifically, and coming back to Syracuse where I went to medical school, I really appreciate the fact that I can go 10 minutes in any direction and feel like I'm in a different part of the planet and in a really rural community.

And it's really nice to see, and I think many of our rural residents share that interest. It's also a part of being that community. You really become an integral part of that smaller community in a rural site. That's been a real great thing to see.

Host Amber Smith: I know a lot of people that sort of pine for the small-town lifestyle and values, and there you have it, all around us in all of these rural communities, it seems like.

Justin Meyer, MD: Yeah, I think so.

Host Amber Smith: Well, thank you so much for making time for this interview, Dr. Meyer. I appreciate it.

Justin Meyer, MD: Absolutely. It's been a pleasure. Thank you for having me.

Host Amber Smith: My guest has been Upstate psychiatrist Dr. Justin Meyer. I'm Amber Smith for Upstate's "HealthLink on Air."

Should you see a doctor of family medicine? Next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

Many specialties in medicine are tied to a particular organ or disease, but doctors of family medicine are specialists who are qualified to treat a range of illnesses and provide comprehensive health care to people from birth into the senior years. Today I'm talking about family medicine with Dr. Sana Zekri. He's a doctor of family medicine at Upstate.

Welcome back to "HealthLink on Air," Dr. Zekri.

Sana Zekri, MD: Thanks for having me. I love talking about family medicine.

Host Amber Smith: Well, let's start by talking about the education of a family medicine doctor. Medical school is typically four years, right?

Sana Zekri, MD: That's right.

Host Amber Smith: How soon do people know that they want to practice family medicine?

Sana Zekri, MD: Some people know before they go into medical school that they want to be a family medicine doctor. Others, it takes them time to figure it out. They need to get exposure to all the types of medicine and decide which one is the right type for them. In general, you have to choose your specialty in your fourth of because that's when we apply for our specialty trainings, called residency.

Host Amber Smith: Why did you choose this specialty?

Sana Zekri, MD: Well, I went into family medicine because somewhere along the line in medical school, I started to feel that there was a double standard between men and women. It seemed like men were able to go to a single doctor for their primary care needs, but women were more likely to be told that they needed to see both a primary care doctor and a gynecologist for their woman organs. And that seemed kind of ridiculous to me. Half the population is women, and they were frequently being told that they needed to see a separate doctor for their basic needs. And that was what really drew me to family medicine instead of other specialties. I wanted to be able to provide basic care to everybody, at every point in their life.

And I also really love delivering babies and taking care of the children after the baby was delivered. And that's a unique thing to family medicine. We take care of pregnant women, and then we take care of the whole family afterwards. That's just really special to me, to see families growing under your care, watching the development of these children to have their own personalities. It's magic.

Host Amber Smith: So tell me about your family medicine residency. What, what was that like? How long does it typically last?

Sana Zekri, MD: So, typical family medicine residencies are three years. Some family medicine programs are four years. And if you do a fourth year, you usually get extra specialization in some particular field of family medicine. I did a four-year program. I did three years of general family medicine and then one year of family medicine with obstetrics, where I did more training in what I would call medium risk obstetrics. That's pregnancy care.

Host Amber Smith: Since we're speaking about primary care, is a GP, or a general practitioner, is that the same thing as a family medicine doctor?

Sana Zekri, MD: That's a really good question. So a general practitioner is an older type of doctor. They're actually pretty rare now. These were doctors who only did one year of training after medical school, and then they started to practice. Family medicine as a specialty was actually created because there were concerns that general practitioners didn't have enough experience in primary care prevention and care for broad populations to be really effective. So general practitioners still exist, but they're much less common than they were in the later half of the 20th century.

Host Amber Smith: I understand family medicine -- you do some pediatrics, and you do some obstetrics and gynecology as part of family medicine -- what is the difference between family medicine and internal medicine?

Sana Zekri, MD: The biggest difference between family medicine and, really, all the other primary care specialties is the emphasis on the full life spectrum care. Internal medicine tends to take care of only adults, and they may be less likely to do standard screenings for women. Pediatrics only takes care of children. And obstetrics and gynecology only takes care of women in both pregnancy and after pregnancy. But family medicine has the capacity to do all of it.

Host Amber Smith: Can you tell me about the range of things you might do on a given day?

Sana Zekri, MD: On an average day, I might go to labor and delivery to do a c-section, and then I might help with a newborn resuscitation on another baby. And then I have my clinic session where I take care of newborns, children, pregnant people, and older adults in various states of health. And the reason that I can do this is because I did extra training, called a fellowship, to get extra competency in something called maternal child health. So in my fellowship, I gained the competency to take care of some moderate to high risk pregnancies and to do uncomplicated cesarean sections. And I also got more experience in care of newborns and comprehensive family planning.

Host Amber Smith: With medicine being so complicated these days, how can a family medicine doctor maintain confidence in the care of babies, teens, adults, seniors. How do you stay current with everything that's going on with everyone?

Sana Zekri, MD: Yeah. All fields of medicine are constantly expanding. And physicians are constantly learning. This is even more important for family medicine because of the scope of patients we take care of. This is made easier for us through curated articles and podcasts that bring together the most consistent and evidence-based data to help inform us of changes in practice as they come up.

But mostly it comes down to learning new guidelines and learning and taking large sets of data and putting them together to know what to do for the patient that's in front of you. There's a lot of changes that happen in medicine on almost, it seems, a day-to-day or week-to-week basis, but not all of those changes matter in the long term. Sometimes you have to wait for all of the information to come together to render a good opinion for what you need to do for all of your patients.

Host Amber Smith: At what point might you send a patient with a heart ailment to a cardiologist, or a patient with diabetes to an endocrinologist? Do you use other specialists to help?

Sana Zekri, MD: Absolutely. And a natural question might be, why do other specialties exist, if family medicine does everything? These other specialties must have something that family medicine doesn't. And that is true. Family medicine is very good at doing preventive care and managing common problems. We're very good at identifying when something is wrong and doing the first steps to fix it, and sometimes we need to get experts in other specialties involved if we don't feel comfortable addressing it all on our own.

So, for example, I would feel very comfortable taking care of most patients who have type 2 diabetes and most patients who have high blood pressure and high cholesterol, and maybe even heart failure and asthma and COPD (Chronic Obstructive Pulmonary Disease.) And that's what most people have problems with. But if it gets to be beyond my realm of expertise, if a patient doesn't respond to the common therapies. If a patient is progressing in their disease, despite my best efforts, at that point, I'm bringing in a specialist to help me with the most cutting edge information and with the things that I may not know, the things that are relevant to just their specialty.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with doctor of family medicine, Sana Zekri. He's an assistant professor at Upstate, and we're talking about the role of family medicine in America's healthcare system.

Now, depending on what insurance coverage a person has, they may have to choose a doctor from a list of practices within a particular network. What could a patient do to determine if they're going to like a doctor's philosophy or style of practice?

Sana Zekri, MD: Well, personally, I want patients to feel like we are on a team for their health and that they're active members of the team. And I want them to know that we both have the same objective, which is keeping them as healthy as possible.

Most commonly, I hear from patients that they want to feel heard and they don't want to be talked down to, and I think it's important to know that. Just because your doctor is nice or easy to talk to doesn't mean that they're practicing evidence-based medicine, but still, it's hard to want to listen to someone who you don't feel gives you the respect you deserve as a person.

I don't think there's anything wrong with going to a doctor's office and giving the doctor a few appointments to see if their style fits what you're comfortable with. And don't be afraid to voice your concerns with your doctor. If you're afraid to do so or if you feel dismissed, maybe you need to consider a change in doctors.

Remember that a doctor's job is to give you their best medical advice, and they should package it in a way that's understandable to you. You may not agree with their medical advice, and that's okay. . You should choose what you do and don't do with your body. But remember, they're still trying to give you their best medical advice and trying to keep you healthy.

Host Amber Smith: So, do family medicine doctors want patients to see them as someone who will be taking care of them their whole life?

Sana Zekri, MD: Absolutely. Family medicine doctors are kind of a part of the family. We want our patients to come to us at different phases in their lives and to bring other members of their family to be a part of that practice. We want to see families grow and unfortunately, we will also see members of families die. It's part of this amazing care that we can provide, that we can see people from the very beginning until the very end and be one of the constants there.

Host Amber Smith: How often do you find an issue, a medical issue, in a patient that you also end up treating in their family members? Because a lot of diseases run in families, right?

Sana Zekri, MD: I would say it's important to keep track of a person's family history. I don't particularly see it that often, that there's something in one family member that I proactively find in another family member. But in the situations where I do find it, I'm usually very glad that I'm taking care of more than one member of their family because it's easy to explain everything.

Host Amber Smith: How would you advise someone to prepare for their first visit with a new family doctor that they're going to see?

Sana Zekri, MD: It's important to know your family history, to know about what has happened in your family, what illnesses people in your family have had. If you have a family history of cancer, it's important to know what type of cancer and at what age your family members were diagnosed with those problems. It's also important to know what other problems you've had from childhood or in adulthood, what surgeries you've had. Having that information is really, really meaningful and helpful.

It's also really important to be open and honest with your doctor, and you have to be comfortable being open and honest with your doctor. Remember, your doctor's not there to judge you. Your doctor wants you to feel safe talking to them. If you have a condition that's sensitive or something that's a health problem that's sensitive, your doctor wants to know about that so that they can help prevent any problems from coming up from those health conditions.

Host Amber Smith: Well, Dr. Zekri, thank you for making time to tell us about family medicine. I appreciate it.

Sana Zekri, MD: Thank you for having me.

Host Amber Smith: My guest has been Upstate doctor of family medicine Dr. Sana Zekri. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air," why might baby food contain lead?

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

The Food and Drug Administration is seeking to set a maximum limit for the amount of lead allowed in some baby foods. Here to help us understand why this matters is Dr. Travis Hobart. He's an assistant professor of pediatrics and of public health and preventive medicine at Upstate and also serves as the medical director of the Central/Eastern New York Lead Poisoning Resource Center.

Welcome back to "HealthLink on Air," Dr. Hobart.

Travis Hobart, MD: Hi. Thank you for having me.

Host Amber Smith: Now, why is there any lead in baby foods?

Travis Hobart, MD: So, that's a great question, and I think it may come as a surprise to a lot of people when they hear that there's lead in their baby foods. The lead really comes from the environment in which the food was grown or the way that the food was processed to become baby food.

For instance, if the food is grown near a place where there used to be lead paint or lead gasoline that got into the soil, then sometimes the rain may wash some of that lead into the soil where the food is grown, and so you may see contamination that way.

Host Amber Smith: Is there any way to tell which foods contain the most lead? It sounds like, I mean, where ...

Travis Hobart, MD: Yeah.

Host Amber Smith: ... where they're grown would be, you'd need to know that first, I guess.

Travis Hobart, MD: I guess I would say there's no practical way, looking at a piece of food, to tell how much lead is in there, if there's lead in there, how much is in there, in the spur of the moment.

But in general, we know that certain foods are more likely to contain lead than others, so probably the things that contain the most lead are the root vegetables, and a lot of that is just because they are in the soil, right? And so, if there's lead in the soil, the carrot, for instance, or potato is touching that soil, and so you might have some lead on the surface of it.

And the good news about that kind of lead is you can wash it off, before you cook the vegetable, or if you peel the vegetable, that would peel that off.

Unfortunately, some of those vegetables do absorb a little bit of the lead, too, in the roots generally, but that's a pretty small amount, and, hopefully, that can be limited by good farming practices and obviously trying not to plant in soil that's heavily contaminated.

In general, the leaves and fruit of plants grown in lead are not as contaminated, so while it may be absorbed into the roots, usually that's where it stops, so the lettuce or the tomato don't have nearly as much lead, if any at all, really, and most of the lead in those situations might come from, again, contamination that they're dirty when they're processed -- the soil gets on them during processing.

Host Amber Smith: What about other metals that may be found in the soil: arsenic, cadmium, mercury? Is there equal concern about those turning up in baby food?

Travis Hobart, MD: There is also concern about those, and those have a different set of health risks and different levels that show up in the food.

Probably the thing that has received the most press and also is the highest contaminant, in baby foods anyway, would be arsenic. I know there's a lot of talk about that over the past few years, about arsenic and rice. Typically, arsenic is found in rice. When people test baby foods, that's the main source.

And again, the reason that arsenic is in the rice is often because of the area that the rice has grown. and because arsenic is commonly found in groundwater sources, and rice is flooded -- as you may know -- rice is flooded during the growth and harvesting process, so a lot of water gets on the rice, and if there's arsenic in that water, it can get it on the rice, and it also can be absorbed by the rice. So that's one of the major other sources of the major other heavy metals that we sometimes find in baby foods, is in those rice cereals.

We're talking about FDA regulation. In addition to lead, there's been regulation on arsenic and trying to reduce the arsenic in rice, and there has been some reduction over the past few years of that.

In terms of cadmium, again, that's often washed from industrial uses, washed and runoff and that kind of things, gets into the soil, where it can soak through the soil and be taken up by plants. It's a little bit less likely to be in plants than either lead or arsenic, so I'd say it's less of a concern. But the thing that might be more of concern is that it can actually be taken up by the plants more readily than some of the other things, so into the leaves of your lettuce or something like that.

And then finally, mercury. The primary concern for mercury that people may have heard about is in fish. And that mercury actually, believe it or not, comes from burning coal primarily, so those coal-fired power plants, in addition to producing greenhouse gases and warming the planet, are also putting mercury into the atmosphere that then settles on the surface and in the water and primarily gets taken up in fish. And so that's often where you get exposed to that.

So most baby foods, per se, wouldn't have as much mercury because most baby foods are not fish. But if you were feeding your baby fish, you'd want to just be a little bit careful about which kind of fish you used. And the ones with the highest contamination of mercury are the tuna fish and shark and swordfish. There are resources online that tell you which fish might have mercury.

One other thing to be aware of here in Syracuse is that there is some mercury in Onondaga Lake, so you probably should not be eating fish, and especially certain types of fish, caught in that lake. And certainly if you're a child or a pregnant woman, you should definitely not eat any of the fish from that lake.

Host Amber Smith: So if you are a consumer at a grocery store, though, looking in the baby food aisle, or, I guess, anywhere in the store, is there any way to tell whether that particular jar contains food that has lead or unsafe levels of lead in it?

Travis Hobart, MD: There's not a good way to tell when you're looking at the food in front of you, which is what I think is a frustration for many parents when they hear this kind of news, that there's lead in the baby food, and there's no way to know what's there in front of you.

Probably the best recommendation I can give is to give your baby a variety of foods. Because as I was saying, that a lot of the lead is found in certain foods, but not as much in other foods. So even if you're giving your baby carrots some of the time that may have lead in it, you're going to give them apples and pears and other foods, broccoli, et cetera, that wouldn't have lead in it or much less likely to have lead in it.

So I think just using a variety of foods is kind of the key to minimizing exposure.

Host Amber Smith: Does organic, does the label organic, mean anything with regard to lead contaminants?

Travis Hobart, MD: No, not really, and I don't want to discount the idea of an organic food. Organic food has a certain meaning, and it certainly may have benefits. I'd say primarily those benefits are environmental. There are maybe some health benefits. You certainly reduce your exposure to pesticides and herbicides. So I think there's the health benefit there, too, for organic food, but in terms of lead, the organic label doesn't really seem to make a difference because that contaminated soil can kind of be anywhere.

So whether it's an organic farm or a conventional farm, it's not going to necessarily change whether lead was nearby and then contaminated the food.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with pediatrician Travis Hobart about lead in baby food.

The Food and Drug administration was estimating that new guidelines could reduce a child's exposure to lead by 25%.

Would that be an appreciable difference?

Travis Hobart, MD: Yeah, I think so. Of course, a child's exposure when you're talking about percentage is going to depend on what other sources of exposure they might have as well, but certainly if you're reducing it by 25%, that's going to make an appreciable difference, I would think.

But it is, like I said, it's contingent on where else they might be being exposed. In particular, while I'm concerned about lead in baby food, and I want to reduce the amount of lead exposure to all children, I think the primary source of lead exposure in kids is from their homes, from the paint in their homes, and in older homes, the paint from before 1978.

So if you have a kid that's living in a heavily contaminated home, then the percentage of lead that they get from their baby food is going to be much smaller, probably, than the percent that they would get from exposure to that lead in their living environment.

So certainly, it's important to reduce that in the baby food, but I think on those sort of individual levels and as a society, we should be also focused on reducing the lead in indoor housing and paint.

Host Amber Smith: Well, let me ask you if we can talk a little bit about why lead is so dangerous for children in particular. Why is it a problem or a concern?

Travis Hobart, MD: Lead is a brain toxin, essentially, so it causes problems. When a child is exposed at a young age, and when an adult is exposed, too, it damages parts of the brain, and we're much more concerned about kids being exposed because their brain is rapidly developing.

So during that rapid development process, if a child is exposed to lead during that process of brain development, they may have long-lasting effects from that lead. Those effects typically are seen in later years, during school, for instance, when children may have trouble with attention or trouble with behavior. They may affect how they're able to learn and how they're able to succeed in school and in life.

One of the major effects that we see is sort of what we call "executive function," which is your ability to make decisions and decide what to do with your day or with your life, et cetera. And so we know that kids exposed to lead at a young age are more likely to commit crimes, for instance, as teenagers, and the young women are more likely to get pregnant as teenagers if they've been exposed to lead in childhood. And we think there's some connection there, that maybe decisions that they're making are less considered because of that lead exposure as a young child.

Host Amber Smith: So it sounds like some of these young children who are exposed to lead, you don't find out about that until they're older. Can you reverse the damage that's been done?

Travis Hobart, MD: The damage is actually very hard to reverse. Some of it may be reversed if we identify it early and take away the lead exposure, because the brain is going through that rapid development.

They may be able to reverse some of it, but much of it is permanent. And the data on reversing it is all very new and sort of not established, so generally we think of this as being a permanent problem. And it is true that we often don't know at the time when a child is exposed.

Now, fortunately, in New York state, the law is that all children at age 1 and 2 are supposed to be tested for lead poisoning, so they're supposed to get a blood test to make sure if they've been exposed, because usually there are no symptoms. You wouldn't look at your 1-year-old and say, oh, I think he's been exposed to lead because I can see whatever. There's not a symptom of lead exposure, which is why your doctor should be testing your child, at age 1 and again at age 2.

Host Amber Smith: So if a child does the blood test at age 1 or age 2, and if the results come back and show lead poisoning, what's the next step?

What does the pediatrician do with that information? Is it too late to help, or is that why you have the test at that age, so that you can intervene?

Travis Hobart, MD: I'd say the question of "Is it too late to help?" -- I think no, it's not too late. I think, unfortunately, some of the damage may be done and may be not able to be fixed, but we can prevent future damage.

And so, for instance, if you see a child at age 1 that has a level of 4 or 5 or 6, we often see that those kids, as they grow and develop and explore their world further as they go from being age 1 to age 2, we sometimes see the level go up, so it may be 6 at age 1, and then at age 2, it's 25 or much higher.

The important thing is, when we do see that high level, and that's why we're so on top of it and the Health Department is involved, that's when we try to make sure that the child is not exposed further. So we've got to remove any lead exposure from the environment as best we can or remove the child from the environment by helping the family move to a new environment, so that either the lead in the environment is fixed, or we're able to get the family to another living environment, where they can be safer.

And, like I said, any kid that has a level above 5, that's going to trigger the Health Department to come to the home and do an inspection and look for those sources of lead and help the family or the landlord know how to repair them or mitigate them.

Either replace them or paint over the areas that are a problem, to fix them so that the lead is contained or removed from the home, and the child is no longer exposed.

Host Amber Smith: In your role as medical director of the Central/Eastern New York Lead Poisoning Resource Center, what concerns you about Syracuse in particular with regard to lead exposure?

Travis Hobart, MD: The biggest concern I have in terms of Syracuse is that it's an old city, and a lot of the housing was built a long time ago. We know that if the housing was painted before 1978, which much of it was because much of it was built in the teens and '20s and '30s (of the 20th century), then those environments are much more likely to have lead at some level in the home.

And unfortunately, we see that there's a disparity here, as well. So, in a home that may be a rental home, maybe the landlord and/or the tenant don't have the money, the resources to fix the wall when the paint is breaking down and deteriorating, then that lead that's buried deep in the paint layers and the wall can come out and settle to the floor, as dust, usually, and children can be exposed in that way.

So, those older homes, and especially those homes that may be in disrepair because of poverty, those are homes that are much more concerning.

And the other thing that I would mention, too, is that, unfortunately, some of this is created by our systems that have oppressed certain populations over in the past. So some areas of town back in the '30s and '40s, the banks wouldn't let a black person get a loan to live in a nice part of town. They were only allowed to get a loan to live in certain parts of town, so there was really overt racism there that meant that certain types of people could only live in certain parts of town. And, unfortunately, that meant that those areas of town didn't get the money, didn't get the resources to improve the housing over time.

And we still see those disparities now. Those parts of town are more likely to have limited resources. Those houses are less likely to be maintained well, and the kids there are more likely to have lead poisoning. So we have this legacy of historical racism that has led to kids today being poisoned by lead.

Host Amber Smith: I saw recently data said that 12% of black children had high levels of lead, compared with just 6% of white children. Is that the disparity you're talking about?

Travis Hobart, MD: Yeah, that's exactly right. And because of that racism, the history of who was allowed to live in certain parts of town back in the '30s and '40s by the banks, the banks and the government sort of colluded to make sure that the city looked in a certain way.

And so black children are much more likely to live in those parts of town even today. And those parts of town have less resources to repair the homes and make sure that they're safer for children.

And we also see that there's a disparity. In terms of the racial disparity, black children are more likely to be exposed, as you mentioned. There's also a disparity the further you get from Syracuse; out in Onondaga County as a whole, the rates go down the further you get from the city, again, because of differences in resources available. Those homes tend to have been built later the further you get out of the city and also tend to be people that are more well off and more able to repair the home and put resources into the home.

Host Amber Smith: Do you know what percentage of kids have an unsafe level of lead in their blood in this area of Central New York, and then how that compares statewide?

Travis Hobart, MD: In the city of Syracuse, it is about 11% of children that have an elevated lead level. In the county as a whole, it's down to about 6%, and actually I'm blanking on the number for statewide right at the moment, but what we generally see is that it is a localized problem in that most of the kids that we see with lead poisoning are in the cities, where, again, the housing is older, there's less resources to repair the housing. They're more likely to be renters as well, because the landlord may not be as attuned to the repairs as a homeowner might be, or attuned to the needs of the tenant as a homeowner might be.

But we generally see that across the state. Syracuse is similar to the other major cities across the state: Buffalo, Rochester, Albany -- they all have this same problem. New York City certainly has this problem.

Some cities have made a little more progress in recent years, I think. Rochester's a good example, that changed the laws a number of years ago, to make landlords more responsive, to force landlords to be more responsive to lead issues.

Syracuse has been working the past couple years to really put laws into effect to do that, so we see when you look at Rochester compared to Syracuse, you see a little bit of a decrease in the number of kids with lead poisoning because of some of those laws. But Syracuse has actually been working, working very hard in the last few years, to really address this issue.

Host Amber Smith: So if I understand correctly, the majority of kids with lead poisoning today come from living in houses with lead paint. Is that how most of them are, being infected?

Travis Hobart, MD: Yeah, that is most of the kids that we see. When the Health Department finds the source of lead, it's due to paint in the home. The most dangerous parts of the home are, the Health Department would tell you, are windows, doors, porches and floors. Those are the places that, most often, the paint is broken down, the moving parts of windows and doors or people walking on a floor, a porch being outside in the elements. Those are places where the paint breaks down more quickly, and the lead paint is more likely to surface.

Host Amber Smith: So, can you safely cover old lead paint with new paint, and that takes care of the problem entirely?

Travis Hobart, MD: Yes.

I wouldn't say it takes care of it entirely, but it takes care of it for a time, anyway. And there are even products that are really made for that, paint that is meant to really block the lead and keep the lead inside the wall.

And the Health Department can help with identifying those products and even sometimes, depending on the situation, sometimes providing some of those products to families to help them fix it. but even regular latex paint will cover it up to some degree.

But that said, anytime we're covering it up, it is a good solution, and it's an affordable solution. So it's good. It's worth doing. But it is also a temporary solution. Three, five years down the line, especially if you have kids that may be doing what kids do and damaging paint or horseplay and that kind of stuff, the paint may break down again, and it may need to be redone down the line.

In an ideal world, when we have this situation, in an ideal world, we would want to remove the lead, but obviously that's much more expensive and much more time-consuming, so it often isn't a viable solution.

Host Amber Smith: We talked about some of the effects of lead poisoning later in life and the impact on executive functioning. Medically, does the fact that you were lead poisoned in childhood have an impact on your cardiac health or your cancer risk, later, as an adult?

Travis Hobart, MD: Yes. I mentioned the sort of neurologic effects, the developmental effects, of lead as the ones we're primarily concerned about, especially in childhood. But you're correct. There are other effects of lead. So it does seem to be associated with some cancers, particularly like the gastrointestinal tract or the urinary tract cancers.

It also seems to affect the kidneys, and that can lead to high blood pressure, so there's definitely an impact on high blood pressure that's been determined in more recent years. So that seems to be a concern for people that may have been exposed in childhood that are now adults, wanting to make sure their blood pressure's under control.

And then also, sort of more acutely in childhood, but it can cause anemia, which is a problem, and also affects the child's growth and development, as well.

It's definitely got other effects besides just the learning and developmental effects that we see.

Host Amber Smith: I know community leaders are aware of this and working on it, and the county Health Department is involved. Are there other things that need to be done to rectify this at this point?

Travis Hobart, MD: There are several groups, and I'm part of a coalition of many of these groups that are working together to address this issue.

A couple of the things that we're focusing on, and actually the county executive has recently set aside a lot of money to help do some of these initiatives.

So I would say there are a few steps in the process that we're working on, I guess the most important being the sort of primary prevention to prevent a kid from being exposed, ever. So the way that that's happening is, we're working to try to make sure that more people, more construction workers and contractors, are trained to identify lead in a home and fix it in a safe way. And hopefully, as more housing gets repaired and renovated and rebuilt, we'll see less lead in the environment. So that's one thing that we'd like to see.

Kind of tied to that is some of the laws I mentioned earlier about making sure landlords are more accountable when lead is found in the home, to making sure that the landlord has an incentive to fix it. And that there's some punishment associated with not fixing it and making sure that punishment is enforced.

And also making sure that we're testing the houses more frequently.

And then also there's a lot of loans and grants available to landlords and homeowners that helps them pay for those repairs. There's federal government money now and some more local money that's been put into this problem to be able to fix the problem.

The next step that we work on is, even though it's required to test all children, we see that not all children are getting tested, so trying to identify ways where we can make sure that:

A -- doctors know that they're supposed to do the testing,

B -- that patients are able to get tested when it's recommended by the doctor.

And so, sometimes that means making sure that the testing is easily and readily available at the doctor's office or near the doctor's office, so they don't have to go to yet another place when they have busy lives and other children to care for.

The Health Department is going to, sometime, probably this year, institute some kind of mobile testing unit. That was part of the money that the county executive put aside to help make that more feasible for people to have the Health Department do testing in the community or testing at other locations.

And then finally, the other piece that we need to do is make sure that these kids that are exposed get the resources they need to succeed in life, even if they've been exposed, because we don't want to leave those children and those families hanging by not providing the help that they need to succeed. Because again, there are effects of lead poisoning that are permanent, but it's not a death sentence. Those children are still able to succeed and still able to be functioning and happy members of society.

We don't want to just leave them hanging, so making sure that they get appropriate developmental assistance, preschool and school education, et cetera, is really important.

And one of the other things that the Health Department is going to institute, based on a program out of Buffalo called Lead It Go, is to try to get families who've been exposed those developmental resources immediately, before the child necessarily shows any signs of developmental delay, but to get the resources immediately so that those problems can be identified immediately.

Host Amber Smith: Well, Dr. Hobart, thank you so much for your time.

Travis Hobart, MD: You're welcome. It's been a pleasure.

Host Amber Smith: My guest has been Dr. Travis Hobart. He's an assistant professor of pediatrics and of public health and preventive medicine at Upstate, and he also serves as medical director of the Central/Eastern New York Lead Poisoning Resource Center.

I'm Amber Smith for Upstate's "Health Link on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Liana Meffert graduated from medical school last May. She is currently a resident in emergency medicine in Washington, DC. She sent us a poem, "2:23," which captures the drama of an unsuccessful resuscitation and tells us how the true story is never really known.

"2:23"

Bullets are funny things,

that something so small can

hurt so much.

His phone keeps ringing,

hardly heard over the rhythmic thump

of the machine forcing blood

through his heart.

If you ask nicely,

I'll spoil the end for you,

if that's what you want.

The end of the story

is the bullet was never found,

though we hunted for one nestled

in the crest of his clavicle

& other places -- we searched

for an answer to save us all.

His phone keeps ringing:

a second life he's left

hanging on its cradle

above the kitchen sink,

backdrop of peeling wallpaper,

a story, a cord,

wound around a finger.

Here, the pressure's dropping:

his heart a heavy slab of muscle

with no dance.

Attending says it's time to call it

like a promise with an end.

Everyone steps away as

the room eats itself whole.

A towel is placed over his eyes,

heavy blanket over his body,

blood & epi still hanging high.

Someone keeps calling.

The end of the story

is the bullet was never found.

The phone rings:

a plea of a song

we don't dare answer.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," who needs hepatitis B testing?

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink On Air" is produced by Jim Howe with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.