What Is the Health Impact of Fracking?

Does fracking impact health? It’s a question that some want to answer before projects begin. After all, we know pipelines have caused massive damage before. Since 1993, there have been 5,613 significant pipeline incidents that cut short 367 lives. Ten people were killed last year. In 2010, a pipeline in San Bruno, California, ruptured. The fire from that explosion destroyed 37 homes, damaged 18 others, and killed 8 people. Many more were injured.

But no one is quite sure what the overall health impact is – and it’s not getting any easier for researchers to find out.

Earlier this month, the New York Senate Majority Coalition blocked a vote on a fracking moratorium in the state. In March, the New York Assembly passed the moratorium. Now, it looks like the legislation may be doomed, since it must arrive on the Senate floor before their session ends on June 20.

"Anti-fracking demonstration outside New York Governor Cuomo's office.” Adam Welz/CREDO Action. CC BY 2.0, 2012.

“Anti-fracking demonstration outside New York Governor Cuomo’s office.” Adam Welz/CREDO Action. CC BY 2.0, 2012.

There’s reason to be concerned. Spectra Energy will complete its 16 mile pipeline from New Jersey to New York in November. This pipeline will pump 800 million cubic feet of hydrofracked gas below Manhattan’s West Village every day.

But what do we know about the public health impact of fracking? On May 30 and 31, the National Academy of Sciences hosted a workshop on “Risks of Unconventional Shale Gas Development.” In their presentation on the public health risks, John Adgate, Bernard Goldstein, and Lisa McKenzie reviewed the literature. In their abstract, they wrote:

In worker populations the most serious risks are job-related mortality from worksite or traffic accidents. Based on existing data from conventional hydrocarbon development industries the principal chronic morbidity concerns for shale gas workers are though to be silicosis and cancers associated with hydrocarbon exposures (e.g., leukemia) as well as respiratory and dermal diseases related to these exposures. People living near shale gas operations report noticeable odors and, in some cases, upper respiratory, neurological, and dermatological symptoms that they consider related to development and production activities.

Other presenters discussed the impact of fracking on water resources. Avner Vengosh of Duke University’s Nicholas School of the Environment discussed both the short and long term risks. In the short term, they worry about stray gas contamination and potential spills. In the long term, there are concerns about water shortage, pathways for gas and brine to flow into drinking water, improperly sealed or abandoned wells, and improper disposal of wastes.

“The industry brushes these impacts off. But there are far too many correlations, far too many stories of very serious and very scary health impacts. It’s an area where we know the impacts are happening and we need more information on how widespread they are,” said Katherine Nadeau, Water & Natural Resources Program Director of the Environmental Advocates of New York.

But some people argue that fracking can be done safely. In a review for Science, R.D. Vidic and colleagues argue that it is possible to “avoid an adverse environmental legacy.” The authors minimize the negative consequences. They cite “only one documented case of direct groundwater pollution.” Other incidents, they write, were “quickly mitigated.” With the proper water management, drilling, and cementing practices, the authors suggest that fracking can be safe.

"Natural Gas Fracking.” Daniel Foster. CC BY 2.0, 2013.

“Natural Gas Fracking.” Daniel Foster. CC BY 2.0, 2013.

Others aren’t so sure. “This is major industrial activity and major industrial activities carry major consequences. I don’t think there are blanket assertions that really fit. When something does go wrong, we see major consequences,” said Nadeau.

“It’s a very difficult question to answer with current information,” said Miriam Rotkin-Ellman, Staff Scientist at the National Resources Defense Council. “There’s a huge vacuum in information.”

This information deficit is convenient for some supporters of fracking. Here’s how this works. The collection of evidence is prevented. Then the lack of evidence is cited in support of their position.

See Elizabeth Ames Jones, a past chairman of the Texas Railroad Commission, who brushes off “the frightful accusations” because of their “precious little evidence.” Or a spokesman for Energy in Depth who cautions against “blaming impacts on the most convenient thing (i.e. hydraulic fracturing) without scientific evidence.”

But a fracking moratorium would allow the collection of scientific evidence. Now, it seems like it might not happen in New York. This would be bad news anywhere. However, this particular source of natural gas, the Marcellus Shale, seems particularly dangerous.

“There is considerable variation within, and among, the different shales. What in one area is a health risk may not be a health risk in another area,” said Rotkin-Ellman.

The Marcellus Shale seems to be especially hazardous, because of its radon concentration. Radon causes lung cancer. A report by Marvin Resnikoff, of the Radioactive Waste Management Associates, states that “wellhead concentrations in Marcellus shale are up to 70 times the average in natural gas wells throughout the U.S.”

Perhaps the most important question, then, is not, do we know the health impact of fracking? The better question is, why don’t we know the health impact – and why are some politicians standing in the way of finding out?

Category: Determinants of health | Tagged , , , , | 2 Comments

Why we should all place our babies to sleep in cardboard boxes… or just give up and move to Scandinavia

 

If only cute baby photos could make a compelling case for maternal health...

If only cute baby photos could make a compelling case for maternal health…

You may have seen this curious headline, or a similar version of it, in the news recently:

Why Finnish babies sleep in cardboard boxes.

It certainly caught my eye. I read the BBC news article with curiosity, but little surprise.  The gist of the story is that antenatal care in Finland includes a box filled with several hundred euro worth of baby clothing and supplies including a mattress and snowsuit for the icy Finnish winters (1).  All an expectant mother has to do is visit an antenatal care clinic or doctor once in the first trimester of her pregnancy to receive the box for free.  In itself, the box is brilliant piece of preventive public health care. It incentivises the receipt of crucial early pregnancy care with free essential goods.  The end result is healthier, happier babies and mothers: good for the family and for the state.

 

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The ‘Nordic Model’: nothing to do with fashion

Finland is among the five Scandinavian countries famous for their welfare states (also Denmark, Iceland, Norway, and Sweden).  Hence, its provision of excellent antenatal care service is not surprising.  Although there is variation between the Scandinavian countries in political and economic operation, all follow a principle of universality in their ‘Nordic Model’ of welfare provision (2).  Taxes are steep for the countries’ residents, but social and health care spending are high.  Evidence for the effectiveness of this equality-driven Nordic model is clear: Scandinavian countries rank among the highest in the OECD for life satisfaction, work-life balance, and life expectancy (3-5).  So that’s some of the context at hand.

What do we all think?

People in other countries are tuning into the Finnish ‘baby box’ story with open ears. Reactions are a mix of mild interest to slight shock that the Finns would dress their babies in identical state-issued clothes and place them to sleep in a cardboard box; some appear jealous of the programme and wonder why it is not a common practice elsewhere.   You see, the programme is almost a no-brainer.  A person’s health as a baby is crucial to health in later life.  Increasing evidence from epidemiological ‘lifecourse’ studies shows that in-utero and early life exposures may play a role in later health conditions such as asthma  and some cancers (7-9).  Furthermore, maternal health is a strong indicator of a country’s development. Improvement of maternal health in poor countries is one of the WHO’s Millennium Development Goals (6).  So, what about using the Finnish model to promote antenatal and early life care in other countries?

Well, Finland is not like many other countries.  Finland is highly developed, ranking at 21 out of 186 UN member-states for the Human Development Index in 2013 (10).  Public health strategies that work in rich countries like Finland often don’t work in poor developing countries.  With respect to maternal deaths, over half that occur globally are in sub-Saharan Africa and one-third in South Asia (11).  Proper antenatal care, such as that promoted by the Finnish ‘baby box’, would help prevent maternal deaths in these places.  The barriers to antenatal care in these regions of the world, as listed by the WHO, are poverty, distance, lack of information, inadequate services, and cultural practices (11).  Obviously, all the baby boxes in the world won’t make a difference to removing the latter four barriers to antenatal care.  However, the box would bypass financial constraints on purchasing many essential items for new mothers in poor countries.

…. and other rich countries?

What about the potential for baby boxes in rich, developed countries?  It’s an interesting thought.  Antenatal care is crucial for the lifelong health of all people, although it’s taken for granted in rich countries where services are high-quality and abundant.  However, several countries do have a long way to go: infant mortality is twice as high in the United Kingdom as in Finland and three times higher in the United States than in Finland (from 2008 and 2012, infant mortality was 4 deaths per 1,000 births in the UK, 6 deaths per 1,000 births in the United States, and 2 deaths per 1,000 in Finland; 12).  Unfortunately, the provision of ‘baby boxes’ in Finland is linked to a political ideology that, while not extreme, is unacceptable in many places.  For example, the Nordic welfare state is too socialist to be compatible with American politics – the United States does not even have a public health care system.  Furthermore, the individualistic attitude of people living in many countries like the United States probably precludes a desire for many to have their baby dressed up in the same clothes as all other babies born in the country in that year – which is one aspect of using the box in Finland.

Don't we all wish a 'baby box' would come with this?

Don’t we all wish a ‘baby box’ would come with this?

No one likes logistics

Unfortunately, the ‘baby box’ costs money.  This is a problem not only for poor, developing countries where infrastructure for basic services is a more immediate concern, but also for developed countries in the current global economic climate.  Health and social spending is largely being reduced in most places; most governments are unlikely to be in positions to start providing boxes of free baby care goods, no matter how essential they are.

Hope – and the bigger picture

I don’t mean to imply that Finland is the only country in the world with amazing antenatal and infant care strategies.  Apparently Boot’s (a British pharmacy) provides a similar baby box that at least used to be redeemable with a voucher from a GP (I could not find current evidence for this).  Countries with public health care systems such as Canada and the UK provide antenatal care and support through their health systems, although you must be self-motivated to access much of it.

And let’s not forget that the ‘baby box’ is only small piece of public health care within a broader mosaic of political, economic, and social conditions in Finland. Finland has emerged from a poor economic climate in the 1930s, when the box was introduced, to being among the richest and most developed today.  This shift likely has had a bigger impact on infant mortality and maternal health than the ‘baby box’.

However, let us keep the Finnish ‘baby box’ in mind as an aspirational piece of legislation.  The box is inscribed with the line ‘Every child matters. Every family matters.’ (13).  While corny, this message of equality is one of the Nordic Model that every country in the world should be listening to with keen attention.

 

 

 

References

1)      Lee H. Why Finnish babies sleep in cardboard boxes. The BBC. June 4 2013. http://www.bbc.co.uk/news/magazine-22751415 (accessed 8 June 2013).

2)      The Nordic Council. The Nordic Welfare Model. http://www.norden.org/en/about-nordic-co-operation/areas-of-co-operation/the-nordic-welfare-model (accessed 8 June 2013).

3)      OECD. “Work and life balance”, in How’s Life?: Measuring Well-being. OECD Publishing. 2011. http://dx.doi.org/10.1787/9789264121164-8-en

4)      OECD. “Health”, in OECD Factbook 2013: Economic, Environmental and Social Statistics. OECD Publishing. 2013. http://dx.doi.org/10.1787/factbook-2013-109-en

5)      OECD. “Subjective Well-Being”, in How’s Life?: Measuring Well-being. OECD Publishing. 2011. http://dx.doi.org/10.1787/9789264121164-14-en

6)      WHO. Health topics: Millennium Development Goals (MDGs). http://www.who.int/topics/millennium_development_goals/en/ (accessed 9 June 2013).

7)      Zhou C, Baiz N, Zhang T, Banerjee S, Annesi-Maesano I. Modifiable exposures to air pollutants related to asthma phenotypes in the first year of life in children in the EDEN mother-child cohort study. BMC Public Health 2013;13(1):506.

8)      Park SK, Kang D, McGlynn KA, Garcia-Closas M, Kim Y, Yoo KY, et al. Intrauterine environments and breast cancer risk: a meta-analysis and systematic review. Breast Cancer Res 2008;10(1):R8.

9)      Franco-Lie I, Iversen T, Robsahm TE, Abdelnoor M. Birth weight and melanoma risk: a population-based case-control study. Br J Cancer 2008;98(1):179-82.

10)   Malik K, Human Development Report 2013 team. Human Development Report 2013: The Rise of the South: Human progress in a diverse world. United Nations Development Programme. 2013.

11)   WHO. Fact Sheet No. 348: Maternal Mortality. May 2012. http://www.who.int/mediacentre/factsheets/fs348/en/index.html (accessed 9 June 2013).

12)   UNICEF, WHO, World Bank, UN DESA, UNPD. Mortality rate, infant (per 1,000 live births). http://data.worldbank.org/indicator/SP.DYN.IMRT.IN/countries?display=default (accessed 9 June 2013).

13)   Picard M. Why Canadian babies should sleep in cardboard boxes like Finnish babies do. The Globe and Mail. June 7 2013. http://m.theglobeandmail.com/life/parenting/why-canadian-babies-should-sleep-in-cardboard-boxes-like-finnish-babies-do/article12371884/?service=mobile (accessed 8 June 2013).

Image sources:

Baby: Cindy Smith at New Art Funny Wallpapers Jokes

Northern Lights: Chirag McEwan at Go to the World

Crib: Donna Virginx at Cribs

Category: Determinants of health, Health systems, Maternal health | Tagged , , , , , | 1 Comment

Heading to #CPHA13

Ottawa is a beautiful city in the summer - hopefully we'll be able to enjoy it! | Photo credit: Atif Kukaswadia

Ottawa is a beautiful city in the summer – hopefully we’ll be able to enjoy it! | Photo credit: Atif Kukaswadia

EDIT: I have been informed that we will be using #CPHA2013 for the conference. My apologies for any confusion.

Just a short note today – I (Atif) will be heading to the Canadian Public Health Association Conference next week, which is being held in my home town of Ottawa, Ontario. I’ve never been to the CPHA Conference, so I’m looking forward to it.

I’ll be tweeting findings from the conference using the #CPHA13 hashtag, #CPHA2013 hashtag and I’m hoping others will be too. There are a wide range of presentations this year, and I’m excited to hear about all the research that people are doing, as well as the vision that CPHA has for themselves and for their role in promoting public health in Canada.

I’m going to presenting a poster on one of the studies from my PhD titled “A Cross-sectional Analysis of Immigrant Status and Its Relation to Physical Activity Among Canadian Youth.” I’ll be by my poster for the breaks, so drop by Canada Hall 2 to learn all about it.

If you’re attending the conference, leave a comment with details of your own presentation so that other readers can attend your talks. And if you see me at the conference, be sure to say hi!

This was posted simultaneously on my blog MrEpidemiology.com

Category: Admin, Science Outreach | Tagged , , | 1 Comment

History of Epidemiology: Jonas Salk and The Eradication of Polio

Better Know An Epidemiologist/History of Epidemiology is an ongoing feature where we highlight important studies that have been significant breakthroughs in public health. All of the articles are listed here.

Poliomyelitis is an infectious viral disease. It enters through the mouth and is usually spread by contaminated drinking water or food. The virus passes through the stomach and then replicates in the lining of the intestines. Most healthy people infected with virus experience little more than mild fever or diarrhea. However, some people develop paralysis, and some die as a result.

Franklin Delano Roosevelt, 32nd President of the United States of America, suffered from Polio

Franklin Delano Roosevelt, 32nd President of the United States of America, suffered from Polio | Photo Courtesy Wikimedia Commons

In 1952, approximately 58,000 new cases of Poliomyelitis occurred in the United States. In 1953, approximately 35,000 new cases were reported. This was up from an annual average of 20,000 cases. The 1952 infections left 3,145 people dead and 21,269 with mild to disabling paralysis. However, even before the 1952 and 1953 outbreaks, labs had been worked diligently to find a cure for Polio. Relief finally came when Jonas Salk developed a vaccine.

The Salk vaccine is prepared from a sample of the virus that is first killed using heat and chemicals. In theory, the killed vaccine is safe, because the killed vaccine should be incapable of causing the disease. However, this is a balancing act: If the virus is too strong, the vaccine will be capable of causing the disease. If the virus is too weak, the vaccine will be ineffective. This had the potential to lead to problems once the vaccine was widely adopted.

But first, Salk had to show that the vaccine worked.

To prove that the vaccine was effective, one of the largest epidemiologic studies ever was undertaken. Two parallel studies were created. In one, children in grades 1 through 3 were randomized to either receive the vaccine or a placebo. Infections from Polio were then compared between treatment arms. In the second study, children in Grade 2 were given the vaccine, and children in Grades 1 and 3 were used as controls. Two study designs were employed as Polio resistance can be transferred between children. In total, approximately 1.8 million children were enrolled into the study.

The findings were astounding. In the first study design, there were 57 confirmed cases of polio (28 cases per 100,000 children) in the vaccinated group versus 142 cases (71 cases per 100,000 children) in the group receiving a placebo. Similarly, in the second design, 56 cases (25 per 100,000) were reported among those vaccinated compared to 391 cases (54 per 100,000) among those not vaccinated. These results provided all the evidence required to start a large, national, vaccination program. The vaccine was rolled out nationally and Salk became a celebrity across the world. He received awards and accolades, and some suggested he should have won the Nobel Prize in Medicine for creating the first vaccine that used an inactivated form of a virus.

However, there were problems. The Salk Vaccine marked the first time a pharmaceutical company manufactured a vaccine, not the government. Since the vaccine is only used once, it is not a big money maker for drug companies, and this led to vaccine shortfalls. In 1955 Cutter Laboratories was one of several companies producing the polio vaccine. While companies were having trouble producing the dead vaccine, most carried on as normal. However, a bad batch of the Cutter vaccine contained the live polio vaccine. In a terrible pharmaceutical disaster, several thousand children were exposed to the live polio virus, which caused 56 cases of paralytic polio and 5 deaths.

However, despite this, people kept getting vaccinated. Combined with the passive immunity passed through people, the annual number of polio cases fell from 35,000 in 1953 to 5,600 by 1957. By 1961 only 161 cases were recorded in the United States. The Oral Polio Vaccine (OPV) was also developed at this time, and together, they have been used throughout the world to combat polio.

Reported Polio cases in 2012 | Photo Courtesy Wikimedia Commons

Reported Polio cases in 2012 | Photo Courtesy Wikimedia Commons

Polio is now endemic to four countries: Pakistan, Afghanistan, Nigeria and India (although India only had one reported case in 2010), and cases have been reported in the Democratic Republic of Congo, Chad, Angola, Mali, Cote d’Ivoire, Burkina Faso, the Republic of Congo, Niger, and Gabon. Worldwide, there were only 241 cases reported in 2011.

The legacy of the Salk Vaccine Trial echoes on. The sheer scale of the study, combined with the novelty of the vaccine (the Salk vaccine was the first vaccine to use an inactivated form of the virus), the public-private partnerships and the humanitarian effect of saving millions of lives show how incredibly powerful Epidemiologic studies can be. Within a generation, a disease that affected and claimed tens of thousands of lives annually became all but eliminated in the West. Hopefully within our lifetime, it can be eradicated completely.

References
Francis T (1955). Evaluation of the 1954 poliomyelitis vaccine field trial; further studies of results determining the effectiveness of poliomyelitis vaccine (Salk) in preventing paralytic poliomyelitis. Journal of the American Medical Association, 158 (14), 1266-70 PMID: 14392076
Monto AS (1999). Francis field trial of inactivated poliomyelitis vaccine: background and lessons for today. Epidemiologic reviews, 21 (1), 7-23 PMID: 10520470

Ed note: A version of this post originally appeared on Mr Epidemiology back in August 2011

Category: History of Public Health | Tagged , , , , , | 1 Comment

Why DIY fecal transplants are a thing (and the FDA is only part of the reason)

Michael K. was three days away from surgery to remove part of his intestine (the last-resort treatment for his ulcerative colitis) when he heard about a treatment his doctor had never recommended: fecal transplants. He canceled the surgery, sought help from a mentor, and chose a friend who he thought would be a good source of healthy donor material. What happened next sounds a bit like an oddball marriage proposal: he took the friend on a hike, made a few poop jokes, and then popped the question.

The friend said yes, as he writes in his success story on The Power of Poo, a website created to help patients find help with fecal transplants (DIY or otherwise.) The two moved in together for more convenient poop swapping, since he wanted to do the transplants frequently, and they need to be fresh.

If you want something done, you’ve got to do it yourself?

Is the age of the do-it-yourself fecal transplant upon us? That was several experts’ concern after the FDA’s recent decision to regulate fecal transplants as an investigational new drug. (Judy Stone‘s is one take worth reading) As a result, the treatment, which was on a trajectory toward mainstream acceptance, will once again–temporarily–be rare and hard to get in the US.

Fecal matter occupied a gray area, neither drug nor device nor tissue, when Maryn McKenna reported two years ago that “fecal transplants work, but the regulations don’t.” At the time, several researchers were applying to begin clinical trials. That would be the road toward getting the transplants, known as FMT (for “fecal microbiota therapy”, although there are a lot of other names: stool transplant, fecal bacteriotherapy, human probiotic infusion…) approved and widely available. Now, FMTs are considered to be in Phase 1 of a three-phase process.

In the meantime, doctors operated within the gray area and tried it out. It worked, they shared results, and soon FMT got its own billing code (44705) and a set of guidelines that include a battery of tests for donors: blood tests for diseases like HIV, and stool screening for parasites and the like. The price of donor testing is estimated at anywhere from $500 to $1500+, depending on who’s doing the estimating and what tests they include. Good luck getting insurance to cover it.

If you have the cash, though, FMT is worth it. The studies that have been done so far are astounding: in one trial of patients suffering from C. difficile infection (a diarrheal disease that can be life-threatening and antibiotic-resistant), an infusion of feces cured 94% of the patients. The usual treatment, an antibiotic called vancomycin, only cured 27%. The trial was stopped early because the difference was so drastic; it was unethical to keep half the patients on antibiotics alone when a better treatment was available. Gastroenterologists agree: FMT is not just effective for C. diff, it’s extremely safe. The American College of Gastroenterology writes in their C. difficile treatment guidelines that “no adverse effects or complications directly attributable to the procedure have yet been described in the literature.”

Dr. Michael Edmond, who used to offer the procedure, blogged recently about canceling patients’ appointments and applying for the Investigational New Drug permit that is now required. (The FDA will approve or deny the application within 30 days, but won’t tell him the criteria they use to decide.) He told The Verge: “by trying to make fecal transplants safer, the FDA is actually pushing them underground.”

The underground

They have been underground for a while, of course. Only a few clinics offer the treatment, and some (like the Centre for Digestive Diseases in Australia) give patients instructions on doing the procedure at home. Meanwhile, sufferers of inflammatory bowel disorders are already sharing tips and support online, so DIY instructions fit right in. If you are desperate and willing to try anything, Dr. Google and Dr. Facebook are there for you.

The gross-out factor probably contributes to the scarcity of medical professionals offering the treatment. Tracy Mac, who runs the Power of Poo website, describes her gastroenterologist’s reaction when she suggested a fecal transplant: “He screwed up his nose like a seven-year old and observed ‘but it’s putting someone else’s poooo inside of you’. An interesting comment coming from someone who makes a living sticking cameras up bums!”

The thing is, if you have Crohn’s, C. diff, or ulcerative colitis, fecal transplants mean dealing with less poop, less often. “[I] realize that doing the fecal enemas is not that bad,” Michael writes. “Afterall the illness caused me to poop my pants with bloody diarrhea at times.”

Also spurring the do-it-yourself phenomenon: those amazing results I mentioned earlier are from C. diff infections, but many patients seeking the treatment have ulcerative colitis, Crohn’s, or sometimes other disorders. The evidence is less definitive on those, although still promising. It may be the nature of the disease: If you have C. diff, your problem can be traced back to a single misbehaving species of bacteria.

This one.

For inflammatory bowel disorders, the disease and its causes may be more complex. Tracy Mac attributes mental health problems to an unhappy gut, which is not as far-fetched as it may sound: a recent study found that gut microbes can influence brain function in humans. Scientists in the Netherlands are testing fecal transplants for weight loss and insulin resistance. The gut microbiome seems to be a key player in health and disease, so FMTs have a lot of potential. Potentially.

How it’s done

While C. diff treatment often uses one transplant or a short series, sufferers of inflammatory bowel diseases like ulcerative colitis and Crohn’s often prefer a long term strategy. Kathy explains why she has been doing FMTs for her daughter for the better part of a year: she was in a trial testing fecal transplants for ulcerative colitis, and did so well that they decided to continue at home. “We have kept up the FMT because we believe the intestines take a long time to heal, and because we don’t think it can hurt,” she writes. “While we have faith in the treatment, we don’t want to stop it yet, either.”

Kathy has a fascinating, simple, instructive video on youtube. Neatly dressed–and still spotless at the end–she prepares a sample in her bathroom, as she does several times a week. She has a dedicated blender, cup, strainer, and spoon, and she wears gloves. Ten minutes for prep, she says, five minutes for cleanup, and about thirty seconds to administer. Afterward, she used to ask her daughter to lie down and watch a movie; after nine months of treatment, she’s as likely to do a handstand for a few minutes and then go about her day.

In a hospital setting, the transplant is often performed with colonoscopy equipment, to infuse the sample as far back in the colon as possible. It’s also possible to run a tube from the patient’s nose down past their stomach. For the do-it-yourselfers, the more accessible option is to simply use an enema bottle. (The smaller size, I keep hearing: a little goes a long way.) In fact, there is research suggesting that enemas may be the most effective delivery method, but there’s just not enough data yet to say for sure.

What? Sometimes a glass of chocolate milk is just a glass of chocolate milk. Photo by mynameisharsha.

What now?

There are lots and lots of questions about fecal transplants. We’re just coming to grips with the gut microbiome’s impact on health and disease, and we know so little about what is actually in that magical brown pellet (which is about 55% bacteria, in case you were wondering.) Does a donor have to be matched to the patient, or is any healthy stool good enough? Do some patients respond to the treatment and others don’t – maybe in a predictable way? Does the sample need to be fresh, and if not, what is the best way to store it? Can poop be replaced entirely by a synthetic, probiotic concoction? Are there legions of failed FMT patients who are too disappointed, or embarrassed, to publish negative results?

I’m looking forward to hearing the answers to those questions, and I hope the FDA’s rules don’t keep life-saving treatment from those who need it (They have promised emergency approvals in dire situations). In the meantime, if you want to hear about the current state of the science from those on the front lines, the transcripts from the recent FDA workshop will make excellent reading on the beach this summer. All summer. We’re talking 600+ pages. Enjoy?

(Update: I’ve corrected this piece to refer to inflammatory bowel diseases, or IBD, an umbrella term for diseases including Crohn’s and ulcerative colitis. That’s distinct from irritable bowel syndrome, which is what I originally wrote. Not the same thing! Thanks to Tracy for setting me straight.)

Category: Uncategorized | Tagged , , , | 7 Comments

Cultural Comic Books for Educating Asian Americans about Hepatitis B

There’s the story of a young Chinese American couple planning on getting married, but on the day of the proposal the bride-to-be confesses to her fiance that she has hepatitis B. Then there’s the one about a Korean immigrant family in which the father, who prefers traditional Asian medicine over Western medicine, discovers that his brother has liver cancer. Lastly, there’s the story of a Vietnamese American nail salon owner whose husband is diagnosed with hepatitis B, which was probably contracted by sharing razors with an infected roommate in college. No, these are are not vignettes from an Asian American film about coincidence.* These are cautionary tales used in cultural, comic book-like photonovels that were developed to raise hepatitis B awareness among Asian Americans–the racial/ethnic group with the greatest risk of contracting hepatitis B.

chinese couple

“I have something important to tell you. Actually, i have chronic hepatitis B infection.”
“What? Why didn’t you tell me earlier?”

Hepatitis B is an infectious liver disease caused by the hepatitis B virus and is spread through contact with bodily fluids such as blood, semen, or vaginal fluids. It can also be passed from mother to child during childbirth. Contracting the virus can lead to either acute infection with symptoms that include liver inflammation, jaundice, fever, and nausea lasting several weeks or chronic infection, which may not present with symptoms but is a leading cause of life-threatening conditions such as cirrhosis (scarring of the liver) and liver cancer. Hepatitis B, however, is treatable and preventable through limiting exposure (i.e. not sharing needles, safe sex, etc.) and vaccinations.

ChronicHepatitisB_350px (1)

(image from CDC website)

Asian Americans, particularly recent immigrants, are especially vulnerable to hepatitis B infection because hepatitis B is endemic in many countries from which Asian Americans originate and Asian Americans have low rates of hepatitis B screening and vaccination. As a result, according to the CDC, of the estimated 1 million Americans with chronic hepatitis B about half are from the Asian/Pacific Islander (API) communities. For comparison, Asian Americans make up roughly 5% of the US population. Nearly 1 in 12 Asian Americans are chronically infected with hepatitis B, but many are unaware of their status. This further poses a public health risk since infected individuals can unknowingly spread the virus.

The low rates of hepatitis B screening and vaccination in the Asian American community may be due to a combination of barriers such as hepatitis B awareness, fluency in English, access to healthcare, and cultural beliefs and norms surrounding disease and medicine. To overcome some of these obstacles culturally-appropriate photonovels can be used to increase the effectiveness of a public health message. These are educational materials that use images of ethnic characters, cultural issues, and language to tell a story that is highly relatable to a target community. Photonovels, for instance, have been used with success to educate immigrant Latino communities on various health issues. The effectiveness of photonovels, however, have not been addressed for diverse Asian American communities which have do not have a unifying language such as Spanish for Latino communities.

korean family

“I’ve been feeling so drained these days, but now I’m much better, owing to my stone bed.”
“I should make you feel better. It cost us more than $2000!”

Faced with this obstacle, Sunmin Lee and her colleagues at the University of Maryland School of Public Health and Johns Hopkins Bloomberg School of Public Health developed three photonovels in Korean, Chinese, and Vietnamese languages with the help of focus groups from those communities. These focus groups aided in incorporating not only characters and simplified language into the photonovels, but also identifiable cultural norms such as the stigma of having a disease, misconceptions of traditional medicine and Western medicine, and the idea of luck and misfortune that surrounds disease.

storyline.medium

Summary of the storylines for each photonovel. Click for larger image. (Lee S. et al., 2013)

These photonovels were used as one component of a 90-minute hepatitis B educational program consisting of a video, slideshow presentation, and a Q&A session aimed at increasing hepatitis B screening rates to decrease the incidence of liver cancer among Asian American communities. A follow-up survey of participants was conducted a month after the educational program was delivered to evaluate the photonovel. A clear majority (nearly 90%) of survey respondents agreed or strongly agreed that the photonovels presented useful and easy-to-understand information on hepatitis B screening for liver cancer prevention. A similar majority of respondents also found that the stories were written by someone who was familiar with their respective communities (~77%) and a good teaching tool (over 80%). Perhaps most importantly, the authors of the study found that individuals who had never been screened for hepatitis B or were unaware of their infection status and who had evaluated the photonovels positively were more likely to indicate that they felt capable of and intended to undergo hepatitis B screening.

Furthermore, when the authors analyzed the responses based on income and education they found that individuals with less education and on the lower end of the income scale were more likely to evaluate the photonovels positively. Interestingly, when broken down by specific communities, Vietnamese respondents were most favorable overall towards the photonovels compared to their Korean and Chinese counterparts. Vietnamese participants also tended to be less highly educated, so the authors speculate that educational materials such as photonovels that rely on pictures more than text might be an effective strategy for this demographic. However, since the photonovels were all different it could be the case that the Vietnamese photonovel just happened to be better developed than the Korean or Chinese  photonovels and, therefore, more effective for the Vietnamese community.

vietnamese couple

“…Oh, by the way, honey, why were you mad at Aunt Mai?”
“She kept talking about liver infection and cancer! That’s so unlucky!”

The study, however, is not without its limitations. To start, it is a relatively small study of 347 survey respondents. The authors also caution that since their target population was not easily reached, participants were recruited through community organizations rather than through a random selection process. As such, the groups analyzed may not be representative of Asian American communities in the US. Additionally, the photonovels were one component of a larger educational program. Exposure to the 90-minute presentation may have primed the participants to read and understand the photonovels. It would be good to know how effective the photonovels are independent of the presentation as well as how it compares to educational materials that are more text-dependent or written in English. Lastly, to determine if this campaign effectively translates into higher hepatitis B screening rates, it would be essential to know how many of the participants ultimately underwent hepatitis B screening. As it stands, the survey only asked if the participicants felt capable of undergoing a hepatitis B screening and what their likelihood of undergoing a screening.

Despite its shortcomings, the positive reaction of the Korean, Chinese, and Vietnamese participants to the photonovels is encouraging. The study, although small, suggests that culturally appropriate photonovels may be an effective strategy for increasing hepatitis B awareness and lowering the liver cancer rates in the rapidly growing Asian American community. In fact, the Vietnamese photonovel won the Health Education Materials Contest Award in the Printed Category at 2011 American Public Health Association Meeting.**  The study’s methods in consulting focus groups also provides a template for designing future public health education campaigns targeting other immigrant and at-risk populations.

In the meantime, if you’re Asian American don’t let the stigma of having a disease, traditional medicine, or the taboo of discussing illness stop you from getting screened for hepatitis B. Your liver might thank you for it later.

The photonovels are available as pdf here.

*Speaking of coincidence, May is Asian-Pacific American Heritage Month and Hepatitis Awareness Month.

** Post updated 5/26/13.

References:

Lee S., Yoon H., Chen L. & Juon H.S. (2013). Culturally Appropriate Photonovel Development and Process Evaluation for Hepatitis B Prevention in Chinese, Korean, and Vietnamese American Communities., Health education & behavior : the official publication of the Society for Public Health Education, PMID:

Category: Cancer | Tagged , , , , , , | 3 Comments

Médecins Sans Frontières Scientific Day 2013

PLOS Medicine was one of the sponsors - check out the swag!

PLOS Medicine was one of the sponsors – check out the swag!

Last Friday, I had the fortunate opportunity to attend the Médecins Sans Frontières Scientific day at the Royal Society of Medicine in London.  If you didn’t get a chance to check out the coverage via online streaming or twitter, I’ll give a quick run-down of things here.

 

What is Médecins Sans Frontières?

Médecins Sans Frontières, or Doctors without Borders, or just simply MSF, is an international humanitarian aid organisation. MSF gives rapid, non-discriminatory emergency aid in situations of humanitarian crisis, such as during armed conflict, natural disasters, and disease epidemics. In 1999, MSF won the Nobel Peace Prize ”in recognition of the organization’s pioneering humanitarian work on several continents“.

 

What is MSF Scientific Day?

MSF conducts scientific research alongside the health care relief that they provide in emergency situations. For example, MSF responded to a major outbreak of lead poisoning among children in northern Nigeria in 2010. In addition to providing care for the affected children, MSF scientists conducted research among the children to determine the factors associated with neurological symptoms caused by lead poisoning and to assess the effectiveness of their treatment programme (research presented at the 2013 Scientific Day). The purpose of the Scientific Day is to disseminate this research produced by MSF scientists to the greater public.

 

So what?

As I learned throughout the day, the balance between providing health care in a crisis while conducting research is extremely delicate. MSF has to deal with many sensitive and ethical issues such as:

- How can resources be devoted to research when they are so badly needed for health care treatment, particularly in low-resource settings?

- How can it be ensured that the research conducted is high-quality, addressing the most important issues for the people who are the research subjects, and actually making a difference?

- How can scientific objectivity and neutrality be maintained in research when the humanitarian situation demands strong advocacy?

 

Things are now becoming a little more complicated. The morning sessions of the day covered results of recent research MSF has conducted, with exciting findings such as the positive effects of blogging among multi-drug resistant TB patients around the world and an effective TB treatment programme in Somalia, which is an extremely dangerous conflict setting. But, is conducting this type of research withdrawing precious resources from aid efforts, is the research addressing the big problems that the affected people are most concerned with, and is it having the highest impact possible? Enter Hans Rosling:

 

Lessons from Hans Rosling

If you have not heard of Hans Rosling, stop reading immediately and listen to his TEDTalk. Right now. Seriously, do it.

Hans Rosling is a Swedish medical doctor and academic who is one of 2012’s 100 Most Influential People in the World according to Time Magazine. He co-founded ‘Gapminder’, which is amazing software that makes data accessible and interactive for people to use – a ‘modern museum on the Internet’. He has a whole string of TEDTalks online and I recommend listening to any one of them to get fired up about making change and reducing inequality in the world.

Hans Rosling worked in Mozambique as a medical doctor in the early 1980’s and came to share with us his experience of working in a poor, low resource area where there were only two medical doctors for a population of 300,000 people. You must, must, must watch the video from his Scientific Day talk. He is a hilarious speaker and told an inspiring story about his experiences (including an encounter where Fidel Castro attempted to participate in designing his research study!).

I won’t rehash his talk (although it involved wildly jumping up on a table, almost knocking over a glass water jug, and sending his pointer stick flying across the room in the span of a minute), although he left us with three main lessons:

 

  1. If you are responding to a humanitarian crisis and want to conduct research, you need extra resources. When human lives are at stake and you have few resources to begin with, health care is the priority;
  2. If you are in a situation where politics can influence your work (the Fidel Castro situation), you must define who you are: a researcher. That means being as unbiased, neutral, and as objective as one can be and not letting yourself be used as a political pawn;
  3. If, as a humanitarian response, you do something perfectly, you have taken a resource away from somewhere else where it could have been used. Listen to the people who are affected and give them what they need, rather than aiming to be the “perfect” humanitarian aid worker. You will never do it, and you don’t want to leave a place in a situation where your intervention is not sustainable.

 

Thank you, Hans

Thank you, Hans

In short, it was an extremely enlightening and thought-provoking day. The issues brought up are extremely important to human health, development, and rights and we need to be having conversations about these issues. Please check out the online feed of the Scientific Day (it won’t be available online until May 17th, but you can see the posters for now), take a look at Gapminder, and comment below or on twitter (#MSFSci) to continue the discourse!

 

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Patient Zero: The origins of disease

Better Know An Epidemiologist/History of Epidemiology is an ongoing feature where we highlight important studies that have been significant breakthroughs in public health. All of the articles are listed here.

Gaetan Dugas, Air Canada flight attendant and one of the first diagnosed cases of HIV

Patient Zero is a common infectious disease epidemiology term. It refers to the first known case of the disease of interest, and is useful when tracking disease outbreaks. Knowing where the disease starts allows us to track not only the spread of the disease, but also how it spreads – through water, air, person-to-person contact etc.

I heard an absolutely phenomenal podcast through WNYC’s RadioLab podcast about Patient Zero, and that formed the inspiration for this post. I highly recommend listening to it when you have a chance – either through iTunes, on their website. They cover several different “Patient Zero’s,” including Typhoid Mary and Gaetan Dugas (pictured above).

Today, I’ll be talking about Typhoid Mary. To listen exclusively to the Typhoid Mary segment of the RadioLab podcast, click here.

Click the image to go to the RadioLab podcast about Patient Zero.

A historical poster cautioning people against acting like Typhoid Mary (pic goes to Wikipedia article)

Mary Mallon was born September 23rd, 1869, and is of interest to Epidemiologists as she was the first known asymptomatic case of typhoid fever. Typhoid fever is estimated to affect between 16 – 33 million people annually. Fatalities from typhoid drop to less than 1% if treated quickly with oral rehydration therapy. However, when untreated, death occurs in 10% – 30% of those infected (for more information about the disease itself, check out this excellent Infection Landscapes post). The name is derived from the Greek word “typhus” or stupor, as infected individuals suffer from malaise and a high fever. It is spread through the feces of contaminated individuals, generally after those feces come into contact with either food or water. The typhoid bacteria can be destroyed by cooking food thoroughly and boiling water before drinking it. Washing hands and cleaning dishes also prevents transmission of the bacteria.

Now back to Mary Mallon. Mary was born in Ireland, and moved to the US in 1884. She was a cook, and in 1900, she was working for a family in Mamaroneck, NY. Soon after she started there however, the residents developed typhoid fever. She moved to Manhattan in 1901, and worked for a new family. Sure enough, this family developed typhoid fever also. After this, she moved to Oyster Bay, Long Island, infecting a third family.

George Soper, a typhoid researcher, found Mary was the link between the first three families, and approached her to obtain a stool and blood sample. As you can imagine, this conversation didn’t go over well – not only was there no prior evidence for asymptomatic typhoid fever, this isn’t exactly something you can ask someone for after accusing them of making people sick (or at any time really). Adding to this was the anti-Irish and anti-immigrant sentiment of the time, feeding Mary’s view that she was being unfairly persecuted.

Soper published his findings as a case-report in JAMA, charmingly entitled “The work of a chronic typhoid germ distributor.” Mary chased him away multiple times, wielding kitchen utensils as weapons. Soper wrote about his experiences in a 1939 article in the Bulletin of the NY Academy of Medicine.

Dr Sara Baker was sent to Mary Mallon’s house, as it was felt that a female doctor may be more persuasive than a male. After being refused again, Dr Baker went to Mary’s workplace with police officers, and had her arrested. Mary was tested, deemed to be a carrier, and placed in isolation on North Brother Island.

Part of the New York American article of June 20, 1909, which first identified Mary Mallon as “Typhoid Mary.” Photo Credit: New York County Clerk Archives via Planck’s Constant (click pic to go to their site)

Mary was kept in isolation from 1907 to 1910. However, in 1910 the New York State Commissioner of Health decided that disease carriers should no longer be kept in isolation, and so Mary was allowed to return to work, provided that she did not work as a cook. She left, and started working as a laundress, washing clothes. However, this paid less, so she adopted the name Mary Brown, and returned to life as a cook. She got a job working at New York’s Sloane Hospital for women, and is suspected to have infected a further 25 people with typhoid fever before being caught by the health authorities again in 1915. She was sent back to isolation, and lived out the rest of her days there. She passed away on November 11th, 1938 from pneumonia.

But wait. Something doesn’t sit right here.

The bacteria can be destroyed by washing hands, using clean utensils, and above all, by cooking food thoroughly. So how did Mary Mallon transmit the disease? Assuming she kept her hands clean, cooked food thoroughly and cleaned plates, she shouldn’t have passed it on right?

For the answer, you’ll have to listen to RadioLab’s podcast. And trust me, it’s worth it.

Ed note: A version of this post originally appeared on Mr Epidemiology back in January 2012

References:

SOPER, G. (1907). THE WORK OF A CHRONIC TYPHOID GERM DISTRIBUTOR. JAMA: The Journal of the American Medical Association, XLVIII (24), 2019-2022 DOI: 10.1001/jama.1907.25220500025002d

Soper GA (1939). The Curious Career of Typhoid Mary. Bulletin of the New York Academy of Medicine, 15 (10), 698-712 PMID: 19312127

http://cythereabast.wordpress.com/2007/02/20/the-board-of-healths-exile-of-mary-mallon-was-it-justifiable/

http://history1900s.about.com/od/1900s/a/typhoidmary.htm

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Do we have something against red meat, or just complexity?

We’ve thought for decades that red meat is unhealthy. Earlier this month we found out why, a neat story involving a molecule called carnitine found in meat, metabolized by the bacteria that live in our gut. The resulting chemical, according to studies in mice, is linked to heart disease. Here is the paper. Open and shut case? That would be nice, but no.

There is a larger and more uncomfortable story here, and I don’t mean the fact that they got a vegan to eat a steak for science. (Although I would love to have heard that conversation.)

Sirloin Steak, Baked Potato, and Sauteed Carrots

Let’s eat some steak … for science!

 

Here’s what I mean. The carnitine study was shouted from the rooftops, or the New York Times which is basically the same thing. But two more studies that came out in the following weeks resulted in less-than-triumphant coverage: one agreed with the first study, but opened up the complexity of the metabolic pathway involved. No longer just carnitine and TMAO, this one mentioned lecithin, choline, and betaine.

The other study claimed that carnitine, as a supplement, protects against heart disease. This meta-study looked at outcomes in patients who had already had one heart attack, and were assigned to take carnitine or placebo. The supplement was associated with lower risk of death, angina, and arrhythmia – but not heart attacks themselves, which is already a little weird.

Who is right? Well, they looked at different things. MedPageToday published what amounted to a mostly polite argument between the authors of the two studies. The pro-carnitine researcher pointed out that his study concluded that carnitine was good for humans, by studying carnitine and its outcomes in humans, while the other study involved mice, biochemistry, and small sample sizes (one single human being stood in for all of vegan-hood). His anti-carnitine counterpart reminded readers that meta-analyses often produce “apparent statistical results that don’t hold up on further direct experimental testing.”

They’re each right about the flaws in the other’s methodology, but that doesn’t help us much if we’re trying to decide whether to avoid meat or start taking a carnitine supplement. Which brings us to the question of what these chemicals are, anyway.

Francisco de Goya y Lucientes - Still-Life - A Butcher's Counter - WGA10068

A Butcher’s Counter by Francisco de Goya y Lucientes

Carnitine is an amino acid found in meat, hence the name, and apart from its possible cardioprotective effects is used as a supplement in energy drinks and for athletes, despite a lack of convincing studies saying that it does anything. (If a chemical can be sold in pill or powder form, you can guarantee that there is an article on bodybuilding.com aiming to convince you, the muscle-seeking reader, that you must buy some. Here is the article for carnitine.)

The risk-raising molecule in the first study was TMAO (Trimethylamine N-oxide), which the researchers concluded was made out of carnitine by gut bacteria. Carnitine-rich meals resulted in high levels of blood TMAO, but if the subjects took an antibiotic first, TMAO levels stayed flat. That was in the subjects that were used to eating meat. The vegetarians and vegans’ TMAO levels stayed low when they ate carnitine, whether it was from a pill or a steak. The mouse component of the study established the link between TMAO and heart disease, at least in one heart-disease-prone strain of mice.

Predictably, fans of meat-rich diets did not like this study. This article from Beef Magazine earnestly appeals to beef’s “good taste” as a counter-argument. More seriously, paleo diet fan Chris Masterjohn took the study to its logical conclusion: if meat is bad for you because it produces TMAO, then other foods that produce TMAO in the body should be bad for you too. These foods include lecithin, found in eggs (and added to foods like chocolate, mmm chocolate) and – the biggest culprits of all – fish and shellfish. They have massive amounts of TMAO; in fact, its precursor trimethylamine is known for its fishy smell. People who cannot convert trimethylamine to TMAO have what’s called fish odor syndrome.

Within a week, the other shoe dropped. The same researchers that published the first carnitine-is-bad study (Stanley Hazen’s group at the Cleveland Clinic) came out with another paper about lecithin. Expanding on a similar 2011 paper, this study associated TMAO with heart disease risk in humans. Once again, food (in this case, egg yolks) resulted in higher TMAO levels. The effect was gone, however, after a course of antibiotics.

What’s really amazing here–whether the results hold up or not–is that we are finally hearing about what gut bacteria do, not just who they are. Many studies on our internal ecosystems are just cataloguing the players, creating a modern-day version of the medieval bestiary without really understanding how the species interact and what they do for us. The meat-eaters, for example, had guts dominated by Prevotella bacteria, but who’s to say Prevotella was the microbe responsible for making TMAO, or even that meat-eating was what caused the TMAO makers to grow in meat-eaters’ stomachs? There is evidence linking Prevotella to consumption of whole grains, so the dietary culprit, if there is one, could be a meat/grain combo.

Sloane278 f.48v Elephants,Dragon,AndMandrake

Page from a medieval bestiary

There are hundreds of species in our intestines, many of which we can’t grow in the lab, and the tough questions of what exactly they do, how they interact, and how they make use of our food are not ones we are currently able to answer with any sense of completeness. We have crude tools that have only advanced a little since the must-read parables of the geneticist and biochemist. (I’ll wait while you read the whole thing, but here’s a taste: Trying to understand how cars are made, the biochemist grinds one up and announces that cars are 10% glass, 25% plastic, 60% steel, and 5% other. Meanwhile, the geneticist ties the hands of workers going into the factory and examines how and whether the resulting cars crash. He concludes that seatbelts are vestigial since the cars still function without them.)

I wrecked this car for science!

The other reason these studies are hard to wrap our heads around, aside from the sheer complexity of the question (what else was in that steak, anyway? Does it matter if it was grass-fed or factory farmed? How similar is one carnivore’s gut microbiome to another’s?) is that we like answers we can act on now. I can read a study about steak today and switch to veggie burgers tomorrow. Messing with diet is popular because it’s totally within our control and we can do it three times a day. Popping a pill is not much more of a commitment, but understanding the metabolic pathways of a collection of symbiotic organisms? That’s going to take a little longer.

Category: Uncategorized | 5 Comments

More Treatment, Less War: The White House Drug Policy Reform

Many people who want substance abuse treatment can’t get it. The White House wants to fix this. Can they do it, and will it help?

On Wednesday, April 24, the White House Office of National Drug Control Policy (ONDCP) released its 2013 National Drug Control Strategy. They say their position has evolved. “We cannot arrest or incarcerate our way out of the drug problem,” they write. No longer do they see the nation’s drug problem as primarily a criminal justice matter. They see it as a public health issue. And because they see it as a public health issue, their new report – which they call a 21st century approach – spends a lot of ink on access and treatment.

Here the ONDCP gives us the broad strokes on why it cares about expanding access to treatment – and why we should, too:

Research shows that addiction is a disease from which people can recover. In fact, success rates for treating addictive disorders are roughly on par with recovery rates for other chronic diseases such as diabetes, asthma, and hypertension.
Recognizing this, the Obama Administration has taken unprecedented action to expand access to treatment for millions of Americans. Through the Affordable Care Act, insurance companies will be required to cover treatment for addiction just as they would cover any other chronic disease. We estimate that with the Affordable Care Act, 62.5 million people will receive expanded substance abuse benefits by 2020, with 32.1 million gaining those benefits for the first time. To support this expansion, the President’s FY 2014 Budget includes an increase of $1.4 billion for treatment over the FY 2012 amount, the largest such request for treatment funding in decades.

"No More Drug War Rally.” Nikki David and Neon Tommy. CC BY 2.0, 2011.

“No More Drug War Rally.” Nikki David and Neon Tommy. CC BY 2.0, 2011.

Here’s where we stand. Only one in ten people who need substance abuse treatment get it. In 2011, this meant that nearly 22 million people needed treatment, but only 2.3 million received it. Of the remaining 19 million, many did not think they needed help. But those who wanted help, and made an effort to get it, and still could not, shared common barriers. Nearly half ran into an insurance wall. 37% did not have health insurance and could not afford to pay for it. Another 10% had health insurance, but it did not cover treatment. The Affordable Care Act promises to fix this.

Here’s another way the ONDCP wants to help. In their lengthy report, they cite – and praise – the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Access to Recovery Program. This program provides “grants to states and tribes to provide vouchers to people who are seeking or are in recovery, enabling them to choose the treatment and recovery support services they need.” These services aren’t clinical. They help provide job networks and stable housing. In Missouri, for example, their program has a focus on “social connectedness.” And they also provide faith-based recovery support.

It looks like the Access to Recovery program works. SAMSHA reports that 82.1% had no substance abuse within a month of services and 96% had reduced or no involvement with the criminal justice system.

We’ve seen similar positive results elsewhere. In 2009, researchers from the University of Washington and Washington’s Department of Social and Health Services published a study on the impact of Access to Recovery programs in their state. The team started by identifying program clients and creating a comparison group. To achieve similarity of the groups, they matched by five variables (substance abuse treatment history, arrest history, employment history, Medicaid utilization, and health status).

They also found benefits for the Access to Recovery Program. In their study, clients stayed in treatment for 42.5 days longer and stayed employed at a rate 1.6 times greater than those who did not participate in the program. But they also found that timing is important. Here, the target seemed to be 31 to 180 days after a client started substance abuse treatment.

Timing matters. In 2011, Christy Scott and colleagues published a paper on substance abuse treatment, abstinence, and mortality. They found treatment beneficial – as long as you got it early.

This is an impressive study. They recruited their sample of 1326 people between 1996 and 1998 and followed them for 9 years. During this period, 131 participants died – or 11%, nearly 3 times the rate of their community.

Here’s what they found. If a person participates in a substance abuse treatment program early, then they’ll likely see a benefit. But if the person participates later in life, or spends a longer period of his or her life in treatment facilities, then this benefit seems to vanish. The researchers argue that this means addiction follows a chronic disease model.

Much of the drug war is justified by moral claims. But when people lose 22.5 years of their life because they receive punishment when they should receive treatment, there’s nothing moral there. If we give people only punishment, and not treatment, and send them back into their old communities with fewer resources and greater disadvantage, we shouldn’t ask what is wrong with them. We should ask what is wrong with us.

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