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.

Yes, our insurance system is an expensive, dysfunctional headache... but...

Marketplace Radio aired an enlightening piece about the burden of our private insurance system: http://is.gd/2coJF (Thanks to twitter.com/garyschwitzer for the alert.)

As I commented on the Marketplace web site...

Yes, our system is weighed down by the inefficiencies of the free-for-all of the fragmented private insurance system. The burden of all those billing people is also matched by the unmeasured burden on patients and families trying to manage payment for their claims.

However... and this is a big 'however'... even if we magically erased the 20% administrative cost... well, that's what my premiums rose just this spring. [As a small business owner I pay 100% of our family's health care premiums and other costs.] And I expect a similar jump next year, just like last year.

Streamlining administration is necessary... but it's a one-time saving. Unless we change how we develop and deploy health care itself, the upward arc will continue.

OK... I won't make you wait to see the whole article.

Just go to the op-ed section of the Portland Oregonian newspaper. Here's the direct link to my commentary:

http://is.gd/1ivyr

and remember, if you were on a bike, you'd be happy now.

- Andrew

Twitchy Comment

I'm posting a serial tweet comment about self-righteous cyclists... actually it's a look at the clash of perspectives between those behind the wheel and those above the handlebars. It was inspired by the Pearls Before Swine comic strip by Stephen Pastis.

The final tweet in the series will be a link to the full essay.

You can find the series through the #pearlb hashtag or my HoltzReport Twitter unsername.

Thanks for reading and thinking.

- Andrew

Scanning: Who Pays?

A fellow journalist asked for information on screening scans, CT, MRI, Ultrasound exams, etc., like those increasingly being offered as ways to look for heart disease, cancer, and other diseases, without the risks of some other tests.

She wanted to know how much do they cost and who pays?

Well, leaving aside the serious issues of the thin or nonexistent evidence to show that scanning a healthy person is going to do more good than harm.

"Harm?," you ask. "Aren't these scans non-invasive?"

Well, other than the radiation dose from CT (which can add up), it's true that you are unlikely to be physically hurt by an imaging scan. But they can lighten your wallet, may not offer much useful information... and may send you into follow-up rounds of further (and possibly more hazardous) testing.

Here's some more of what I answered to the original query:

The costs vary widely, from a couple of hundred dollars to thousands, and insurance usually only pays when they are recommended by a physician to check on a suspected problem... not for screening healthy people. (Mammography being an exception.) A release from the Radiological Society of North America has some numbers and contact info: http://www2.rsna.org/pr/target.cfm?ID=235

One thing to include is the likelihood, costs and risks of follow-up investigations of screening scans. For one thing, screening scans almost always find something "abnormal."

Take a look at
http://radiology.rsnajnls.org/cgi/content/abstract/237/2/385?etoc

These researchers studied 1200 whole-body screening CT scans (about a third ordered by physicians, two-thirds self-referred by the customer). Almost 90% of scans resulted in at least one abnormal finding... and almost 40% of the people who got a screening scan were told they should have follow-up tests... usually more scans.

Who pays for the follow-up tests? And what if a "non-invasive" scan results in a recommendation of a biopsy or other invasive test?

A few years ago, Elliott Fishman, MD, at Johns Hopkins told me that if people decide to get screening scans that aren't recommended by a physician, then they should be responsible for the cost of follow-up, which may be tens of thousands of dollars. He said the cost of screening scans that aren't supported by evidence of effectiveness shouldn't be dumped on taxpayers and insurance premium payers. If you want to see his quote, go to: http://www.oncology-times.com/pt/pt-core/template-journal/oncotimes/media/HoltzWholeBodyCTScanning-PTFeb102003.pdf

And Bruce Hillman, MD, Chair of Radiology at the University of Virginia, has said that screening healthy people may cost $150,000 or more per year of life saved.

Update on U.S. Breasts

The CBSNews.com web site invited me to comment on their coverage of health and medicine.

Since CBS is one of the US news organizations that didn't report the international review that highlighted some of the of risks associated with mammography screening... while instead doing a series on just the benefits... I elaborated on my comment about the puzzling differences between how health stories are reported by U.S. and British news organizations.

See the full text here:
http://www.cbsnews.com/blogs/2006/12/01/publiceye/entry2221641.shtml

Are U.S. Breasts Different?

Or is it just how we look at them?

OK, now that the headline has hooked you... here's my question: why did a review of studies examining the balance of risks and benefits of mammography get widespread coverage in the UK, but almost no mention in the US news media?

Of the two dozen stories picked up in a Google News search, almost all were from the UK, Australia and other Commonwealth nations... but there were no US news stories found. The story hasn't appeared on NYTimes.com, Washingtonpost.com or LATimes.com. CNN.com mentioned it only in its international section as part of a world news digest.

The systematic review of major mammography studies concluded that women who get mammograms are about 15% less likely to die of breast cancer... but they are also much more likely to undergo unnecessary treatment. The review concluded that for every 2,000 women who are invited to get mammograms for 10 years, one potentially lethal cancer will be detected and successfully treated. However, 10 healthy women will be treated for cancer unnecessarily. And an additional 200 women will be given false positive results.

Inform or Persuade?

The BBC and others had headlines like: "Breast Screening Concerns Raised" and "Researchers Question Benefits of Breast Cancer Screening."

Meanwhile, US news outlets ran story after story on breast cancer (October is National Breast Cancer Awareness Month)... but almost none mentioned the potential downsides of mammography. The "rah-rah" leads of these stories advocated mammography for every woman without reservation... stating flatly that "Mammograms are good" and "No more excuses for not getting mammograms."

It seems British and Australian editors have a different view from those in the US about what sort of info is relevant to their readers and viewers.

Is it the job of journalists to inform women about mammography... the benefits and the risks? Or should journalists follow the lead of breast cancer advocacy groups... and avoid talking about any doubts or skepticism, for fear such questions might dissuade some women from getting screened?

This latest review of the science... from the Cochrane Collaboration... concludes that, on balance, mammograms do reduce breast cancer deaths... but this benefit is not free.

When I mentioned this issue to some colleagues... the responses varied.

One journalist at AuntMinnie.com said that they had indeed reported on the Cochrane review.

Another wrote that wrote, "I pitched an article covering both the benefits and risks of mammography to several magazines, but so far, no one is going for it."

And then a couple of MD's ran to the defense of mammography. "It is very-well established that mammograms in the U.S. save lives, and we don't want to discourage women from getting them," wrote one physcian/journalist.

Mammography isn't the only medical topic that generally gets a free pass from US journalists. Screening tests of all types tend to be seen as inherently good... when reality is more complicated. Most reporters and editors report without question the assertion that early detection saves lives. But the fact is that screening tests often lead to further tests, anixiety and even treatment that does not always improve health or extend life.

But I'm digressing into another large and thorny issue.

What do you think? Can women handle the news that mammography is not perfect... and that the promise of life-saving detection comes with hazard of anxiety and unncessary treatment?

"Celebrating" the end of cancer treatment

Today I heard from a fellow health journalist who was having trouble with a story. Here's what she said her editor at a national magazine wanted her to write about:

"The story is about cancer survivors doing something unique/amazing/different/unusual after their treatment, to sort of commemmorate their experience and treatment. For instance, one person joined a group to climb a mountain."

But she said she was having difficulty actually finding such people.

So I wrote back to say that maybe one reason it's tough to find people who fit the story is that the editor's perception of cancer survivors may not match the reality.

As an editorial comment in the March 2006 American Journal of Nursing put it:

"According to the American Cancer Society's Cancer Facts and Figures 2005 (www.cancer.org/downloads/STT/CAFF2005f4PWSecured.pdf ), the five-year relative survival rate, for all types of cancer combined, is 64%. But survival often comes at a significant cost-psychosocial, physiologic, spiritual, and existential long-term and late effects are increasingly recognized. Many don't become evident until years after completion of therapy.
"With long-term survival now a reality, many survivors find a "new normal" in their lives after cancer. They return to work, go to school, participate in recreational activities, and form and nurture families, friendships, and other relationships. But survivors of cancer frequently experience long-term changes and obstacles, such as impaired immune response, vital organ dysfunction, hormonal changes resulting in infertility, altered sexual function, cognitive changes, ongoing fatigue, depression, anxiety, family distress, and economic challenges, to mention only a few."

(see the full issue at: http://www.nursingcenter.com/library/static.asp?pageid=623591#contents )

So I wonder if the image of a survivor "celebrating" the end of treatment is more of a "And They Lived Happily Ever After" fairy tale... and not really fitting for a news article that should reflect what survivors actually have to deal with.

One of the items I've discussed with cancer experts is the burden put upon cancer survivors when they constantly see media images of amazing individuals like Lance Armstrong... and then have to wonder why they can't live up to that standard.

In closing, I offered the writer my wish for good luck with her article, because it's no fun when the facts don't neatly fit an editor's assignment.

Pitfalls of Health Info Technology

The Center for Health Transformation, founded by Newt Gingrich, just posted an interactive map of the US to highlight "transforming solutions in Medicaid." www.healthtransformation.net

The map links do not appear to work with the Firefox web browser.

One of the stated goals of the group is to:

"Create secure electronic health records and e-prescribing with expert systems to maximize accuracy, minimize errors, reduce inefficiencies and improve care."

The unreliable map is a good example of how challenging it will be to guarantee interoperability of electronic infomation systems in health care... where the stakes are very high indeed.

"Page Cannot Be Displayed" is not want you want the ER doc to see when you roll in on a gurney and she's trying to access your electronic health record.

Run, Jeff, Run!

Jeff Deitch, a former broadcaster and now attorney, is running for the state legislature in Colorado.
He's an old friend and got in touch to talk about health care reform. He said local politicos advised him to avoid talking about health care issues... that it'd kill his campaign.

I think those politicos are wrong. What's killing us is the status quo.

People are desperate for change.