Our future selves will mock this (I hope)

Smiling people holding hands. Walking on the beach. Inexplicable doves flying through blue skies. Terrible side effects discussed cheerily by a honey-voiced narrator.... That's right, this post is about direct-to-consumer pharmaceutical advertising. Niam Hardimh, writing at Crooked Timber, shares one of the odd things about living in the US -- for those who aren't used to our TV:

One thing that is striking, compared with European TV, is what is advertised and how. In particular,  I don’t think you see ads for prescription medicines in Europe, certainly not in Ireland or the UK. They seem to be all over American TV.

I am particularly struck by the way these ads are made. The visuals  typically show someone having a happy and trouble-free life while using these drugs, overlaid with soothing music and a reassuringly bland voice-over. But clearly the US FDA requires advertisers to include all the small print in their ads as well.

Do you read all the known downsides of the medicines you take? Don’t...

It's easy to become habituated to these since they're everywhere, but it hasn't always been that way, and in most places it still isn't -- the US and New Zealand are the only two countries that allow direct advertising of drugs. Here's an exemplary ad for Vioxx, which was pulled off the market because it caused health problems (which Merck systematically lied about):

Ice skating. A minor celebrity. Inspiring music. They even note that "Vioxx specifically targets the Cox2 enzyme." How many Americans can even define what an enzyme is? I'm sure consumers are more likely to remember that than the mentioned side effects ("bleeding can occur without warning")... Other lovely examples include this other ad for Vioxx, and one for Zocor.

For more examples and some background on how the ads came to be, check out "Sick of pharmaceutical ads: here's why they won't go away" on io9.

Facebook's brilliantly self-interested organ donation move

How can social media have a big impact on public health? Here's one example: Facebook just introduced a feature that allows users to announce their status as organ donors, and to tell the story of when they decided to sign up as a donor. They're -- rightly, I think -- getting tons of good press from it. Here's NPR for example:

Starting today, the social media giant is letting you add your organ-donation status to your timeline. And, if you'd like to become an organ donor, Facebook will direct you to a registry.

Patients and transplant surgeons are eager for you to try it out.

Nearly 114,000 people in this country are waiting for organs, according to the United Network for Organ Sharing. But there simply aren't enough organs to go around.

It's an awesome idea. Far too few Americans are organ donors, so anything that boosts sign-up rates is welcome. As Ezra Klein notes, organ donation rates would be much higher if we simply had people opt out of donating, rather than opt in, but that's another story. (And another aside: I hope they alerted some smart people beforehand to help them rigorously measure the impact of this shift!)

Call me a cynic, but I think the story of why Facebook chose to do this -- and in the way they did it -- is more interesting.Yes, there's altruism, but Facebook is a business above all. Maybe they're just trying to cultivate that Google ethos of "we sometimes spend lots of money on far-sighted things just to make the world a better place." Facebook will certainly garner lots of public good will from this.

But I think, even more importantly, Facebook gets magnificent cover for introducing new modules on health/wellness. Check out the screenshot from their newsroom post on the new features:

That's right -- in the new Health & Wellness section you can enter not only whether you're an organ donor, but also these categories: "Overcame an Illness," "Quit a Habit," "New Eating Habits," "Weight Loss," "Glasses, Contacts, Others," and "Broken Bone."

All life events some people may want to share, of course. But Facebook makes money off of advertising, and just think of how much money Americans spend on weight loss, or on trying to quit smoking (or more usually, continuing it), or on glasses and contacts. Then think how much more advertisers will pay to show ads to segments of the billions of Facebook users who have shared the fact that they're actively trying to lose weight.

Maybe Facebook has seen this sort of health data as a major growth area for some time, but was wary of introducing such features in the wrong way. On any other news day the introduction of these features would have triggered a new outbreak of the "Facebook feature prompt privacy outcry" and "Why does Facebook need your health data?" stories. Sure, we'll get some of those this time, but I think any backlash will pale in comparison to the initial PR bump.

I don't think there's necessarily anything wrong with the move, and I certainly welcome any boost in organ donor registration. It may just be that this is a case where Facebook's business interests in inducing us to share more of our personal information with them just happens to happily coincide with a badly needed public good. Either way, the execution is brilliant, because so far I've mostly seen news stories talking about how great organ donation is. And I just updated my Facebook status.

Obesity in the US

One of my classmates whose primary interest is not health policy posted this graph on Facebook, saying "This is stunning... so much so in fact that I'm a bit skeptical of its accuracy." The graph compares obesity rates by state in 1994 vs. 2008, and unfortunately it is both terrifying and accurate. (I can't find the original source of this particular infographic, but the data is the same as on this CDC page.)

I think those of who study or work in public health have seen variations on these graphs so many times that they've lost some of their shock value. But this truly is an incredible shift in population health in a frighteningly short period of time. In 1994 every state had an adult population that was less than 20% obese, and many were less than 15% obese. A mere 14 years later, Colorado is the only state under 20%, and quite a few have rates over 30% -- these were completely unheard of before.

I did a quick literature search, trying to understand what causal factors might be responsible for such a rapid shift. It's a huge and challenging question, so maybe it should be unsurprising that I didn't find an article that really stood out as the best. Still, here are three articles that I found helpful:

1. Specifically looking at childhood obesity in the US (which is different from the rates highlighted in the map above, but related): "Childhood Obesity: Trends and Potential Causes" by Anderson and Butcher (JStor PDF, ungated PDF). Their intro:

The increase in childhood obesity over the past several decades, together with the associated health problems and costs, is raising grave concern among health care professionals, policy experts, children's advocates, and parents. Patricia Anderson and Kristin Butcher document trends in children's obesity and examine the possible underlying causes of the obesity epidemic.

They begin by reviewing research on energy intake, energy expenditure, and "energy balance," noting that children who eat more "empty calories" and expend fewer calories through physical activity are more likely to be obese than other children. Next they ask what has changed in children's environment over the past three decades to upset this energy balance equation. In particular, they examine changes in the food market, in the built environment, in schools and child care settings, and in the role of parents-paying attention to the timing of these changes.

Among the changes that affect children'se nergy intake are the increasing availability of energy dense, high-calorie foods and drinkst hroughs chools. Changes in the family, particularly increasing dual-career or single-parent working families, may also have increased demand for food away from home or pre-prepared foods. A host of factors have also contributed to reductions in energy expenditure. In particular, children today seem less likely to walk to school and to be traveling more in cars than they were during the early 1970s, perhaps because of changes in the built environment. Finally, children spend more time viewing television and using computers.

Anderson and Butcher find no one factor that has led to increases in children's obesity. Rather, many complementary changes have simultaneously increased children's energy intake and decreased their energy expenditure. The challenge in formulating policies to address children's obesity is to learn how best to change the environment that affects children's energy balance.

2. On global trends: "The global obesity pandemic: shaped by global drivers and local environments" by Swinburn et al. (Here's the PDF from Science Direct and an ungated PDF for those not at universities.) Summary:

The simultaneous increases in obesity in almost all countries seem to be driven mainly by changes in the global food system, which is producing more processed, affordable, and effectively marketed food than ever before. This passive overconsumption of energy leading to obesity is a predictable outcome of market economies predicated on consumption-based growth. The global food system drivers interact with local environmental factors to create a wide variation in obesity prevalence between populations.

Within populations, the interactions between environmental and individual factors, including genetic makeup, explain variability in body size between individuals. However, even with this individual variation, the epidemic has predictable patterns in subpopulations. In low-income countries, obesity mostly affects middle-aged adults (especially women) from wealthy, urban environments; whereas in high-income countries it affects both sexes and all ages, but is disproportionately greater in disadvantaged groups.

Unlike other major causes of preventable death and disability, such as tobacco use, injuries, and infectious diseases, there are no exemplar populations in which the obesity epidemic has been reversed by public health measures. This absence increases the urgency for evidence-creating policy action, with a priority on reduction of the supply-side drivers.

3. Finally, on methodological differences and where the trends are heading: "Obesity Prevalence in the United States — Up, Down, or Sideways?" (NEJM, ungated PDF). Evidently there's some debate over whether rates are going up or have stabilized in the last few years, because different data sources say different things. Generally the NHANES data (in which people are actually measured, rather than reporting their height and weight) is the best available (and that's what the maps above are made from). An excerpt:

One key reason for discrepancies among the estimates is a simple difference in data-collection methods. The most frequently quoted data sources are the NHANES studies of adults and children, the BRFSS for adults, and the CDC's Youth Risk Behavior Survey (YRBS)4 for high- school students. Although sampling strategies, response rates, age discrepancies, and the wording of survey questions may account for some variability, a major factor is that in calculating the BMI, the BRFSS and YRBS rely on respondents' self-reported heights and weights, whereas the NHANES collects measured (i.e., actual) heights and weights each year, albeit from a considerably smaller sample of the population. Since people often claim to be taller than they are and to weigh less than they actually do, we should not be surprised that obesity prevalence figures based on self-reported heights and weights are considerably lower than those based on measured data.

I would greatly appreciate any suggestions for what to read in the comments, especially links to work that tries to rigorously assess (rather than just hypothesize on) the relative import of various drivers of the increase in adult obesity.

On food deserts

Gina Kolata, writing for the New York Times, has sparked some debate with this article: "Studies Question the Pairing of Food Deserts and Obesity". In general I often wish that science reporting focused more on how the new studies fit in with the old, rather than just the (exciting) new ones. On first reading I noticed that one study is described as having explored the association of "the type of food within a mile and a half of their homes" with what people eat. This raised a little question mark in my mind, as I know that prior studies have often looked at distances much shorter than 1.5 miles, but it was mostly a vague hesitation. And if you didn't know that before reading the article, then you've missed a major difference between the old and new results (and one that could have been easily explained). Also, describing something as "an article of faith" when it's arguably something more like "the broad conclusion draw from most most prior research"... that certainly established an editorial tone from the beginning.

Intrigued, I sent the piece to a friend (and former public health classmate) who has work on food deserts, to get a more informed reaction. I'm sharing her thoughts here (with permission) because this is an area of research that I don't follow as closely, and her reactions helped me to situate this story in the broader literature:

1. This quote from the article is so good!

"It is always easy to advocate for more grocery stores,” said Kelly D. Brownell, director of Yale University’s Rudd Center for Food Policy and Obesity, who was not involved in the studies. “But if you are looking for what you hope will change obesity, healthy food access is probably just wishful thinking.”

The "unhealthy food environment" has a much bigger impact on diet than the "healthy food environment", but it's politically more viable to work from an advocacy standpoint than a regulatory standpoint. (On that point, you still have to worry about what food is available - you can't just take out small businesses in impoverished neighborhoods and not replace it with anything.)

2. The article is too eager to dismiss the health-food access relationship. There's good research out there, but there's constant difficulty with tightening methods/definitions and deciding what to control for. The thing that I think is really powerful about the "food desert" discourse is that it opens doors to talk about race, poverty, community, culture, and more. At the end of the day, grocery stores are good for low-income areas because they bring in money and raise property values. If the literature isn't perfect on health effects, I'm still willing to advocate for them.

3. I want to know more about the geography of the study that found that low-income areas had more grocery stores than high-income areas. Were they a mix of urban, peri-urban, and rural areas? Because that's a whole other bear. (Non-shocker shocker: rural areas have food deserts... rural poverty is still a problem!)

4. The article does a good job of pointing to how difficult it is to study this. Hopkins (and the Baltimore Food Czar) are doing some work with healthy food access scores for neighborhoods. This would take into account how many healthy food options there are (supermarkets, farmers' markets, arabers, tiendas) and how many unhealthy food options there are (fast food, carry out, corner stores).

5. The studies they cite are with kids, but the relationship between food insecurity (which is different, but related to food access) and obesity is only well-established among women. (This, itself, is not talked about enough.) The thinking is that kids are often "shielded" from the effects of food insecurity by their mothers, who eat a yo-yo diet depending on the amount of food in the house.

My friend also suggested the following articles for additional reading:

• Food deserts are complex and real (Amanda Behrens, Center for a Livable Future)
• Baltimore food czar: food deserts studies don't apply (Adam Bednar, North Baltimore Patch)
• Nischan, Nestle Weigh In On Food Deserts (Eleanor West, Food Republic)

Outbreak control

The latest MMWR (Morbidity and Mortality Weekly Report) from the CDC  has a summary of a meningitis outbreak in Oklahoma and how public health authorities responded: "Outbreak of Meningococcal Disease Associated with an Elementary School - Oklahoma, March 2010." MMWR reports have a consistent style that I think is helpful for this sort of notice: they're short with tight editing and little superfluous information. They also often present harrying situations that are made more disturbing by the clinical detachment. In this case:

Five cases of meningococcal disease (including one probable case) were identified among four elementary school students and one high school student. Two students died; two recovered fully, and one survivor required amputation of all four limbs and facial reconstruction.

They also often include a helpful summary answering three questions: 1) What is already known on this topic? 2) What is added by this report? and 3) What are the implications for public health practice? I think some other publications (especially in the social sciences) would benefit from this helpful little formatting addition.

Before you get all excited about male birth control

When you're a public health grad student and something related to health hits the news, your friends make sure you see it. Since there's a lot of bad science writing on the internet this can be rather frustrating. In the last few hours I've seen several people post this  to Facebook, and another emailed me with the subject line "Woh" and asked if this was too good to be true.... So what's the story? Techcitement has a breathless article titled "The Best Birth Control In The World Is For Men" by Jon Clinkenbeard, which he followed up with "Could This Male Contraceptive Pill Make a Vas Deferens in the Fight Against HIV?" The first article starts with this hook:

If I were going to describe the perfect contraceptive, it would go something like this: no babies, no latex, no daily pill to remember, no hormones to interfere with mood or sex drive, no negative health effects whatsoever, and 100 percent effectiveness. The funny thing is, something like that currently exists.

Clinkenbeard is describing RISUG, or "Reversible inhibition of sperm under guidance." Wikipedia explains:

RISUG is similar to vasectomy in that a local anesthetic is administered, an incision is made in the scrotum, and the vas deferens is tugged out with a small pair of forceps. Rather than being cut and cauterized, as it is in a vasectomy, the vas deferens is injected with [a] polymer gel and pushed back into the scrotum.

Sounds awesome? Why don't we have it already? Clinkenbeard continues:

The trouble is, most people don’t even know this exists. And if men only need one super-cheap shot every 10 years or more, that’s not something that gets big pharmaceutical companies all fired up, because they’ll make zero money on it (even if it might have the side benefit of, you know, destroying HIV).

Before you go injecting something in your scrotum... not so fast! Yes, in one sense it exists. But on the other hand we don't really know how well it works, and we don't really know how safe it is. Clinkenbeard makes it sound like it's a done deal, and claiming that Big Pharma is standing between you and the cure for babies (not to mention HIV!) certainly helped the article go viral. He then links to a bunch or articles and a few petitions.

While pharmaceutical companies do all sorts of things to manipulate data (start here if you don't believe that), I think they could actually make TONS of money on this if it worked. The price of medicines isn't usually based on how much they cost to manufacture but on how much they can be sold for, and I think there's clearly a market for male contraception: just think how much men would pay for the insurance to both avoid pregnancy and not have to use condoms. A drug company could conceivably make a lot of money off this product by getting it to market first.

Guha's initial studies were very small. A Phase II clinical trial published by Guha et al in 1997 featured a grand total of 12 men (PDF). (It also contains this humorous understatement: "Objective data on posttreatment frequency of intercourse could not be obtained.") In another study 20 men received an injection, but one man's partner still got pregnant.

Before a drug can (or should) go to market, it needs to be tested for both efficacy and safety, and everything needs to be done up to certain standards. Guha's original work wasn't. From a Wired article on RISUG by Bill Gifford, published this time last year:

In its report, the WHO team agreed that the concept of RISUG was intriguing. But they found fault with the homegrown production methods: Guha and his staff made the concoction themselves in his lab, and the WHO delegation found his facilities wanting by modern pharmaceutical manufacturing standards. Furthermore, they found that Guha’s studies did not meet “international regulatory requirements” for new drug approval—certain data was missing. The final recommendation: WHO should pass on RISUG.

These barriers can be overcome, if the researchers can get the investment necessary to make high quality product and run clinical trials. The Wired article describes how they've made progress and are now running clinical trials in India -- but the results are still a few years out. In the same article we get this:

"Pharmaceutical companies are not interested in one-offs," Weiss says. "They’re interested in things they can sell repeatedly, like the birth control pill or Viagra."

But that's not as true as it used to be. These arguments used to explain why pharmaceutical companies didn't invest in developing vaccines, but then they realized they could charge obscene amounts for individual doses -- orders of magnitude higher than what they charged before. They've managed these high prices because 1) there are always new cohorts of kids needing the vaccine (as there would be with men needing RISUG) and 2) because the health benefits are so large that even at the higher prices the vaccines are cost effective.

So are pharma companies just disinterested in male contraception? No. For quick and dirty evidence check ClinicalTrials.gov, where US clinical trials must be registered. I find 436 studies on contraception, of which 84 are specifically about male contraception. There's a disparity there, but it's explained in part by the fact that many of the non-male contraception studies are about delivery methods (like this one involving text message reminders) and you can't even start do this sort of research on male birth control before we have effective methods. Maybe they're under-investing a bit -- drug R&D is risky, as firms spend an average of $1.3 billion on research for every one drug  brought to market -- but it's not being ignored.

In closing, that Wired article from last year has some of the same breathless new-techthusiasm as the new Techcitement piece, but it's a lot better at explaining where things stand today. Clinical trials in India are ongoing, but it will be another year or so before we hear any results. If those are considered high quality and they're successful, it might spur the drug behemoths to up the massive amounts required for clinical trials in the US.

Generally, getting your science news from the coauthor of "The Pirate Treasure of the Himalaya" does't seem like the best idea. Drugs and treatments fail at every stage of the clinical trials pipeline, and that's a good thing because it means consumers will be less likely to spend money on ineffective or unsafe drugs. If everything works out with RISUG, it could be an incredible success story and a great public health tool. There might well be hope on the horizon, but contrary to Clinkenbeard's assertions we don't yet know very well if this works, and we don't yet know if it's safe. For that, we need good ole clinical trials, not petitions.

Fluoride in New Jersey

I saw this poster at a bus stop on campus a couple weeks ago:

If you can't read it, the title reads: "Stop the New Jersey Public Water Supply Fluoridation Act" and it goes on to say "Fluoride is a toxic chemical even in the smallest doses and when pumped into our water supply it is impossible to control the level of consumption." (emphasis added)

I took a picture but didn't think about it again until I saw this article on Friday: "In New Jersey, a Battle Over a Fluoridation Bill, and the Facts" (NYT) by Kate Zernike. I appreciate that she calls the fearmongering what it is -- a conspiracy theory:

While 72 percent of Americans get their water from public systems that add fluoride, just 14 percent of New Jersey residents do, placing the state next to last... A bill in the Legislature would change that, requiring all public water systems in New Jersey to add fluoride to the supply. But while the proposal has won support from a host of medical groups, it has proved unusually politically charged.

Similar bills have failed in the state since 2005, under pressure from the public utilities lobby and municipalities that argue that fluoridation costs too much, environmentalists who say it pollutes the water supply, and antifluoride activists who argue that it causes cancer, lowers I.Q. and amounts to government-forced medicine.

Public health officials argue that the evidence does not support any of those arguments — and to the contrary, that fluoridating the water is the single best weapon in fighting tooth decay, the most prevalent disease among children.

But they also say they are fighting a proliferation of misleading information. While conspiracy theories about fluoride in public water supplies have circulated since the early days of the John Birch Society, they now thrive online, where anyone, with a little help from Google, can suddenly become a medical authority.

The whole article is worth a read. I think it's a pretty good journalistic take on a charged issue that is a political controversy but not a scientific one. It gives some context as to why people are against it -- a few misleading studies amplified by word of mouth and the Internet -- but also emphasizes which side the evidence base (overwhelmingly) backs up.

Further, there are some echoes here of the anti-vaccine movement,  in that a move to reduce the threshold of acceptable fluoride levels  by HHS was taken to be an acknowledgment that the worst fears of the fluoridation foes were vindicated. That parallels how any mention of efforts to improve vaccine safety (a good thing) is misshapen by antivaccine activists into an acknowledgment that their theories have been vindicated. In short, I'm looking forward to Seth Mnookin's take on all this.

The US health care non-system

I spent much of yesterday thinking about the past, present, and future of the American health care system. I've largely chosen classes with an international or methodological focus so this was a bit of a departure from my normal fare. In one day I finished up some readings on health reform, wrote a brief paper speculating on what US healthcare will look like in 2030, attended a talk by Uwe Reinhardt largely based on this paper (PDF), and went to a three hour lecture on US health care (part of a class on the economics of the US welfare state). It's a mammoth subject, and there are many bloggers who write exclusively about domestic health policy -- the guys at the Incidental Economist have smart stuff to say on it every day. There's so much to be said and done even on the somewhat narrowed subject of the Affordable Care Act (ie, "ObamaCare").

But that's not what keeps popping into my head.What keeps getting reinforced is how our system really isn't a system at all, but a weird conglomeration of lots of different approaches for various fragments of our society that emerged for quirky historical and political reasons. I found this description -- from a report comparing various industrialized countries' systems -- humorously understated: "The U.S. does not have a 'health system,' but rather a variety of private and public institutions and programs that regulate, finance, and deliver care." (source)

Paul Starr's classic Social Transformation of American Medicine is a good start for trying to understand how we got to the 'variety' we have today.  The end result is that it doesn't serve very many people well at all. The US is a great place to get the most advanced care if you can afford it, but even then you're going to pay a lot more for it. For the non-wealthy the expenses are amplified and we end up rationing care by ability to pay. By pretty much every standard other than innovation (ie, including the delivery of that innovation to those who really need it, not just those who can pay) the US falls dreadfully short. We get poor life expectancy, magnified inequalities, and spending that's roughly twice as much per person as in any other wealthy country.

Ironically, whether the Affordable Care Act goes into effect in 2014 depends largely on whether Obama gets reelected, and whether Obama gets reelected or not depends largely on what the unemployment rate does between now and November. So the future of the US health system depends in a very real way on fluctuations in the economy over the next eight months, and no one really understand that well at all.

If you're just looking at the trajectory of the American health system the ACA is a major reform, even a fundamental one.  It will do (and has already started to do) a lot of good things, but I'm skeptical that it will do all that much to fix costs or shift our focus to public health ---prevention over treatment. There are a lot of good small fixes in there, but nothing revolutionary when you compare us to other countries.

And this is why I find domestic health policy profoundly depressing. It's why I've chosen to focus more on international health than domestic politics. In international health I think the prospects for witnessing and contributing to massive, heartening, orders-of-magnitude positive change in my professional lifetime are quite real. On US health policy, I'm less optimistic. My friend and classmate Jesse Singal wrote a description of the US health system -- in the context of astonishingly ridiculous remarks by some conservatives on contraception -- that I think about sums it up:  "...our medical system is an octopus riding a donkey riding a skateboard into a sadness quarry."

Princeton epidemiology: norovirus edition

Princeton is in the midst of an outbreak of norovirus! What's norovirus, you ask? Well, it looks like this:

Not helpful? Here's the CDC fact sheet:

Noroviruses (genus Norovirus, family Caliciviridae) are a group of related, single-stranded RNA, non-enveloped viruses that cause acute gastroenteritis in humans. The most common symptoms of acute gastroenteritis are diarrhea, vomiting, and stomach pain. Norovirus is the official genus name for the group of viruses previously described as “Norwalk-like viruses” (NLV).

Noroviruses spread from person to person, through contaminated food or water, and by touching contaminated surfaces. Norovirus is recognized as the leading cause of foodborne-disease outbreaks in the United States. Outbreaks can happen to people of all ages and in a variety of settings. Read more about it using the following links.

My shorter translation: "Got an epidemic of nasty stomach problems in an institutional setting (like a nursing home or university)? It's probably norovirus. Wash your hands a lot."

The all-campus email I received earlier today is included below. Think of this as a real-time, less-sexy version of the CDC's MMWR. Emphasis added:

To: Princeton University community

Date: Feb. 6, 2012

From: University Health Services and Environmental Health and Safety

Re: Update: Campus Hygiene Advisory

In light of continuing cases of gastroenteritis on campus, University Health Services and the Office of Environmental Health and Safety want to remind faculty, staff and students about increased attentiveness to personal hygienic practices.

A few of the recent cases have tested positive for norovirus, which is a common virus that causes gastroenteritis.  While it is usually not serious and most people recover in a few days, gastroenteritis can cause periods of severe sickness and can be highly contagious. You can prevent the spread of illness by practicing good hygiene, such as frequent hand washing, and limiting contact with others if sick.

Gastroenteritis includes symptoms of diarrhea, vomiting and abdominal cramps. Please take the following steps if you are experiencing symptoms:

--Ill students should refrain from close contact with others and contact University Health Services at 609-258-3129 or visit McCosh Health Center on Washington Road. Ill employees are encouraged to stay home and contact their personal physicians for medical assistance.

--Wash your hands frequently and carefully with soap and warm water, and always after using the bathroom.

--Refrain from close contact with others until symptoms have subsided, or as advised by medical staff.

--Do not handle or prepare food for others while experiencing symptoms and for two-to-three days after symptoms subside.

--Increase your intake of fluids, such as tea, water, sports drinks and soup broth, to prevent dehydration.

--Avoid sharing towels, beverage bottles, food, and eating utensils and containers.

--Clean and disinfect soiled surfaces with bleach-based cleaning products. Students and others on campus who need assistance with cleaning and disinfecting soiled surfaces may call Building Services at 609-258-8000. Building Services also will be increasing disinfection of frequent touch points, such as doorknobs and restroom fixtures.

--Clean all soiled clothes and linen. Soiled linen should be washed and dried in the hottest temperature recommended by the linen manufacturer.

In the past week, University Health Services has seen more than the usual number of students experiencing symptoms of acute gastroenteritis. The New Jersey Department of Health and Senior Services tested samples from a few of the cases, which were later found positive for norovirus. Because norovirus has been identified as the chief cause of gastroenteritis currently on campus, further testing is not planned at this time, but the University is urging community members to take steps to prevent the further spread of illness.

Noroviruses are the most common causes of gastroenteritis in the United States, according to the Center for Disease Control and Prevention. Anyone can become infected with gastroenteritis and presence of the illness may sometimes increase during winter months. While most people get better in a few days, gastroenteritis can be serious in young children, the elderly and people with other health conditions. Frequent hand washing with soap and warm water is your best defense against most communicable disease.

I bolded a few passages because I think the very last sentence (wash your hands) is actually the most important single part of the message and is much clearer than encouraging someone to increase "attentiveness to personal hygienic practices." But still a good message overall. At least one friend has come down with this and it sounds unpleasant...

Coincidence or consequence?

Imagine there's a pandemic flu virus on the loose, and a vaccine has just been introduced. Then come reports of dozens of cases of Guillain-Barré syndrome (GBS), a rare type of paralysis. Did the new vaccine cause it? How would you even begin to know? One first step (though certainly not the only one) is to think about the background rate of disease:

Inappropriate assessment of vaccine safety data could severely undermine the eff ectiveness of mass campaigns against pandemic H1N1 2009 influenza. Guillain-Barré syndrome is a good example to consider. Since the 1976–77 swine influenza vaccination campaign was associated with an increased number of cases of Guillain-Barré syndrome, assessment of such cases after vaccination will be a high priority. Therefore, it is important to know the background rates of this syndrome and how this rate might vary with regard to population demographics. The background rate of the syndrome in the USA is about 1–2 cases per 1 million person-months of observation. During a pandemic H1N1 vaccine campaign in the USA, 100 million individuals could be vaccinated. For a 6-week follow-up period for each dose, this corresponds to 150 million person-months of observation time during which a predicted 200 or more new cases of Guillain-Barré syndrome would occur as background coincident cases. The reporting of even a fraction of such a large number of cases as adverse events after immunisation, with attendant media coverage, would probably give rise to intense public concern, even though the occurrence of such cases was completely predictable and would have happened in the absence of a mass campaign.

That's from a paper by Steven Black et al. in 2009, "Importance of background rates of disease in assessment of vaccine safety during mass immunisation with pandemic H1N1 infl uenza vaccines". They also calculate background rates for spontaneous abortion, preterm delivery, and spontaneous death among other things.

Infectious history

The late Joshua Lederberg, a Nobel-winning molecular biologist (at the age of 33!), wrote an essay on the history of our fight against microbes titled "Infectious History." It's readable and covers a lot of ground fairly succinctly, and there's a non-paywalled version here. (The formatting isn't great, so it's a great excuse to install the Readability plugin if you haven't already.) One of my favorite excerpts:

Bacteriology's slow acceptance was partly due to the minuscule dimensions of microbes. The microscopes of the 19th and early 20th centuries could not resolve internal microbial anatomy with any detail. Only with the advent of electron microscopy in the 1930s did these structures (nucleoids, ribosomes, cell walls and membranes, flagella) become discernible. Prior to that instrumental breakthrough, most biologists had little, if anything, to do with bacteria and viruses. When they did, they viewed such organisms as mysteriously precellular. It was still an audacious leap for René Dubos to entitle his famous 1945 monograph "The Bacterial Cell."

And on diminishing returns on extending life expectancy (at least in industrialized countries) since 1950:

Other statistics reveal that the decline in mortality ascribable to infectious disease accounted for almost all of the improvement in longevity up to 1950, when life expectancy had reached 68. The additional decade of life expectancy for babies born today took the rest of the century to gain. Further improvements now appear to be on an asymptotic trajectory: Each new gain is ever harder to come by, at least pending unpredictable breakthroughs in the biology of aging.

Read the rest. I came across Lederberg's article in a footnote to Adel Mahmoud's article "A global road map is needed for vaccine research, development, and deployment."

Platform evaluation

Cesar Victora,  Bob Black,  Ties Boerma, and Jennifer Bryce (three of the four are with the Hopkins Department of International Health and I took a course with Prof Bryce) wrote this article in The Lancet in January 2011: "Measuring impact in the Millennium Development Goal era and beyond: a new approach to large-scale effectiveness evaluations." The abstract:

Evaluation of large-scale programmes and initiatives aimed at improvement of health in countries of low and middle income needs a new approach. Traditional designs, which compare areas with and without a given programme, are no longer relevant at a time when many programmes are being scaled up in virtually every district in the world. We propose an evolution in evaluation design, a national platform approach that: uses the district as the unit of design and analysis; is based on continuous monitoring of different levels of indicators; gathers additional data before, during, and after the period to be assessed by multiple methods; uses several analytical techniques to deal with various data gaps and biases; and includes interim and summative evaluation analyses. This new approach will promote country ownership, transparency, and donor coordination while providing a rigorous comparison of the cost-effectiveness of different scale-up approaches.

Understatement of the day

It is ironic that modern capitalist societies engage in public campaigns to urge individuals to be more attentive to their health, while fostering an economic ecosystem that seduces many consumers into an extremely unhealthy diet. According to the United States Centers for Disease Control, 34% of Americans are obese. Clearly, conventionally measured economic growth – which implies higher consumption – cannot be an end in itself.

That's economist Ken Rogoff, asking "Is Modern Capitalism Sustainable?". And of course it goes beyond ironic; it's tragic. Changes in policy that address that "economic ecosystem" itself are usually considered outside the realm of public health, which is exactly why public health folks have to (and do) engage on broader policy issues.

Genesis

I highly recommend Patient Zero, the  latest episode of the podcast RadioLab. It covers Typhoid Mary, the origin of HIV, and the diffusion of ideas. Evocative as always, but what I like the most is how they add new information to stories you think you know. For one, you really feel sorry for Mary. And I've read quite a bit on the origin of HIV (a great way to learn more about phylogenetics!) but RadioLab takes it back even further and highlights some research I hadn't seen. Related: I haven't read it yet, but Tyler Cowen really likes Jacques Pepin's new book, The Origin of AIDS -- more happy reading for Christmas break.

Ugh!

There are many things we can do to avoid illness and injury. Given the proper resources and opportunity, you'd think we would all maximize our well-being: eat well, exercise, get your vaccines, and wear your seatbelt for starters. But no, not only do we not do those things, we humans go far out of our way to expose ourselves to all sorts of exotic risks. Four recent illustrations of collective human stupidity from the news: (1) Epidemiologist Tara Smith writes, "Does bestiality increase your risk of penile cancer?" (See Cowen's First Law: there is literature on everything.) These Brazilian researchers should win an Ig Nobel. And true to form for public health, they coin an acronym: SWA (Sex With Animals). Prof. Smith read the paper so you won't have to  -- but you should at least read her summary to get the complete mental picture.

(2) Why is Delta Airlines running anti-vaccine in-flight infomercials? Doh-inducing background and petition here.

One of my Hopkins classmates who does not yet have a blog (but should) emailed a small group the following two stories:

(3) Parents in the US are mailing each other chickenpox-infected lollipops, amongst other things, to spread the disease and acquire natural immunity. Her summary: "Because asking your child to exchange bodily fluids with a sick stranger is a great idea!" True.

(4) Finally,though this one strikes me as an example of the "They're calling it [...]!" genre of local news stories about teenaged antics based mostly on hearsay, someone somewhere tried it: "Teens using vodka tampons to get drunk." My friend helpfully notes: "Your vagina does NOT have a gag reflex." Very astute. [Update: For the record, Scopes calls this one "undetermined."] OK, this one was an urban legend -- sorry.

I can't even begin to write an appropriate closing sentence for this post.

The state of mHealth

Amanda Glassman of the Center for Global Development and Vicky Hausman of Dalberg Global Development Advisors write about the "elusive power of mHealth" (ie, mobile phones and technology for global health efforts, a hot field):

Yet despite these successes, mHealth remains in its infancy, with many of the characteristics and issues typical of young industries.  The majority of deployments are still small-scale pilots, so much so that it’s been said there are more pilots in mHealth than there are in the US Air Force.   In many of these pilots, the evidence base that would enable decision-making and prioritization for further investment is missing.  Finally, mHealth tools are not always clearly linked to health systems’ needs and priorities, at times leaving solutions in search of a problem rather than products and services designed with end-user preferences and needs in mind.

Their five recommendations for moving forward:

1. Invest in the evidence base.
2. Align on standards and systems.
3. Ground mobile and information and communications technology (ICT) strategies in country-level realities, needs and opportunities.
4. Share learnings and best practices.
5. Build a coalition of global health funders to improve coordination.

You can read the details here. If you're a student who's interested in mHealth, you should join this Google Group.

Off by a factor of 100

GiveWell is an "independent, nonprofit charity evaluator" that finds "outstanding giving opportunities and publish[es] the full details of [their] analysis to help donors decide where to give." Their Giving 101 page is a good place to start regarding their methodology and conclusions. I want to highlight a recent blog post of theirs titled "Errors in DCP2 Cost Effectiveness Estimate for Deworming". DCP2 stands for "Disease Control Priorities in Developing Countries," a report funded by the Gates Foundation and produced for many partners including the World Bank.

The DCP2 blog post and its comments are wonky but worth reading in full because of their implications. It's a pretty strong argument for why calculations need to be as transparent as possible if we're going to make decisions based on them:

Over the past few months, GiveWell has undertaken an in-depth investigation of the cost-effectiveness of deworming, a treatment for parasitic worms that are very common in some parts of the developing world. While our investigation is ongoing, we now believe that one of the key cost-effectiveness estimates for deworming is flawed, and contains several errors that overstate the cost-effectiveness of deworming by a factor of about 100. This finding has implications not just for deworming, but for cost-effectiveness analysis in general: we are now rethinking how we use published cost-effectiveness estimates for which the full calculations and methods are not public...

Eventually, we were able to obtain the spreadsheet that was used to generate the $3.41/DALY [Disability-adjusted life year] estimate. That spreadsheet contains five separate errors that, when corrected, shift the estimated cost effectiveness of deworming from $3.41 to $326.43.

From later in the post:

Whether or not the long-term effects are taken into account, the corrected DCP2 estimate of STH treatment falls outside of the $100/DALY range that the World Bank initially labeled as highly cost-effective (see page 36 of the DCP2.) With the corrections, a variety of interventions, including vaccinations and insecticide-treated bednets, become substantially more cost-effective than deworming.

Frequent health miles

Perhaps surprisingly, the most interesting incentives have been developed in an emerging economy: South Africa. The Discovery group, based in Johannesburg, has crafted a programme called Vitality that applies the “air miles” model to health care. You earn points by exercising, buying healthy food or hitting certain targets. You rise through various levels, from blue to gold, as you accumulate points (rewards are adjusted to your starting level of fitness to give everybody a chance of making progress). And you are given a mixture of short- and long-term rewards ranging from reduced premiums to exotic holidays... This model has taken Discovery from “one man and a desk” in 1992 to become South Africa’s largest health insurer, with 5,000 employees.

That's from the Economist. One disagreement: I don't find it surprising that some of the most innovative models are coming out of an emerging economy -- in fact I imagine that if you're looking for innovative social ventures and policies, BRICS are the countries to keep an eye on.

US global health architecture

How confusing is the US global health bureaucracy? Here's a sentence with 6 acronyms to help clear it up:

We tried to map out what the USG GH architecture might look like with USAID as the GHI leader, and OGAC as the PEPFAR coordinator; after several attempts to create a diagram, we gave up.

From "Is USAID Being Set Up to Fail on the GHI?" by Nandini Oomman and Rachel Silverman.

Polio and confidence

Maryn McKenna writes about a new report (PDF) on polio eradication at Wired's SuperBug blog. The report comes from the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI). The GPEI has existed for 23 years now, and while they've made much progress (polio cases are down 99% since the campaign started) the campaign has repeatedly missed the deadlines it sets for itself for eradication. The latest goal is to interrupt polio transmission worldwide by 2012, and despite a recent infusion of funding and enthusiasm the campaign is -- according to the IMB -- likely to miss yet another of its own goals. McKenna writes, "Possibly the biggest problem, the board concludes, is a get-it-done optimism so ingrained in the 23-year effort that it cannot acknowledge when things are not working." She quotes the report to the same effect:

The Programme has an established narrative of positivity – a pervading sense of "nearly there". The danger comes in how the Programme deals with information that does not sit well with this narrative. We have observed that the Programme:

• Is not wholly open to critical voices, perceiving them as too negative – despite the fact that they may be reporting important information from which the Programme could benefit.
• Tends to believe that observed dysfunctions are confined to the particular geography in which they occur, rather than being indicative of broader systemic problems.
• Displays nervousness in openly discussing difficult or negative items.

This report is likely to ruffle some feathers as the public discussion regarding polio eradication often suffers from the same dearth of criticism. One reason for that -- and likely for GPEI's own "get-it-done optimism" -- seems to be that polio eradication is an epic high-stakes gamble. If we can do it the benefits are huge: no more polio, and less need for continued vaccination (though much of the projected cost-savings are predicated on the idea that the US and other countries will stop polio vaccination, which is highly unlikely given fears of vaccine-derived strains or bioterrorism). But if we can't do it then it might be better to spend resources on some other priority in global health; spend some lesser amount on polio, allow a bit of resurgence (but not too much), and focus resources on other vital needs. Thus the real battle is over the general donor consensus around whether polio eradication will be achieved soon. As soon as the global health donor community decides that eradication isn't actually possible, that belief will become a self-fulfilling prophecy.