Storm Clouds Parting

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Wrapped in three blankets, beads of sweat on her forehead, she shivered, sat up, laid down, and rolled over in a futile attempt to find comfort. An emesis bag in her shaking hand, she looked up from her sunken eyes and said in a soft voice, “I can’t go on living like this…. I need to do this for my kids.” A year ago this young woman had an operation and was prescribed oxycodone; her postoperative recovery was complicated which resulted in more pain medications. Then she had dental work done- more pain pills. Meanwhile, the oxycodone helped numb difficult feelings from stressful life events. She soon found if she did not take them, she felt terrible. When doctors became reluctant to prescribe the medications, she bought them on the street. The pills were expensive- heroin was cheaper. She never intended to become addicted; she never thought it could happen to her, but it did.

My patient is not alone: America is in the midst of an opioid epidemic. Addiction to prescription opioid drugs (oxycodone and hydrocodone, for example) and heroin is at a record high and continues to increase. There are currently 2 million Americans addicted to pain medications and 500,000 addicted to heroin. Every day 90 to 100 people in our country die from overdose. The number of people addicted to opioids each year continues to rise, and there does not seem to be an end to the epidemic in sight. It is as if there is a dark storm cloud over the country, a cloud we all wish would just go away so we can see the sun again.

To add to this gloomy predicament, the majority of those addicted to opioids are young, typically in their 20s and 30s, and there is often no cure for this disease. Addiction to opioids is a chronic disease, characterized by remissions and relapses over a lifespan.

Just as there is no simple cure for opioid addiction, there is no one solution to reverse the current epidemic. Solutions to our opioid epidemic will take time, persistence, and a variety of interventions over many years. We need the help of the companies who make the medications,  healthcare providers who prescribe them, and you, a potential recipient of pain medications. Here are a few ways in which we can all work towards ending this epidemic:

1. Pharmaceutical companies should stop heavily marketing the symptom of “pain” and their prescription pain pills. Historically the pharmaceutical industry has successfully popularized medical problems through advertising when there is a drug to sell, be it for insomnia, erectile dysfunction, or low testosterone, for example. The stakes are too high to push treatment of pain with opioids.
2.  Doctors, physician assistants, and nurse practitioners have to reduce the number of prescriptions they write for opioid medications. Since 2010, the number of opioid medication prescriptions written in America has steadily declined, which is terrific news. Despite this trend however, healthcare providers in America currently prescribe four times as many opioid medications as doctors in Europe. Having more pain pills in circulation enables more people to become addicted to them.
3.  Patients who receive prescription opioid medications need to be more careful with these powerful medications. Research has shown that 57% of people who become addicted to opioids begin their path of addiction after having first received opioid medications from family or friends. If you are prescribed pain pills by your doctor, do not share them with others. In addition, store unused medications where they cannot be stolen, or better yet, dispose of them.
4.  Communities need to de-stigmatize opioid addiction. Addiction is a disease, not a moral failing. Like the young woman I have described, people who become addicted are our neighbors and our friends’ children. It is important to acknowledge that anyone can become troubled by opioid addiction and that everyone needs our support.
5. If you or someone you know becomes addicted to opioid medications or heroin, there is help in the form of “medication assisted treatment.” Buprenorphine, or “suboxone,” is a medication that doctors can prescribe in an outpatient clinic setting that enables a person to live a normal, addiction free life. These medications help but can be expensive; tell your representatives in government to support policies that fund opioid addiction treatment. In addition, to be allowed by the FDA to prescribe Suboxone, physicians must complete an eight hour trianing course that can be done at a live conference or online. Encourage your healthcare provider to pursue training in order to prescribe this life changing medication.

Ending America’s opioid epidemic will take time and action in a variety of ways. Reversing the epidemic will require efforts from pharmaceutical companies, our government, healthcare professionals, as well as individuals such as you. It will truly take a concerted effort. We are all in this together.

My patient received her first dose of Suboxone that day. An hour later she was no longer shivering, perspiring or vomiting. She looked exhausted, but relaxed. “You look a lot better, I commented.” She looked up at me and wearily replied, “At least I don’t feel like I’m dying anymore.”

The following day she returned to the clinic for follow up. I entered the room to see a happy and extremely grateful young woman; she smiled and said, “I feel normal now.” Her skin had a rosy color and was bright with light. While my patient will need continued treatment with Suboxone for many years, or even her entire life, the dark cloud of addiction had departed in the exam room that afternoon. The sun was shining bright.

Everyday Heroes

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The image of Ellensburg as a heart in the middle of Washington is captured beautifully at Dick and Jane’s Spot near downtown Ellensburg. I love the notion that we- collectively and as a community- are a heart.  Amazing, courageous, inspirational individuals.

There are heroes all around us. Every community is full of amazing individuals who show great courage in the face of adversity as they live their lives from day to day. Ellensburg is no exception.

On a recent lazy summer afternoon during a backyard party, I had the privilege to connect with a friend who has been battling cancer for several years. This past year has been perhaps one of the most difficult for her- the cancer has spread, and a cure is not possible. Intelligent, articulate and accustomed to contributing to her community, she is no longer able to work but instead is immersed in the intense world of cancer treatment.

“I don’t feel very amazing,” she said in response to my statement that she was. “Oh but you are very amazing,” I replied. “ You have approached a difficult situation with grace, courage, a sense of humor and determination. You are very amazing.” She looked at me almost as if I was describing someone else.

“These amazing people don’t see it- they don’t realize they are heroes,” I thought to myself.

A hero is one who “shows great courage.” In my experience, the heroes I see in healthcare are numerous, and are the last to see they are exceptional. A privilege that comes with my work as a physician is that I come face to face with heroes everyday.

Recently, for example, I saw a man with multiple sclerosis who was struggling to maintain his independence in the face of worsening muscle weakness. He had worked hard all his life performing manual labor. Despite his body failing him, he has pushed on and continued to work, because in working, he feels whole. At a recent visit with his neurologist, my patient was told he may not be able to drive any longer- a necessity to his work. “What happens now?” he said as he stared at the ground, determined to find some way forward.

On that same day I met with a woman, who in the midst of grieving the sudden loss of her husband, experienced a stroke. Her passion in life is playing her musical instrument, and the stroke weakened her arm and impaired her coordination. “Our symphony has to play Beethoven’s 9th soon which is very difficult. I’m going to play it, but it won’t be pretty.” Although she lost her husband and then was knocked back by a stroke, she rose to her new challenges and strove to live her life fully.

And to finish the afternoon, I met with a young man and his mother. This well-loved man in his early 20’s had his life in front of him, but was now in the throws of heroin addiction. He was unable to take the steps he needed to regain his life. His mother was doing her best to support him despite seemingly endless painful setbacks. She was sad, discouraged and heartbroken, but each day did what she could to help him and mustered hope that her son may someday regain his life.

These are my heroes: people with cancer, multiple sclerosis, strokes, drug addiction. These are people right here in our community, individuals who draw from their inner strength to manage disease and disability.

And a remarkable quality common to these unique individuals is that, as a general rule-of-thumb, they all do not see that they are amazing. They take one day at a time and do their best to make the best of profound and difficult health circumstances. One step in front of the other- that’s what is on their minds.

These are American heroes, right here in Ellensburg. They don’t see that they are all remarkable, but of course they are. Next time you see one of them, help them look up from their daily struggles to see the sun and see the reality that they are our heroes.

Tell them they are amazing.

Our Relationship With Science

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On Earth Day this year, “The March For Science” was a organized as an effort to show support for science. People gathered and walked in cities and towns across America as well as around the world.

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Walking alongside thousands of other people in Seattle, I felt almost as though I was part of a meandering river of people flowing through downtown, filling the banks of a two way street. There were children and adults of all ages carrying a diverse array of placards that highlighted the importance of science in our lives. Be it biology, chemistry, ecology, physics, or medicine, science was the unifying theme. I carried two cardboard signs to illustrate gifts of science near and dear to my heart: “Science cures cancer, ” and “Vaccines save lives.” As I walked I reflected on the role science plays in our society, and how it supports each of us everyday, in a multitude of ways. I also reflected upon the support we in return, give to science.

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As a physician, nearly everything I do is because of science. Whether it is the stethoscope I use, the medications I prescribe, the diagnostic tests I order, or even how I make medical decisions, it is the result of science. Science encourages a manner of thinking that is invaluable: the scientific process is a method of thinking that utilizes objective evidence, and helps separate the useful from the useless. We live in an era where information is in excess, and the way scientists evaluate information helps illuminate the truth, and provides me with the tools I need to practice medicine. As I walked not far from the Seattle Cancer Care Alliance, through the busy downtown and beneath the Space Needle, I wondered if our relationship with science has become a one way street. In other words, while science supports us every day in most everything we do, do we as a society in return fully support science? I wondered if we take science for granted- if we have begun to pick and choose what to support depending on how it fits into our existing belief systems, or how it aligns with our lifestyle.

The most obvious example that came to mind is “Climate Change.” Scientific research consistently supports the notion that because of fossil fuels – and the subsequent accumulation of greenhouse gases- Earth’s climate is warming. However, these findings have often been met with skepticism, because supporting climate change frequently is at odds with a lifestyle and economy that relies heavily on cars and a society founded upon energy consumption.

Another common scenario – one I encounter every fall- is beliefs regarding the influenza vaccine. It is not uncommon for patients to readily accept every vaccine I offer, except the influenza vaccine. Research has clearly shown that receiving the flu shot significantly reduces the chance of hospitalization or death from influenza. Despite this knowledge, the reasons I hear from patients for not receiving the vaccine are diverse and not based on logic: “I don’t believe in the flu shot,” “I never get the flu shot and never get the flu, so I don’t need it,” or simply, “I don’t do the flu shot”, end of discussion.

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The common theme between these examples is the tendency to selectively choose what scientific data to believe depending on how the information aligns with lifestyle or preexisting beliefs . It is almost as if science has become a buffet, and individuals take the data they want and skip that which is undesirable or inconvenient.

As a society we cannot afford to have a buffet style, inconsistent perspective when it comes to science. Science may reveal concepts that challenge- or be at odds with- existing belief systems, but that’s how science is and always has been. Facts are facts. To pick and choose facts depending on what may be convenient to believe is dangerous. As a cancer survivor, I am alive because of science, and without the benefit of science to aid me in my work as a physician, many more of my patients would experience suffering and premature death.

Science truly supports each and every one of us, every day. The time has come for all of us to acknowledge this truth, and the time has come to consistently support the scientific process and to be open minded to the conclusions it reveals. A supportive relationship should be a two way street.

Hidden Gems and a Guarantee

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This is an open letter to everyone everywhere, especially people who live in small communities such as mine:

If you drive to work, you are missing out.   If someone offered you an opportunity to improve your health, enhance your happiness and creativity, boost your self esteem, and even make you richer, what would you say?  Many might think it would be an offer that was too good to be true– a scam; what’s the catch? There is no catch; I want to share how commuting to work on foot or by bicycle can do all these things. It can be a bit addicting, but this addiction is a good thing.

First the obvious: a self-propelled commute is exercise, and regular exercise has tremendous benefits for health. Physicians typically recommend exercise in the range of 30 minutes five days per week because research supports the notion that this amount of exercise reduces the chance of developing chronic diseases (heart disease, diabetes, arthritis, as well as many cancers, for example). For many people who live in small communities, work is within range of a 30 minute walk or bicycle ride.

Another clear benefit of walking or biking to work has to do with money; everything costs much less than driving. Compare a new pair of shoes or a bicycle with the cost of maintaining a car and paying for fuel, and there is no contest. Cars as a means of getting to and from work in America have become an expensive habit, and sometimes a good way to break a habit is to realize how expensive it is.

The hidden gems with a non-motorized commute, however, have to do with creativity, self esteem, and happiness. While exercise in itself has been shown to boost these qualities, I believe exercising while going to and from work increases these traits much more.

Whether it is preparing for a busy day, solving a problem, or finding solutions to conflicts, the time on a bike or walking allows the brain to wander, to consider out-of-the-box solutions, to be creative. Personally, some of my most creative thoughts occur before or after work while I am pedaling away. It is the exercise combined with the time of day combined with being disconnected from computers and smart phones. Just as some of the best vacations are when one is in a remote location and “unplugged,” some of the best parts of the day are when one is alone, in that transition between work and home. It may sound crazy, but it is a mini mind and body vacation, a time to figure things out.

But, one might say, “exercise is hard, I’m tired after work, it’s windy, and no matter which direction I am going, it’s up hill!” There is no argument from me– I agree entirely. However, in these sentiments lies exactly the reward, and why I have come to enjoy my commute more and more over time. There have been many times when I have walked out the clinic door, tired from a busy day, and thought about getting a ride home. And there have been times, half way home, when I have wondered where my strength had gone. By mustering the strength, though, I almost always get on my bike, and I always get home just fine. I have gradually realized what this has done for me. My body and brain have become stronger and stronger, and I have faith in my ability to succeed. Self esteem, inner confidence, resilience, whatever you want to call it– I’ve got more of it now, and my commute has helped me get it.

Meanwhile, I have come realize over time that getting to work on bike or foot has made me a happier person. We all want to be happy, and it is well known through research that exercise improves mood and decreases the chances of becoming depressed. This mood-enhancing effect of exercise occurs right after an exercise session, as well as over the long term with regular exercise. In other words, biking or walking to work is a handy tool to improve the chances of having a good day at work. And what is really remarkable is if one adds up all those good days at work, the result is an improved chance of being happy at work in general. Everyone spends a lot of time — most of our adult life, actually– at work, why not improve the odds that we will be happy during that time, that we will like our job? I think this is in a sense an important foundation of job satisfaction.

It takes longer to get to work in the morning and there are errands and tasks to complete that require a car…. the list goes on and on. Changing or creating new habits is difficult, and it is common at first to see numerous seemingly insurmountable barriers. In reality though, there are creative solutions to almost every barrier, and meanwhile it is rewarding in itself to plan for and achieve new healthy behaviors. And of course it can be done; I witness patients changing behaviors every day in the clinic. I never cease to be amazed at the strength and determination of the human spirit.

My advice is to treat yourself and leave your car at home. Whether your commute is by bike or by foot, I guarantee (how often do doctors guarantee anything?) that with time you will be healthier, happier, richer, more creative, and have greater confidence in yourself.

The Right Tool

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fullsizerender“I’ve got to use the right tool,” I thought to myself as I attempted to pound a nail into the wall with the bottom of my coffee cup. Kneeling on the exam room table, I was attempting to hang a picture on the wall before the clinic day began. I have all sorts of useful tools in my clinic – scalpels, special scissors and a multitude of precision instruments for surgical procedures and other medical care. But on that day I did not have a hammer for pounding in a nail to hang a picture. I smiled, and reflected on how comical I must look, awkwardly perched on the exam room table trying to put a nail in the wall with a coffee cup. I had opted for what was convenient but not what was appropriate. Without the right tool, I was not successful in getting my job done and was wasting valuable time. Hoping I was now a little wiser, I climbed off the exam table with the picture, walked back to my office, picked up my stethoscope, and began the clinic day seeing patients.

Using the right tool is critical. I was immediately reminded of this as my first patient – a 65 year old man – came in for a physical. As is the case for many Americans, the biggest threat to his health was the risk of having a heart attack or a stroke. He had several important risk factors for heart disease: he was overweight, had high cholesterol, high blood pressure, and was recently diagnosed with diabetes. He needed to lose weight, but weight loss was difficult for him. During the course of the visit we discussed his weight, and he shared with me that he was trying the “Ketosis Diet” to help him lose weight. He had read about this diet on the internet and purchased a book. He explained the diet was rich in cheese, bacon, and other meats. Apparently by avoiding all carbohydrates and eating mostly fat, one loses weight. The diet fit in nicely with his existing eating habits. After considering his diet, I cautioned that the types of foods he was eating were exactly the type of foods medical research recommends avoiding to prevent heart disease. I attempted to steer him towards the right tools – heart healthy foods and physical activity – for his job, the job of preventing a heart attack.

When it comes to preventing disease, individuals need to stop pounding nails with coffee cups. Pounding a nail requires the right tool: a hammer. When it comes to medicine, the hammer is science. Evidence based research – the scientific process – is the perfect tool for promoting health and has an excellent track record. Modern medicine has been successful at preventing and treating disease because of the scientific process. To make health decisions based on the latest internet popular opinion is using a coffee cup instead of a hammer to pound a nail.

Healthcare providers need the truth of science to guide them in making sound recommendations for both individual patients and for the population as a whole. Vaccines are a perfect example. Vaccine medicine is medical science at its best, in that it offers a clear example of scientific research that originates in the laboratory, and that is later applied to people and populations to prevent deadly infections. Every day, vaccines prevent diseases that could have been; every day, vaccines save lives. Thanks to science, Polio is almost eradicated from the globe and the Americas have been declared free of Measles. Meanwhile, looking forward into the future, Zika – a more recent threat – may well prove to be a short chapter in history books, as a number of promising Zika vaccines are currently undergoing clinical trials. Vaccine science is the right tool to prevent infectious disease.

The scientific process is critical not only for advancing medical care and vaccine science, but is vital to all realms of scientific research. Whether it is medicine, public health, or climate change, science is the best tool to understand our world. Science has a proven track record; it works. The alternative to using science is nothing more than a popularity contest of opinion. If we as a society choose to value proclamations devoid of facts over scientific research, we might as well equip all the carpenters in America with coffee cups. We need to choose the hammer and get the job done; science is the right tool to improve health, prevent disease, and has the potential to make the world a better place.

Medical Detectives Explore Mystery of Mumps Outbreaks

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The past year was a big year for the mumps virus. With 5,311 cases in 2016, the United States experienced the most mumps infections since 2006. The majority of the outbreaks occurred in the Midwest, however Washington State recorded 486 cases in the past 5 months. Mumps was a very common viral infection prior to the development of a vaccine in 1967, and for over the past 50 years has been well controlled. In attempting to understand the recent increased number of mumps infections, a rational explanation is that the affected individuals had not received all of their routine MMR (Measles, Mumps and Rubella) shots. However, the mumps infections have in fact occurred in populations where individuals have been up to date on their shots, having received the recommended two doses of MMR at around 1 and 4 years of age.  The question remains then, why has the mumps virus made such a commotion this past year?  Has the mumps vaccine become less effective? What does this mean for routine MMR vaccination in the United States? The recent rise in mumps cases has raised intriguing questions such as these for scientists to explore and attempt to answer.

 

A very refreshing aspect of the scientific process is that when events don’t quite make sense, scientists approach a problem by attempting to observe and note the facts, and then study the possibilities with objective research. With the recent increase in mumps infections, researchers are actively involved in the process of being “medical detectives.” They are looking at the data, evaluating possibilities, and figuring out how to test their ideas. While we do not yet know why the mumps outbreaks have occurred, there are clues that may offer insight into this mumps mystery.

 

The mumps infections have typically occurred in vaccinated populations, in which people have been living in high density environments, such as college campuses. This close proximity makes transmitting germs easier. Meanwhile, the mumps component of the MMR vaccine is good at preventing mumps infections, but not quite as good as the measles and rubella components. For example, the measles vaccine prevents measles infection with about a 98% success rate. Mumps “vaccine efficacy” is a little lower, at approximately 88%. This slightly lower vaccine efficacy can allow the infection to spread more readily. In addition, after a child receives the second MMR at age 4, the level of mumps protection declines gradually over time, which also increases the possibility of infection. All of these reasons – high density living situations, good but not great vaccine efficacy, and declining immunity over time – may have contributed to the mumps outbreaks.

 

However, perhaps some the most fascinating reasons why mumps has had a big year may have to do with the “big picture” perspective. Scientists know that some viruses naturally go through cycles over time, where infections increase at somewhat regular intervals. For example, before the advent of the rubella vaccine, rubella epidemics occurred every 7-8 years. It is possible that mumps may have a similar natural history, and perhaps this past year was time for a natural epidemic to occur. If this is the case, the vaccine could have blunted the spike of infections but not prevented it altogether. With this hypothesis in mind, it will be interesting to see if mumps naturally quiets down over the next couple years on its own accord.

 

In addition, measles and rubella have been completely eradicated from America, such that new cases in The United States are imported from travelers arriving from other countries. Mumps on the other hand has not been eradicated from America, and may be circulating within the country more than previously thought. It is known that approximately one third of mumps infections occur without symptoms, which in turn could enhance spread of the virus without our awareness, or “below the radar.” This phenomenon could have contributed to the increased number of infections. These are some of the thoughts scientists are considering, but they are only ideas at this time. Similarly, it may make sense for a third dose of MMR in the setting of a local outbreak; however, objective data is necessary before making this change.

 

Lastly, an interesting – and reassuring – observation from the recent mumps outbreaks is that while mumps infection occurred in several thousand people this past year, no complications of the infection have been seen. Before the vaccine was routinely used, mumps infection was associated with a 4% risk of hearing loss, 4% risk of pancreatitis, 30% risk of inflammation of the testes or ovaries, and resulted in approximately 5% of patients becoming hospitalized. This raises the question of whether those recently infected with mumps in fact had enough protection from the vaccine to prevent potentially serious complications. At this time we don’t know, but this is another hypothesis that scientists are exploring.

 

Medical epidemiologists are doing their fact checking in an attempt to understand the mumps outbreaks better. While science may sometimes be portrayed in the popular media as stodgy or lacking creativity, our current mumps mystery illuminates just how creative science can be with problem solving. Scientists have to “think outside the box” to figure out these problems, both in formulating possible explanations as well as determining how to use the scientific process to test their ideas. In addition, nothing is a given- no matter how good an idea it may seem – until it is supported by the evidence of high quality research. In fact, in science nothing is really ever permanently a “given” as science promotes an ongoing process of evaluating and reevaluating. However, the more research studies that come to the same conclusion, the more likely a concept may be true.

 

While there have been an increased number of mumps cases this past year throughout the country, and it is not entirely clear why, there are interesting observations – or clues – for researchers to explore. It will be exciting to see what our creative, problem solving medical scientists discover. In the meantime, be sure to encourage MMR childhood vaccination.  A profound consideration is that use of the MMR vaccine has reduced mumps infection by approximately 99% compared to the pre-vaccine era.

 

Air Pollution and You

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Air pollution is a problem. We all know it is not healthy to breathe polluted air. However, everyone needs to breath; we have no other choice but to inhale and exhale (roughly 23,000 times a day) as we venture out into our community to work and live our lives. We notice the annoying symptoms of scratchy throats and itchy eyes, but the most profound damage to our health occurs deep in our lungs, where the particulate matter settles.

Locally as well as globally, air pollution is an increasing health concern and is taking its toll on human health. The International Energy Agency recently released a report attributing an annual 6.5 million premature deaths to air pollution worldwide. Particulate matter in the air increases the risk of being hospitalized and dying from pneumonia, heart attacks, strokes, and asthma. In addition, research has shown that when air quality is poor, mental health conditions such as anxiety are more likely to worsen, and pregnant women are more likely to go into premature labor. Those most vulnerable to the adverse health effects of air pollution are our children and the elderly.

There is little argument that air pollution is a concern. Somehow though, it often seems to be someone else’s problem. It is easy to blame someone else’s burn pile or inefficient wood stove. And yet, whether it is burning firewood, yard waste, or irrigation ditches, many of us play a role in producing air pollution. The smoke from burn piles or chimneys may seem as though it drifts up and far away from us, but the truth is that most of it stays in our local atmosphere. For our valley, our local air pollution is in general home grown: particulates from wood smoke are produced in Kittitas Valley and are inhaled in Kittitas Valley. During the winter months, high pressure systems – those bright blue winter skies – trap our pollution here for all of us to breathe.

Residents of Kittitas Valley pollute Kittitas Valley air, are harmed by air pollution, and can help reduce air pollution. Since air pollution is our own problem that we have created, we – as individuals – must contribute to the solution.

Learn more about how your health is effected by air pollution:

1. The American Lung Association: http://www.lung.org/our-initiatives/healthy-air/
2. Moms Clean Air Force: http://www.momscleanairforce.org
3. The CDC: https://www.cdc.gov/nceh/airpollution/default.htm

Know when local air quality is poor: https://fortress.wa.gov/ecy/enviwa/

Take individual action:

1. Replace an inefficient wood fireplace or stove with one that is clean burning. Talk to your neighbors and encourage them to do the same. There is financial assistance to do so: https://hopesource.us/woodstove.
2. Check out the helpful information provided by The Kittitas County Health Department: https://www.co.kittitas.wa.us/health/programs/environmental-health/air-quality.aspx
3. Instead of burning yard waste, take it to the transfer station composting center: https://www.co.kittitas.wa.us/solid-waste/waste-prevention.aspx.

Air pollution is quietly harming your health and the health of your loved ones. Poor air quality occurs from our individual actions, is difficult to escape, and is something each one of us can do something about. Our air quality will likely only get worse unless we do something about it.