Domestic Threats to Public Health in the United States

True story.

If you’ve been watching the news, you might have noticed that something interesting is going in Italy. They just had a general election, and their results were very interesting. This is from The Atlantic:

“Anyone who’s spent more than a vacation in Italy knows it’s a country with deep reserves of discontent, economic stagnation, and political dysfunction. So the anti-establishment Five-Star Movement, which promises universal basic income and says it wants to clean up politics, and the right-wing League party, which made immigration and economic anxiety central issues, had plenty of anger to tap into ahead of Sunday’s national elections. And then they became the biggest winners, with more than half of the electorate between them.

The people have spoken. But what are they saying? There are two main ways to read the results, and both have major consequences for Europe. One—and this is entirely new—is that one of the three pillar countries of the European Union now effectively has a euroskeptical majority in parliament; both Five Star and the League have called for rewriting treaties with Europe to give Italy more sovereignty. (Although it’s a big question whether they would team up to form a government; the election results have produced a hung parliament.) The second is that voters are punishing Italy’s governing elites—Renzi’s Democratic Party, but also Silvio Berlusconi’s Forza Italia party—for overseeing the country’s decline.”

But there is also a public health component to the outcome of this election. From Time Magazine:

“Just over two years later that debate has gone from an online feud to a live political issue in the Italian general election due on March 4. As skepticism about vaccines has become widespread in Italy, so-called “anti-vaxxers” have become a voting bloc for the populist parties vying for votes. As a result, two of the leading populist parties — the far-right League (formerly the Northern League) and the anti-establishment Five Star Movement (5SM) — have pledged, if elected, to scrap a law passed in July that made ten vaccinations compulsory for children under the age of 16. If they do, health experts warn it could be a huge step backwards in the global fight for children’s health.”

And why would that be a bad thing? From The New York Times:

“Measles cases soared in Europe last year, and at least 35 children died of the highly infectious disease, according to the World Health Organization. The virus found its way into pockets of unvaccinated children all over the continent, from Romania to Britain. The number of recorded cases quadrupled, to 21,315 in 2017 from 5,273 in 2016, a record low.

The biggest outbreak last year was in Romania, where there were 5,562 cases and which accounted for most of the deaths. The country’s large rural Roma population — also known as Gypsies — often do not vaccinate their children and may not take them to hospitals promptly when they fall ill. The country also has an underfunded public health system.

The second biggest outbreak was in Italy, with 5,006 cases and three deaths; 88 percent of those cases were in people never vaccinated, and another 7 percent in people who had not had all the recommended doses, the European Center for Prevention and Disease Control said.”

So, seeing what happened in Italy, can we look at the United States and see where similar threats of public health are allying themselves with political discontent? I’m looking at you, Texas… From The Daily Beast:

“And then there’s the anti-vaxxer stuff. LaHood, whose son has autism, has appeared at anti-vaxxer conferences, using his district attorney title as proof of credibility. And in a promotional video for the anti-vaxxer movie Vaxxed, LaHood says: “I’m Nico LaHood. I’m the criminal district attorney in San Antonio, Texas. I’m here to tell you that vaccines can and do cause autism.”

Asked about his views at the Feb. 8 debate, LaHood said they were based on “a personal belief” based on “what my wife and I go through medically.” After his son developed autism, “we have an opinion of how that happened.”

In reality, there is absolutely no evidence that vaccines cause autism, and all major medical associations and the Centers for Disease Control and Prevention have affirmed the safety and necessity of vaccines. The one study that spawned the anti-vaxxer conspiracy has been debunked and retracted. Since it was published, 17 studies performed in seven countries on three continents involving hundreds of thousands of children have found that its hypothesis had been wrong. Meanwhile, parents refusing to vaccinate their children have led to outbreaks of measles across the U.S.

Now, as a district attorney, LaHood’s views on vaccines don’t come into play very often. Then again, some would say that science is not a matter of “personal belief,” and that subscribing to an anti-scientific conspiracy theory, even as a result of personal trauma, is relevant to how a prosecutor evaluates evidence.”

Mr. LaHood would eventually lose the primary, but he’s not the only candidate with anti-vaccine views.

It’s not just anti-vaccine politicians that are a threat to public health. (Or, rather, the policies they would pursue would be a threat.) You also have the candidates who oppose laws favoring safer guns, helmets while riding motorcycles or bicycles, pollution regulations to stave off global climate change, etc. There are very smart and/or very charismatic people vying for political office right now who are not afraid to throw out the science and evidence and go with their gut or with popular sentiment.

I worry also about the demonization of immigrants coming to the United States. There are, of course, hundreds of “news” stories about immigrants bringing diseases into the purity of our country. Never mind that measles cases are being brought in by US residents who travel abroad and are not vaccinated, for the most part. Never mind that children from “third world” countries are well-vaccinated, or that refugees escaping war are well-screened for infectious diseases as part of the process of coming into the United States.

Unfortunately, it’s not just the anti-immigration people in this country who are focused on public health threats from abroad. Back in 2009, everyone expected the next influenza pandemic to come from Asia in the form of avian (bird) influenza. A scientist at CDC told us at a conference that she expected the next pandemic to be swine flu from North America. Guess what? It was swine flu from Mexico, and the first cases were found in Texas and California.

When the Ebola epidemic was going on in West Africa, how many news reports pushed the possibility of cases landing in the United States and killing us all? How many politicians overreacted to those speculations and ordered American citizens into quarantine upon their return from helping save lives in West Africa? Meanwhile, that winter, between 3,000 and 49,000 people would die from influenza in the United States.

I mean, if you just look at the tables for the top causes of death in the United States, threats from abroad are not really anywhere near those lists. We are dealing with hundreds of thousands of deaths a year from heart disease, cancer, stroke, diabetes, Alzheimer’s, and suicide. Terrorist attacks? Yeah, there’s been a few, but none of them have come close to killing as many people as sedentary lifestyles and high-fat diets have.

Can you imagine if screeners at the airports stopped overweight and obese people and called them a threat to our public health? Or if cops came after you for smoking? And what if we forced the elderly to do puzzles all day and get plenty of exercise to stop Alzheimer’s? Or we forcibly medicated anyone and everyone who suffered from suicidal ideations? How many excess deaths would we prevent?

I know. I ask too many questions. But did you notice what all of those things have in common? They’re all things that we as individuals do to ourselves. Or, rather, there is the perspective that we do it to ourselves. No one is forcing us to sit for hours and eat unhealthy meals, but we can’t help it sometimes (or many times). Maybe Big Sugar and Big Fast Food haven’t gotten around to sending us political communiques as they threaten us with fatness, so we don’t consider them as enemies.

I’ve noticed this tendency to look out at the world with fear at the school of public health as well. There is a series of events coming up for “Public Health Practice” week, and a lot of the discussions and presentations are about what is going on outside the United States, particularly in areas with armed conflicts. The closest thing I’ve seen to a domestic issue is hurricane relief for Puerto Rico, and, even then, some students are not aware that Puerto Rico is a US Territory.

My sincere hope is not that we turn public health in the United States into some nationalistic version of what it is now. “America First” is just as hazardous to our health as focusing only on threats from beyond our borders. But there is something to be said about panicking over a physician or nurse coming back from helping out in West Africa and getting the sniffles instead of panicking over thousands of people who will needlessly die each winter because we can’t come up with a better influenza vaccine and/or because not enough people get the flu vaccine when they need to.

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The Thing About Hotspots

No, I’m not talking about wifi hotspots that help you connect to the internet so you can watch cat videos. I’m talking about the symbology used on maps in order to emphasize an area (or areas) where there is a lot of something going on. For example, in infectious disease epidemiology, I might use a map to show where there are a lot of cases in a relatively small area, or where the number of cases observed has exceeded the number of cases expected.

You know, something like this:


This map was created using a geographic information system (GIS) and data from the Centers for Disease Control and Prevention (CDC). It took incidence of deaths from heart disease and mapped them out, then broke down the data to show where there were increased levels of heart disease deaths, where there were the expected levels, and where there were the lower levels (aka “cold spots”). As you can see, Texas has a big problem. (Then again, Texas always has some big problem or another.)

But there are hotspots and then there are hotspots.

The map above doesn’t tell us the whole story. The higher incidence in the DC Metropolitan area might be due to social, environmental and genetic conditions different than those in Texas or South Carolina. The “cold spot” in Oklahoma might be indicative of something at play there that is completely the opposite of what is going on in Texas or DC. This is where epidemiology comes in.

This is where we ask the questions.

And that right there is the problem with these maps. Taken out of context, they might be misused. For example, what do we know about heart disease and deaths from it? Well, we know that a bad diet and sedentary lifestyle can contribute to obesity and heart disease. We know that lack of access to primary healthcare can also contribute to heart disease complications. And we know that some people are just more predisposed to heart disease based on how their bodies process saturated fat and cholesterol and deposit those compounds on their arteries.

If you make the mistake of thinking that the hotspot in Texas is due to one thing and not the other — or a combination of things — and you try an intervention, you might fail miserably. Or what if you implement the same intervention in Texas that you did in DC but get completely different results? Again, you might be wasting resources. So you need to understand the context of the hotspot analysis that you’re performing.

To understand the context, you need to ask questions of person, place and time. Who is dying from heart disease? What are their ages? What are their genders? What are their racial/ethnic profiles? What are their socioeconomic profiles?

While the map answers some of the questions about place, we need to be a little more analytical and find out if those counties showing the hotspot are poorer/richer than their neighboring counties, or if the people dying are dying at a hospital or at home. Are they dying in particular neighborhoods or buildings?

And, when it comes to time, are the deaths happening with any kind of seasonality? Is there a variation in the time of day? Are these hotspots new, or have they been there for several years or across generations?

Yes, I know these are a lot of questions to ask, but they’re the kinds of questions that help inform the stakeholders on what needs to be done about the hotspots that have been detected. It is not nearly enough to just present the map and walk away. You have to tell the story of what is going on so you can one day tell the story of how it was fixed, and to guide the response(s) toward fixing things.

After all, the world is much simpler when you’re fixing things. I know it is for me.

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Whose Fault Is It That I’m Fat?

We were talking in an epidemiology class the other day about the association between obesity and diabetes. It’s a pretty strong association, with a lot of good evidence that obesity causes diabetes. As the students and the professor talked about this, the other teaching assistant in the course took some pictures of us. I was standing at the podium as he took the pictures. When I saw the pictures… Well, I’d be dishonest if I didn’t admit that I was a little bit disgusted by my appearance.*

I’m huge.

I had managed to trend downward in my weight all of 2016 and some of 2017. But then the baby girl arrived and with her came very little sleep. That triggered habitual snacking, poor food choices for the main meals, and a total lack of will to go to the gym or head outside. Little by little, I gained back the weight I lost in 2016 and then some.

Now, I’ve been going to the gym and swimming as much as I can over the last few months, but I traded in swimming, running and cycling each and every single day for a swim every few days. Sometimes I’d skip a week. The pressures of parenting and doctoral school came down hard.

The other problem is that I have a ton of bad food options on the way to the school of public health. Because of the lack of sleep, or because I have to take the baby to daycare, or because of some other thing, I run out the door late and don’t have time to make a good breakfast. As my blood sugar is probably way down from not eating overnight, I crave just about everything I drive by… Or I crave the donuts in the display at the gas station. Before I know it, I’m eating something made with the least natural ingredients, loads of fat and carbohydrates, probably no vitamins and minerals, and I’m eating a lot of it to satisfy the overnight fast.

So I’d posit that it is my fault that I’m fat for not being more mindful about planning meals, choosing better foods when I do stop somewhere, and working out a good schedule with my wife so we can maximize our sleep. The thing is, all of those things become secondary or tertiary, or lower, when the baby gets sick, when the baby needs to go to daycare, when the baby has to be picked up from daycare early or dropped off late.

Planning also takes a back seat to my work on my doctoral dissertation. I have all the data lined up. I just need to find time to write it. This has brought upon me a certain degree of anxiety over getting it done in time for a final defense in the summer. That pressure and anxiety are then dealt with by snacking, or by overeating. So I’d posit that it’s my parents’ fault that I’m fat because they always dealt with stress through eating.

Then there are family gatherings, which we’ve been doing more of now that my wife’s parents and my siblings want to get to know Baby Ren. All of those gatherings revolve around food. We either make a lot of food or order some unhealthy food from the Italian food place down the road. Then we eat and eat and eat while chatting or enjoying the baby’s shenanigans. Calories are not counted at family gatherings, though those calories certainly do count.

So now it’s my culture’s fault.

You see where I’m going with this, right? There isn’t one overarching reason why I’m fat. There are many reasons, and personal choices/responsibility is one of them. But that personal fault is just a small cog in a very big mechanism that had me gaining weight to the point where I really felt sorry for the big Mexican at the podium… So sorry that I went and swam a mile and then did 5 miles on a stationary bike and 20 minutes on a treadmill. (More on this later.)

The same can be said for large swaths of the population who are overweight, obese or morbidly obese. There’s the personal responsibility of being mindful of how much food they’re eating, but then there is the complex mechanism around them. If they live in a food desert, they’re probably not getting healthy meals. They’re probably getting — for very little money — some of the most unhealthy food out there. But that’s all they can get. Also, poverty bring with it crime. Who wants to go for a jog when there’s a real chance of being the victim of a crime?

Like with very many public health issues, obesity and its consequences is a very complex one. There are things that can be done at an individual level, but they’re very much worthless if the environmental influences are not changed. I can work on getting a schedule down, only eating what I cook at home, and exercising more. But none of it will work if I am not able to attain healthy food to cook, or a job that allows me the flexibility to deal with life’s unexpected things (especially with the baby).

The opposite is also true. We can fix an environment so only healthy food is attainable and open spaces for exercise are plentiful. But none of that will matter if we don’t find a way to motivate people to eat better and get moving. This is where both public health and individual medical practices need to join forces. The former can influence large groups while the latter can influence individuals.

So while all that is being sorted out, I’ve gone ahead and done two things. Number one, I’ve made a commitment to find at least one hour each day to work out. Either I work out when Baby Ren is at daycare and I stop at the gym before going to get her, or I put her in the stroller and head out for a walk if the weather is cooperating. If the weather is not cooperating, I get the playmat out and throw some toys on it for Baby Ren to play while I make use of the dumbells in the basement. Just one hour a day is all I need to reverse the weight trend and feel stronger and more agile.

Number two, my wife and I have gotten rid of unhealthy snacks around the house. Instead of grabbing a bag of something processed and munching on it while I work on the dissertation or while I fret about some stressor in my life, there are now oranges and bananas that I can eat to my heart’s desire. (Yeah, they have calories, but they make up for it with fiber, vitamins and minerals.) The next step is to always make breakfast quickly in the morning or having something ready to go from the night before.

Future steps include being mindful of what I buy at places on the way to and from school/work. That one is tricky because the mind can be a tricky thing. You drive by a fast food place and you make a deal with yourself that you’re only getting one thing — or a healthy thing — and, before you know it, you’re getting the supersized fries and sugary drink. This step is going to require some reprogramming, which humans are notoriously bad at doing for themselves.

Finally, I haven’t given up on my goal of doing a triathlon someday soon. It’s just that I can’t do one with all this weight on me because it might actually be damaging to my health. So I’m taking baby steps towards that goal. The mile I swam was more in anger than anything else, and I’ve been paying for it with soreness and some pain. That could discourage me from swimming next time. (I wrote could because I’m not going to let it.) Once the weather gets better, there’s more bicycle time planned, including getting something so Baby Ren can come along. (She’s too young still, though. But soon!)

If you’re struggling with your weight, don’t despair. There are a lot of things out there that are science-based and evidence-based and have been shown to work. For many people, more exercise and a better diet are enough. Others need medication or a medical intervention such as gastric bypass or a gastric band. Still others need psychotherapy because food has gotten a stranglehold on their lives. The first step is to take inventory of what you are doing to gain the weight and/or not lose the weight. Then take that inventory to your healthcare provider.

If you don’t have a healthcare provider, find one. If you can’t find one because they’re not available where you live, or because you cannot afford them, look to other sources of help with nutrition and exercise planning. Many local organizations are tasked with helping people improve their lives and prevent obesity and its accompanying diseases and conditions. There has to be something out there. (Drop me a line in the comments if you really can’t find something.)

When you accept that there is balance that can be achieved in how many calories you consume and how many you burn, and that the imbalance is not 100% your fault (though you do have some control over the situation), you start moving in the right direction. Good luck… We’re going to need it.

*Yeah, I was disgusted by my appearance but only because I realized I’d let myself go. Once I realized that there were sensible and plausible steps that I could take to correct the situation, I wasn’t so disgusted anymore. The fact that I want to fix this is plenty of evidence that I am not disgusted with myself.

The Parent Ren, Part VII: The Pathogens Strike Back

I remember being a child and having Strep throat in the summer a couple of times. It was miserable. It was so bad that I could not wait to go see the doctor and have my grandmother give me a shot of penicillin. (I spent most summers with my grandparents in the ancestral hometown in Mexico.) She would bundle me up in a blanket, in the Mexican summer heat, and take me to the doctor’s office. He would stick that wooden stick in my mouth and take a look and agree that I needed antibiotics. He’d write the script and off we went to the pharmacy. At the pharmacy, my grandmother would get the penicillin, a vial of injectable saline, and a syringe. Then it was back to the house to get my shot, fall asleep, and wake up feeling so much better.

Speaking of sleep, one time when I had something that was more akin to the flu, my grandfather gave me a soup spoon full of equal parts tequila, honey, and lemon juice. He basically got me drunk, as I was around ten years old. I crashed back to sleep and woke up feeling better some 36 hours later. Dad said I had the highest fever, but both my grandparents told him not to wake me up and to let the fever do its work. (Fevers can be dangerous if allowed to go too long and/or get too high. So don’t try this at home.)

The next big respiratory infection would be the flu in 1997. That one was scary as I was living on my own. I remember starting to feel sick in the morning at school and not quite remembering how I got home later that evening. Then I remember bits and pieces of the next day, opting to stay home and sleep instead of doing anything. Finally, a friend came by looking for me to go play soccer and woke me up out of a stupor. He saw how sick I was and drove me to the university’s health clinic. The prescription was more sleep, but to throw in some acetaminophen for the fever.

After that, I wouldn’t get another big respiratory infection until 2008, when not only did I get the flu but I also managed to have it develop into a whopping walking pneumonia. I remember going to my wife’s apartment (we were dating) and helping her move around some furniture. I then crashed on the couch, out of breath, and she listened to my lungs. “Alright, which ER do you want to go to?” she asked.
“What do you mean? I’m just a little winded,” I replied. That “winded” was because my lungs were filled with fluid. Even the emergency room physician asked me how I was up and walking around.

The best part of the pneumonia story is that I gave a talk about influenza surveillance at a gathering of state epidemiologists and public health workers, and I was coughing up a lung, feverish, and probably made little to no sense. And I nailed it. (Kind of.) I remember people coming up to me to talk more about influenza surveillance, as I had the flu and as I tried hard to sip tea while my throat burned out of control. I wonder how many people I got sick that day?

Bad epidemiologist. Bad.

But that’s the thing about us silly humans, isn’t it? We are teeming with germs and we can’t wait to share them. Our habits and traditions as humans are such that they have allowed all of these bugs to travel the world with us. We greet each other by shaking hands or, as in my Latin American culture, we add a hug or a kiss on the cheek. No better way for respiratory infections to travel, especially if hand washing is not readily available.

Then there’s sex. Almost 99.99999% of humanity will have sex if they live to be old enough to do so, and there are germs that travel with sex as well. From gonorrhea to HIV, we share more than you really want to know when we have sex, sometimes to deadly consequences. When it comes to all the things that could kill us, absolute abstinence would probably save millions of lives each year… But abstinence-only strategies to controlling sexually transmitted infections is as effective as telling people not to eat or drink in order to avoid diarrhea.

Great comparison, I know.

Now that I’m a father, I’ve come to be a little more afraid of germs. It’s not that I’m afraid of what they’ll do to me. I’ve been known to run into an influenza outbreak without personal protective equipment once or twice, and not knowing what we were dealing with one of those times. (My wife still chides me over that one.) Now, I’m afraid of what they might do to Baby Ren. She’s so tiny and delicate that I worry that any little cold will knock her out and really hurt her.

The sleepless nights are bad enough, sure. But the worrying over her breathing and being comfortable really takes its toll. While I try to get things done and continue to write my doctoral dissertation at 3am in the morning while I listen for her coughing, I’m still focusing a lot of my attention her way. Then the brain starts playing the What if? game, and I get worried about her. And then the rational brain reminds me that plenty of children go through these infections and come out the other side with a stronger immune system.

And, of course, the really deadly stuff has been vanquished thanks to vaccines. Baby Ren will never get to know smallpox, and her chances of meeting polio are infinitely small. She got her 2 month vaccines and is going in for her 4 month vaccines right after Christmas. And she’ll get her 6 month vaccines in February, including the two doses of influenza vaccine.

Still, listening to her congested nose and her hacky cough is scary, because she’s my daughter. She’s become a huge part of my life, obviously. While I know that these infectious microorganisms don’t have a mind of their own, I think that it’s a little bit funny that I’ve devoted my life to fighting them and here they are fighting us, making Baby Ren feel sick and making me worried sick.

So I continue to drink sips of coffee to help me stay awake, continue to do research for my dissertation — maybe draw some maps and do some geostatistical analyses — and continue to look over and make sure she’s breathing as she sleeps in complete peace and calm. Parenting ain’t easy, but no one said it would be.

The Perfect Disease Surveillance System

How is it that we get to know about diseases like Zika or Ebola? Is it just dumb luck that we encounter patients and then go from there? In a way, yes. These diseases, especially novel ones, have a way of just popping onto the radar without warning. Then we respond vigorously because we weren’t able to do something about the first few cases before the whole thing got out of control.

But what about other diseases? Continue reading

Where do you begin to understand Zika?

It’s all the rage these days to get worked-up about Zika. Just like last year with Ebola, this year we’re freaking out over a disease from “over there” coming “over here” and hurting Americans. Also, the observed association between Zika infection in pregnancy and microcephaly is scaring the crap out of people. (It’s really scaring the far-right, anti-abortion people because women will start thinking of abortions as an alternative to having a microcephalic or anencephalic child.)

A letter went out to students and faculty at the school the other day asking for students to help do research to pin down the incubation period of Zika. The incubation period is the time from initial exposure/infection to the time of initial symptoms. It’s somewhat hard to pin down this time with Zika because it is transmitted primarily by mosquitoes. If you go to a place teeming with mosquitoes, it’s hard to figure out if yesterday’s exposure lead to infection, or the one from last week.

This problem is the same one we see with foodborne diseases. We eat a few times a day, so out opportunities for exposure are many, and they are continuous. But we figure out the likely culprit when different people start reporting the same exposure, e.g. eating the same food at the same event or from the same restaurant. So what do you do when the exposure is mosquito bites all the time, every day, all over the place?

For those, you look at people who travel into and then out of the areas with heavy mosquito presence and then got sick. You determine when the last day they were there was and count from there to get the soonest incubation time, then you determine when they arrived at the endemic area and get the latest incubation time. You this over and over again with as many travelers as possible, and then you figure it out.

As it turns out, Africa, Asian and South American researchers have done this. Even some European scientists who responded to a large outbreak in French Polynesia in the South Pacific have come out with a good estimate of the incubation period. They all agree that it’s between 5 days and two weeks, and that the disease lasts about one week (as long as two weeks). However, for some reason, the school is recruiting students to do a literature review to figure this out. (I cheated. I contacted tropical disease epidemiologists who’ve already done the work.)

And this is the thing about epidemiology education in the United States. As I mentioned before in “The Two Kinds of Epidemiologists“:

“The research and academic epidemiologist looks at a public health problem and designs a study to better understand it. He or she makes sure that the measurements are valid and that the information collected from the study is reliable. They take good care to choose the subjects carefully so as to not introduce bias into the study. With data in hand, they test several hypotheses about the mechanisms that cause whatever disease or condition that they’re studying. They use the “dark arts” — as one frequent reader/commenter has called biostatistics — to make sure that their observations are not due just by chance, or that they’re not being influenced by things seen or unseen. Finally, they put all of their findings in a research article and get it published at one of many reputable scientific journals.”

And then all that information sits in a journal, waiting to be used. Take, for example, the story of Brian Foy. From the Washington Post:

“Brian Foy, a researcher who studies mosquito-borne diseases, said in a 2011 paper that he had found likely evidence of a little-known virus spreading through sex. If true, it would be the world’s first documented case of sexual transmission of the virus, he said at the time.

Foy wanted to study it further, but no one would give him the funding he needed: He had found just one example, and the virus — known as Zika — was too obscure, he was told.”

I read that the other day, and my head exploded.

She gets me.

My head exploded because it was yet another example of how public health is failing to take all that knowledge into action. In 2010, two researchers published a really good paper on “Present and Future Arboviral Threats.” (Arboviruses are viruses transmitted by arthrobods. ARthropods + BOrne + VIRUS, get it?) They wrote:

“Perhaps the greatest health risk of arboviral emergence comes from extensive tropical urbanization and the colonization of this expanding habitat by the highly anthropophilic (attracted to humans) mosquito, Aedes aegypti. These factors led to the emergence of permanent endemic cycles of urban DENV and chikungunya virus (CHIKV), as well as seasonal interhuman transmission of yellow fever and Zika viruses.”

Had I been sitting at the White House and read that paper, I would have convened a panel from CDC, NIH, etc., to come up with an immediate plan to survey for these infections the world over and both track them and combat them… Years before they came to the United States.

But that’s the thing. There are plenty of us doing research and writing papers, and few of us working to put that knowledge into action. What is worse is that those of us who are working on it are not communicating well with each other. We either want to be protective of our work, or we just plain don’t know how to communicate our work. (Look at how we fail miserable to communicate the importance of vaccination in, say, Orange County, California. Effective communication would make anti-vaccine advocates be no more credible by the general public than people who believe the Earth is flat.)

We desperately need a Neil deGrasse Tyson of Public Health.

So the answer to the question I posed in the title is not “in the literature,” to be honest. The answer is “from each other… And now, before the next thing comes.”

“This is the time when things must be done before their time.” – 1949, Vol 5. No II of the Bulletin of the Atomic Scientists. 

Violence as a public health problem, an infectious disease, and a conquerable demon

I told you the other day about my thoughts on gun control and gun violence. My thoughts boil down to what I mentioned in a comment: I’m not about getting rid of guns. The solutions to problems like these is not one extreme or the other. As someone said during an interview about the Oregon shootings, “The choice shouldn’t be between doing something and doing nothing at all. Doing nothing should not be a choice.” I think that this is something that reasonable people can agree on. There are thousands of deaths from gun violence in this country, and we need to do something about it.

The first question that is usually asked when people in public health want to do something about gun violence is whether or not gun violence is a public health problem. It is. Unequivocally, gun violence is a public health problem. People are dying and being hurt by gun violence. In fact, there is good evidence that deaths from gun violence are about to outpace deaths from car accidents, something you only see in war zones. (Gun deaths already outpace motor vehicle deaths in Michigan.) When we saw that thousands were being killed in automobile accidents, we instituted some common sense laws to make cars safer and to make the people operating those cars operate them safely.

But the National Rifle Association tells us that the comparison between guns and cars is not a good one to make:

“Just as lacking in resonance is the anti-gunners’ theory that government regulation reduced deaths involving vehicles, so the same ought to be true for those involving firearms. From 1981 through 2013 (the first and last year of data reported by the federal government), deaths due to accidents involving “unregulated” firearms decreased 73 percent, while those due to accidents involving highly-regulated motor vehicles decreased only 31 percent. And, two-thirds of the decline in motor vehicle accident deaths has occurred during the last six years, a half-century after Congress imposed the National Traffic and Motor Vehicle Safety Act, authorizing the federal government to dictate how cars should be manufactured and roads should be constructed.”

Of course, the operative word in that whole article by the NRA is “accident.” They compare accidental gun deaths to car accidents and find that there is no comparison, as their thesis seems to be that we should allow more people to have guns because they’re less likely to have accidents with those guns. But that logic is flawed because we’re comparing deaths to deaths, no matter the manner of death. And we do this because a death is a death, and because defenders of the rights of guns keep telling us that traffic laws only stop “good people” from doing bad things and don’t stop “bad people” from doing bad things.

That “good people” versus “bad people” argument holds water if we are to believe that only bad people commit gun violence. If you look at the data — data that is sound but incomplete because of Congressional bans on gun research — you’ll see that the biggest proportion of people dying from gun violence die from suicide by gun, and that there is a strong correlation between owning a gun and the risk of suicide by gun:

“A study by the Harvard School of Public Health of all 50 U.S. states reveals a powerful link between rates of firearm ownership and suicides. Based on a survey of American households conducted in 2002, HSPH Assistant Professor of Health Policy and Management Matthew Miller, Research Associate Deborah Azrael, and colleagues at the School’s Injury Control Research Center (ICRC), found that in states where guns were prevalent—as in Wyoming, where 63 percent of households reported owning guns—rates of suicide were higher. The inverse was also true: where gun ownership was less common, suicide rates were also lower.”

Of course, correlation does not equal causation, but we can’t exactly randomize people into a group with guns and a group without guns and leave them alone to see what happens. But that research did adjust for almost all confounders. In essence, all things being equal, you have a higher risk of offing yourself with a gun if you have a gun, and that makes sense. People who are suicidal and have a quick and available way to do it won’t often think twice about it. “It’s like turning off the lights,” someone once said.

Whenever I bring up these kinds of facts, people who want to protect guns more than protect children in classrooms tell me that gun violence is a mental health issue. After all, only people who have mental health issues kill themselves, right? This leaves out the fact that impulsive people — like teenagers and adults with not-fully-cooked brains — do impulsive things. If they lack conflict resolution skills, they just grab the gun and end the conflict. If a “patriot” sees a cop coming to their home, they might think, “This is it! Obama is coming to get my guns!” And then what happens?

The next move from people who think a few massacred children here and there is a good price to pay for liberty is that someone who is suicidal or homicidal will use just about anything else for violence. “The gun is only a tool,” they say. Yeah, but it’s a very effective tool. If you’re a “patriot” and see the police coming to your door, and all you have is knives, you’re not exactly going to “stand your ground” and take out someone who is just there to let you know that stolen car has been found. And if you’re on the road and someone cuts you off and you don’t have a gun but are prone to violence, about the only thing you can do is throw your car at them.

“Ha! You admit that cars can be used as weapons too!”

Well, yeah, but cars have been engineered to withstand some pretty good licks. Those engineering controls didn’t appear out of thin air. It wasn’t until car manufacturers met a combination of laws and regulations and really expensive lawsuit settlements that they decided that maybe it was time to make cars safer, putting in air bags and checking their brakes for quality. Unfortunately, we cannot ask the same of gun manufacturers. They have complete and impenetrable liability protection:

“The Pavelka family filed a lawsuit against the gun dealer who sold the guns used to shoot Matthew [a cop], arguing that the dealer did not take reasonable steps to prevent the sale of the firearms to the straw purchaser who likely intended to resell the weapon on the black market. In an ordinary case involving any product other than guns, the family could have gathered evidence and subpoenaed witnesses to build their case and learn more about the sale. Yet the family’s suit was dismissed almost immediately thanks to a special legal immunity that Congress gave gun manufacturers, distributors and dealers, and their trade associations, in 2005. Unlike any other industry, the gun industry can commit negligence with impunity.

In 2005, when Congress passed the Protection of Lawful Commerce in Arms Act, granting the gun industry immunity in state and federal court from civil liability in most negligence and products liability actions, the National Rifle Assn. called passage “vitally important” and fought hard for it. Although there are exceptions in the law, it has been broadly interpreted to preclude most negligence lawsuits. The result is that — unlike the makers of chain saws, knives, automobiles, drugs, alcohol or even cigarettes — gun manufacturers and sellers have a lesser obligation to act with reasonable care for public safety.”

Yes, ladies and gentlemen, the National Rifle Association protects guns to the extreme that reasonable engineering and sales controls to prevent police officers from being shot cannot be forced upon gun manufacturers. If we are to have things like serial numbers that cannot be erased, background checks on all sales of firearms, and ammunition that tells you exactly which gun fired what bullet, we need to sit around and wait for gun manufacturers to put these things in place out of the kindness of their hearts. We are really lucky that the auto industry didn’t bribe legislators into having a similar bill back in the 1970s or we would have never seen the big reduction in vehicle deaths that we have seen because car manufacturers were forced into giving us seat belts, air bags, and good brakes.

That protection of gun manufacturers by legislators who drool at the sight of a wad of cash in their coffers and laugh at the idea of saving college kids from being shot in the head one by one is exactly why the whole theory that only “bad people” would have access to guns falls flat. If bad people have access to guns, but we had engineering and sales-tracking controls of guns, we would be able to find those bad people and punish them so harshly that they idea of owning a gun would make them sick to their stomach. Or we would avoid them from getting those guns to begin with in a lot of cases. (Not all cases. Let’s not fall for the Nirvana Fallacy here.) But we don’t even get that, and families of slain officers and regular citizens have lawsuits that “have been dismissed on the basis of the law, even when the gun dealers and manufacturers acted in a fashion that would qualify as negligent if it involved other products. Victims in these cases were denied the right to introduce evidence of negligence and seek justice.”

But let’s switch gears 1,500 words into this blog post and talk about violence in general and how we in public health are starting to see it as something more akin to an infectious disease which has a mechanism of action and can be preventable. (Though it can’t be grown in a petri dish.)

Image derived from “Welcome” by Phil Rogers via Flickr, CC by -NC 2.0
There was a workshop in 2013 on the “contagion of violence.” From the summary:

“Violence is a contagious disease. It meets the definitions of a disease and of being contagious—that is, violence is spread from one person to another. This paper will clarify (1) how violence is like infectious diseases historically by its natural history and by its behavior; (2) how violence specifically fits the basic infectious disease framework—and how we can use this framework to better understand what is known of the pathogenic processes of violence; and (3) how we can provide better guidance to future strategies for reducing violence, in order to get more predictable results, and develop a clearer path to putting violence into the past.”

As an epidemiologist, I found this to be fascinating. The rest of the paper makes sense to me because the epidemiological terms used for infectious disease investigations can be applicable to violence. If you are the victim of violence, you are more likely to be violent toward others. Or, if you live in a violent home/neighborhood/society, then you are more likely to be violent toward others. Thus, violence is contagious.

Violence is also preventable. (I wish it were as easy to prevent as giving someone a vaccine.) Through information, education, and engineering controls, we can prevent most of the violence that happens anywhere. Sure, it takes a herculean effort, but it’s not like we haven’t come together on other Manhattan Projects before. Yet, before we can do something that is effective, we need to know what the size and scope of the problem is. When it comes to gun violence, politicians who tear out the Second Amendment and save it while using the rest of the Constitution as toilet paper have tied the hands of the Centers for Disease Control and Prevention — as well as other agencies — by limiting the amount of gun violence research that can be done.

This is not to say that nothing can be done. As you saw above, public health institutions are looking into the association of guns and violence to things like suicide. Lucky for us, there are people who don’t want to see the world burn, people who see those who do want to burn down the world and swear that we will fight them with everything we’ve got.

So let’s start at the beginning in dealing with violence as a contagion. First, let us confirm the diagnoses and establish our baselines. Then we determine who is being affected and how. And then we evaluate our interventions so far and the interventions to come. If all of that sounds familiar to you, it should. Those are the functions of a public health surveillance system.

I hinted at a surveillance system for violence a while back when I was telling you about the new epidemiologists. This is because I’ve been looking at such a system as the basis for my DrPH thesis. I’m thinking that, if we use the tools of epidemiology in general and disease surveillance in particular, we can come up with some really good information and ideas on how to conquer the demon that is violence in this country.

Take, for example, this graph of criminal incidents in Baltimore:

Don't look too closely at the average. I'm still working on that part.
Don’t look too closely at the average. I’m still working on that part.
Notice that there is a dip in crime that starts toward the end of the year and ends around springtime. One thing that I have noticed is that the media reports “surges” in crime between February and April, then just pretty much become “numb” during the rest of the year. When those “surges” occur, politicians come out and proclaim their latest, greatest crime prevention program. Federal, state and local police agencies tell us that they’re working together to stop it, and that the criminals will not win. Then crime levels out at a higher level and dips again in the fall.

Of course, if you see historical data and put the current surges and dips into context, you would understand that something else is working to influence crime levels. You might even be tempted to say that the surges and dips are “expected,” something that politicians would try to stay away from saying. But, if you look at the evidence, this up and down pattern has been repeating itself for a while now.

It almost looks like the flu season graph of pediatric deaths by year, doesn’t it?

Yes, it comes off as callous to say that we expect a certain number of deaths from influenza or any other disease each year. But we in public health don’t say that in a vacuum. We say it because we want the public to understand the past, current and future situation. If we see a surge in crime in April and say that it is expected, it’s not to belittle the efforts of the police. It’s to keep the public from panicking. Nothing good happens when you panic.

Also, there is a little bit of an element of pressure on the authorities when we say that we expect a surge in crime. It’s a way of telling them that something is coming and that they better get to it before it happens, just like we tell people to vaccinate — and institutions to offer the flu vaccine — well before the flu season that we know is going to come.

A proper surveillance system that looks at crime patterns and trends would help as an “early warning system” of sorts to alert the authorities that, based on previous years’ data, we are about to experience a surge in crime. This way, with a few weeks warning, things can be put into place to minimize the surge, just like we do with the flu vaccine each year.

Violence of all kind, but especially gun violence, is a huge public health problem in the United States. There are plenty of other democracies with similar values and institutions as ours where mass shootings are unheard of. The common denominator in gun violence incidents are guns, but our elected leaders seem to be more about protecting the rights of guns to exist. Simple, common sense fixes can be put into place that would not take away anyone’s guns. Instead, guns would be safer, and the people who own them would use them in a safer and more responsible way. Furthermore, those who would use guns for a nefarious purpose against others (or against themselves) would be kept away from guns, but politicians can’t even come together to prevent dangerous (not good or bad) people from obtaining guns, and engineering controls are not being put into guns by manufacturers because they don’t have to and no one is telling them to.

The good news in all of this is that more and more public health researchers, workers and policymakers are coming to the conclusion that violence can and should be treated like an infectious disease. There are plenty of prevention efforts that could be adopted to prevent violence, and there are plenty of “outbreak” response-type efforts that could be deployed to counter violence. It all starts with surveillance, though. A good surveillance system — like the ones deployed already in Colombia and Mexico City — can give tons of reliable information to decision makers, public health and public safety to attack violence and crime before what is expected comes true.

What keeps me up at night?

Glad you asked.

If you have been a long-time reader of this blog, you might think that what keeps me up at night is the anti-vaccine movement that is so pervasive in this country. They don’t keep me up at night. You might even think that it’s a doctoral student in epidemiology who is one year removed from their PhD and is blatantly anti-vaccine. They and the harm they may inflict on public health also don’t keep me up at night. Heck, you might think that it’s the Orioles melting down in a spectacular fashion this season, or whether or not Mexico make it to the World Cup in soccer.

None of that keeps me up at night. Continue reading

Colombia, Addendum #3: The origins and causes of disease at a population level

For the record, I’ve never claimed to be smart. Heck, I’m convinced that getting into the most prestigious public health school in the world is a fluke, more the result of inspiration and guidance from some very smart people than from my actual achievements. Some people tell me that I’m suffering from “impostor syndrome,” but I’m pretty sure I’m the dumbest person walking those halls… The dunce amongst the nerds.

Upon seeing a picture of the places where I went the other day, and reading the story of the mother with the special needs child, a brilliant friend of mine and fellow student at the school asked something that has had me thinking. He asked if the woman having mosquitoes in her house was a result of her ignorance or her poverty, or both. This made me think about it a lot because it speaks to the kind of interventions needed to keep Chikungunya at bay here and in other places in the world. (And not just Chikungunya. There are plenty of other vector-borne diseases.) Continue reading

A slow and painful death

Over on Skewed Distribution, I was not surprised to see a blog post about antivaxxers wishing death upon people who promote vaccines. The antivaxxer in question wrote a comment wishing pro-vaccine people “a slow and painful death.” I jokingly commented that the joke is on them, since vaccines prevent slow and painful deaths. That got me thinking about people dying from vaccine preventable diseases, and how ridiculous it is that we still have measles and polio in the world in a time when we could eradicate them in the blink of an eye, metaphorically speaking. Continue reading