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Posts Tagged ‘public health’

In Excess

August 10th, 2011 No comments

Has this ever happened to you?

You’re at a fabulous outdoor party, taking a break from a harrowing game of croquet (the hedgehogs keep running away; PETA is harassing you) and go in search of something delicious to eat. Alas, the other guests are so déclassé that they’ve eaten everything scrumptious, leaving only the deviled eggs.

But there’s a reason they’re left. They’ve been sitting in the sun for hours, and you can think only of the public health peril, not of the benefits of the incredible, edible egg.

It didn’t need to happen, though. Because had the hosts an ounce of sophistication (to say nothing of basic human decency), they would have invested in a deviled egg server. This top-shelf item, sold by the fine folks at Frontgate, cradles the eggs lovingly in a cold-insulated, round serving tray; viz:

Super Chill Deviled Egg ServerYep, it lives up to its “super chill” description all right — and yours for only $99.50!

I’d love to know how many of these have been sold. It might be more interesting yet — though impossible — to find out how many would buy the thing if they had unlimited funds. As INXS memorably sang, every single one of us has the deviled egg server inside.

Think about it: a hundred clams for something that can’t even hold clams — deviled eggs only, please. Is this really right for today’s multi-taskers?

Every now and then — not often, or I couldn’t function — I look at something like this and think about the ever-widening gulf between the very rich and the rest of us.

Oh…excuse me. I have to go and synch my iPhone, iPad, and PowerBook.

Arrested Development in Tennessee*

May 12th, 2011 No comments

(*Sorry, I couldn’t help thinking of that old-school hip hop song.)

This week’s 365gay column discusses the threatened “don’t say gay” bill in Tennessee, which would permit the discussion of only one kind of sexuality (guess which one?)  in all public schools except at the high school level. I address the issue from a number of perspectives: constitutional; public health; basic safety.

There’s No Such Thing as a Natural Disaster

March 13th, 2011 No comments

That’s not completely true, of course, and in the aftermath of the triple-barreled horrors in Japan — earthquake, tsunami, nuclear meltdown — it might even seem callous to suggest otherwise, as the title of this post does. Surely the first two of these are natural disasters in the purest sense.

But calling something a “natural disaster,” while a humbling reminder of the fact that, as one seismologist said, “nature always bats last,” sometimes gets in the way of looking into the deep questions that make such disasters more or less catastrophic. Indeed, Andrew Sullivan wrote:

Readers have asked why we haven’t covered this event exhaustively. My answer is that this is a natural disaster, unlike, say, a revolution or a war, which requires little added comment.

I couldn’t disagree more. Consider:

Hurricane Katrina was barely one when it reached New Orleans — the big story there was the ineptitude of the Army Corps of Engineers, local, state, and federal politicians and bureaucrats, and the ham-handed efforts by the Department of Homeland Security (forced into a public health role for which it had little appetite and less competence, as dramatized so chillingly in Zeitoun).

The earthquake that decimated Haiti was, in its effect, far worse than the one that hit Japan, even though the magnitude of the first — 7.0 — was far less than the 8.9 (or is it 9.0?) of the more recent one.What’s the difference between 7.0 and 9.0? Here’s a quick Richter scale refresher:

[E]ach step on the Richter scale is 10 times greater than the one before it. An earthquake that measures 8.0 is ten times stronger than one that measures 7.0, and an earthquake that measures 9.0 is one hundred times stronger than one that measures 7.0. So Friday’s earthquake in Japan was almost 100 times stronger than the one in Haiti in 2010.

So why was the less powerful natural disaster more consequential than the much stronger one? Largely because of the vast differences in infrastructure and public health preparedness between the two island nations. It’s by now a commonplace of public health doctrine that any naturally occurring, negative incident — say, infectious disease or (let’s use the term here) natural disaster — will have far worse consequences for the poor than for the rich. And while Haiti is the poorest country in the Western Hemisphere, Japan remains one of the wealthiest nations on the planet. So the Haitian government estimated 230,000 dead (others guessed fewer, but all agree that the number exceeded 100,000), while the Japanese devastation, though too early to quantify yet, will almost surely be much lower. (As I write this, 20,000 is the new “best guess.”) So the earthquake about 100 times stronger (in Japan) will likely end up causing the deaths of about one-tenth as many people as the weaker one (in Haiti). Please don’t think I mean to minimize any of this. I’m trying to make a point, and I can barely stand to watch these images.

There’s plenty more to do, and to say, than to simply gawk at the horror and tally the dead. There are questions of constructing buildings to withstand earthquakes (and boy, did Japan do a good job there — not even one of the strongest quakes in recorded history caused a single skyscraper to topple; again, compare Haiti), personal preparedness for disaster (and the interesting psychological questions relating to why we don’t prepare for low-frequency, but high-impact events), and, inevitably, the safety of the nuclear power industry.

In its way, a natural disaster causes us to think about, report on, and try to fix just as many things as does a revolution; just in a different way. And it’s a mistake to think that one raises more complex questions that the other.  There are simply two very different kinds of entropy to be dealt with.

Public Health Gone Mad! (Manipulations on Abortion and Marriage Equality)

March 15th, 2010 1 comment

Public health has a lot to answer for. Aside from its many justly celebrated triumphs from the mundane (clean water and improved sanitation) to the dramatic (the polio vaccine, the development of antibiotics), it has also been guilty of using people, especially African Americans, as a means to an end. The best-known example of public health gone wrong is of course the Tuskegee Study of Untreated Syphilis in the Negro Male conducted by the Public Health Service (predecessor to the CDC) in conjunction with the Tuskegee Institute. The CDC has a good timeline and explanation of the study here, but the essential point is that the researchers allowed the study subjects’ syphilis to go untreated even after the development of penicillin. The study began in 1932 and wasn’t discontinued until forty years later. Since then, compensation and a national apology have followed, but the damage has been done. Many African Americans harbor a deep, and to an extent justified, distrust of public health authorities.

At its more extreme form, this kind of sour taste spins off theories of vast conspiracies to wipe out the population. During the early stages of the HIV/AIDS epidemic, a rumor that the virus was a plot to cause genocide against blacks had some currency. Even more recently, about half of African-Americans surveyed either believed that HIV was a man-made virus created for black genocide or were “unsure” whether that was the case.1

It should be obvious that such distrust, and such theories, can impede prevention efforts. Nowhere is this more depressingly apparent than in a recent effort by the Georgia legislature to pass what must be the stupidest — just stupidest — bill ever considered in the effort to prevent abortions. Under the proposed law, aborting a fetus because of its race or gender would be a serious crime by a health care provider (not the woman who has the abortion). This piece of cosmic idiocy is being supported by an unlikely coalition of conspiracy-theorists and “traditional” anti-abortionists. A horrifying stew of toxic conspiracy theories can be found at this site, which seems to be a clearing house for several groups claiming, variously, that abortions are being performed on black women because doing so is profitable for abortionists, that abortion is some kind of plot to eliminate African-Americans, and that abortion is a way of controlling the birth rates of blacks (and the poor).

As with many conspiracy theories, this one has some basis in historical fact: This page does offer some useful information and links on the eugenics movement, which not surprisingly targeted African-Americans to a greater degree than the majority population. But the idea that those who are willing to perform abortions — in the face of protests, threats, and often for little financial reward — are part of some whispered effort to control or limit the African-American population is…well, nuts. But it’s this theory that accounts for the idea of punishing doctors for performing abortions: “They’re aborting to get rid of African-Americans! These genocidal maniacs must go to prison!”

How many cases do you expect would be brought, or would be successful? Very few, obviously. But the radical edge of the pro-life wing is willing to abandon principle or reason in service of any law that might possibly cause a drop in abortion rates. The hope is that by adding another threat to abortion providers, the increased in terrorem effect will be enough to drive more of them away from helping women to realize the full range of their options.

Now it’s true that black women abort their fetuses at a much higher rate than do white women. The Radiance Foundation brought forth the numbers on Georgia here, but their effort to dismiss this report by the Guttmacher Institute doesn’t work. The plain fact is that a higher incidence of unintended pregnancies, which is itself caused by deep and systemic inequalities plaguing the African-American population, is a sufficient and much more plausible explanation for the disparity. The author of the analysis had this to say:

Antiabortion activists in minority communities who are trying to protect African American women and Latinas from themselves by restricting access to safe and legal abortion have it backward. They should instead focus their efforts on reducing the disparities in access to quality health care and in health outcomes more broadly. And if they are most concerned about the disproportionately high abortion rates, they should begin by advocating for improved access to high-quality contraceptive services to reduce the disproportionately high rates of unintended pregnancy in these communities.

But the Operation Rescue crowd will take whatever allies, and whatever arguments, they can get.

Distrust of public health shouldn’t lead to an abandonment of the scientific and population-based tools that public health uses; principally, epidemiology. But the inability or unwillingness to use public health where convenient is common. Let me finish this long post with a quick note on another disturbing case, this one from Iowa. Here is a statement from the President of The Iowa Family Policy Center:

“The Iowa Legislature outlawed smoking in an effort to improve health and reduce the medical costs that are often passed on to the state,” said Chuck Hurley, president of the group. “The secondhand impacts of certain homosexual acts are arguably more destructive, and potentially more costly to society than smoking.”

He continued: “Homosexual activity is certainly more dangerous for the individuals who engage in it than is smoking.”

Hurley was relying on a recent CDC report on the disturbing incidence of HIV and syphilis on MSM (men who have sex with men). And these statistics are disturbing. But will his solution — rolling back marriage equality in Iowa — do anything to fix the problem? And is he right on the smoking comparison? No and no. And this shows that talking-head ideologues should try public health only at home, to twist a well-worn phrase.

Gay men in stable relationships are less likely to have multiple partners than those who aren’t in such relationships. The more partners, the higher the likelihood of STDs. Marriage improves stability, as its proponents tirelessly remind everyone. (And by the way, he makes no case against lesbians.)

As for the smoking comparison? He has no evidence — none — for the assertion that homosexual activity is certainly more dangerous to the individual than smoking. But who needs evidence when demonization will do?

  1. As the survey shows, they’re not the only ones with this belief, but the percentages are highest among African-Americans, and, according to some studies, Latinos.

Catching up to Reality on Blood Donations by Gay Men

March 7th, 2010 No comments

When Obama was seeking the Presidency, the GLBT community had a well-defined punch list of action items, and he promised big things on all of them: repeal of DADT; repeal of DOMA (although he doesn’t support marriage equality); passing ENDA; passing inclusive hate crimes law (the only hole punched so far). A few others, notably the administrative implementation of the-then recent repeal of the insane prohibition against HIV-positive immigrants, were perhaps further down on the list, but also up for discussion. Conspicuously absent from the mainstream agenda has been an item of interest to the public health community: lifting of the ban on gay blood donors.

So I was buoyed to see that just a few days ago, a group of sixteen U.S. Senators sent a letter to FDA Commissioner Margaret Hamburg, urging the agency to reconsider its twenty-seven-year-old lifetime ban (“deferral” is the quaint term used, but it’s politely Orwellian in this case) on blood donations for men who have had even one sexual encounter with another man.

The policy is long overdue for an overhaul. As the letter notes, the policy is inconsistent with various other exclusions, and is an artifact of a time when all that was really known of HIV infection — and we weren’t even calling it that, in 1983 — is that it disproportionately struck gay men. Even today, MSM (“men who have sex with men,” which is the term used by the CDC because it focuses on sexual behavior, rather than on orientation) are prohibited, forever, from donating blood if they have had sex, even once, with another man, at any time since 1977. The Senators’ letter points out the many inconsistencies in the policy, including the fact that there’s no exclusion of those who have had high-risk, unprotected heterosexual sex, no matter how recently. Even more absurdly, those who have had heterosexual sex with those known to have HIV are only deferred for one year; not for 33! And “sex” isn’t defined when it comes to MSM: the safest kind of protected sexual acts are, in theory, treated the same as the riskiest.

It should go without saying that none of this can be justified from a public health perspective.

These inconsistencies should be enough to sink the policy which, as the letter notes, has lately been repudiated by the major blood banking organizations, most significantly including the Red Cross. But the problems are much deeper and more serious than even the letter recognizes. A few years ago, I discussed the issue in detail in this law review article. Here, I’ll summarize the arguments I made there that weren’t explicitly raised in the letter.

First, while the CDC is careful to distinguish behavior — men having sex with men — from identity, the FDA policy undermines this sound epidemiological distinction by effectively collapsing the two. By excluding any man who’s had any kind of “sex” (not defined!) with even one other man during the past thirty-plus years, the FDA has created a policy that isn’t about relevant behavior, but about some weirdly expansive view of (gay) sexual orientation. Because if it were about behavior, the line would have been drawn in an entirely different place; say, for a year after specifically identified, high-risk behavior.

Second, the policy undermines trust in public health in a few related ways. Obviously, as a practical matter the policy isn’t enforceable, and the sheer breadth of it has doubtless caused many to ignore it. People aren’t stupid: Gay men who know they have an HIV-negative serostatus might give blood, understanding that they pose no threat. (According to this very unscientific poll over at 365gay.com, almost 200 of 800 respondents admitted to having lied about their sexual practices on the questionnaire.) But by attempting to fence them out, the FDA has sent gay men an unwelcome message that could undermine the community’s trust in other ways. One important public health principle is that it recognizes the long-term value of respecting the dignity of all populations.

Why has the policy persisted for so  long? One argument seems sensible, at first blush: If the exclusion were changed to, say, one year, there would be some infinitesimal increase in the number of HIV-positive blood transfusions (well less than one in a million, it’s estimated), so why do anything to increase the risk? But the “let’s not do anything if there’s a tiny risk of harm” canard — which, by the way, is also prevalent in arguments against marriage equality — wouldn’t be, and hasn’t been, applied to any other category of people, or of conduct. Of course there will be some tiny uptick, not  because of the three-week window period between infection and ability to identify it, which any contemplated new rule would  easily accommodate, but because of the irreducible human error associated with the process: If you add more people, some will get through who should not. But this could be said of any proposal to add donors; it’s just that “MSM” have had such a draconian policy applied to them for so long that the donor baseline is essentially zero for this group.

It seems that uprooting this policy is fairly far down on the priority list for the LGBT community. Indeed, this story seems to have attracted but little attention. But messages matter. The radical, embarrassingly outdated FDA policy sends a terrible signal that ought to concern us. It’s good to see that someone is finally suggesting action. Will Obama back them up?

Projecting A Cyber Snowball from my Laptop

February 25th, 2010 1 comment
A useful spell in the tub.

A useful spell in the tub.

Just a few short minutes ago, as the snow began to really pile up and the wind to howl, I hit “send” on the manuscript my seven co-authors and I have been working on for what seems like a decade. (In fact, the project began with a symposium almost two years ago; we signed with Cambridge almost a year ago; and the chapters began coming in by this Fall). I’m the editor of the volume, with all of the great and challenging tasks that position commands. So what is this book, and when will you be able to find it at a bookstore near you? Thanks for asking.

The book takes some of the most red-hot, and polarized issues on the political landscape and puts them through a public health, population-based wringer. The topics are: reproductive (abortion) rights; end of life matters; marriage equality (my chapter); the persistent connection between racism and health disparities; gun violence; domestic violence; and tort law and reform. How might these questions and issues be illuminated by looking at them from a perspective that didn’t focus so much on rights and morality, but on the health and welfare of the population? Through some cosmic stroke of good fortune, I managed to convince some of the very brightest and most thoughtful legal and public health scholars to participate, and editing the book was a special privilege (albeit an exhausting and occasionally frustrating one, as when documents wouldn’t do what they were requested, then commanded, to do. I hate Word but that’s another issue entirely.)

I’m guessing at this point that the book will be out later this year, but it’s a bit early to say for sure. But now I can say with confidence that it’s going to happen. (Now where did I put that Grand Marnier?)

I’ll be shamelessly flogging the book in the months to come. What is its title, you might wonder? Well, that’s the one thing I’m not crazy about — it has a tentative title that can still be changed. I’ve been wracking my brain, but for some reason the perfect title yet eludes me (and all of us). Any ideas, readers? Please? A valuable prize to be named later awaits whoever can bring me to my feet in an Archimedes-inspired exclamation. (Archimedes might never have actually yelled “Eureka!” — but I will.)

Rachel Maddow and John Birch at CPAC

February 19th, 2010 1 comment

CPAC 2010 – A Conversation with Rachel Maddow

Watch the conversation between Rachel Maddow and a couple of guys from the John Birch Society (including President John F. McManus) on the Society’s webpage here. Is there a more charismatic television personality than Maddow out there today? You can tell how much she’s enjoying herself, how relaxed she is, and how well she understands the importance of actually talking to people with whom you most strongly disagree. (Compare: the lately unwatchable Keith Olbermann, who (just for instance) compared the Supreme Court’s corporate financing decision to…Dred Scott?!…in one of his increasingly embarrassing “Special Comment” segments. And this is a guy I mostly agree with!)

These John Birch nuts opposed the fluoridation of drinking water; listen and watch how well Maddow discusses the point with them, and how she somehow manages to resist arching her eyebrows when McManus discusses his view that there’s a straight line between forced fluoridation and (wait for it!) putting birth control substances into the public water supply. (Nuanced, these guys aren’t.) You might even learn something about iodized salt. All in all, a quick miseducation in public health.

Who’s Left to Love?

February 15th, 2010 No comments

This depressing article in today Philadelphia Inquirer relates a familiar tale: The poor are being vilified for taking government money, blamed for having made bad choices, called “breeders” for having kids they can’t support (with an icky overlay of moral disapproval for having many of these children out of wedlock). As the story points out, much of the anger is diffused and untroubled by facts: welfare rolls have been slashed mercilessly since the so-called Welfare Reform Act of 1996; the payments are so meager that no one would seek this as a viable means of support (and it lasts five years, max, anyway); most of those receiving assistance are children.

The anger is sometimes startling, as when South Carolina Lt. Gov. Andre Bauer recently compared the poor to “stray animals who breed,” or when pandering, no-nothing politicians make symbolic shows of making life even more humiliating for people who can’t get by:

Pennsylvania State Rep. Garth Everett (R., Lycoming) has tried for a year to pass a law that would have [Temporary Assistance to Needy Families] recipients drug-tested and fingerprinted, a practice in some states. “People’s wallets are tighter these days, and they don’t want funds going to folks with drug problems,” he said.

Asked to back up his claims, Everett said, “I don’t have evidence that people are using it [TANF money] to buy drugs. I do get feedback from a significant part of my constituency that they have the feeling that folks on welfare are using drugs.” He added that his proposed bill “is not going anywhere” because Democrats oppose it.

His constituents “have the feeling” that folks are using money — some of the very generous $403, per month, for a mother and two kids — to buy drugs. That’s enough for Everett, who can make a political show of his solidarity with the angriest elements of his constituency without having to deal with the consequences. Among them is the likelihood that the money spent on drug testing and fingerprinting would far outweigh any cost savings from denying benefits to those using drugs, and thereby end up costing the state more money. As a bonus, it would feed into the discredited view that  drug addiction is a matter of choice and not a medical, public health issue that requires complex intervention.

Given that the poor take such a tiny percentage of the state’s money, the anger isn’t really about the money. It’s more the product of a deep and justifiable frustration by the broad swath of the increasingly left-behind middle class that they’ve done everything right, but can’t get ahead. Like a tire skidding endlessly on ice during our tundra-like winter here in the Mid-Atlantic, they work harder and harder and fall further and further behind. So to them, anyone who gets anything for “nothing” is bound to be the target of some vitriol. But would they change places with those they condemn?

No, they’d rather change places with the Wall Street bankers and financiers whose complex machinations were a significant contributing factor in the national and global meltdown that continues apace. But they know that’s not possible, and they’re too beaten down — and realistic — to think that people as well-connected as these modern-day robber barons (there! I said it! let the angry responses begin) will be brought to heel, or even asked to cut back by one yacht. Government is detested, but there, too, the problem seems too big and complex for them to have any effect.

This culture of fury and jealousy, whatever its understandable origin, isn’t healthy. I might want to blame right-wing talk show hosts like the morbidly obese Rush Limbaugh who, without apparent irony, recently wailed about how food stamp recipients are spending their money on unhealthy choices (including the outright lie that some of it is going to booze; it can’t), but the most accurate thing to say is that they’re only amplifying resentment and confusion that’s already out there. (If you want to make a symbolic stand against the worst (and most effective) offender, join this Facebook group).

As Sarah Palin understands (and she doesn’t understand much), there’s a fortune to be made in tapping into this anger. Obama, meanwhile, has the more difficult responsibility of connecting with our deeper but often less accessible sense of community and collective responsibility. He’s not always done this effectively, unfortunately, but this is the area in which we really need that “hope-y, change-y” thing. Otherwise, I fear that “the centre cannot  hold.” While I’m on Yeats, here’s a tired but apt close:

The best lack all conviction, while the worst
Are full of passionate intensity.

Public Health and Welfare in State of the Union Speech

January 28th, 2010 1 comment

State of the Union

Despite my current frustration with Obama — or maybe because of it — I watched the entire State of the Union speech. I’m sure it’s being endlessly picked apart by all kinds of talking heads, bloggers, and the like. Me, I’m watching the Australian Open. (The indomitable Serena Williams just beat back a tough challenge from the letter-limited Li Na to advance to the final. No news there.) But I do want to pause to grant some limited props to Obama for mentioning two of my pet issues: Public health and the repeal of “Don’t Ask, Don’t Tell.”

The promise on DADT had generated an anticipatory, bloggy buzz, and it was heartening to hear the President speak to it. I’m confident it will happen. (Missing, though, was any mention of the Employment Non-Discrimination Act which I had thought was also likely to pass into law this year. I was reminded that this issue had been raised in a State of the Union as long ago as the end of the Clinton Administration. Can we please get there? The goal seems to shimmer and recede….)

The DADT comment came towards the very end of a pretty good speech, and very close in time to another issue near and dear to me: public health. Of course, everything the President mentions is public health to me (health care reform is just the most obvious example, but I can’t bear to talk about it right now). But to hear him pledge energy, money and effort to public health efforts to fight terrorism and infectious disease — now that was something. My night was made in five minutes.

Now, to bed. Oh, wait…the recently unretired Justine Henin is taking the court….

Of Oysters and Mammograms

November 20th, 2009 No comments

“I can’t believe they would put an economic value over the lives of fifteen or more people.” (Statement of a woman whose father died as a result of eating raw oysters that contained a deadly bacteria.)

“Let the rationing begin.” (Rep. David Camp, Ranking Republican on House Ways and Means Committee, responding to U.S. Preventive Services Task Force Report that recommends women delay routine mammograms until age 50).1

Public health takes a beating again.

In the first case, the FDA has had to eat crow. Just last month, the agency trumpeted its “public health” duty to prevent a predictable number of deaths each year by banning the sale of untreated, raw oysters during the summer months. But now the FDA has been shut up by the industry and by too-powerful Louisiana Sen. Mary Landrieu. (She can pretty much get anything she wants, including her own Mardi Gras Float, at least while the health care reform bill is pending.) The agency has slunk away, murmuring something about studying “feasibility and costs.”

In the second case, the jumpy recommendation against routine mammograms (and self-examinations) to detect breast cancer has brought a howl of protests. The objection: “Yes, the test only picks up one cancer case out of every 1,900 — but what if you’re the one?” For opportunists in the Camp camp, this cold-blooded calculation serves as a timely, exploitable proxy for everything  that’s wrong about health care reform. Never mind that the proposed legislation does a dismal job at controlling anything — costs or procedures — and that rationing is a fact of life now under managed care.

And when it comes to the battle against breast cancer, stirring outrage is a pink breeze.  Anything that would lead to even one more death — period — will be decried as the heartless elevation of population-based data over real lives.

It’s not clear that federal authorities, here representing a population-based, public-health perspective, were right in either case. Perhaps they could have continued efforts at education in the first case (which the FDA said it had tried, without success for a decade), rather than requiring irradiation (which has its own PR cost). In the second case, even public health authorities are split on whether the evidence justifies the new recommendations. At least this was a non-binding task force, easily overcome by political outrage.

There are two issues here. First, public health works best when it can explain and justify its position in a way most reasonable people will find at least defensible. Even then, though, its recommendations — or even coercive steps — can be defeated when other forces (like the oyster lobby or the breast cancer survivor community) are more powerful.

But the more important point — and the one no one wants to discuss — is that we do make safety and efficiency trade-offs, all the time. We couldn’t function without doing so, either in our own lives, or societally. Would routine mammograms be cost-justified if, say, they saved one life in one million? One can always say: “What if you’re that one person?”

  1. The quote appears in Gail Collins’ reliably insightful and amusing column.