Yelping the CDC

It's one of those ideas that seems obvious... after someone else thinks of it. Public health researchers in New York City searched Yelp for complaints that sounded like food poisoning. Only 3 percent (15 of 500) of the suspicious incidents had been reported to the city. The researchers caution that it took a lot of work to review and follow up on the Yelp complaints, that they weren't able to identify any of the infectious agents in the outbreaks they found, and that despite all their work they still may have missed cases.

So this experience indicates that while social media may be useful in identifying food borne illness outbreaks, it's not simple.

Read the full report in this week's MMWR from the CDC:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6320a1.htm?s_cid=mm6320a1_w

What the Higgs boson and health care reform have in common

Along an undulating ridge just south of Menlo Park, Calif., SLAC runs laser-straight. It is my path not taken.

Credit: SLAC National Accelerator Laboratory

When I arrived for a tour during freshman orientation, SLAC stood for Stanford Linear Accelerator Center. The name has changed to the SLAC National Accelerator Laboratory, but the function is the same. It’s a drag strip that causes crashes. But rather than hosting funny car dragsters screeching to a few hundred mph, SLAC shoots particles with funny names to nearly the speed of light, just to see what happens when they hit head on.

SLAC is a direct ancestor of the Large Hadron Collider that produced subatomic fireworks that in turn produced fireworks in the physics, cosmology, and philosophy worlds with word that the Higgs boson almost certainly exists.

As I toured SLAC, I saw my Stanford studies possibly leading to a life-long pursuit of meaning in the squiggles of particle collision representations like those displayed with Higgs announcements. But my path veered off from the two-mile-long subterranean particle gun to another basement home: the newsroom of KZSU 90.1 FM. Halfway to a BS in physics, I pivoted from science to science journalism and ultimately to the health beat.

But that personal thread is not the Higgs - health care link to which the title of this note refers.

Do you understand what a Higgs boson really is? How it relates to photons, electrons, neutrinos, quarks, gluons, gravitons and other denizens of the quantum world? That’s okay. I can’t say I’ve got a solid grip on it all… and I studied this stuff (or at least what was taught about it decades ago) in a department liberally sprinkled with Nobel winners.

Representation of likely Higgs event. Courtesy CERN.

So what’s it got to do with health care reform? Well, it took me a lot of hard hours in classes like “The Philosophical Problems of Quantum Mechanics” to make peace with the chasm separating normal human experience from the quirky ways of quarks and their kin. Similarly, I’ve come to terms with health care only by surrendering any expectation that it works like normal business.

That’s not to say the quantum world or health care are without order and rules; it’s just that they aren’t the rules of the world most of us see and touch. We live in a Newtonian world. When I’d push through a swinging door on my way to introductory physics class, diagrams of vectors and angular momentum would pop into my head. I could feel the physics in my hand on the door. But in the quantum world, a photon is both a wave and a particle. Electrons don’t orbit an atomic nucleus the way planets loop around a star, they exist in probabilistic clouds, sort of everywhere and nowhere at the same time. Schrödinger's cat is simultaneously alive and dead.

It seems crazy, but do the right experiments and you get the same results every time. The formulas, the rules, work. They predict what will happen… even if the consistent result feels so wrong, so unnatural, so at odds with normal experience.

Likewise with health care. In normal life, demand drives supply; increasingly supply usually brings down prices. In health care, supply creates demand; prices may bear only a tenuous relationship to either the supply/demand balance or the cost of production. Double the number of MRIs in a city and the number of scans usually rises to try to satisfy the increased capacity. Meanwhile, under conventional fee-for-service payment, prices may actually rise if the machines (with largely fixed overhead) aren’t used as efficiently. Oh, and as far as health goes, the increased number of MRIs (and the increased spending on scans) will probably produce little or no additional health benefit, because when it’s easy to schedule a scan, people with less urgent need tend to get scanned, even if they’d probably be just fine without one.

You hear people say we should buy health care like we shop for other consumer items. Sure, if you are in the habit of buying a TV without knowing how much it will cost or whether it will tune in the stations you want to watch until after you bring it home and hire a crew to install it. No returns. And remember, you don’t really decide what to purchase, your doctor does. Next time you go shopping for a car, just give the salesperson a blank check and tell her to recommend whatever car she thinks you need.

But again, as with the quantum world, health care is not chaos, even if the order is difficult to discern. Most of us can’t make sense of things… but that doesn’t mean there are no rules. It does mean that expecting health care to work like home electronics is like expecting Higgs bosons to behave like billiard balls. Ain’t gonna happen.

There is one important way this analogy doesn’t work. Making health decisions and enacting health care policies based on a simplistic belief that health care works like normal things is likely to cost lives… and much of our economic future. In contrast, believing that the quantum world should behave like the world we see and feel is not likely to kill you… unless you are Schrödinger's cat.

Smoking, Fat & Sex. Quick note on public health reports

Among updates from the American Journal of Public Health, these caught my eye:

Smoking

Tobacco control crusader Stan Glantz and colleagues comment on how people in the global tobacco control community have not only developed a consensus on the evidence, but figured out how to advocate for policies and actions that can reduce the public health of tobacco.

The Nature, Scope and Development of the Global Tobacco Control Epistemic Community

Bonus vocabulary lesson: ep·i·ste·mic/ˌepəˈstemik/ It means something to do with knowledge. In this case it refers to the body of scientific evidence that tobacco control experts developed and draw on.

Fat

There are a few reports relating to how fat we're getting. One draws a line connecting obesity in the United States and our poor showing on international measures of life expectancy. The researchers looked at how much longer people could expect to live once they reach middle age. Using 2006 data, they say obesity may slice almost two years off life expectancy for middle age Americans and that's a substantial part of the difference between the US and other countries. The article is Contribution of Obesity to International Differences in Life Expectancy.

Then  there is a re-examination of the effect of obesity in later life. Some reports have indicated that being fat may make less of a difference to life expectancy as we get older. But this analysis concludes that there might be a problem with how some researchers have used the data. The apparent diminishing effect might actually be a mirage caused by the fact that people in older generations aren't as fat as those in younger generations. So being obese in old age may be just as hazardous to your health as being fat when you are young. See Reexamining the Declining Effect of Age on Mortality Differentials Associated With Excess Body Mass: Evidence of Cohort Distortions in the United States.

And then an experiment in Australia concluded that PE classes in elementary school do a better job of keeping kids thinner if they are led by specialists rather than general classroom teachers. There was also some improvement seen in some measures of academic performance. Physical Education, Obesity, and Academic Achievement: A 2-Year Longitudinal Investigation of Australian Elementary School Children

Sex

Boyfriends and girlfriends deserve more attention than husbands and wives, at least in the circumstances addressed by a British study.

Imagine you are a local public health official trying to contain a sexually transmitted disease. When you find a case, which makes more of a difference: notifying spouses or other steady partners or tracking down casual hookups? These researchers say that based on their analysis of chlamydia cases, notifying casual partners was a more effective way of interrupting transmission. It takes more work, but the effort may be worth it.  Estimating the Likely Public Health Impact of Partner Notification for a Clinical Service: An Evidence-Based Algorithm

Neurotransmitters, Immune Function and Social Determinants of Health

There is a fascinating article on The Scientist web site about "Neurotransmitter-Regulated Immunity."

It reports on a pair of research articles delving into the relationship between our brains and our immune responses. The experiments were done on mice. Normally, I resist paying much attention to animal experiments, because they often turn out to not really tell us much about human health. But these research efforts are shining some light on basic mechanisms that could help explain phenomena that we've all seen play out in real life.

One of the most consistent observations in population health is that people in wealthier neighborhoods tend to be healthier and live longer than those in poor neighborhoods. What is particularly striking is that even after you take into account differences in lifestyle (smoking, physical activity, body weight) some of the discrepancies persist.

Then there is the data indicating that people with higher status jobs tend to be healthier than those at the bottom of the work hierarchy. Again, some of the difference persists even when researchers try to factor in lifestyle and other characteristics. It seems there is something about being at the top of the heap that translates into better health.

These health disparities are also seen in countries (Britain for example) that have universal health care coverage and where the differences in the kind of health care available to rich and poor are much less extreme than in the United States.

Along the same lines, researchers continue to investigate how racism itself might explain some of the health disparities between members of majority and minority communities.

Stress has been offered as one potential explanation for a link between social factors and physical health. Much of the attention has gone to corticosteroids. These naturally-occurring hormones (also distilled for use as medications) can sometimes suppress immune function.

The research discussed in The Scientist involves a different set of substances in our bodies, including acetylcholine and noradrenalin. The animal research indicated these neurotransmitters can affect how the immune system works.

Maybe it's another piece of the machinery that connects how we live, how we feel... and how likely we are to get sick and die.

Blaming the Victim for Pedestrian Killings

I just came across a copy of a letter of mine the Oregonian newspaper printed earlier this year. I wrote it in response to an editorial that put a lot of the blame for a spike in pedestrian deaths on the pedestrians who died, largely absolving the drivers who killed them.

If we are to be less obese, less prone to diabetes and heart attacks, overall healthier, we have to make walking safer and more enjoyable. Endorsing the view that walking is inherently dangerous and that anyone who wants to walk rather than sit in a car does so at her or his own risk condemns us to an increasing cycle of inactivity, ill health and ever greater dependence on medicine to sustain us.

Text of my letter:

She was asking for it. The way she was dressed. The way she acted. Didn't she know the kind of people she might run into there? Who could really blame them for what happened to her?

I'm not talking about rape. I'm paraphrasing typical comments about people who are just trying to walk down the street.

Imagine your daughter (or son) were hit while walking to catch the bus to school. Maybe she was distracted. Maybe she didn't jump into the roadside mud quite fast enough. Maybe she was dressed to please her friends, rather than a safety monitor. Would you want drivers, police, road authorities or even newspaper editors to conclude that, “She was asking for it”?

A Twist on Income Inequality & Health

A multitude of studies has found an association between income inequality and health; that is, in places where there is less of a gap between rich and poor, people tend to be healthier and live longer.

Now there's a study that adds a twist. The study sought to explain why health care costs more in the United States than in other countries. The researchers concluded that physicians in the U.S. get paid substantially more than physicians in other countries and it is that difference in fees, rather than factors such as the amount of health care people get, that explains much of the differences in health care spending.

Here's where income inequality comes in. The researchers compared doctor salaries to the range of incomes in certain countries. One conclusion:

"High physician fees in the United States may reflect the cost of attracting skilled candidates to medicine in a society with a relatively more skewed income distribution."

In other words, since high income earners in the US do so much better than the average person here, doctors expect to get similarly big paychecks compared to people doing other jobs. In countries where there is less of a gap between the salaries of CEOs and line workers, doctors earn less on average... and that means health care doesn't cost as much.

When we debate health, the discussion often seems narrowly focused on what pills or procedures are available, or what's cooking in medical research labs. But medical science and clinical skills are not the whole story. This latest report illuminates one more way in which other factors, such as income inequality, influence health care and health.

An Honest Reply to a PR Pitch... and the telling silence that followed

SEE UPDATE AT BOTTOM OF POST

I received this impersonal pitch from a PR firm. I couldn't resist replying.
(Identifying information disguised because I'm a nice guy.)

From: E.... . [mailto:e....@....pr.com]
Sent: Monday, July 18, 2011 10:40 AM
To: E.... .
Subject: Request for editorial calendar

Good Afternoon!

I was hoping you could please provide me with your editorial calendar for the 2011-2012 year.
Please let me know if this is possible, thank you so much in advance.

Have a great day!

Best,
E....
--
E.... S.....
.... Associates
(...) ...-....
.....@....pr.com
----------------------------------

Dear Ms. S.....,

The editorial calendar is in flux. We would be pleased to see submissions related to the following topics:

• The influence of marketing on medical decision-making
• Comparative effectiveness trials that include behavioral or social interventions, akin to the Diabetes Prevention Program http://is.gd/jYjWYm
• Conflicts of interest in medical research and clinical practice (although we doubt we can catch up to the stellar reporting of John Fauber at the Milwaukee Journal-Sentinel that was recognized by the Association of Health Care Journalists, http://is.gd/seMf14)
• Community-Based Participatory Research (such as The Multisite Translational Community Trial http://is.gd/zsBrsp) that investigates actual benefits and harms of medical interventions in clinical practice, rather than the idealized setting of a typical Randomized Controlled Trial
• Research into community, economic, political, educational and other determinants of health that can help illuminate the reasons that health in the United States is steadily falling behind that of countries that spend far less on medicine
• Research into health care system designs that track and reward health outcomes, rather than just health care inputs

I could go on, but I think you get the gist. I would be very interested in any leads on these and other related health topics.

Regards,

Andrew Holtz, MPH

---

I'll let you know if I hear back from this PR company. Don't hold your breath.

--------------------------

Well, whaddya know... I did get a response, though I'm waiting to see if any substance follows.

From: E.... . [mailto:e....@....pr.com]
Sent: Monday, July 18, 2011 2:21 PM
To: holtzreport@juno.com
Subject: Re: Request for editorial calendar

Andrew-

Thank you so much for your help!

Best,
E....

---

UPDATE 8/18/11

Well, it's been a month now. I've heard nothing more. Seems my journalistic interests and the marketing of their clients don't appear to match up. What a surprise.

Sad to say, though, I will bet they had more success elsewhere getting their messages placed. Sigh.