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The nuances of language

The professor asked the class what a “confounder” was. I raised my hand and answered, “A confounder is something that is associated with both the exposure and the disease, but is not in the causal pathway between an exposure and a disease.” That is how I learned what a confounder is. That is how I explain it to people.

The professor smiled and then mentioned that we needed to be more “nuanced” with the language we used to describe a confounder. He then proceeded to give us three rules for identifying a confounder.

So what was so different between my answer and the professor’s definition of a confounder?

I said “associated” instead of saying that a confounder “causes” the disease. I guess I should have said that the confounder is “causally associated” with the disease. However, I used “associated” because I was explaining the relationship between the confounder and the exposure and the disease. I wasn’t explaining the relationship of just the confounder and the disease, or just the confounder and the exposure.

The reason I’m writing about this is because this has been a continuing issue with the way that questions are asked by some professors, especially in the context of exams. (I’ve written before about my issues with how professors are not particularly good teachers.) When the instructions on an exam state that there is “one best correct answer,” then that implies that there are other answers which may be correct, though not to the satisfaction of the professor. It turns a question like “What is two plus two” into a riddle where we have to read the minds of the professor and wonder if the answer is “four,” “six minus two,” “one half of eight,” or “three.” It confuses things.

The real world is even more confusing. Consider a study from back in the day which stated that coffee causes pancreatic cancer. This is from The New York Times:

“A statistical link between the drinking of coffee and cancer of the pancreas, the fourth most common cause of cancer deaths among Americans, was reported yesterday by scientists of the Harvard School of Public Health. The discovery was unexpected, and its significance is not yet clear.

”If it reflects a causal relation between coffee drinking and pancreatic cancer,” the report said, ”coffee use might account for a substantial proportion of the cases of this disease in the United States.””

That’s from 1981. Here we are, almost 35 years later and Starbucks is booming selling the stuff. What gives? Isn’t coffee dangerous?

As it turns out, the researchers failed to account for some bias in their study and for an enormous confounder: Smoking.

You see, the subjects of the study were being drawn from a GI (gastrointestinal) medical practice, so they were more likely to be in treatment for things like pancreatic cancer. Also, many of them were smokers, so they were more likely to have pancreatic cancer. When you “adjusted” (aka “controlled,” “accounted”) for smoking, it turns out that the smokers who drank coffee were the ones contributing to the elevated risk of cancer, not the non-smokers who drank coffee.

This is the same mistake (among many) that we saw Brian S. Hooker commit when he re-analyzed vaccine and autism data. He thought he saw an association between African American children at 36 months and vaccines and autism, when the actual association was only between their age and autism… Not their race nor their vaccine status. (Children are diagnosed the most at around that age.) Once those confounders are adjusted for, the association he saw disappears, and we get a picture closer to the truth. In his defense, Brian S. Hooker is quoted as saying that he prefers simpler statistics because he is “not really that smart.”

Simple statistics don’t always tell the whole truth, as you can see.

Anyway, back to language…

I’m not planning on going into academia, though I may — from time to time — give a lecture here and there on epidemiology and other stuff that interests me. Instead, I’m going into public health practice. I’m going to be using the evidence that exists, and is yet to exist, to address public health problems. A lot of that comes with using language, so, yes, I have to be careful of what language I use. However, my language is not going to be the language of epidemiologists. Instead, I’ll be translating the language of epidemiologists into plain English (or maybe even Spanish).

That is where the courses in the DrPH program are failing me. We do a lot of journal club reviews of articles, but they’re all done in “epi speak.” When I took the comprehensive exams last year, someone mentioned that it was clear that my approach to the essay questions on policy were not those of an epidemiologist but those of a public health practitioner. That was a good thing. Because I’m going to be that practitioner while being an epidemiologist, and I’d rather my language be that which translates evidence into action, not the language that leaves people confused.

And certainly not the language that confuses people on purpose.

Categories: Blog

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René F. Najera, DrPH

I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
About History of Vaccines: I am the editor of the History of Vaccines site, a project of the College of Physicians of Philadelphia. Please read the About page on the site for more information.
About Epidemiological: I am the sole contributor to Epidemiological, my personal blog to discuss all sorts of issues. It also has an About page you should check out.

4 replies

  1. I’ve had information security tests, where it was multiple guess and four correct answers were presented, leaving one to find the “most good” answer (meaning, more detailed and all of the correct factors in defining a term, practice or attacker).
    I’ve also had “trick questions” on those tests.
    We’ll suffice it to say, the writer of the tests wants to be quite certain that the person taking the test is knowledgeable, careful in their reading and does not read part of the information and answer from that sparse information. I like it for one reason, it keeps me on my toes.

    But then, real life is like that as well.
    Such as last evening, whist going through the 1700 or so alerts I normally receive, one attracted my attention and garnered great interest and praise when our morning shift and managers arrived.
    Nearly 700 alerts of someone logging into one of our web portals, using a proxy avoidance and anonymizer service. One that is popular all over the world and also used by both malware and malicious actors, in particular, a set of foreign state actors who are quite effective at gaining access to networks that they do not belong accessing.
    First, I ascertained characteristics of the session. It was purposeful and it was from a logged in account.
    I noticed that two services were used, a web knowledge sharing service and a forms service. Multiple different URL’s were used, with some repeated.
    The services are dedicated for country B (I’m in country A), the account is a country B worker.
    Country B recently had a network incursion where credentials were harvested (so did county A, country C and country D).
    Suspicious: Usage of anonymizer/proxy service, account from country where breaches recently occurred and credentials were exfiltrated to a known foreign power backed APT (Advanced Persistent Threat).
    I wrote up an incident report, which the incident handlers will address (along with our security incident response team).

    My opinion: It’s a user who was likely doing something he shouldn’t have been doing, such as pirating software or visiting pornographic sites that his country filters and said user forgot the software was “anonymizing” him (it isn’t really, that software was broken back when I was in the Middle East, at least for governments).

    For a hint to the service, Silk Road was shuttered because of the breaking of the anonymizing service and a parallel investigation ensued, using an inserted human agent, as the FBI was aware of his need of a specific set of qualifications holding individual and had their agent answer his advertisement.
    As the parallel investigation was more than sufficient to convict and the initial investigation only uncovered the identity of the suspect and that was a lawful investigation (but used sensitive techniques, tactics and practices), there is no wiggle room for an appeal.

    But, such is life, where incidents in various fields turns into “trick questions” and “best answer”.
    The webserver logs, which I requested a review of, will tell the tale partially. Two other sources will prove the truth, one being the user, if he’s honest.

    I don’t mention the countries involved, or the service, to avoid attribution, should it be an APT and due to an NDA.


    1. Yeah, I guess I do understand that they’re making sure that we are reading for comprehension, but it’s just so goddamned hard to read their minds.


      1. I’m rather surprised. You’re a native Spanish speaker, who learned English after.
        Usually, when going cross-language or cross-cultural, one “learns” “mind reading”.
        I’m not proficient at many languages, although I can curse in seven languages.
        I can *think* naturally to comprehend mutual commonality enough to build bridges between my culture and Asian cultures, African cultures, Iraqi culture (a mix of Assyrian and Arabic, with a tint of Iranian and Turkish culture), Bedouin culture and even Saudi culture.

        Perhaps it’s age upon exposure to the different culture and language. I’m rather good at Yiddish. But, since shortly after birth until I was nearing nine, I was in a mixed Jewish neighborhood and my father worked for a Jewish boss who insisted I called him Zaida, Yiddish for Grandfather.
        Something I quickly realized, even as a toddler, that the owner of that business respected and loved my father enough to have partially adopted us into his family. That was especially apparent when my father came home related how he slammed the front door open hard enough, after an unfortunate company experience in the field, that he shattered all of the glass in the door. But, suffered no penalty, well, other than that that door was bolted shut.
        Today, that door remains bolted shut, the windows still wooded over, although the company died shortly after my father retired, due to a heart attack.
        Zaida died, his son Herb inherited the business and subsequently, both his workforce *and* his clientele, something nearly a monopoly in the region, gasoline station reconstruction and especially, tank work. Men my father trained have moved on to replace that company.
        A truism at that company was also a company joke. Herbie started around the time my father did at the company. Herbie was “kicked out” for six weeks, giving my father seniority over him. Zaida actually confirmed it.
        Damn, but I miss Ed, Joe Goldfine (our family physician) and a large number of people enough to make a grand wedding party!
        That’s a common enough thing for people in their 70’s, but dammit, I’m only 53!
        But then, my father didn’t want me to go into concrete work (he also learned plumbing, electrical work and was nearly competent at carpentry.
        I’m a bit better at carpentry, great at masonry overall, proficient at plumbing, expert at electrical, superlative at electronics, the same for killing people and treating injured or diseased people.
        The latter two, courtesy of something I entered as a profession, the military.
        Today, I’m an information security professional and, as usual, good at that.
        For my father taught me, via his disadvantaged youth and movement forward, learning new fields and moving onward.
        At least I didn’t, in my youth, shake down DuPont children for their lunch money.
        My parents gave me, either enough lunch, or more infrequently, enough lunch money to eat that crap in the school cafeteria.
        I far preferred the packed lunch.
        As both my wife and I (courtesy of my mother’s teaching) are both excellent cooks (I’m actually also a former chef), I prefer leftovers or a freshly made treat.

        Hm, perhaps we should create a secondary blog. One on shared recipes, derived from oneself or family.
        My “trick” when meeting new and rather villages was to institute a recipe exchange.
        First, we have Americans infamous for a spiceless diet. Second, my recipes already suggest spices, they also impart flavor and texture.
        Yeah, we *quickly* found common ground.
        I suspect that is why my retirement package took nine months to process.


        1. Hmmm… A blog on recipes… I’ll give it some thought.

          I’m very visual with everything. So I need to see a person’s mannerisms as they speak in order to get a better feel for what they’re thinking. Simply reading words on paper is sometimes not enough. Well, it’s many times not enough. This has gotten me in trouble because I’ve failed to understand the meaning of emails and such from the “adults” at my various jobs.


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