I know it seems like the obvious choice, but I would not run a randomized clinical trial.
I have recently lamented the pernicious influence, within my domain of public health practice, of hyperbolic headlines proclaiming “this,” followed unfailingly by equally and oppositely hyperbolic headlines reactively proclaiming “that.”
But we are obligated to acknowledge that there are, generally, research studies underlying the headlines, however extreme the pop culture distortions of the actual findings. So to some extent, the problem originates before ever the headlines are a gleam in an editor’s eye, with our expectant anticipation of the next clinical trial, and the next, and the next.
By all means, bring on the clinical trials! They serve us well. They advance the human condition. I run a clinical research lab — my career is devoted to just such trials.
But still, I wouldn’t conduct one if my foot caught fire.
Of course, there is a very good case for running such a study, as many vitally important questions about the right response to a foot on fire are at present unanswered. What, for instance, would be the ideal volume of water? Should it be hard water, or soft? Fluoridated, or not? A controlled trial is very tempting to address each of these.
The vessel is even more vexing. What would be the best kind of bucket? What size should it be? What color should the bucket be, what composition, and what’s the ideal kind of handle? I think the variations here are the basis for an entire research career.
Perhaps the notion of running randomized, double-blind, controlled intervention trials to determine the right response to a foot on fire seems silly to you. But if so, you must be suggesting that science does not preclude sense.
That’s rather radical thinking in some quarters.
Continue reading “What I Would Do If My Foot Caught Fire”
Filed Under: THCB
Tagged: academic research, Clinical Trials, David Katz, Evidence Based Medicine, public health, Wellness
Apr 16, 2014
Fred Shaw went to St. Martin and all he got was a painful virus called chikungunya.
On an island stop during his Caribbean cruise vacation, Mr. Shaw was infected with the mosquito-borne virus that causes a severe fever and an arthritis-like condition in people, similar to dengue fever. After infection, the virus still may cause long periods of fatigue and incapacitating joint pain.
Writing on Facebook, Mr. Shaw said, “The fever, leg rash and swelling were bad enough, but then followed by months of headache, joint pain and malaise, I finally have gotten over it (I think).”
Chikungunya virus was first described during an outbreak in Tanzania in 1952 and was subsequently discovered in other parts of Africa and Asia. The name ‘chikungunya’ is derived from a local phrase that means ‘that which bends up’ and describes the stooped appearance of sufferers with joint pain.
In late 2013, chikungunya was found for the first time in modern history on islands in the Caribbean. Based on our research and the evidence we have observed, it is likely that the virus is on its way to the U.S.
Vector-borne viruses—which are transmitted to people by an animal or insect—threaten half the world’s population and are responsible for millions of human infections annually. Various mosquitoes and ticks transmit a subgroup of these viruses that are called arboviruses.
There are over 100 known arboviruses that infect humans and can cause neuroinvasive diseases like encephalitis, febrile illnesses and hemorrhagic fevers. Except for yellow fever, tick-born encephalitis and Japanese encephalitis, there are no commercially available vaccines for most arboviral disease.
As the world becomes flatter and the globe opens to new opportunities for international trade and travel, viruses that used to be confined to “over there” are increasingly coming “over here,” and they are arriving sooner rather than later.
Continue reading “Are We Prepared For The Next Viral Disease Threat?”
Filed Under: THCB
Tagged: chikingunya, FutureMed, Global Virus Network, public health, Robert Gallo, Scott Weaver, Sharon Hrynkow, vector-borne diseases
Apr 6, 2014
In their best-selling 2013 book Big Data: A Revolution That Will Transform How We Live, Work and Think, authors Viktor Mayer-Schönberger and Kenneth Cukier selected Google Flu Trends (GFT) as the lede of chapter one.
They explained how Google’s algorithm mined five years of web logs, containing hundreds of billions of searches, and created a predictive model utilizing 45 search terms that “proved to be a more useful and timely indicator [of flu] than government statistics with their natural reporting lags.”
Unfortunately, no. The first sign of trouble emerged in 2009, shortly after GFT launched, when it completely missed the swine flu pandemic. Last year, Nature reported that Flu Trends overestimated by 50% the peak Christmas season flu of 2012. Last week came the most damning evaluation yet.
In Science, a team of Harvard-affiliated researchers published their findings that GFT has over-estimated the prevalence of flu for 100 out of the last 108 weeks; it’s been wrong since August 2011.
The Science article further points out that a simplistic forecasting model—a model as basic as one that predicts the temperature by looking at recent-past temperatures—would have forecasted flu better than GFT.
In short, you wouldn’t have needed big data at all to do better than Google Flu Trends. Ouch.
In fact, GFT’s poor track record is hardly a secret to big data and GFT followers like me, and it points to a little bit of a big problem in the big data business that many of us have been discussing: Data validity is being consistently overstated.
As the Harvard researchers warn: “The core challenge is that most big data that have received popular attention are not the output of instruments designed to produce valid and reliable data amenable for scientific analysis.”
The amount of data still tends to dominate discussion of big data’s value. But more data in itself does not lead to better analysis, as amply demonstrated with Flu Trends. Large datasets don’t guarantee valid datasets. That’s a bad assumption, but one that’s used all the time to justify the use of and results from big data projects.
Continue reading “Google Flu Trends Shows Good Data > Big Data”
Filed Under: Tech
Tagged: Big Data, flu, Google Flu Trends, Kaiser Fung, OCCAM framework, public health, statistics
Mar 26, 2014
If Obama’s nominee for the position of Surgeon General, Vivek Murthy, is not endorsed by the Senate because Senate Democrats from conservative states are too scared to vote for him for fear of losing votes from a population, egged on by the National Rifle Association (NRA), that passionately supports firearms, the first words that come to mind are ‘unfortunate,’ ‘tragic’ and ‘daft,’ although not in that particular order.
Words that do not come to mind are ‘surprising’ or ‘unprecedented.’ This is the natural result of decades of actively encouraging science to mix with politics.
In an ideal world, or I should say reasonable world, noting that perfection is not a pre-requisite to being reasonable, it would scant matter what Murthy thought about firearms.
He would be judged on his (impeccable) credentials, (unmistakable) leadership, and (imaginative) entrepreneurship not to mention his gumption in standing up for what he believes.
It would, of course, be utterly naïve to believe that in the real world his politics do not matter.
I doubt Murthy would have advanced so precociously, let alone been nominated for the position of Surgeon General, if he were a second amendment absolutist, an implacable limited government advocate or had written extensively about the role of free market in healthcare, all things else being equal.
We applaud him for standing up for his convictions not just because of his standing up but for the nature of his convictions.
This is not to suggest that Murthy’s worldview is expedient. There’s no reason to doubt its sincerity. It’s to suggest that a certain weltanschauung is incompatible with progress in academia and beyond.
That’s because despite living in an age of unprecedented reason we have been unable to render unto science what is unto science and render unto politics what is unto politics, a distinction our species has made little progress in making in the last two thousand years.
Continue reading “Mixing Politics and Science Is Injurious to Public Health”
Filed Under: Uncategorized
Tagged: Gun Control, NRA, public health, Saurabh Jha, Senate, U.S. Surgeon General, Vivek Murthy
Mar 18, 2014
In a recent column, security expert Bruce Schneier proposed breaking up the NSA – handing its offensive capabilities work to US Cyber Command and its law enforcement work to the FBI, and terminating its programme of attacking internet security.
In place of this, Schneier proposed that “instead of working to deliberately weaken security for everyone, the NSA should work to improve security for everyone.” This is a profoundly good idea for reasons that may not be obvious at first blush.
People who worry about security and freedom on the internet have long struggled with the problem of communicating the urgent stakes to the wider public. We speak in jargon that’s a jumble of mixed metaphors – viruses, malware, trojans, zero days, exploits, vulnerabilities, RATs – that are the striated fossil remains of successive efforts to come to grips with the issue.
When we do manage to make people alarmed about the stakes, we have very little comfort to offer them, because Internet security isn’t something individuals can solve.
I remember well the day this all hit home for me. It was nearly exactly a year ago, and I was out on tour with my novel Homeland, which tells the story of a group of young people who come into possession of a large trove of government leaks that detail a series of illegal programmes through which supposedly democratic governments spy on people by compromising their computers.
I kicked the tour off at the gorgeous, daring Seattle Public Library main branch, in a hi-tech auditorium to an audience of 21st-century dwellers in one of the technology revolution’s hotspots, home of Microsoft and Starbucks (an unsung technology story – the coffee chain is basically an IT shop that uses technology to manage and deploy coffee around the world).
I explained the book’s premise, and then talked about how this stuff works in the real world. I laid out a parade of awfuls, including a demonstrated attack that hijacked implanted defibrillators from 10 metres’ distance and caused them to compromise other defibrillators that came into range, implanting an instruction to deliver lethal shocks at a certain time in the future.
Continue reading “Computer Security as an Exercise in Public Health”
Filed Under: THCB
Tagged: Computer Security, Hacking, Information-Sharing, NSA, public health, Transparency
Mar 17, 2014
Jennifer Anyaegbunam is a Fellow at The American Resident Project. Her post appears on THCB as part of The Health Care Blog’s partnership with ThinkWellPoint. Stay tuned for more. Follow the American Resident’s Project on Twitter @Amresproj.
I’ve spent the past four weeks learning about primary care on my Family Medicine rotation. A significant portion of patient care in this setting is focused on “health maintenance” or disease prevention.
Physicians can provide their patients with evidence-based recommendations for various screening tests and vaccinations, but it is ultimately up to the patient to decide what services he or she will receive.
According to the Centers for Disease Control and Prevention (CDC), the best way to prevent influenza, more affectionately called “the flu,” is to get vaccinated each year. During flu season, which extends from October to May, many primary care physicians offer their patients the flu shot as a routine part of their health maintenance.
Over the past month I’ve had a number of interesting conversations about the flu shot that have allowed me to evaluate my role as an educator. How do you assess patient understanding? How hard do you need to drive certain points? Will patients perceive you as bossy or overbearing?
I respect my patients’ right to choose, but sometimes I’m concerned that they make choices based on fiction rather fact. It’s been quite a challenge learning how to debunk misconceptions, without seeming too pushy.
This week I helped care for an elderly woman named “Ms. Jade.” She visited the office for a follow up visit to manage her hypercholesterolemia, or high cholesterol. After discussing her chronic condition, I took the opportunity to assess her health maintenance and check if she was up-to-date with all the assessments recommended for a woman of her age.
Ms. Jade was on track with everything from her annual vision screening to her colonoscopy. The only preventive health maintenance item she was missing was the flu shot. Her chart read “flu shot advised 2012, declined,” meaning that she was offered the flu shot last year and opted not to take it.
Continue reading “The Flu Shot and a Patient’s Right to Choose”
Filed Under: THCB
Tagged: Flu vaccine, FutureMed, Jennifer Anyaegbunam, prevention, public health, Wellness, WellPoint American Resident Project
Jan 25, 2014
We don’t make a lot of New Year’s predictions, but we are happy to make this one: 2014 will be the year the get-well-quick mentality driving corporate and individual health choices implodes…and people start taking genuine steps to be healthy. The way to ensure that 2014 is your year for good health? Start with a double negative: (a) wellness industry advice is almost always wrong; and (b) most people don’t keep their New Year’s resolutions. Hence, making the New Year’s resolutions recommended by the wellness industry is not the best way of ensuring your good health in 2014.
For simplicity, we’ll divide this list into individual and corporate wellness industry resolutions, and start with individual ones.
Take more health advice from celebrities. Whether it’s hoping that Kim Kardashian’s personal trainer can help you or pining for Dr. Oz to cure what ails you with green coffee bean extract and raspberry ketones, a good way to put off doing worthwhile things is to do worthless ones.
Start a weight loss program. The medical establishment could not head off the obesity dilemma at the pass, and they have no solution for it now, other than to crow about more drug companies diving into this expanding market. There is zero evidence that weight loss programs can produce sustainable long-term weight loss (and much evidence that they don’t), and we don’t know of a single one shown to improve fitness. That will not, however, prevent weight loss companies from trying to claim their little piece of the wellness landscape because they are losing so many individual customers to free dieting apps, such as LoseIt.com. Improve the quality of your diet first, and weight loss may follow, which is a bonus.
Give yourself a cleanse. America’s obsession with cleanliness is now running smack into the reality of evolution and human physiology. Surely if bacteria in your colon were bad for you, mankind would have died out eons ago.
Stock up on supplements. The only things better than raspberry ketones and green coffee bean extract: all the other vitamin and mineral supplements on the market that fail to make sick people better or healthy people healthier. Who’s left to try to help, Martians? Never mind that risk is not endlessly reducible and the four most important things you can do for your health don’t come out of a bottle of magic jujubes: exercise, don’t smoke, eat well, and keep as close to a healthy weight as you can.
Remove saturated fat from your diet. Just like in the 1960s, when we all traded in “the high-priced spread” for sticks of partially hydrogenated vegetable oils fit for a king to avoid saturated fat, we may be mis-demonizing this longstanding and naturally occurring component of our diet. The entire nutrition dialectic in our culture over the past 20 years has focused on a string of individual no-nos: fat, saturated fat, cholesterol, and now refined grains and sugars (because we bought the government’s wrong advice to eat low-fat). It’s time to revive the notion of healthy eating patterns, not healthy eating isolates. In fact, here is the world’s simplest diet advice for 2014: eat less junk. That alone would be a landmark nutritional achievement for Americans.
Eat organic and stay away from Starbucks. Within a week of each other, the New York Times published an account of a woman damaging her health eating an obsessively healthy and organic diet, and USA Today wrote of another who ate exclusively at Starbucks for a year, with no apparent ill effects and no weight gain.
Continue reading “Ten Health and Wellness Resolutions Not to Make in 2014″
Filed Under: THCB
Tagged: 2014, Al Lewis, prevention, public health, Vik Khanna, Wellness
Jan 5, 2014
Even the greatest among us can stumble.
As the world mourns the passing of Nelson Mandela, it is important to look at the one area where the iconic former president of South Africa slipped — AIDS. The most outstanding moral figure of our age did not do what was needed as HIV began to destroy the country he loved. But his actions after he realized his failures are an important part of his legacy.
South Africa is beset with the worst epidemic of HIV in the world. According to the United Nations, out of a South African population of just over 51 million, 6.1 million of its citizens were infected with HIV in 2012, including 410,000 children under the age of 14. An estimated 240,000 South Africans died in 2012 from AIDS. There are 2.5 million children orphaned because of the disease. The grim social, economic and medical toll AIDS has exacted on Mandela’s country is almost beyond description.
In 1990, when Mandela was released from a 27-year prison sentence, the rate of HIV infection among adult South Africans was less than 1 percent. When the anti-apartheid activist was elected president four years later, AIDS was on it way to being an out-of-control plague, with infection rates doubling every year. In 1998, the rate of HIV infection among adults in South Africa was almost 13 percent, with 2.9 million people HIV positive.
Mandela and his party were more or less indifferent to AIDS throughout his five-year tenure. There were other huge challenges in rebuilding the new post-apartheid nation — but the indifference was not just a matter of priorities. Mandela and his party did not want to admit they had a problem.
Why they did not take prompt action to slow the epidemic’s spread is not clear. Perhaps Mandela and his people — like United States President Ronald Reagan and his administration in the 1980s — found the disease and its modes of transmission too repellent to acknowledge. Maybe they did not want to tarnish the new state with a problem that at the time carried so much stigma and shame.
Continue reading “Mandela’s AIDS Legacy of Silence and Courage”
Filed Under: OP-ED
Tagged: Arthur Caplan, HIV/AIDS, Nelson Mandela, public health, South Africa
Dec 9, 2013
Between October 1 and 17, the federal government ceased all nonessential operations because of a partisan stalemate over Obamacare. Although it is premature to declare this the greatest example of misgovernance in modern U.S. Congressional history, this impasse ranks highly.
One casualty of the showdown was any consideration of changes to lessen the impact of the across-the-board sequestration cuts that began on March 1. The cuts have caused economic and other distress across the nation, including serious impacts within the health care sector. Nearly eight months into sequestration, we can move beyond predictions and begin to quantify these effects.
Consider the following impacts of sequestration on Federal health agencies and activities:
NATIONAL INSTITUTES OF HEALTH
Cuts to the FY13 budget: $1.71 billion or 5.5%
A 5.8% cut to the National Cancer Institute, including 6% to ongoing grants, 6.5% to cancer centers, and 8.5% to existing contracts
A 5.0% cut to National Institute of General Medical Sciences, and a 21.6% drop in new grant awards
Among the effects:
- 703 fewer new and competing research projects
- 1,357 fewer research grants in total
- 750 or 7% fewer patients admitted to NIH Clinical Center
- $3 billion in lost economic activity and 20,500 lost jobs
- Estimated lost medical and scientific funding in California, Massachusetts, and New York alone of $180, $128, and $104 million respectively.
Dr. Randy Schekman, whose first major grant was from the National Institutes of Health in 1978, said winning this year’s Nobel Prize for Medicine made him reflect on how his original proposal might have fared in today’s depressed funding climate. “It would have been much, much more difficult to get support,” he said. Congresswoman Zoe Lofgren (D-Calif.) noted the irony that because of sequester cuts, NIH funding was reduced for the research that resulted in Yale’s James Rothman sharing in the 2013 Nobel Prize for Medicine.
Continue reading “The Sequestration Cuts That Are Harming Health Care”
Filed Under: OP-ED
Tagged: CDC, FDA, federal budget deficit, government shutdown, John E. McDonough, Medicare, NIH, public health, sequestration
Oct 24, 2013
At least two-thirds of the perpetrators and victims of gun violence are males under the age of 30. What else do they have in common? They live in neighborhoods with high crime rates and low family incomes, they knew each other before the violence broke out, they usually aren’t employed.
But there’s another commonality these young people share which isn’t often mentioned in discussions about gun violence and crime.
It turns out that the part of the brain that controls processing of information about impulse, desire, goals, self-interest, rules and risk develops latest and probably isn’t fully formed until the mid-20s or later. And while adolescents and young men understand the concepts of ‘good’ versus ‘bad’ as well as older adults, they tend to let peer pressures rather than expected outcomes guide their behavior when choosing between risks and rewards.
Take this neurological-behavioral profile of males between ages 15 to 30 and stick a gun in their hands. The brain research clearly demonstrates that kids and young adults walking around with guns understand the risks involved. Whether it’s the NSSF’s new Project ChildSafe, the NRA’s Eddie Eagle or the grassroots gun safety programs that have expanded since Sandy Hook, nobody’s telling the kids something they don’t already know.
So what can we do to mitigate what President Obama calls this ‘epidemic’ of gun violence when the population most at risk consciously chooses to ignore the risk? I suggest that we look at what communities have done to protect themselves from other kinds of epidemics that threatened public health in the past.
And the most effective method has been to quarantine, or isolate, the area or population where the threat is most extreme. It worked in 14th-century Italy, according to Boccaccio in The Decameron. Why wouldn’t it work now?
Last month the city of Springfield, Mass., recorded its 12th gun homicide. If the killing rate continues, the city might hit 15 shooting fatalities this year, a number it actually surpassed in 2010. This gives the city a homicide rate of 10.2 per 100,000 residents, nearly three times the national rate. Virtually all the violence takes place in two specific neighborhoods bounded by Interstate 291 and State Route 83, and all the victims are between 15 and 30 years old.
Continue reading “If Gun Violence is a Health Epidemic, Can We Quarantine It Like a Virus?”
Filed Under: Uncategorized
Tagged: at-risk youth, crime, gun violence, Mike Weisser, Population Health, public health
Oct 20, 2013