Some links - I know, again

We're all about to leave for the CSTE Annual Conference in Portland, OR. So there's not too much time for a full blog post.

However, here are some links for some plane reading:

• A May MMWR article discusses attitudes toward mental illness. It's an interesting read. Hopefully the public will give more well-needed sympathy to those suffering from mental illness after more attention is given to the subject.
• Jerome Groopman discusses toxic chemicals in a recent New Yorker article.
• You may have already seen this NY Times article about salt.
• Ah, how to allocate the huge pot of cash from the health care reform law to the public health community? Is there such thing as too much money? Robert Gould discusses in Kaiser Health News.
• This is a long report, but the executive summary of this GAO report about food safety weaknesses should prove to be interesting.

Happy reading!

Interesting links

Things are crazy here while we prepare for the CSTE Annual Conference, but here are a couple of links to satisfy your public health craving:

• Big Decline in Heart Attacks If All States Had Smoking Bans - an interesting article from Bloomberg saying that heart attacks would drop by 18,000 per year. Isn't that an incentive to implement smoking bans. 39 states currently have some sort of smoking ban.
• No Benefit in Delayed Immunization - That's right, folks, another immunization article asserting that vaccinating your kids against deadly and debilitating infectious diseases is a good thing! This one is from the Wall Street Journal.
• British Medical Council Bars Doctor Who Linked Vaccine With Autism - Dr. Andrew Wakefield has been banned from practicing medicine after his widely known Lancet journal article was retracted recently. This New York Times article discusses the recent news.
• In E. Coli Fight, Some Strains Are Largely Ignored - I will admit that I haven't finished reading this article, but it basically discusses how some strains of e. coli are tested for in labs and some are not, and the implications of this situation. Should be a good read.
  

Happy reading, readers!

Maternal Deaths Decline Sharply Across the Globe

Great, some good news in public health! The NYTimes reports that maternal deaths are declining worldwide. The interesting point brought up in the article is that some advocates want to keep the news relatively quiet for fear of funding drying up because the problem is perceived as solved. The author of the study insisted that the new data are really positive and need to be shared with the world!

The data dispelled the belief that the statistics had been stuck in one dismal place for decades, he said. So money allocated to women’s health is actually accomplishing something, he said, and governments are not throwing good money after bad.

Salt intake: the new public health hot topic shaking onto the scene

A recent New England Journal of Medicine article discusses reducing salt intake and its benefit to society. A national effort to reduce salt intake by 3 g (1200 mg of sodium) per day could reduce the incidence of coronary heart disease by 60,000-120,000, stroke by 32,000-66,000, and heart attacks by 54,000-99,000. Wow! The number of deaths annually due to these diseases could decrease by up to 90,000. Wow! And... for those number-crunchers, this could save the country $10-24 billion annually. Yes, annually.

And: "Even if the intervention reduced salt intake by just 1 g per day, the benefits would still be substantial and would warrant implementation." Now that's saying something.

The authors say there are 2 approaches to reducing salt intake:

1. The individual approach involves individual consumers to reduce their daily intake through voluntary dietary decisions. However, the authors say, this method has been attempted and does not work.
2. The public health approach involves getting manufacturers to reduce the amount of salt in processed foods.

New York City has started an initiative to get restaurants to reduce the amount of salt in food served to New Yorkers - a 25% reduction over 5 years has been proposed. The Institute of Medicine (IOM) is about to release a report about salt intake. And the FDA is considering
changing the designation of salt to a category that would give consumers more information. [All from this New York Times article.]

One editorial article from the New York Times mentions that most salt in people's diets comes from processed foods, not from adding salt individually. So the processed foods are what we should be targeting - restaurants and food manufacturers. Let the battle begin!

This post comes in honor of World Salt Awareness Week, according to CDC. (There's a week/month for everything, eh?) Check out this fact sheet about salt and salt intake.

And check out this previous post by Lisa for more about reducing sodium levels.

Smoking Cessation Part 2: Public Health's Response

Now that I've discussed smoking cessation options and the cost-effectiveness of smoking cessation, it's time to bring public health into the story (of course). This post will focus on what public health does to encourage smoking cessation on a population-wide level.

Naturally, public health encourages individuals to stop smoking. CDC's website offers how to quit, the benefits of quitting, etc. But there are several big-picture strategies that public health has employed to encourage the population to stop smoking.

1. Smoking cessation education campaigns - This method includes public service announcements, ad campaigns, etc. Smoke-Free Illinois has this ad campaign. Tobacco Free California has some great materials and website, including clever e-cards that you can send smoker friends. And check out this video from Iowa's Just Eliminate Lies video that works to eliminate tobacco companies' effects on youth.
   



2. Smoking bans - Many states have enacted smoking bans to restrict smoking in public places. According to the American Lung Association, 26 states and D.C. have enacted laws banning smoking to some degree. And these bans seem to work; air pollution in restaurants and bars have decreased, and some areas have reported decreased heart attacks and other health effects, although these findings are somewhat debatable. A recent IOM report states that "smoking bans can have a substantial impact on public health."
   
   
   
3. Scare tactics - Ah, the scare tactic. Yes, this fits in with #1, but it is a particular type of ad campaign. This type is sometimes employed by public health departments and other times by private non-profit organizations. The Truth campaign is probably the most well-known of these campaigns. However, this tactic may not work. A recent article stated that this public shaming technique may not be effective: "People are made to feel really, really bad about their smoking and are treated quite badly, but feel quite helpless in quitting," said Kirsten Bell, a medical anthropologist.
   
   
   
   
4. Cigarette taxes - Taxes, the American way, right? Well, it's true in the case of cigarette taxes. Taxes on cigarettes range from $0.07 (South Carolina) to $3.46 (Rhode Island). And according to the Campaign for Tobacco Free Kids, these taxes work: For every 10 percent increase in the price of cigarettes, youth smoking decreases by 7 percent and overall smoking decreases by 4 percent. Click here for related scientific studies. And the federal tax increased in 2009 from $0.39 per pack to $1.01 per pack.
   

So there are a few ways public health tries to curb smoking. These along with individual smoking cessation tactics are aimed at improving the public's health overall, a noble cause.

Smoking Cessation: Effectiveness and Cost Effectiveness

Smoking is a gigantic problem in the U.S. According to CDC, smoking is the single most preventable cause of disease, disability, and death in the U.S. Over 40 million adults smoke in this country, and 126 million adults and children are exposed to secondhand smoke. Although trends have indicated that tobacco use is on the decline, it is still a huge issue.

And it's pervasive in our society. I mean, even movies like Avatar feature characters who smoke! The WHO encourages media to limit or eliminate smokers highlighted in TV shows and movies.

If you smoke, stop! It's hard, no doubt. It takes the average smoker several times for quitting to actually stick. And here are some options to do so:

1. Quitting cold turkey - Quitting all of a sudden and sustaining it undoubtedly requires a great deal of will and determination. Enlist your friends, family, and coworkers to help you quit.
2. Nicotine fading - This method involves reducing your tobacco intake slowly until you eventually quit. This option is inexpensive, easy, and reduces the potential for withdrawal.
3. Nicotine replacement therapies (NRTs) - These therapies include nicotine gum and nicotine skin patches, and they are recommended with reservations as part of a "comprehensive smoking cessation program."
4. Finally, there are prescription medications such as Zyban that help people stop smoking.
5. Support groups and counseling can also help greatly when combined with other methods.
   

Insurance companies are covering smoking cessation aids more and more, recognizing the cost effectiveness of helping their patients quit. The benefits and cost effectiveness are overwhelming. One article states, "The results of existing economic evaluations consistently indicate that smoking cessation interventions are relatively cost-effective in terms of cost per life-year saved." An article in JAMA also suggests smoking cessation is cost-effective. Based on a study of various interventions, the study found that smoking cessation is a particularly cost-effective intervention, compared with other preventive health interventions. "The more intensive the intervention, the lower the cost per QALY [quality-adjusted life year] saved, which suggests that greater spending on interventions yields more net benefit."

And that smoking cessation is cost-effective just makes common sense! "If you’re paying about 10 bucks a day for a pack of cigarettes in New York City, that adds up to about $6,000 over two years," said Thomas Glynn, of the American Cancer Society. "You could check yourself into the in-patient program at Mayo Clinic for that," he says in this recent New York Times article.

Of course, the tobacco industry is ridiculously powerful. This webpage (albeit a little extreme) showcases tobacco companies and their truths. Another site also highlights the pervasiveness of tobacco companies. Tobacco companies claim to aid in smoking cessation, but from their business's perspective, why should they? If smokers across the country quit, they buy fewer cigarettes, and their profits decrease, equaling no more company. It's in their financial interest to keep smokers smoking!

The bottom line: Tobacco use is a problem in the U.S. Quitting benefits your health and it is cost effective to do so. Resolve to quit today!

Here are more resources:
http://www.naquitline.org/
http://www.smokefree.gov/
http://whyquit.com/
http://www.cdc.gov/tobacco/quit_smoking/how_to_quit/index.htm

Once again - some links for you

1. I wrote a few weeks ago about unsexy health threats, and chronic disease could probably fit under that category. Certainly the Global Alliance for Chronic Disease thinks so. This organization, founded in June, is trying to increase awareness of the prevalence of chronic disease around the world, even in developing countries. This article details more about this organization and this issue.
2. Food safety legislation has been given the next push forward in the Senate. This article says that the full Senate won't take up the legislation until 2010, but Congress is certainly looking to move on food safety legislation of some sort this session. "The Senate bill would expand U.S. Food and Drug Administration (FDA) oversight of the food supply and shift its focus toward preventing, rather than reacting, to foodborne outbreaks. FDA would have the power to order recalls, increase inspection rates and require all facilities to have a food safety plan."
3. I have briefly mentioned the economy's effect on public health, and this article repeats that message - the economy has affected the public's health and well-being. Respondents to a recent survey indicated that they were more likely to overeat and less likely to exercise due to stress about the economy. Respondents were also less likely to take care of health problems in a timely manner. And, last but certainly not least, emotional health was adversely affected by the economy.
4. And finally, our favorite topic du jour - the recent change in the U.S. Preventive Services Task Force's recommendations on breast cancer screenings.
   
   This article provides a good, solid perspective on the recommendation change, explaining a bit about why the public has a hard time accepting the fact that screenings are not always in our best interests: "Statisticians and epidemiologists know this for a fact. The problem is, there's no way to tell which of the tumors are dangerous and need to be treated and which are harmless and would be best left alone. So all of them get treated, often aggressively. The medical establishment calls this overdiagnosis."
   
   This article's title, "New mammogram guidelines are confusing, but here's why they make sense," says it all. The article notes that the new guidelines are in line with international recommendations and goes through the recommendation in a detailed manner, explaining each point. The potential harms from widespread mammogram screening include radiation exposure, false-positives, and the incorrect notion that early detection is always a good thing. It's a good article.
   
   This NY Times op-ed piece by Robert Aronowitz has an interesting premise: "Why do we keep coming around to the same advice — but never comfortably follow it?" The column details some of the history of cancer screening and treatment and how increased diagnoses of cancer led to increased pressure to screen earlier and diagnose earlier and more often. He makes a very good point:
   

   "You need to screen 1,900 women in their 40s for 10 years in order to prevent one death from breast cancer, and in the process you will have generated more than 1,000 false-positive screens and all the overtreatment they entail. This doesn’t make sense. We could do more research and hold more consensus conferences. I suspect it would confirm the data we already have. But history suggests it would never be enough to convince many people that we are screening too much."

   
   And, finally, "What watching ESPN could teach us about mammograms" - this title immediately caught my eye. Basically, this article says that statistical data are presented in the sports world every day and understood - why can't the same thing be done in public health? Why is the message clouded? Great question! The answer is that we have messaging problems, we public health professionals. It's true. It also gives a link to the National Cancer Institute's breast cancer assessment tool - interesting.
   

Some links for you

1. Massachusetts public health officials explain the dissemination of their H1N1 vaccine allotment. Patience, all you patients out there!
2. The WHO has discovered new data that show that 1.2 million people over the age of 5 die of foodborne illness each year in Southeast Asia and Africa. That number is significantly higher than previously estimated, providing new reason to address this issue in the developing world.
3. In case you're one who needs everything, check out these iPhone apps about H1N1.
4. There is a new tool to show where AIDS treatment and care in San Francisco is lacking. Click here for the map itself.
5. Obesity is an alarming public health issue, and this latest article has alarming numbers. If trends stay as they are now, 43% of adults will be obese in 2018. Wow.
6. This article highlights that many public health professionals around the country are being reassigned from their normal job duties to work on H1N1 assignments. This is disrupting usual public health activities that address ongoing problems that are not going away simply because this pesky flu virus has shown up. It's a problem, but it doesn't appear it will be solved.
7. Representative David Camp says in this article about the breast cancer screening recommendations: "I mean, let the rationing begin. This is what happens when bureaucrats make your health care decisions." Right, the U.S. Preventive Services Task Force is bureaucrats. They're not experienced physicians and trained professionals. Sure.
8. Lots of money is being poured into fighting healthcare-associated infections. This article details the stimulus funding being given to the issue.
   

Unsexy health threats

There are lots of sexy-sounding health problems. Some of the topics du jour include HIV, malaria, and, currently, influenza. But what are the actual leading causes of death, in the U.S. and internationally?

In the U.S., the leading causes of death are heart disease, cancer, and stroke - all chronic conditions. While pandemic influenza may be causing a lot of morbidity these days, it is chronic disease - caused by obesity, mostly - that cause the greatest number of deaths in the U.S.

Abroad, it's a different story. According to the Global Health Council, the leading causes of death among children are pneumonia and diarrhea, both preventable diseases. Maternal health is also a huge issue; it is the second leading cause of death among women worldwide. These tables from the WHO outline leading causes of death by the country's income level, revealing interesting disparities between low-income countries and high-income countries.

Nicholas Kristof has done a great job reporting about deaths due to pregnancy or childbirth; he quotes the U.N. in a July column, saying " in Pakistan, a woman dies every 35 minutes because of problems from pregnancy or childbirth." He also spoke out about pneumonia: "pneumonia gets very little attention from donors or the public health community, yet it kills more than two million children a year, according to Unicef and the World Health Organization."

This article in the NY Times on October 29 compelled me to blog about this. After all, this blog is devoted to domestic public health issues. But this article was too important to ignore. "Diarrhea kills 1.5 million young children a year in developing countries — more than AIDS, malaria and meaasles combined — but only 4 in 10 of those who need the oral rehydration solution that can prevent death for pennies get it." Diarrhea is, most certainly, not a sexy topic, but it is one that is vital to discuss.

While AIDS continues to be a huge problem that needs attention, especially in certain parts of the world like Africa, these smaller diseases also need equal attention, especially because they are treatable.

Social determinants of health

It may be intuitive to those who are public health-minded, but one's environment influences one's health. Social determinants of health has a large body of literature, and this post will attempt to summarize it.

According to the WHO, the social determinants of health are "the conditions in which people are born, grow, live, work and age, including the health system." A person's circumstances heavily influences his or her health status as well as overall health inequities.

Recently, the NYTimes and the Robert Wood Johnson Foundation reported that "research suggests social circles influence public health behaviors." For example, one study cited in the article found that a person's risk of obesity increased by 10% when a friend gained weight. According to this pie chart, lifestyle can determine up to 51% of one's health. If that lifestyle is centered around unhealthy environments and behaviors, influenced by one's surroundings, we can improve health drastically by changing one's surroundings.

This image, from the Commission on Social Determinants of Health's final report, illustrates the relationship between determinants of health and health inequities. The report says, "the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries." This Commission called for three areas of action: to tackle the daily living conditions in which people are born, grow, live, work and age; to tackle the structural drivers of those conditions at global, national and local levels; and to carry out more research to measure the problem, evaluate action and increase awareness.


There are several reasons and theories of why socioeconomic status (SES) influences health so heavily. I won't detail them in this posting as there are many articles that do so quite well (try here and here). Included in the theories are reasons of income disparities, social capital, racial discrimination, access to medical care, social support, and more. Lifestyle and physical environment causes may explain many of these issues; these two factors point to broader cultural and social trends that construct a framework in which health may be 'doomed' to be poor.

There are numerous articles citing the lack of healthy eating options, sidewalks, and safe neighborhoods for poor communities. Driving in Atlanta, this situation is abuabundantly clear. The nice neighborhoods have great grocery stores, walkable sidewalks, and overall lovely atmospheres; in contrast, the poorer neighborhoods have small and dingy grocery stores, unwalkable streets, and rundown atmospheres. These poor environments are not conducive to healthy eating or physical activity, but perhaps more importantly they may make it difficult to have a happy and meaning life with high social capital and support, crucial to overall well-being.

In sum, there are a number of factors beyond genetic makeup and personal behaviors that determine health status. These factors are crucial for public health to address in order to improve the population's health.

Obesity & Upstream Issues

Essentially, obesity boils down to one issue: People take in more calories than they expend. But of course we know there are many other issues that contribute to this: cost of food, access to healthy foods and environments, media and advertising, school lunch programs, agricultural subsidies, and more.

According to CDC, obesity costs the U.S. $47.5 million, and that's a 1998 figure! This USA Today article puts that figure much higher, around $147 billion. And check out this website to see a chronological view of how obesity has spread throughout the U.S. from 1985 to 2008 - it's disgusting how widespread it is!

The new movie Food, Inc. hits on some upstream issues associated with obesity, some of which are mentioned above in this posting. Cost of and access to healthy foods and environments are a huge issue; healthy foods cost more than unhealthy foods.

Agricultural subsidies are a huge part of this. The U.S. government pays farmers to grow tons upon tons of corn and soybean crops which lead to tons upon tons of high fructose corn syrup, hydrogenated soybean oil, and feed for beef and pork. I did some fascinating research on this subject in grad school and found that many, many issues are intertwined to make this issue very complex.

Some links to get you started:
A report from UC-Davis
A NY Times article
A British Medical Journal article
"The Fat of the Land"
Food and Water Watch - a watch-dog type group
A Michael Pollan article

Happy reading! Now you'll see why I try to eat organic or grass-fed beef and chicken now. And why the Farm Bill should be called the Food Bill.

It's all connected. A very interesting topic.

Some headlines ... briefly

See below for more details, but this blog will be light this week due to our Annual Conference. But here are a few headlines to peruse:

Tom Frieden to take over CDC Monday
State public health laboratories in the spotlight
This article highlights how much states and counties are hurting.
A general public health opinion/human interest piece.
Is FDA regulation of tobacco a good idea or a bad idea? Hard to say, there are lots of arguments (which I cannot get into now with my current time contraints) but this article has quite an opinion!
I told you - H1N1 has not gone away. Click here.

New links!

Lots going on this week, let's start right in:

First, H1N1 influenza. This situation has stretched local and state health departments even thinner than they already were. This is a major problem, as resources across the country are tight but expectations are high to handle the epidemic smoothly and without causing fear or panic. Speaking of panic, this article reveals some psychology about the fear and panic we humans tend towards. And this article examines the risk of new infectious diseases and people's reactions to that risk. Is there any way to reign this epidemic in? Find out here. And, finally, now that public concern is dying down (in conjunction with media attention waning, not coincidentally) will our focus on hand-washing die away too? Let's hope not.

On to other topics. As you may be aware, calorie counts on menus are popping up at fast food joints across the country, notably in New York City and in Chicago. This article examines the phenomenon and its impact, especially as federal legislation is pending.

The FDA is developing a new system to track and report adverse events of its products. We'll see how this story develops, but here is a summary article.

Finally, an article about parental refusal of the pertussis vaccine is in the latest issue of Pediatrics. The study found that children whose parents refuse the vaccine are at an increased risk of developing pertussis. The authors conclude that "these findings stress the need to further understand why parents refuse immunizations and to develop strategies for conveying the risks and benefits of immunizations to parents more effectively."

HIgh School Smoking

Has the vigilance in fighting cigarette use waned in the media for the past decade or is it just me? Perhaps other things to be vigilant about have been crowding the public health spotlight or perhaps the evidence behind the effects of tobacco has been too overwhelmingly clear that controversy and conversations around the addictiveness, poison of tobacco have dissipated. Regardless, a recent study by the National Center for Chronic Disease Prevention and Health Promotion reported in the Morbidity and Mortality Weekly Report on “High School Students Who Tried to Quit Smoking Cigarettes (United States, 2007).”

My first qualm with this report is the lack of denominator data. The authors reported that of students who have smoked cigarettes daily, 60.9% of them have tried to quit. They also reported the percentage of these students who were successful in quitting (12.2%). Now, I am sure the data can probably be found somewhere else, but my question is how many students smoke daily?! You don’t need to tell me the breakdown of who the people are that smoke but at least give the reader something to work with.

Anybody reading these reports wants to know… is whatever I am about to read important? And one of the ways the reader figures this out is by asking how many people this issue effects. If it affects .01% of the population then OK, the issue might be interesting but I really don’t need to think about it outside of this context. However, if the percentage is 5% with an issue such as daily smoking in high school students, that would be quite alarming.

I just don’t understand why the only two behaviors that were examined were:
1) Ever smoked cigarettes daily and tried to quit smoking, and
2) Ever smoked cigarettes daily, tried to quit smoking cigarettes, and were successful

Doesn’t it just seem logical to have a preceding question:

0) Ever smoked cigarettes daily

The Youth Risk Behavior Survey (YRBS) probably does ask this question in the survey, but why is it not reported as background to this study?

This report leaves the reader asking more questions like what about socioeconomic status? What about private school students versus public school students? Are there other differences that might explain why some students are more successful at stopping than others? The survey must have more to offer than just grade level, sex, and race/ethnicity…

The title looked fascinating to me but that was about it.

Links for the week

The Kaiser Family Foundation reports results from a survey that show Americans find the HIV epidemic less urgent, even after the latest incidence estimate showed that more people than previously thought are contracting the virus each year. Interesting results - one would think public pressure to do something about the HIV epidemic would be even higher, but it's not.

Generally, public health is important! If you're reading this, the concept is nothing new - I'm preaching to the proverbial choir. This article brings home the point once again. Epidemiology and surveillance, clean water, disease treatment and prevention, food safety, and more. The author, Valerie Bassett, puts this very eloquently: "Who needs public health? We all do. Every resident of the Commonwealth - whether aware of it or not - relies on a strong, functioning public health system - a system that is greatly endangered. Without public health, there is no way for the Commonwealth to succeed in education, economic growth, environmental innovation, or civic engagement."

Take a look at this article about doctor shortages. While not directly public health, it certainly has an impact on public health.

In case you haven't heard, red meat isn't good for you.

See my next post for updates on swine flu!

A couple more links

This senior in high school won an award for an epidemiology paper she wrote. Great job, Marilyn! Go epidemiology! Now go to college, get your MPH in epi, and work to improve capacity at the state level!

French kissing can give you infectious diseases. Apparently (duh) saliva transmits some infectious diseases. Is it worth the risk? That's not for me to say...

Counterintuitive: This article reports on a study that says the addition of healthy menu choices can lead to unhealthier decisions. Huh? Apparently when a side salad was an option, consumers were more likely to choose french fries. Why would that be? Maybe I shouldn't comment since I love french fries, but it doesn't seem to make sense to me.

Colon cancer prevention: According to this article, colon cancer prevention in Utah is about to get a big boost. Generally chronic disease and cancer are getting a lot of attention these days, as Obama has highlighted it. Rightly so - both are huge public health issues, and it's about time they get addressed as a national priority!