Black Lives Matter

I've taken a long break from writing as I was on leave last year. But this article in the Epi Monitor was something that I wanted to post about as I've been thinking a lot about the responsibilities of those of us in public health to work deeply and meaningfully on what we know are important causes of poor health. Nancy Krieger's 2011 book, "Epidemiology and the People's Health", and her chapter about the various strains of social epidemiology first got me thinking about radical epidemiology. The reason I had gotten into epidemiology in the first place was because I wanted to learn answers to questions I felt I needed to know the answer to in order to contribute to solving some serious problems in the world. Nancy's book and that chapter in particular really got me thinking about the tools we have in epidemiology and the types of questions that have historically been asked by epidemiologists and how those do not necessarily reflect what is important for health.

Take, for example, our usual treatment of race and socioeconomic status. Both factors are often considered "confounders" - nuisance variables that we attempt to remove the effect of when we are examining the relations between an exposure and outcome. We do this because race and socioeconomic status are hugely important contributors to many health risks (exposures) and many health outcomes. But instead of actually designing interventions to actually improve socioeconomic status or reduce racism or inequality, we examine other factors and whitewash the effects of these "confounders."

I am gratified to see this push within epidemiology and public health to actually study the effects of racism and design interventions to change our society (and ourselves).

The dangers of anti-trafficking work....

The topic of human trafficking for sex work is very important to me, but it is one that I haven't done much research on since I wrote my Masters thesis. When I was researching my thesis, which addressed government and non-governmental agencies' responses to trafficking and sex work in Nepal, I came away with the impression that many of these organizations - while motivated by good intentions - harmed women. 

I published my observations that organizations who used what I termed a "labor exploitation framework" achieved results that supported the fulfillment of human rights by all women more easily than organizations who employed what I called a "prostitution framework." In the latter framework, all prostitution is considered evil and no distinctions are made between those who have no freedom of movement, cannot exercise agency over the types and number of sex acts they perform, and do not earn money from their work and those who exercise quite a bit of agency over the types of sex acts they perform, can stop engaging in prostitution at any time, and earn money from their work. 

An article published today in the New York Times, The Price of a Sex-Slave Rescue Fantasy, documents the manipulations of one organization and its founder and spokesperson - who herself had claimed to be a survivor of sex trafficking. The allegations implicate many others, however, in the scandal. Importantly, they call into focus the monetary support that Westerners provide to many of these agencies that, as I found in Nepal, perhaps do more harm than good and certainly are taking a less optimal approach to combatting a very real problem of exploitation.

If you are interested in reading my article, you can find it here.

Systematic reform in medicine - the case of early elective delivery might offer a model

This interesting article in the New York Times tells the story of the dramatic reduction in early elective deliveries since 2010. This is not something I've followed before, but apparently early elective delivery (meaning an induced delivery or elective cesarean section before 39 weeks gestation that is not medically necessary) accounted for 17% of all births in 2010.

Although early elective delivery had been identified as an unsafe practice in 1979 and medical groups and non governmental organizations had lobbied for years for reform, the changes to practice have been slow. Yet since 2010, there has been a 73% decline in these procedures and the national average last year was 4.6%.

This article provides a good description of some of the catalyzing factors, including a couple of scientific articles offering examples of how hospitals had reduced the practice, increased pressure to measure the incidence of these procedures, and leadership by two states, South Carolina and Texas, to dramatically reduce their rates. South Carolina, for example, assembled a team of providers from all hospitals in the state. The team meets monthly and best practices are shared and challenges are discussed. Then, after a couple years of that, the state stopped payments to hospitals (through Medicaid and the main private insurer) for early elective deliveries. Over the following 6 months, rates dropped by 45%.

This is a nice example of how concerted efforts to produce reform can lead to real changes.

e-cigarettes and the importance of knowing your audience

The second article in a series by the New York Times about electronic cigarettes points out an important challenge facing researchers investigating all topics: know your audience. The article discusses how youth are rapidly adopting the use of nicotine delivery devices that adults and researchers are calling "e-cigarettes," but which the kids are calling "e-hookas," "vape pens," and other names - anything but "e-cigarettes."

While one could see this as just a classic case of mom and dad being so out of touch, the impact is real. The Centers for Disease Control and Prevention national tobacco use survey and statewide surveys like the California Health Kids Survey ask youth questions about the use of e-cigarettes. From the reporting in this article, it looks like many young people will answer "no" to that question, believing that the product they are using is not an "e-cigarette," when in fact they have used the type of product that the survey designers are intending to inquire about.

This is not just a matter of social desirability creating information bias - the reporting in this article suggests that youth would feel comfortable reporting their use of these products if the questions asked them about that use in a way that they understood. It is a matter of not knowing your audience.

In my work in West Africa, one of our challenges was to develop a survey that would measure constructs around reintegration in a diverse, but generally uneducated population. The first important practice we employed was to begin with discussions with the group we were hoping to learn about, finding out from them what they thought was important and taking note of the terminology they used for constructs that were sensitive. For example, one of the topics we wanted to address was participation in transactional sex or prostitution. In Sierra Leone, some young women suggested we call that "having boyfriends." This wasn't just a way of easing the stigma associated with the practice, but it helped them understand what we meant because that was how they talked about it among themselves. When we raised the concern that some people might endorse having boyfriends when they were talking about a long-term stable relationship, the girls laughed because that is not how anyone would have answered - the meaning was clear to them, even though it was not necessarily crystal clear to us.

The second practice we engaged in was to pilot test the survey with the inclusion of qualitative probes after each question so we could evaluate whether participants were answering the survey question with the same understanding of what the question meant as the researchers' understanding of the question. An example: after a question asking, "Is your boyfriend or husband supportive of your children?" we probed participants to share with us "how is he supportive or unsupportive?" This yielded very important information. For example, some participants said "No" because they did not have a boyfriend or husband, while other participants said, "No" and explained that their husband refused to have the children eat at the same table or would beat the children. These are two very different kinds of "No" responses.

After the pilot testing, we asked participants for their feedback on the survey - did it measure what they thought it should measure, were there questions they especially did or did not like, was there anything they didn't understand? With this feedback, we revised the survey, deciding to maintain the qualitative probes in the final version so as to have the option of exploring the quantitative findings qualitatively.

This post is getting rather lengthy, so I'll end it here with a final suggestion. For most research to produce meaningful results, study participants should be engaged at all phases of the research, from study design all the way through data analysis. Otherwise, interpretation of the study findings can be at best a murky endeavor and at worst not credible.

Breast cancer screening

I hope the world will take notice of a study just published in the British Medical Journal reporting the results of a 25 year follow up randomized control trial of mammography screening. In the study, almost 90,000 Canadian women were randomized to receive either annual screening mammograms or usual care in the community between 1980 - 1985. The rates of death due to breast cancer in the two groups were indistinguishable over the study period.

The authors suggest that in a country with accessible and available treatment for breast cancer, screening mammography (as opposed to diagnostic mammography) does not improve the chances of survival with breast cancer. In addition, based on the differences in breast cancer rates between the screening and control arm, the authors report that they believe that 22% of the breast cancers diagnosed and treated in the screening arm were what they called "over-diagnosed," meaning that the diagnosed "cancer" would never have resulted in a life threatening disease.

Along with several recent articles in the past few years (like this one that described a push away from calling DCIS "cancer"), these findings suggest that the way that we are currently screening for, diagnosing, and treating breast cancer is flawed. Though it will be hard to counter the "feel good war on breast cancer" that proselytizes screening and early detection as life saving, clearly the science is speaking.

On rights and public health

In an interesting article, Mark Bittman, food writer for the New York Times, discusses a new book Nicholas Freudenberg, “Lethal but Legal: Corporations, Consumption, and Protecting Public Health.” 

The article (and presumably the book, though I haven't read it yet) lumps together several major industries that use a similar framework to justify behaviors that inevitably result in worse public health outcomes. The industries - tobacco, food and beverage, alcohol, guns, pharma, and automotive - use a paradigm of "rights" to counter any assertions that they share responsibility in the widespread adoption of behaviors that are unhealthy (such as smoking).

It's an interesting article and one that I find particularly interesting in light of some conversations about ethics I've recently had with my students. We have been talking about which people might be most likely to be turned off by various public health promotion messages. For example, in discussing campaigns to get people to eat healthier, we have been talking about how shaming tactics may galvanize some people to change their behaviors, but that for others, particularly those who already experience marginalization based on multiple aspects of their identity, shaming tactics are unlikely to prompt behavior change and perhaps more likely to increase dysphoria and a sense of hopelessness.

Bittman's take on this book is centered on the food industry (which makes sense as he's a food writer) and the efforts that food and beverage corporations take to manufacture and market highly addictive and unhealthful food. In a NYT magazine article from about a year ago, The Extraordinary Science of Addictive Junk Food, the back room discussions that have led to some of these decisions were compellingly described. What I am concerned about from a public health standpoint is this pervasive use of "rights" language, when human rights can never be divorced from social protection and status.

In my work with former child soldiers, recently discussed in this beautiful article by Jean Friedman-Rudovsky in the Telegraph, it was clear that women did not feel entitled to access structures to protect their human rights until they felt social acceptance. For example, one woman shared how she had been beaten badly by her boyfriend. While the law protected her, she felt that she could not go to the police because the police would target her because of her past history. It was only after she had gained social acceptance in her community that when another incident occurred, she felt able to speak not yet to the police, but to the local chief who listened to her story and negotiated a settlement between her and her partner. Years later, perhaps she would go to the police. But change like this was incremental. So the "rights" may have been legally endowed, but because of her status and relationship with those who share the obligation to protect rights, she was unable to exercise her rights.

So when corporations that make guns or that sell cookies and soda talk about rights, I always wonder whose rights they are talking about? They say the rights of the consumers, but they mean corporate rights to sell what they want and earn as much money as they can. And whether those who are already likely to suffer worse health in our society because of our unjust history or because of continued social exclusion evident in all domains of our society are the ones most likely to consume these unhealthful products, who has the obligation to protect them? I guess that's where public health comes in.....

Do we need professors?

An interesting debate is taking place in the op-ed pages of the New York Times about the role of professors. Most recent contribution was by Nicholas Kristof arguing for professors to be more vocal and active public intellectuals.

And in another perspective, Adam Grant proposes that we restructure tenure to separately allow for excellence in teaching and in research.