Will Google’s new health search function change the way we manage health?

 

Google

Google says that one in twenty searches is for health information (1). For many people, the Internet has become the first port of call when a strange symptom, the common cold, or morbid curiosity in the ‘Google Images’ bar strikes. However, the ‘armchair medicine’ often doled out by the Internet, along with the unscientific popular health discourse introduced by the likes of Dr Oz, has made for murky waters of health information seeking (2).

How are we to find relevant, high-quality, and evidence-based health advice when the trillions of gigabytes of Internet space are loaded with misinformation?

Enter the brilliance of Google’s search algorithm. Google has just announced that they will now be adding health information directly into search results. It will be included in the Knowledge Graph – the little box that often appears in the upper right-hand corner, showing basic statistics and information about a subject. The health information will be sourced from a database fact-checked by physicians at the Mayo Clinic, adding credibility, quality, and a sound evidence base (1). That is, if it done properly, although there is no reason why it should not be.

This new search addition could be revolutionary, in terms of providing accurate health information to people who need it. In 2008, the U.S. Health Information and National Trends Survey (HINTS) found that while over half of the adult American population turns to the Internet first when searching for health information, trust in the Internet as a reliable source of information was low and had declined over the first decade of this century (3). People often leave Internet health searches feeling frustrated, confused, and likely no closer to the answers they are seeking (4). Given the major shift we are experiencing in online communication technologies and health information technologies – we may not be far off from being able to access our own electronic health records – information must be available in an appropriate and equitable way so that all people can use the power of technology to better learn about and manage their health.

Last year, the Pew Research Center found that 87% of all Americans now use the Internet (5). Ninety percent of them say that the Internet has been a good thing for them personally, and three-quarters say that the Internet has been a good thing for society (5). It seems as though Google’s new health search addition will contribute to this positive attitude – and to the ubiquity of this company in the digital information industry. The transformative power of Internet searching on people’s behaviour and health management is yet to be determined.

References

  1. Ramaswami P. A remedy for your health-related questions: health info in the Knowledge Graph.Weblog. http://googleblog.blogspot.co.uk/2015/02/health-info-knowledge-graph.html (accessed 18 Feb 2015).
  2. Korownyk C, Kolber MR, McCormack J, Lam V, Overbo K, Cotton C, et al. Televised medical talk shows – what they recommend and the evidence to support their recommendations: a prospective observational study. BMJ 2014;349:g7346.
  3. Health Information National Trends Survey. Brief 16: Trends in cancer information seeking. http://hints.cancer.gov/brief_16.aspx (accessed 18 Feb 2015).
  4. Arora NK, Hesse BW, Rimer BK, Viswanath K, Clayman ML, Croyle RT. Frustrated and confused: the American public rates its cancer-related information-seeking experiences. J Gen Intern Med 2007;23(3):223-8.
  5. Fox S, Rainie L. The Web at 25 in the U.S. http://www.pewinternet.org/2014/02/27/the-web-at-25-in-the-u-s/ (accessed 18 Feb 2015).

Image: “Google” by Google Inc. Public domain.

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Let’s stop playing politics with vaccines

Sriram Ramgopal (guest poster)Please welcome a guest post from Sriram Ramgopal, a resident physician in the Department of Pediatrics, Children’s Hospital of Pittsburgh. He is interested in pediatric advocacy and is pursuing a career in Pediatric Emergency Medicine. 

Politically motivated fearmongering about vaccination is putting children in our community in danger. During the Republican presidential primaries leading up to the 2012 election, former representative Michelle Bachmann criticized Governor Rick Perry’s mandate for the HPV vaccine, which protects against a cancer-causing virus. She claimed at the time that she had met parents who believed that the vaccine gave their daughters “mental retardation.” These statements introduced a new precedent of injecting issues of vaccine safety into presidential politics. The American Academy of Pediatrics made emphatic statements at the time to clarify that the HPV vaccine does not cause mental retardation, but by this point the damage had been done: fear had taken hold in parents’ minds.

In 2015, with the presidential election around the corner and a widespread measles outbreak on our minds, the dangerous mix of immunization paranoia and politics continues. Senator Rand Paul, physician and presidential hopeful, claims to have met “many tragic cases of walking, talking normal children who wound up with profound mental disorders after vaccines,” a statement that is dubious at best. His words are grounded in a fraudulent study that has long since been retracted and its author now discredited. Governor Chris Christie has also entered into the debate by stating, “parents need to have some measure of choice in things as well, so that’s the balance that the government has to decide.” By employing the rhetoric of individual rights and a fear of big government, those in public office often attempt to score cheap political points and win public acceptance. Politicians like Senator Paul and Governor Christie are brandishing discredited ideas as tenable arguments against clear evidence-based recommendations to vaccinate, sowing confusion amongst parents.

According to the World Health Organization, measles is a leading cause of death worldwide, despite the universal availability of a widely researched and safe vaccine against it. The disease killed over 145,000 individuals, most of them children under 5 years of age, in 2013. Immunization against diseases like measles not only protects those that receive the vaccines but also helps to protect those who are not eligible to receive them, such as young infants and children with deficient immune systems. It is these children who are also at the highest risk of grave complications ranging from encephalitis to pneumonia, and depend on the rest of us to protect them.

It is no secret that vaccination rates across the country are falling. Based on CDC data, the nationwide measles, mumps and rubella vaccination rate among 19-35 month-olds is 91.9%, down from a rate of 92.3% in 2006. Rates are falling most in Ohio, Missouri, West Virginia, Connecticut and Virginia. It is very possible that more and more parents will choose to opt out of immunizing their children for fear of side effects, thanks to the dissemination of groundless claims. In response to the current epidemic, the American Academy of Pediatrics has released a recent statement once again exhorting parents to vaccinate their children, reiterating what they have said for decades: the measles vaccine is safe and effective.

We are already burdened with a wide number of celebrities, discredited researchers, and physicians relying on anecdotes and hearsay who are more than willing to use the vaccine controversy to gain quick publicity. Politicians should be clear to the public on the proven science of vaccines and should avoid muddying the waters further. It would be better for the candidates, too: it is widely believed that Michelle Bachman lost credibility because of her statements on vaccines in 2008. Senator Paul and Governor Christie should learn a lesson from her failure and be willing to communicate a clear message to the public: vaccines are safe and are effective at protecting against dangerous diseases. Unnecessary vaccine exemptions put our greatest asset – our children – at risk.

The views expressed in this article are those of the author and do not necessarily represent the views of, and should not be attributed to, the Children’s Hospital of Pittsburgh or the University of Pittsburgh.

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What I use the scientific literature for

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Spandrels in the Arc de Triomphe | Wikimedia Commons CC BY-SA 3.0 Thesupermat

As a PhD student, it is fully accepted by myself and by society at large that I have a nerdy side. My dream job is to while away hours in front of my computer, thinking, analysing data, writing, re-writing, writing some more, and of course, reading academic literature.

The PLOS Integrative Paleontology blog recently discussed what the scientific literature is used for, and called for others to weigh in. Although the main metrics we use to gauge the consumption of academic literature are citations and article downloads, it’s difficult to truly discern the tangible impacts of scientific articles on the individual lives of those who consume it.

As a soon to be fully-fledged population health scientist, with toes dipping in the pools of health psychology and social epidemiology, I read and use scientific literature on a daily basis. Although I draw inspiration from many areas outside of science, the scientific literature is my bread and butter.

So here is what I use it for:

  •  My PhD research. This is the most obvious one. My research is on the changes to health literacy skills during ageing among the older population of England, and on the relationship between health literacy and health behaviours. I read and cite relevant articles for my work.
  • Side projects. Although I’m doing my PhD, I have several research projects on the side with other people in my research group. Although most are unpublished at the moment, they relate to my PhD research and to the type of work I want to do in the future.
  • Blogging. This third usage is less common for academics, but for me it’s a bit self-explanatory given this blog. I generally do two types of posts. The first is discussing any new public health research that is interesting, relevant and/or is making news headlines. The second type is a more in-depth piece on a general public health topic that draws from several evidence sources.
  • Figuring out what to do with my academic life. This point is only slightly tongue in cheek. As I prepare to move beyond my PhD, I’m constantly brainstorming research ideas in the back of my mind. Reading what others have done is always helpful and every now and then I read a gem of inspiration. Keeping on top of the literature is always important in the life of an academic, but it feels especially important now. I do my best to read from outside of my field to stretch the way I think about things.
  • Passion. Lateral thinking, discovery, and making a useful contribution to human knowledge are all reasons why we do we what do. I have a folder marked ‘interesting articles’ that have been influential on my thinking. I would recommend any of these articles to any population health science researcher with similar and especially to those with dissimilar inclinations to myself (apologies as some of these are not open access):

Who and what is a ‘population’? Historical debates, current controversies, and implications for understanding ‘population health’ and rectifying health inequalities” – Nancy Krieger. Emphasising the subjective, fluid, and sometimes arbitrary way in which populations are defined, and the resulting implications for the meaningfulness of population means, this review article should be required reading for any population health researcher.

The communications revolution and health inequalities in the 21st century: implications for cancer control” – K Viswanath et al. Just as the title says, this paper discusses how the ‘communications revolution’ that we are currently living through, with widespread and immediate access to people and information through mobile internet may have negative consequences for social equity in cancer control.

Fair society, healthy lives” – The Marmot Review. A landmark public health document detailing the link between health inequalities and social inequalities, and arguing for the reduction of health inequalities as an issue of social justice. The report delivers quantitative statistics and six actionable policy objectives to reduce health inequalities.

An anthropology of structural violence” – Paul Farmer. A physician and medical anthropologist, Paul Farmer argues how disease outbreaks, inadequate health systems, and health inequalities in present day cannot be understood without knowledge of the historical and political circumstances through which they arise. He focuses on Haiti, where the racist history and political economy of the country create public health problems that are a form of structural violence against vulnerable peoples.

The Spandrels of San Marco and the Panglossian Paradigm: a critique of the adaptationist programme” – Stephen Jay Gould and Richard C Lewontin. An exemplary piece of engaging scientific writing, metaphor, and an exercise in causal yet non-deterministic thinking, this paper introduces the biological ‘spandrel’ into Darwinian theory.

What do you use the scientific literature for?

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Why Measles Isn’t Just An Anti-Vaxxer Problem

like a present

Photo by Caselet, CC BY-ND 2.0

I have a little metaphor I use with my kid. When he asks why we get shots at the doctor, I remind him of all the super powers he has.

One day he got super powers against whooping cough and tetanus. Another time I explained that his baby brother just got super powers against rotavirus. I tell him about what these diseases are.

I told him about how I got chicken pox as a kid, just a few years before the vaccine came out, and how I was itchy and miserable for two weeks. He said, in a moment of reflection, that he was glad he got the shot that just hurts for a minute, and won’t have to get chicken pox for two weeks.

Super powers make a great metaphor, and I’ll keep using it, but it’s got a major flaw.

This post is dedicated to all the anti-vaxxers, vaccine choice proponents, and curious people everywhere who have wondered why parents who vaccinate are threatened by those who don’t.

It’s also dedicated to the anti-anti-vaxxers, people who think that those who skip vaccines are weeding themselves out of the population. (Anti-anti-vaxxers, while I admit to laughing at some of your memes–OK maybe a lot of them–you’ll catch more flies with honey and understanding.)

Three reasons disease outbreaks are not just a problem for anti-vaxxers

1. For a first look at why this situation isn’t so simple, check out this humor post about Why We Didn’t Vaccinate Our Child. It’s not what you think! The author writes that he is forgoing the Yellow Fever vaccine because yellow fever isn’t endemic to their area, the Andromeda Strain vaccine because it’s a fictional disease, and the pertussis vaccine because his child isn’t old enough for it yet.

A child has to be a minimum of 12 months old to get the Measles/Mumps/Rubella vaccine. If you show up at the doctor’s office the day before your kid’s first birthday, they’ll ask you to come back later. So kids are 12 months, maybe 13 or 14 before they get the shot. That’s a long time. Your one month old, your two month old, your six month old, your eleven month old, are all vulnerable.

(There is a measles-only vaccine that kids can receive at 6 months. If you spend time around Disneyland regulars, or if you’re traveling to countries where measles is common, ask your doctor about this shot.)

2.There are also people who have medical reasons why they can’t get vaccinated, or why they may be more susceptible to the disease even with vaccination. The last time I wrote about the flu vaccine, this was one of the comments:

I have a low immune system due to another illness and I appreciate it when others get the flu shot. My doctor recommends that all my family members get it for my protection.

And that’s good. I like it when others help to not kill me.

People who can’t get the vaccine rely on others’ immunity. Think of how many people are between you and the nearest measles spreader. Louise coughs on Jim who coughs on Agnes, who coughs on you. If they’re immune, you’re pretty well protected. If they’re all susceptible to the disease, that’s a measles highway.

(There are, of course, multiple pathways between Louise and you. If you’d like to play with scenarios, try the Vax game where you try to separate social networks to prevent the spread of disease. It’s quick and fun.)

3.And the third problem relates to that flaw in the super power story. In comic books, a super hero’s powers Just Work. They might be taken away by a bizarre accident or by the work of some villain, but Superman doesn’t bounce 95 bullets off his chest while, oops, five others get through.

But that’s how the measles vaccine works. The MMR protects 95% of people from measles, and 88% from mumps. For comparison, the flu vaccine is some 70% effective most years (less this season).

We know that five of the Disneyland cases occurred in people who has been fully vaccinated. That means that probably 95 other vaccinated folks were exposed but didn’t come down with the disease. Likewise, although many fully vaccinated hockey players got the mumps this season, they probably only made up 12% of the vaccinated players that were exposed. The other 88% can thank the nurses who brandished scary needles at them twenty years earlier.

People who are not fully vaccinated, or in whom the vaccine isn’t effective, are not only at risk themselves, they are also a stepping stone between someone with the disease and someone vulnerable. Your co-worker who skips the flu shot because he’s young and healthy and says he never gets sick? He might be fine, but could pass it on to his grandma who has lowered immunity, or to the pregnant woman in the next cubicle, or to the baby or the cancer patient he passes on the street mid-sneeze.

Vaccines are important because, with good coverage rates, the vulnerable folks are only the ones in those groups I mentioned: people who are too young for the vaccine, who can’t have it for medical reasons, and whose bodies failed to develop the super powers they was supposed to.

There’s no way around those numbers. But without knowledge and understanding of the risks, other people may opt out of vaccines, deepening the pool of susceptibles in the population.

And I mean we need to understand the risks of both the shot and the disease. No vaccine is 100% safe, but vaccines are far safer than the diseases they prevent. Measles kills 1 in 1000 children who get it. The MMR vaccine has nowhere near that level of risk.

So, anti-vaxxers, your children don’t catch measles and then take it home like a jar of fireflies to enjoy alone or with a few close friends. Instead, they may unwittingly spread it to babies, people with certain medical issues, and a small percentage of the people who have done all they can to try to protect themselves but in whom the vaccine doesn’t work.

And fully vaccinated fans of super powers, 5% of you are vulnerable to the next measles-toting kid who comes along, and you too might pass it to your baby or your immunosuppressed buddy.

Personal vaccination choices have a huge impact on public health, especially for measles where the average infected person spreads it to 12-18 others. Please choose responsibly.

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Why a new antibiotic won’t help diseases of poverty

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Image by Klari Reis at The Daily Dish

Today we warmly welcome Alexander Chaitoff and Joshua Niforatos to the blog. They are medical students at the Cleveland Clinic Lerner College of Medicine with interests in social justice and health equity. See the end of this post for their full biographies.

Just earlier this month, news broke that one of the first new classes of antibiotics in quite some time was discovered. Understandably, the news was met with jubilation. But while many are celebrating this breakthrough, some within the public health community are tempering their excitement.

These news reports generally highlight pharmaceutical and technological developments, yet fail to remind the public that infectious diseases are largely considered diseases of the poor. After all, it is easier to rally behind a “miracle” technology than it is to rally behind a restructuring of society that prevents multi-drug resistant diseases in the first place.

The discovery of a new class of antibiotics does as much to highlight the many economic and social issues in our world as it does to kill deadly pathogens.

Skimming through the pages of the history of medicine, the same infectious diseases that once killed the Romans of antiquity were the same infections that killed poor Americans until the early 1900s. Only one hundred years ago, Americans were more likely to die from infectious diseases, tuberculosis and the flu, than they were to die from the chronic diseases that now afflict the country.

However, with the serendipitous discovery of penicillin by Alexander Fleming in 1928, many felt infectious disease would become a thing of the past. As new classes of antibiotics seemed to be in endless supply, the nation’s brightest minds, and biggest wallets, turned their attention towards new health challenges.

Unfortunately, the antibiotic pipeline has dried up and dangerously resistant organisms have started to emerge. Health leaders are again recognizing infectious diseases as a leading problem, which explains the excitement that has surrounded the recent discovery.

Drug development has major limitations for curing infections of poverty. 

Consider first that this new drug that has garnered so much excitement has not yet been put through rigorous clinical trials. These trials can cost well over 100 million dollars, and less than 8% of drugs that begin trials are brought to market. This means that unless there is the potential for a hefty profit, pharmaceutical companies steer clear of testing many drugs in development.

Herein lies the problem. It is harder for pharmaceutical companies to recoup an investment in treatments for infectious disease. In this case, it also means that there is still a low likelihood that the antibiotic that made the news last week will be available anytime in the near future.

Just as disconcerting, we’ve seen what happens when a pharmaceutical company decides to get behind a cure for an infectious disease. In 2014, Gilead received approval for the first cure for Hepatitis C, a disease that largely impacts those with less education and living in poverty. However, when Gilead priced their drug regiment at over $80,000, they effectively limited access for the patients with real need.

Even if this new wonder-antibiotic is made available, why should anything different be expected?

The problem goes beyond the economics of drug development. Effective treatment of infectious diseases ranging from Ebola to chikungunya does require an understanding of the science behind new antibiotics. However, and equally important, effective treatment also requires an understanding of what it means for an infection to be a disease of poverty.

povertydivide

The north-south continental poverty divide in the United States.
Holt JB, 2007. Data Source: Community Health Status Indicators.

A 2011 Institute of Medicine report revealed alarming data that the poorest of the poor in the United States are disproportionally affected by a host of infectious diseases that preferentially infect those in low-income and middle-income countries. The groups most likely to be afflicted by neglected infections of poverty include minorities; single-family, low-income households; racially segmented cities; the American South; and other groups that live along the fault lines of society. These fault lines within society have deep historical roots in the power relations of class, gender, and race. Our social institutions – political, economic, cultural, religious, and legal – reinforce these unequal power relations.

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane,”

Martin Luther King, Jr. once noted. Health disparities are also one of the most lethal forms of inequity.

As money is filtered into efforts to create antibiotics for infectious diseases, it is astonishing that money is not equally as filtered into resources dedicated to building a more “just” society. These resources would result in society where diseases of poverty do not disproportionately affect the poor. In commenting on how to treat and prevent the spread of Ebola, for example, infectious disease specialist Paul Farmer notes that,

“the only formula we’ve come up with is the following: you can’t stop Ebola without staff, stuff, space and systems.”

A new class of antibiotics is exciting news, but that feeling must be tempered. Unless the world stumbles upon another golden age of antibiotic discovery, one new antibiotic will only buy us time in the fight against the ever-evolving microbes that surround us.

At this point in history, scientific advancement, while very important, is not the real issue in this fight for health. The real issue is that infectious diseases are diseases of poverty. The real issue is that new antibiotics alone will not save us from these diseases, but social solutions just might.

It is far easier and less expensive to fund research into novel drug discovery than it is to develop a society in which everyone has equal and affordable access to quality care. Perverse incentives can inhibit the organization and funding of a public health system that is able to educate, prevent, and treat infectious diseases that primarily infect the marginalized of society. Such excitement concerning the discovery of a single drug without a willingness to make more difficult investments reveals our failure to truly understand how bacteria and viruses actually work.

 

Alexander Chaitoff studied microbiology and political science at The Ohio State University before receiving his MPH as a 2013 Marshall Scholar. Interested in the nexus of scientific and social determinants of health, he has worked and researched for a variety of organizations including the Department of Health and Human Services, the National Health Service, and in 2010 co-founded the 501(c)3 nonprofit research organization the Pure Water Access Project, Inc. He is currently a medical student at the Cleveland Clinic Lerner College of Medicine.

Joshua Niforatos is a medical student at Cleveland Clinic Lerner College of Medicine. Prior to attending medical school, he earned bachelor degrees in both cultural anthropology and biology at University of New Mexico. He then went on to earn a Master of Theological Studies at Boston University School of Theology where he studied theology, anthropology, and ritual. Interested in the intersection of liberation theology and social determinants of health, and reflecting on his public health experience working with immigrants at risk for Type II diabetes in New Mexico, he is a co-founder of a student chapter of Physicians for a National Health Program at Case Western Reserve University. 

 

Image source: Holt JB. The topography of poverty in the United States: a spatial analysis using county-level data from the Community Health Status Indicators project. Prev Chronic Dis 2007;4(4). http://www.cdc.gov/pcd/issues/2007/
oct/07_0091.htm
. Accessed 21 January, 2015.

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How often should you shower?

-It's_an_Old_American_Custom,_Keep_Clean._Take_a_Bath_Every_Day_You_Can._-_NARA_-_514650

U.S. National Archives and Records Administration. Public domain.

At first glance, a silly question. Have you ever questioned your showering practices?

A shower is taken for granted, a daily or near-daily practice that begins or ends our days. It can be soothing, warm, and pleasurable, or a minor annoyance that must be worked into a busy schedule.

The practice of bathing has a long history. Ancient Rome was famous for its baths, or thermae, which played a culturally significant role as community centres focused around the act of bathing. Bathing has long been a communal act in many societies, and still is today in many places, such as in Morocco, where public hammams are visited once weekly by men, women, and children.

Volubilis_bassins

Ancient Roman bath in Morocco.
“Volubilis bassins” by M. Benoist.
Licensed under CC BY-SA 3.0 via Wikimedia Commons

In the Western world, showering or bathing daily is typically the accepted practice. The daily shower is associated with modernity, simply because we live in a modern society (whatever that means) and showering daily is what we do. However, understanding that bathing practices are socially influenced brings about the question – health-wise, is the daily shower necessary? Put simply, the answer is no.

Showering gets rid of the good bacteria

Showering increases the amount of skin bacteria dispersed into the air (1-2). Icky-factor aside, this actually doesn’t make a difference to your personal risk of infection (3). But, it does mean that good bacteria, which are naturally present on your skin and are important for health immune function, are stripped away. They will come back, but there’s no need to get rid of them on a daily basis.

Showering dries out your skin and hair

It depends partly on the climate you live in and whether you naturally have dry or oily skin, but soaps and shampoos strip away natural, healthy skin oils. Over time, especially in a dry climate, this can lead to irritated and cracked dry skin. Lotion helps, as applying it your skin reduces the shedding of skin scales and bacteria post-shower (2).

Showering uses a ton of water 

It is a luxury to have a hot shower every day.  An American taking a 5-minute shower uses more water than the average person in a developing country slum uses in an entire day (4). While rich people using less water won’t help poor people get the water they need, it is important to respect this resource. Be aware of your consumption. Environmentally, this is also important.

Chemical by-products from soaps get into the water system 

Detergents like soaps and shampoos are bad for freshwater systems. They are poisonous to fish, as they damage their mucus membranes and gills (5). While fertilizers and pesticides are the worst pollutants, detergents also pollute the Canadian and American Great Lakes (6). Microbeads from body scrubs and face washes also pollute waterways because they don’t break down (7).

Of course, there are important reasons to shower. Sanitation is a cornerstone of human development. Regular bathing is essential to health. Psychologically, a shower is really nice. Once every two or three days though is plenty.

References

  1. Speers R, Bernard H, O’Grady F, Shooter RA. Increased dispersal of skin bacteria into the air after shower-baths. Lancet 1965;1:478-83.
  2. Hall GS, Mackintosh CA, Hoffman PN. The dispersal of bacteria and skin scales from the body after showering and after application of a skin lotion. Journal of Hygiene (Cambridge) 1986;97;289-98.
  3. Larson E. Hygiene of the skin: when is clean too clean? Emerging Infectious Diseases 2001;7(2):225-30.
  4. Watkins K. Human development report 2006, beyond scarcity: power, poverty, and the global water crisis. United Nations Development Program (UNDP).  2006.
  5. Abel PD. Toxicity of synthetic detergents to fish and aquatic invertebrates. Journal of Fish Biology 1974;6(3):279-98.
  6. Bennett ER, Metcalfe CD. Distribution of alkylphenol compounds in great lakes sediments, United States and Canada. Environmental Toxicology and Chemistry 1998;17(7):1230-5.
  7. Eriksen M, Mason S, Wilson S, Box C, Zellars A, Edwards W, et al. Microplastic pollution in the surface waters of the Laurentian Great Lakes. Marine Pollution Bulletin 2013;77(1-2):177-82.
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Could the Ebola epidemic end this year?

Although the Ebola epidemic is still raging in west Africa, US and European buzz about the disease spiked briefly and then all but disappeared, according to Google search data published in Vox’s in-depth report.

Liberia’s situation is the most promising, compared to the other two countries involved, writes Julia Belluz at Vox. Experts say that Guinea has “no discernible upward or downward trend” of cases, Sierra Leone is “the most challenging front,” and Liberia is the country closest to having the outbreak under control.

Ebola eradication is probably impossible, because the disease seems to simmer in wildlife populations, including bats, making occasional jumps into humans. Until recently, the outbreaks only killed dozens or hundreds of people before fizzling out, sometimes without another recorded case for years. The current outbreak, on the other hand, has been going on for over a year, with an official death toll of, at this writing, over 8,000.

Now, a new model of the epidemic suggests that it may be under control, at least in Liberia, by summer of this year.

I spoke with John Drake, whose team at the University of Georgia studies the dynamics of groups of living things, from wildlife populations to disease epidemics. They have a paper out in PLOS Biology today describing their prediction.

What’s the best case scenario and the worst case scenario here?

The worst case is that it could be quite terrible. If the current vigilance and investment and public buy-in isn’t maintained, it could take a turn for the worse.

I don’t think the worst case scenario is a very likely outcome, because I think that the public, the community, the politicians, the health community have all been galvanized by their battle with Ebola over the summer and fall of 2014. And they’ve made tremendous gains, and I think that they’re going to maintain that vigilance. And I’m optimistic that the great majority of transmission could be eliminated by the late spring, maybe even slightly earlier.

A lot of previous models focused on R0 [the number of new infections that each infected person can cause], but yours takes other factors into account.

A lot of models are based on an ‘if everything remains the same’ kind of assumption, and all that’s changing is the number of susceptible and infectious persons in the population.

But we said, well, no! The baseline is not staying the same, because they’re building Ebola treatment units. So hospital capacity is increasing. And what effect does that have on containing the outbreak? We included that trajectory, that sequence of Ebola treatment units being constructed in the development of our model.

Another important difference is that we focused on the different sites at which persons would acquire infection, whether that was in the hospital, at a funeral, or in the community, and how that would feed back into transmission. If a person acquires the infection in the hospital, then they’re very likely to be treated in the hospital, and the contact rate would be low.

On the other hand, a person who contracted the infection in the community might go to the hospital and effectively be isolated from the susceptible population. But they might be treated in the community, which means a larger number of persons might be exposed. And so this places an emphasis on the willingness of potentially infected persons to seek care and be treated, and allows us to explore better what’s the possible range of outcomes based on the frequency with which patients are isolated.

Another difference is in order to make our work tractable, we took a shortcut. We said, we don’t suspect that what epidemiologists call susceptible depletion, the extent to which previously infected individuals are removed from the population and therefore causing the epidemic to be self limiting—we don’t think we’re in that situation yet. And by making the approximation that susceptible depletion was negligible, that allowed us to make further progress on emphasizing the sorts of things we thought were important.

Your predictions are focused on Liberia, but the epidemic is also raging in Guinea and Sierra Leone. Do you think all three can contain it by this summer?

Our model is Liberia specific. There are differences among these countries; we don’t fully understand what those differences are.

My group decided to focus on Liberia because at the time we began this work, it’s where the epidemic was most out of control, it’s where we thought we could make the greatest contribution, and it’s where we had the best information. And we knew of other folks working particularly on Sierra Leone and Guinea.

Epidemiologically I think Sierra Leone is probably fairly similar. Transmission in Guinea seems to be a little bit different, and I think people are scratching their heads to understand first of all how is it different, and secondly what are the consequences of those differences.

I wouldn’t say the whole thing is coming to a close yet. I think that if Liberia is able to maintain their current level of response, and if they are able to prevent reinfection, reignition of the epidemic within Liberia, then I think we’re on a downward trend for Liberia. But it’s in a context in which there’s going to be interaction with neighboring countries, and there’s a possibility for subsequent flare-ups, so it requires vigilance and rapid response.

I think that the response in Sierra Leone and Guinea will ultimately contain those epidemics. I think that they are working very hard to accomplish that, and eventually that will happen in those places as well. But there needs to be continued investment in those places.

What do people need to know about Ebola now?

I do think the public’s been well informed about this particular epidemic, and I think that people understand that there’s not any reason for hysteria in western Europe or in the United States or places that are contributing health professionals to try and contain this epidemic.

I think that we are learning things about how collectively the world can respond to emerging infectious diseases like this that really pose a threat not just in one region or in a particular country or in the developing world, but that actually expose us all to some level of risk. And how to mobilize our scientists and medics and policy makers in a coordinated way.

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Black lives must matter more in health research

Anyone who thinks America is a ‘post-racial’ society is delusional. ‘Post-racial’ is political discourse that aims to deny any presence of racism or racial inequality in modern society. Racism is visible everyday. From visible neighbourhood segregation to everyday instances of white privilege to population-level statistics, it can be seen and felt (1-7). For example, in 2013, the average white family had a net worth 13 times greater than the average black family ($141,900 vs. $11,000), a gap twice the size it was prior to the Great Recession (1).

PewWealthGap

Why does racism matter for public health?

Racism is not only a social, cultural, political, and legal issue; it is also a health issue. Across history, racism has consistently been manifested in terms of the ultimate health outcome: death. When Europeans colonised the Americas hundreds of years ago, the aboriginal populations perished in scores. America’s legacy of slavery almost goes without mentioning. Still today, the life expectancy of American Indians and Alaska Natives is, on average, 4.2 years lower than all races and origins in the U.S. population combined (6).  Black men are more likely to die than non-black men, with a life expectancy 5 years lower than white men in America (see graph below) (7).

 lifeexpectancy

Recently, we’ve seen the ultimate outcome of racism dramatically played out in the streets of America. This form of overt violence, where unarmed yet ‘suspicious-looking’ black men are shot down by officers of the law is nothing new, yet requires contextualisation. Let’s not forget that while African Americans have been living in the United States for over 400 years, they have only had legal rights for about a tenth of that time. Let’s not forget how recent the civil rights movement was. It will take more than a couple of generations to repair the legacy of slavery, if it ever can be repaired.

The effects of racism on health, while undoubtedly negative, are not well understood. Racism is a personal experience, the manifestation of which is politically and socially situated in specific places and times. It is institutional, interpersonal, overt, covert, and violent.

The field of epidemiology and public health has only accumulated a small body of inquiry into racism and health, and most of it deals with the social experience of racial discrimination in people’s daily lives. As of 5 January 2015, a PubMed search of the term ‘racism’ returns 2,263 articles from all medical disciplines. By contrast, a search for the term ‘obesity’ returns 210,214 articles, about ten times more. This quick example is not meant to imply that obesity is not an important and urgent research topic (it is), or that these are even comparable topics, but rather to demonstrate the relative dearth of knowledge on racism in the quantitative health sciences.

Without empirical research we cannot record the effects of racism on population health and inequalities, we cannot transcribe the embodiment of discrimination in marginalised groups on a large scale.  By ‘embodiment’, I mean the literal embodying of social and ecological environments in terms of their biological effects in and on our bodies (8,9). A useful framework for quantitative health scientists wishing to investigate the effects of race and racism is ecosocial theory (8,9). The ecosocial theory of disease distribution concerns who and what drive social inequalities in health (8). I’ll leave the juicy bits to the paper and book referenced above, but will briefly describe what the theory posits with respect to racism:

Inequitable race relations simultaneously – and not sequentially

1)   Benefit the groups who claim racial superiority at the expense of those whom they deem intrinsically inferior,

2)   Racialize biology to produce and justify the very categories used to demarcate racial/ethnic groups, and

3)   Generate inequitable living and working conditions that, via embodiment, result in the biological expression of racism – and hence racial/ethnic health inequalities. (9)

These ideas are nothing new to those familiar with critical race theory, social constructionism, or intersectionality theory. However, they are often foreign to quantitative health scientists. We are taught how to count, classify, and categorise people in order to fit them into complex statistical models not designed to account for the social construction of biology. So, how do we move forward? We need to ground our work in theory (epidemiology, as a field, is notoriously atheoretical, although that’s a subject for another day), which means looking outside of our discipline to the social sciences. We need to collaborate with other fields and explore mixed methods. As epidemiology evolves, theories like the ecosocial theory may become entrenched in our discipline.

This is important because research is a key piece in the patchwork of knowledge, activism, policy, and public will that is required to make the world a more just place. The media attention and public demonstrations that have occurred in aftermath of Ferguson and other recent incidents of racialized violence perhaps signal a change in the public consciousness. Let’s keep moving in this direction.

 

 

Note: Although I refer to ‘black lives’ in this title, it not to privilege any minority group over any other. Linking to current public discourse and providing a focus for this article, the intent is purely demonstrative. The ecosocial framework can be applied to many inequitable social relations across place and time.

References

1)   Kochhar R, Fry R. Wealth inequality has widened along racial, ethnic lines since end of Great Recession. http://www.pewresearch.org/fact-tank/2014/12/12/racial-wealth-gaps-great-recession/ (accessed 1 January 2014).

2)   Nico Lang. It’s time to wake up from the myth of a ‘post-racial America’. Daily Dot. 25 November 2014. http://www.dailydot.com/opinion/ferguson-michael-brown-post-racial-myth/ (accessed 3 January 2015).

3)   McIntosh P. White privilege: unpacking the invisible backpack. Independent School, Winter, 1990, pp. 31-6.

4)   Vanhemert K. The best map ever made of America’s racial segregation. Wired. 26 August 2013. http://www.wired.com/2013/08/how-segregated-is-your-city-this-eye-opening-map-shows-you/ (accessed 3 January 2015).

5)   Baird-Remba R, Lubin G. 21 maps of highly segregated cities in America. Business Insider. http://www.businessinsider.com/most-segregated-cities-census-maps-2013-4?op=1&IR=T (accessed 3 January 2015).

6)   Indian Health Service: The Federal Health Program for American Indians and Alaska Natives. Disparities. http://www.ihs.gov/newsroom/factsheets/disparities/ (accessed 3 January 2015).

7)   Centers for Disease Control and Prevention. NCHS Data Brief: Death in the United States, 2010. http://www.cdc.gov/nchs/data/databriefs/db99.htm (accessed 3 January 2015).

8)   Krieger N. Methods for the scientific study of discrimination and health: an ecosocial approach. Am J Public Health 2012;102(5):936-45.

9)   Krieger N. Epidemiology and the people’s health: theory and context. New York: Oxford University Press; 2011.

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PLOS Public Health Perspectives Holiday Special 2014

Christmas_cookie_stack

Photo by Nathan2055 at Wikimedia Commons: CC-BY 2.5

The holiday season is here. We’ve compiled a short list of wintertime concerns that many people have:

1. Nutrition

If you’re lucky, the holiday season tends to be a time of over-nutrition. Knowing your body and what your energy requirements are is a first step to not overeating. Here is a simple calculator that will tell you how many calories per day you should eat (and how many if you want to lose or gain weight), based on your age, sex, BMI, and physical activity level: http://www.calculator.net/calorie-calculator.html. To make sure you eat what your body needs, there is one simple nutrition rule that everyone can follow:

“Eat food, not too much, mostly plants.”

These are the words of Michael Pollan in “Food Rules: An Eater’s Manual” (1). Avoid packaged, processed food products and eat a wide variety of real foods, and you will thank yourself for it.

And don’t forget our healthy holiday guide from last year[1] , with tips on navigating holiday buffets and squeezing in some exercise.

2. Exercise

Fur_trim_(4185547877)

This is one way of getting holiday fitness in – Photo by Magnus Manske at Wikimedia Commons: CC-BY 2.0

Exercise can be difficult over the holidays when schedules are disrupted and the weather can sometimes get in the way. Enjoy what you can, in balance with enjoying any downtime that you may have. At home exercise videos on YouTube are a great thing, as they are flexible time-wise and remove any financial and equipment barriers to working out. Whether it’s getting outside for a 30 minute walk each day, doing snow sports, or playing with kids or dogs around the house, exercise will help with not only balancing out any gastrointestinal over-indulgences but also with reducing stress and improving mental health.

3. Keep warm – but not too warm

Calvin and Hobbes by Bill Watterson. Available from Universal Uclick

Calvin and Hobbes by Bill Watterson. Available from Universal Uclick

Early winter snowstorms have been hitting parts of the USA and Canada. With feet of snow and temperatures well below freezing, it’s no surprise that cold weather contributes to ill-health and mortality in older and vulnerable people during the winter (2). Heating is expensive, and many people are fuel poor over the winter.

–          Wear layers of wool and thermal clothing, both at home and indoors. Long leggings and underwear, thick socks, and gloves are important. This sounds like a no-brainer, but it’s the first and obvious thing to do.

 

–          Take advantage of natural sunlight in your windows during the day, but draw your curtains at night to trap heat in. The thicker the curtains, the better.

 

–          Heat up a hot water bottle, or make your own rice bag – fill a sock (or other sack-shaped fabric) with rice, tie it up, and put it in the microwave for a couple of minutes (idea courtesy of Jack Monroe)

 

–          Drink hot drinks and eat warm food. Your body itself is a major source of heat, and you have to keep that engine running.

 

–          Get active – do some exercise at home to produce body heat.

 

–          Keep the central heating around 18 degrees Celsius – or slightly lower if you can stand it. Temperatures from around 15-17 degrees activate brown fat, which is metabolically active fat that burns calories to produce heat within our bodies (3). This process is called “non-shivering thermogenesis” – the production of heat without shivering. It’s a win-win for your health and your heating bill!

 

There are other recommendations from other sources as well – the BBC has compiled a list of tips to help keep your house warm, as well as Jack Monroe’s list from “a veteran of freezing houses, wooden floors, and big windows”.

4. Getting sick

In the northern hemisphere, flu season typically peaks in February, which means the worst is still ahead of us (and holiday parties are a great opportunity for germ swapping). While the flu shot doesn’t protect against every cold, cough, and sniffle that’s going around, it does protect against more than half of the actual flu strains going around (yes, even when it’s a mismatch year.) A good read on the flu vaccine is Tara Haelle’s Debunking ALL the flu vaccine myths: Can the shot give you the flu? No. Is the flu actually dangerous? Yes.

To prevent colds and flu, wash your hands (although this is not a guarantee, because the flu is airborne, but hand washing still helps). Stay away from people who are sick, or if you’re the one who’s sick, keep yourself home for 24 hours after your fever breaks, as the CDC advises.

5. Travel

A lot of travel health concerns seem to focus on the air circulation: Is the air too dry? Does it pressurize us and squish our organs, like the Food Babe said? Read about how airplane pressurization really works on BrainStuff. The air outside the plane is cold, low-pressure, and dry, so it’s compressed (making it roughly equivalent to the air pressure in a mountainous place like Denver, so still less than most of us are used to), as well as heated by the engine, and mixed with air that’s been humidified by—ok this is just slightly gross—being in the air cabin already where people are breathing and releasing some moisture. That still leaves it fairly dry, but you can beat the dry nose feeling by drinking water and using saline nasal spray.

6. Stress

Stress can weaken your immune system, and can contribute to mental health issues like depression. This Mayo Clinic guide to managing holiday stress includes helpful tips like budgeting gifts rather than trying to solve problems by buying happiness, and planning some alone time every day to take a break from things that are pressuring you.

Enjoy the holidays, from all of us at PLOS Public Health Perspectives!

References

  1. Pollan M. Food Rules: An Eater’s Manual. New York: Penguin Group Inc; 2009.
  2. Berko J, Ingram DD, Saha S, Parker JD. Deaths Attributed to Heat, Cold, and Other Weather Events in the United States, 2006-2010. U.S. Department of Health and Human Services. 76, 2014.
  3. Wenner Moyer M. Supercharging Brown Fat to Battle Obesity. Scientific American 2014;311(2). http://www.scientificamerican.com/article/supercharging-brown-fat-to-battle-obesity/
  4. Haelle T. Setting the Record Straight: Debunking ALL the Flu Vaccine Myths. http://www.redwineandapplesauce.com/2013/10/28/setting-the-record-straight-dubunking-all-the-flu-vaccine-myths/
  5. Centers for Disease Control. Personal NPIs – Everyday Preventative Actions. http://www.cdc.gov/nonpharmaceutical-interventions/personal/index.html
  6. Brain, M. How Airplane Cabin Pressurization Works. http://www.brainstuffshow.com/blog/how-airplane-cabin-pressurization-works-keeping-you-comfortable-in-the-death-zone-at-33000-feet/
  7. American Academy of Otolaryngology. Your Nose, the Guardian of Your Lungs. http://www.entnet.org/content/your-nose-guardian-your-lungs
  8. Mayo Clinic staff. Stress, Depression, and the Holidays: Tips for Coping. http://www.mayoclinic.org/healthy-living/stress-management/in-depth/stress/art-20047544

 

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Chagas disease is turning up in (un)likely places. Who is ready for it?

Chagas

Photo by Clonny on Flickr. CC BY-NC-ND

Please welcome another guest post by Charles Ebikeme. –Beth

Chagas is a more dangerous and much more pervasive disease than we give it credit for. A tropical disease that is really no longer quarantined to the tropics, Chagas has been known to turn up in unlikely places — and those unlikely places are becoming more and more important.

Chagas is also known as American trypanosomiasis, and is found mainly in Latin America, where it is mostly transmitted to humans by the faeces of the triatomine “kissing bug”. About 7 to 8 million people are estimated to be infected with Chagas worldwide.

Recently, researchers at the Center for Clinical Epidemiology and Biostatistics demonstrated that bed bugs can transmit Trypanosoma cruzi, the infectious parasitic agent that causes Chagas disease. They found that bed bugs, a not too unrelated cousin of the kissing bug, can transmit the parasite in the same way by which humans are usually infected. Both bed and kissing bugs only feed on blood, and both hide in household cracks and crevices waiting for nightfall and the opportunity to feed on sleeping hosts.

The discovery that bed bugs can transmit Chagas is not the first time the disease has turned up via an unlikely route.

Distribution of Chagas' disease.svg

Traditional distribution of Chagas’ disease by Tomato356 at Wikipedia. CC BY-SA 3.0.

In March of 2001, a 37 year old woman went into surgery in the US to have a kidney and pancreas transplant from a donor that had already passed away. She would die six months later, on the first week of October from Chagas. The parasite had been contracted from the organ transplant.

Outside of the bite and faeces of the kissing bug the parasite can be transmitted in more (extra)ordinary ways — from mother to child, and through contaminated blood or organ donations. In the US blood supplies have only routinely been screened for Chagas since 2007.

In southern states of the US, the kissing bug also roams, and recent research has shown that some cases of Chagas disease are originating domestically. There’s a need to look more carefully for local infections in Texas and elsewhere in the South. And given the pathology of the disease, many people who are infected may not know they carry the parasite.

In recent years, it has become more apparent that Chagas is now not just confined to the Americas. It hasn’t been for some time. Chagas has now spread to other continents, and Europe is its most recent port of call.

The first reported case of Chagas in Europe was in 1981. Ever since then, sporadic cases have been detected in different European countries. Since the turn of the millennium the numbers of reported cases have only increased, particularly in Spain, Italy, and Switzerland. In Europe, the currently estimated number of people with Chagas is somewhere between 68,000 and 122,000, yet by 2009 only 4,290 had been diagnosed.

Chagas is a real threat. The global cost of the disease worldwide is thought to be at around 7.2 billion US dollars per year — an amount that is comparable to cervical cancer.

How prepared is Europe for Chagas?

Researchers, publishing in PLOS, sent out questionnaires on health policy for T. cruzi infection to about a dozen European countries. They wanted to gauge policy on the possibility of infection via blood transfusion, transplantation, and congenital transmissions. Some European countries are slowly beginning to acknowledge this growing public health problem, and some changes in health policies have been implemented.

Some, but not all, European countries have implemented national or regional measures to control transmission, but many countries still have no legislation about Chagas disease within their borders.

For risk of infection via blood transfusions seven European countries have either already implemented, or are in the process of, changing recommendations to enhance detection of cases of infection (France, Italy, Portugal, Spain, Sweden, Switzerland, and the United Kingdom).

No country in Europe has a specific health policy against the risk of infection by organ transplantation. Only in Italy, Spain, and the United Kingdom are donors at risk of the infection being screened.

Of all the three possible routes of extraordinary infection, it is the congenital route that is the least well developed in terms of health policy. This in the face of the fact that control of congenital transmission has been demonstrated to be one of the most cost-effective measures to control the disease, since newborns with acute disease can be cured easily if treatment and diagnosis is early.

The recommendation from authors is an evolving health policy to control Chagas disease transmission in Europe. Across Europe, the map of policies is a mixed one — some laws and directives concerning blood banks and transplant programmes are urgently needed to avoid and reduce the risk of transmission. The differences in regulations emanating from the European Commission are not always in line with the Council of Europe, which should be addressed to give some coherence. Where laws and regulations do exists, more effort needs to be made to evaluate their implementation and impact.

About Charles

charles_ebikeme (1)

Charles Ebikeme is a science journalist with a PhD in parisitology who serves as a Science Officer with the International Social Science Council of UNESCO and writes frequently on global health, health policy, neglected tropical diseases and infectious diseases for The Huffington Post, The Guardian, Scientific American, and Think Africa Press. He is based in Paris. You can find him on Twitter @CEbikeme.

 

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