Top 3 Public Health News of 2009

This year public health undeniably became a part of our national consciousness. In order to ring in the New Year and reflect on the past year at Veritas Health, I've highlighted below what I believe to be the top three issues in public health of 2009. For those interested, the headlines link to my previous posts on the topic.

Nourishing Traditions: A book that gets to the heart of food

There is no arguing that our food system has dramatically changed over the past half century. The American diet has been overhauled with the advent of fast-food, supermarkets, and convenience foods (read: shelf-stable products all found in the interior of your local market or in those vending machines you frequent). These changes have affected public health in unimaginable ways -- not the least of which is the rapid rise of obesity and Type 2 (preventable) diabetes among adults and children of all ages.

This Christmas, I asked my in-laws for a cookbook that could revolutionize the way I think about and interact with food. That book, Nourishing Traditions, is subtitled "The cookbook that challenges politically correct nutrition and the diet dictocrats." And if that doesn't say enough -- it's filled with recipes calling for raw, whole fat dairy, lard and numerous recipes calling for whey (the liquid part of curds and whey -- or that clear, yellowish liquid that settles when you have a tub of yogurt in your fridge).

It's a Water Problem

After spending 3 months thinking and writing about sugar-sweetened beverages, obesity, and school food environments I am a little concerned about the effects of the New York Times' Toxic Waters series and peoples' consumption of water (a great alternative to all those sugary drinks).

The series is exposing the many problems with our nations' water supply (including the dangers hidden in some tap water).

Teenage Pregnancy: A Cool Website

This semester I started working with a group of Harvard School of Public Health (HSPH) students on a student-run social media campaign. After some collaboration with the Center for Health Communication at HSPH we decided to pursue an online campaign that targets pregnant teenagers in the Boston area.

Why? Because teens who become pregnant are less likely to have a healthy pregnancy and less likely to see a doctor for prenatal care. Everything from diet, activity, stress, and support are critical to having a healthy pregnancy. A healthy pregnancy leads to a healthy birth, a health birth leads to a healthy infant, and a healthy infant leads to a healthy child. You get the idea...

Is "Healthier" Healthy Enough for School Vending?

Early on a Tuesday morning, while walking the halls of Winter Hill Elementary School in Somerville, Massachusetts, I was struck by the absence of an item that has become nearly ubiquitous in schools across Massachusetts: vending machines. Vending machines are the most convenient source of exactly what you tell your kids not to eat.

States Cut Tobacco Prevention Funds

According to a recent report by the Robert Wood Johnson Foundation, all states with the exception of North Dakota have cut tobacco prevention funds.

Unfortunately, it doesn't appear to be a result of ineffective prevention efforts.

Debunking American Nutrition Myths

Darya Pino of Summer Tomato (an amazing blog with lots of health and nutrition information) promoted this video. It's amazing -- Dr. Lustig of UC San Francisco debunks popular nutrition myths, particularly related to sugar consumption by tying together the science of public health, nutrition, and biochemistry.



Hope you enjoy!

Mammography Guidelines Revisited

Reaction to the updated mammography guidelines -- see previous posts on the topic -- from the US Preventive Services Task Force (USPSTF), a panel of experts charged with determining guidelines for cancer screening, has reached partisan proportions. Republicans are trending toward outrage and Democrats sympathy.

World Aids Day: Youth Finding a Voice

Today is World AIDS Day. I read an article in the Huffington Post written by a graduate of Harvard School of Public Health, Rena Greifinger, and some colleagues about the impact of HIV on youth. She discusses a global phenomenon that

"Young people 10 to 24 years old make up one of the most vulnerable, yet historically overlooked populations affected by the HIV pandemic."

But brings the issue close to home -- 330 young people currently living in Massachusetts were infected with HIV at birth.

While the numbers seem small, the stigma surrounding life with HIV/AIDS lends a heavy burden to those affected, their friends and family.

Read the article, it's short, it's personal, and it's inspiring.

House of Hope Holiday Cards For Sale!

This past summer I traveled to Nicaragua and Costa Rica to meet with organizations that were trying to help women leave prostitution and that were providing health, education, and other services to women and girls would had been exploited sexually. One of the organizations that I spent the most time at was House of Hope (see my first blog post on my experience).

One of the weekly House of Hope activities is a large group activity where women come from around the city to make greeting and holiday cards each Tuesday. I brought home a bag full of cards to sell here in the States and am hoping that some of you might be interested in buying a pack or two.

Sampling of Christmas/Holiday Cards

Each pack contains 10 cards and envelopes and has been handmade by women, young and old, who are seeking an alternative to prostitution and an opportunity to hear about God and Jesus. Some of the cards use recycled paper that is made right at House of Hope, as well. I'm selling each pack of cards for $6 or two packs for $12, all of the money will go directly to House of Hope.

You can let me know if you prefer to buy Christmas, holiday, or greeting (thank you, happy birthday, even wedding!) cards. House of Hope has pictures of all the Christmas cards and the messages inside or click here for pictures of other greeting cards. I will check my stock if you are interested in a particular design.

Sampling of Birthday/Wedding Cards

House of Hope relies on generous giving in order to provide shelter and free education and health services to the children and families that live at their residential site. When I was there most of the bodegas (homes) were full, but they were unable to expand because they need a committed sponsor before allowing another family to join them.

If you are in the Boston area and interested in buying cards, please comment to the post or send me an email. If you would like me to send you cards somewhere else in the US, contact me, and we can try to work something out!

Sampling of Thank You & Blank Cards

Hope you had a Happy Thanksgiving and enjoy this holiday season!

Making Mammography Screening Guidelines: Two approaches

So how did the "experts" at the US Preventive Services Task Force (USPSTF) come up with the "new" mammography guidelines, anyway?

As you read in yesterday's post, the decision was based primarily (or fully) on the findings from epidemiological data (i.e. population-level health research, rather than medical case studies, case histories).

While an epidemiologist (...a "social epidemiologist," really) at heart, I am taking a decision sciences class that is completely fascinating and speaks to the pitfall of relying on critical research reviews and other ways to "understand the evidence" in a traditional way. For example, rather having the USPSTF make recommendations based on their understanding of epidemiological literature alone, it could use that literature to inform a decision sciences or decision analysis approach, instead.

Here's what I'm thinking...

So without getting to far into it, here's the basic decision science methodology, as I (a newbie) understand it. You create a lot of "trees" that reflect the probability of a particular outcome for a decision that you may make. For example, you can model the survival (the outcome) of a woman with breast cancer that receives a mammogram every year (decision #1) versus a woman that receives a mammogram every two years (decision #2). You can determine how survival is difference given certain predisposing characteristics (or risk factors -- family history of breast cancer, for example) and also consider what her survival would be if she tests positive and truly has breast cancer, as well as if she tests positive and does not have breast cancer.

There are problems with this approach, of course -- for example, if you are basing your decisions off of faulty probabilities or inaccurate scientific data. Nonetheless, decision analysis is well poised to deal with issues related to testing (or screening, such as mammography) where receiving a false positive result (you are told you have the disease when you really don't) is common or when a false negative result (you are told you don't have the disease when you really have it) is common.

I doubt USPSTF used a decision analysis approach given what I've read on their website. What do you think about it? Should we move in a decision analysis direction or should the traditional epidemiological approach be sufficient to make these public health decisions?

Now I get to complete my decision sciences mid-term. Yippee!

Mammography Screening Myths Exposed

The US Preventive Services Task Force (USPSTF) released "new" mammogram guidelines this week. The guidelines have received major backlash from the American Cancer Society and many cancer survivors.

Below is are some of the mammography screening myths floating around:

It's Del-i-CIOUS!

If you haven't noticed my posts on Delicious.com (linked on the sidebar to the right) you should check it out. Many of the posts are discussed in the Veritas Health blog, but many more of the bookmarks reference websites and news articles that I have never gotten to writing about.

Are you on Delicious? If so, I'd love to join your network. Just let me know!

Sugar-Sweetened Beverages the Next Tobacco?

Image from the NY City Department of Health Anti-Obesity Campaign

In class this week, we discussed strategies for reducing the consumption of sugar-sweetened beverages at home. Sugar-sweetened beverages are exactly what they sound like: any drink sweetened with sugar (sodas, fruit juices, "vitamin" or flavored waters, sports drinks, energy drinks....etc.).

The larger question at hand was: Can we utilize the same strategies that brought down the tobacco industry for reducing the consumption and availability of sugary drinks?

The idea of a "soda tax" has come under scrutiny by conservatives who don't like the idea of taxing anything, as well as groups that are strongly supported (i.e. funded) by the food and beverage industry, like the Center for Consumer "Freedom." And, yes, the quotes are my doing...

However, many in public health believe that taxation will curb consumption of sugar-sweetened beverages, particularly among those who consume the most and are most likely to suffer poor health and overweight because of it. Nonetheless, soda is just the tip of the iceberg when it comes to liquid, non-nutritive calorie consumption, especially among kids. There are many other beverages that provide just as many calories and can contribute to weight gain. What will happen when the beverage industry just switches production (and all its marketing!) to these other sugary beverages? Another tax?

Taxation of tobacco has been a primary strategy in reducing its consumption and preventing people from starting to use it. Yet, taxation of tobacco has gone extremely high! Right now the federal tax on tobacco is $1.00 per 20-cigarette pack, and states can tax tobacco even higher ($3.46). Would a soda tax ever get that high? Not likely. Harvard researchers suggest that just a $0.01 per ounce of soda would be enough to change consumption patterns of consumers; a typical 20 oz. soda would be marked with a 20 cent tax.

However, the strategy that I am most excited about is social marketing -- advertising that promotes healthy behaviors and discourages unhealthy ones. If you haven't seen the sugar-sweetened beverage ads out of New York City, check out my other post on this topic. Marketing can't just tell you that something is bad, it must suggest alternatives.

If you are looking for alternatives to sugary drinks here are a couple promoted on the Harvard Nutrition Source website:

• Plain (or Infused) Water -- I think this means throwing some lemons or cucumbers in with the plain water to add flavor without the calories.
• Tea -- Go light on the sugar and honey, of course.
• Coffee -- Choose milk over cream, go sugar-free.
• Sparkling water -- add a splash of 100% fruit juice for flavor, without packing in the calories.

The website even has a recipe for a healthy "fresh fruit cooler," which is a great alternative to store-bought smoothies. Notice, drinks that are "sugar-free" because they utilize artificial sweeteners are NOT included in this list.

Right now there is a national movement to get junk foods and soft drinks out of schools. While I believe this needs to happen soon, most kids get unhealthy foods outside of schools. A 2006 study by Harvard researchers found that 60-80% of sugar-sweetened beverages were consumed by kids at home.

This suggests that we need a national movement, not just to change school environments to provide healthier beverages, like water and low-fat milk, but also change social norms around providing sugary drinks to kids in homes.

What would sway parents to pass up purchases in the beverage aisle and stick to **free** tap water and nutrient-rich milk for kids?

That's a tough question. The strategy needs to incorporate environmental change, excellent social marketing of the health dangers of daily consumption of sugary drinks, and grassroots/community efforts. If we can get sugar-sweetened beverages out of schools (where they have no right to be!), perhaps we can raise awareness about the issues so that we can get them out of homes, too!

Could the tobacco model work? Perhaps. It may be important to look to other public health campaigns; however, to get the most insight into what public health strategies will be most effective. How about alcohol control campaigns?

Healthiest Nation In One Generation - Video

APHA Concluded

The 2009 APHA Annual Meeting is officially over. It was an exciting meeting for me. I loved networking and talking with folks from all over the country who are doing work in food and nutrition policy, public health communications, and the use of social media.

Here I am, in the picture above, presenting my summer work from Nicaragua and Costa Rica and a study that was recently published looking at the intersection of sex work and human trafficking in the International Journal of Gyneacology and Obstetrics. About 60 people were in attendance.

My fellow presenters from Massachusetts General Hospital and the Hispanic Health Council were excellent. Each of us had different approaches to the problem and/or were working with different strata of the sex worker population. The audience asked some great questions about the implications of our findings, for instance -- how can public health practitioners meet the needs of both trafficking victims and sex workers?

I hope I was able to communicate effectively the ripe opportunity for research in this area, as well as organizations' enthusiasm in Central America to partner with researchers to improve their programs and prevention activities (for instance, to inform and evaluate social marketing campaigns).

Safe travels, fellow attendees.

APHA Day 2: Exhibit Explorations

After two hours of perusing the hundreds of booths and five blisters later, I made my way through most (though notably, not all) of the exhibits housed in the Philadelphia Convention Center for the American Public Health Association Annual Meeting. The exhibits promote health and educational products, provide information on the latest medical and online technologies, share program activities and job information, and highlight academic programs in the public health arena.

Here are a few photos of my favorites.

Choosy Kids - a promotional product and education service that uses a character, Choosy, to encourage physical activity and healthy eating among kids. They even sell CD's.

T-fal ActiFry -- free samples of granola and french fries that used a fraction of the typical amount of oil to cook crisp. It cooks food crisper than the oven and doesn't require a deep fry!

PharmaJet - a needle-less injection system that hooks right up to the normal medicine bottle. No more pricks! The medicine is injected by force alone through the skin. Crazy!

Harvard Vaccination Guru Speaks Swine

Still confused about whether the swine flu vaccine is safe?

Don't know whether you should be vaccinated?

Here's an interview published in today's Boston Globe with Dr. Marie McCormick, professor of maternal and child health at the Harvard School of Public Health and the lead advisor on an expert committee that reviewed data related to the safety of the swine flu vaccine.

In response to whether she will get vaccinated, McCormick said, "When it becomes available, I will certainly have it. I do see patients in the fall, and all my patients are younger than 3, so it’s really both for their protection and mine."

APHA Day 1: Environment Matters for Health

Mayor Nutter described Philadelphia, "the city of brotherly love and sisterly affection," as a city of public health firsts during today's Opening Address at APHA. He and several other speakers talked about the many public health "firsts" that Philadelphia can pride itself with: the first medical school, the first water and sanitation bureau, the first city to require water flouridation.... 

APHA 2009 Bound!

 
Veritas Health will be tweeting and blogging from the 137th American Public Health Association Annual Meeting in Philadelphia, PA -- right near her hometown! The conference begins Saturday, November 7th and will last until Wednesday, November 11th.

The theme of this year's conference is Water and Public Health. Dr. Mirta Roses, Director of the Pan American Health Organization will be speaking at the opening session, and the beloved Dr. Howard Koh will be closing the meeting on Wednesday.

If you will be in attendance, come see my presentation on Human Trafficking and Sex Work in Nicaragua and Thailand on Monday, November 9th from 12:30-2:00pm in a session titled "The Good, the Bad and the Ugly of the Sex Worker Industry" Session 3261.1.

Public Health Practioners for Reform, a group started by students at the Harvard School of Public Health, will be marching to CIGNA headquarters on Monday, November 9th at 4pm in support for a public option in health care reform (and demanding that health insurance companies stop lobbying against a public option). If you'd like to join them, you can find more information about the march/rally here.

See you at the conference!

Can What You Eat Prevent Depression?

Did you know that eating a lot of processed foods (most of the foods in the center aisles) may be related to developing depression? A study recently reported by BBC News and passed along to a fellow colleague at Harvard School of Public Health (thanks Rachael!) has reached this conclusion -- and I am apt to agree.

Take-Home Message
Eat a diet rich in whole foods (fruits, vegetables, unprocessed meats, natural fats, and whole grains) and forgo the traditional diet of refined sugars and wheat, artificial fats, and *deli* meat and cheese.

Why should you? 
Because you can might not just impact your waist line, but also your mental health.

Gender and the HPV Vaccine

I need to take a minute to post about a non-school-health related topic: a recent study published in the British Medical Journal concluded that vaccinating males against HPV is not cost-effective. News outlets everywhere have reported on authors' conclusions.

However, are the underlying framework and assumptions of the study authors misguided?

William Saletan published a provocative (go-figure) post on Slate.com on the topic, and I think it is right on. If you have any interested in gender disparities and gender norms this is a very, very interesting topic right now!

Just as a refresher: the vaccine was developed and is currently being used to vaccinate girls. Check out a previous VH post on the male/female controversies of the HPV vaccine that I published earlier this year.

How Healthy is Your Breakfast Cereal?

Cereal is about as commonplace in the American home as peanut butter and jelly (unless you are allergic, I guess). At some point in our nations history, whole cereal grain breakfast that took minutes or hours to prepare were replaced by highly processed refined grain "cereals" that had loads of added sugar and went by the name of Cap'n and Lucky.

Until today's release of the Yale Rudd Center's Cereal Facts website, there was little way to know whether the cereal you were eating was healthy or all hype. Case in point: a friend posted a picture of Facebook with a Fruit Loops box reading "NOW WITH FIBER" on the front package (see yesterday's post for more on this...) which clearly illustrated food industry's widespread marketing of unhealthy food with their "healthy" components placed first, and foremost for consumers to see.

Smart Choices Labeling System Divided, Fails?

The "Smart Choices" label, which was meant to be a guide for consumers to make healthier food choices when shopping the supermarket, may be lying on its deathbed, according to a recent article in the New York Times. A few of the major food industry supporters, including PepsiCo and Kellogg's have cut its ties with the program and will phase out production of products (like Froot Loops cereal) with the Smart Choices logo prominent on the box front. Although, Kraft indicates it has no intentions to remove the logo from its foods.

Mandated H1N1 Vaccination: Right or...Oh, so Wrong?

A good friend and former colleague inspired this post (thanks Joanne) after realizing how media attention to mandated H1N1 vaccination among health workers has grown in the past few weeks. NPR, Time, the New York Times, ABC News all are covering what is an unprecedented move to require health care workers to be vaccinated against swine flu.

While many hospitals and clinics are requiring employees to get vaccinated, the state of New York is requiring all health care workers with patient contact to receive the H1N1 vaccine or face job loss; resistance to this mandate among health care workers has been overwhelming. Fear of side effects and privacy issues top health workers' concerns. However, an August poll shows a vast majority of the public to be supportive of these vaccine requirements among healthcare employees.

There seem to be several streams of thought regarding this issue:

1. Vaccination of all health care workers is needed to protect the public against swine flu spread by providers who come into contact with sick patients
2. Mandatory vaccination is needed to protect other patients in the hospital setting with compromised immune systems (meaning they easily can come down with an illness, like the flu).

But many nurses object, saying that they have never gotten flu in past seasons, so why now? Why this flu shot? Additionally, opponents to mandatory vaccination highlight the fact that the vaccine is not effective 100% of the time. Nurses also worry about the potential side effects of vaccination, particularly whether it would cause them to get sick with the flu.

How to Lose Weight in Ten Days

Gimmicks.

Losing It
Weight loss isn't easy. The following weight loss plans: Atkins, South Beach, Green Tea, Low Carb, Low Fat all have one thing in common: they focus on diet. Why do all these weight loss fads all focus on changing what you eat? The answer may be simpler than you think: results. Changing what you eat is the quickest way to lose weight. Eat fewer calories and you will lose weight, all else being equal.

What does it take to burn 300 calories through physical activity? Likely, an hour of brisk walking or a 3 mile jog. What would it take to eat 300 fewer calories? Forgo the tortilla at Chipotle or the beef in your stir-fry. For many people, changing diet is more convenient and less challenging (mentally and physically) than becoming more physically active.

Battleground School Food

It may be a fluke or it may be fortune that the New York Times has taken up the "cause" of school food and nutrition in the last week or so. First there was the article profiling the cafeteria at a popular New York City public school in Queens. Then, Saturday, they ran an article on the ban of sugary foods from public schools in New York City even for celebrations (think kids' birthdays) and bake sales or fundraising activities. Actually, the 'bake sale ban' is not something new, it was issued in June but is just beginning to be implemented.

After my Public Health in the Media class last year (take it if you get the chance...I'll be the TA!) I am sure that it is not a mere coincidence that school nutrition has landed in the newspaper several times in the past month. I think the reason that the New York Times is talking about school nutrition policy is because people are starting to care about it! People want someone to do something about childhood obesity and schools are a natural starting place.

But it is important to ask: Does the ban on sugary snacks and treats in schools go too far?

School Nutrition Policies, MA on my mind

As I mentioned on Twitter this morning, french fries appear to be the lunch food of choice for students in a popular school in Queens, New York, according to the New York Times. That probably doesn't surprise anyone who works in a school or has visited one during lunch. Unfortunately, I have not.

Nonetheless, my memories of school lunch are not much different. I remember tater tots and pepperoni hot pockets being standard fare. By the time I graduated, there was a salad bar in place; it was not very popular. Occasionally, I opted for the food served as part of the National School Lunch Program (spaghetti comes to mind) and on days of cross-country meets I habitually ate a peanut butter and jelly sandwich, which was a pretty good choice thinking back on it.

Is Extreme Public Health the Answer?

I'm taking off my "reporter" hat for a moment to share some public health talk I've been mulling over lately. You know the uproar over health care reform and the public option? Of course you do! How about the fury and debate over the state and national initiatives to tax soda and other sugar-sweetened beverages? Or the resistance of businesses, "consumer groups" (i.e. backed by the food industry), and others to put nutrition information on menus and point-of-purchase sales in fast food chains and restaurants?

The list goes on and on of public health initiatives that create waves in the ocean endearingly called "status quo."

My question: do public health initiatives have to be extreme to be an effective solution? (I'm going to leave extreme undefined for the moment...but basically, I'm talking about "extreme" as to the degree it causes public reaction, corporate unrest, and resistance). Or, as I asked my mom, "Do you have to be a wacko to get the job done?" I was being facetious, kind of.

My response after much reflection: Yes.

Let's embrace it!

Going to the Park? Walk or Bike!

Just in case you need a little nudge to ride your bike to work or walk to get groceries here's further evidence that "active" transit (i.e. walking or biking to get somewhere) is associated with better health. In the latest American Journal of Preventive Medicine one year of data was taken from a 20-year follow-up study to assess whether walking or cycling compared to only using a car to get around was associated with Body Mass Index (BMI), waist circumference, and fitness.

News Flash

The intersection between the environment and public's health has made recent headlines in the New York Times. I wonder if it is any surprise that conditions related to CAFOs (concentrated animal feeding operations) are implicated in at least one of the public health disasters. Here two of the most interesting (and disturbing) stories I read recently:

• Health Ills Abound as Runoff Fouls Wells - The New York Times reported today that excess cattle manure is contaminating local water systems. The pollution is resulting in a wide-range of health problems including diarrhea, ear infections, and skin rashes. The problem appears to be in the enforcement of laws already on the books. Local communities need more safety mechanisms in place to identify and prevent possible sources of water contamination and to act quickly once a problem is identified.



• Clean Water Laws Are Neglected, at a Cost in Suffering - A Sunday special in the New York Times investigates the problem of contaminated drinking water, beginning with a community in coal country West Virginia. Though legislation is in place (the Clean Water Act and the Safe Drinking Water Act) both are systematically violated resulting in dental caries, skin rashes, and likely far greater medical conditions. Again, regulators are overwhelmed, but urgent action and redress is needed.
  
  
  

Soda Tax To Combat Obesity, Will it Work?

Cigarettes are taxed, alcohol is taxed, why aren't soft drinks taxed?

One huge reason for the dirth of legislation levied against unhealthy foods including sodas is the enormous lobby of the food industry in DC and across the country. Whenever there is serious consideration of restricting access to unhealthy foods (such as in public schools) there is enormous resistance. Big Food has lots of money to manipulate (I mean influence) public opinion so that there is not enough momentum and public support for anti-junk food policies. The sad story is that public health professionals can have nearly the same trouble improving access to healthy, nutritious foods in these same places!!

The lead story of the Business section of today's New York Times was "Tempest in a Soda Bottle: Proposed Tax on Sugary Beverages Debated." It discusses the increased political open-mindedness to the idea of a tax on soft drinks and sugar-sweetened beverages in the US and the likely resistance to such a proposal.

Here's why I think this could be a good idea.

Smoking Outside, A Public Health Threat?

The New York Times has been impressing me recently with its coverage of public health issues. Sure, health care reform makes that coverage pretty much a no-brainer, but today's front page article on the proposal to ban smoking outdoors in New York City definitely peaked my interest. It is part of the "Take Care New York Plan 2012" and includes other public health proposals in addition to banning smoking in public parks and beaches.

New York City has long been an early adopter of public health initiatives, such as eliminating trans-fat from prepared foods, improving menu labeling in fast food chains to include calorie counts, and banning smoking from nearly all indoor spaces.

The proposal, launched by the NYC health commissioner, Dr. Thomas A. Farley, to ban smoking from public, outdoor spaces is not without precendence, as the article points out:

"A number of municipalities — particularly in California — have banned smoking at outdoor parks, playgrounds and beaches. In 2007, Los Angeles extended its smoking ban, which already covered beaches and playgrounds, to include municipal parks. Later that year, Chicago banned smoking at its beaches and playgrounds, though smoking is still allowed in many parks."

Nonetheless, there is much controversy over the need for such a ban. What are its objectives?

Low-Fat Diet Disaster

Saturated fat has historically been the "number one enemy" of dietitians and nutritionists. For decades, popular thought was that the most effective way to lose weight or to prevent weight gain was to eat a diet low in fat. This approach to weight loss and management has had disastrous consequences; however, because of its subsequent timing with the explosion of refined carbohydrates (as opposed to whole grain foods) and sugary beverages.

Indeed, there is little, if no, evidence that eating a diet low in fat will result in weight loss in the long-term. We discussed eating patterns, such as a low-fat diet, in a class I am taking this semester on Obesity Epidemiology with Frank Hu, author of the book by the same title.  In it, he reviews the most current research on the causes of obesity and the health consequences of obesity. Oh, and you thought obesity was itself a disease.

Missing the Health in Health Care Reform

Michael Pollan was preaching to the choir today in his New York Times op-ed piece on "Big Food Vs. Big Insurance." His words were music to my ears:

"...the fact that the United States spends twice as much per person as most European countries on health care can be substantially explained...by our being fatter. ...

That's why our success in bringing health care costs under control ultimately depends on whether Washington can summon the political will to take on and reform a second, even more powerful industry: the food industry."

As excited as I was to hear Obama's rallying cry on health care reform last night, I was disappointed to hear prevention offered as a critical element of reform only one, maybe two, times.  Prevention isn't a sexy or politically inspiring topic, I know. Yet, public health is all about prevention. Public health is about "creating the conditions in which people can be healthy."

The food industry has significantly changed the way Americans (and populations globally) eat. Few countries have been spared. Those that refuse to let huge US-based multinational food manufacturers in, or that limit their reach, have often met much resistance and criticism. Yet, as Barbara Kingsolver would say, these resistant countries are protecting their food culture. They are also consequently protecting their health.

In an effort to get the cheapest, most convenient food we have sacrified quality, nutrition, and health. We have kids in America who are both obese AND malnourished. How have we let that happen?

While I am all in support of health care reform moving forward, it will in no way be a panacea for America's poor health. There are enough players out there who want to profit from sickness, not just the insurance companies. Pollan has brought this to our attention, once again.

Obama Health Care Speech, Meat and Meaning

We know we must reform the system. The question is, 'How?'

- President Obama, Health Care Speech, September 9, 2009

Tonight at 8pm Eastern President Obama made his appeal for passing health care reform. Prescriptions columnist David Herszenhorn had a timely piece in the New York Times this morning, "How to Watch the Obama Speech." Where was Herszenhorn right? Where did he go wrong? This is my attempt at establishing whether, as my journalism professor put it, "it was worth the effort."

Can We Harness New Media for Public Health?

After a year of public health blogging I have numerous questions on the utility and impact of new media on public health. While there is no technical definition of "new media" that I am aware of (please tell me if you have one) this is what I mean by the term:

"Interactive digital media, such as the Internet, as opposed to traditional media such as print and television" (from Wictionary - an example of new media in action).

Other types of new media that I regularly interact with include: Facebook; Twitter; personal and community blogs; Delicious; Yelp; YouTube; LinkedIn; and, of course, my cell phone. A few of these examples fall into the social media category. In other words, it is used to primarily network with others and to build relationships. Others are primarily used for communicating and documenting ideas, activities, and information.

There are a variety of ways to use new/social media...and that brings me to the questions that I just keep on asking myself...

Support Healthier School Lunches TODAY!

Slow Food USA is sponsoring a National Day of Action (today, September 7, 2009) which includes hundreds of "eat-ins" (a.k.a. pot lucks) all across the country. You can log in to their website to sign a petition to improve school lunches, spread the word, or attend an eat-in.

I heard about this too late to attend an eat-in; if I hear of more in the future I will try to get the word out sooner! Labor day was full of activity (including a health care reform rally in the Boston Commons) and you can't be all places at once.

Keep an eye out for the Child Nutrition Act, which has to do with the National School Lunch program and will be up for "reauthorization" at the end of the month. Civil Eats had a recent blog post on the topic which really drives home the urgency and timeliness of this issue!

Banning Peformance-Enhancing Drugs from the Military?

While today's New York Times article is titled "A Focus on the Effects of Dietary Supplements Among Troops in War Zones," the article actually discusses the use performance-enhancing (PE) supplements meant to build  and maintain muscle mass quickly by our U.S. troops.  At first glance I thought the article might talk about Vitamin D or Calcium intake; a poor editorial title choice if you ask me.

These PE supplements have been clearly linked to heart problems and several deaths, and military health experts are concerned that the conditions of deployment (e.g. hot climate, increased stress, high activity) might create a heightened risk for these serious health outcomes.

While performance-enhancing drugs carry with them health risks (many of which have only recently been acknowledged), they also do increase strength, endurance, and help users fight muscle fatigue. It seems to me that these are desirable outcomes for men and women who will be fighting insurgents and charged with strenuous tasks that require peak performance.

This will be a difficult decision for those in the Secretary of Defense. Surveillance of PE supplement use and associated health outcomes should be integrated into the military health system if they are serious about understanding the scope of the problem. 

What do you think should be done?

"Smart Choices" Is Fool's Gold

The New York Times today ran a story today on the "Smart Choices" food labeling campaign that is being heavily endorsed by the biggest food industry players. The program claims to respond to consumers' need to be able to make quick, convenient choices on "healthier" food products. I mean, who has time to read through ingredient lists and nutrition labels? Well...I do. But, I know most people do not. Nonetheless, despite its good intentions, this food labeling system is inherently flawed.

Actually, this is a public health abomination! Walter Willett (whose name often appears on Veritas Health), is actually quoted in the article as saying "These are horrible choices." Enough said.

It is really no surprise to me that the article was titled "For Your Health, Froot Loops." As I've written before, sugary breakfast cereals seem to be constantly popping up in marketing to parents and kids as a nutritious breakfast food. It's as if food manufacturers fear people will find out that highly refined, processed cereals are not that great for them and switch to something that resembles what one might find at a farm somewhere (fruit, eggs, dairy, etc.).

So why am I so upset by this? It's just a few labels, right? Well, not exactly. This is an example of industry exploiting a true (Veritas) public health need. Consumers, parents especially, need to have a more simple, credible system on which to base their food choices. This, as Willett dually notes, is not a credible system.

It is not as though parents are choosing between donuts and Fruit Loops as Eileen Kennedy of the Friedman School of Nutrition Science and Policy is quoted as saying. Indeed, it will be more likely a consumers' choice between Froot Loops and some other "un-labeled" potentially healthier cereal product. One that possibly is unable, or unwilling to pay the annual $100,000 dues for the label.

As Kennedy notes, those products without the "Smart Choices" label will be perceived as nutritionally inferior, and, even worse, that those with the label are good for you. I believe there is a big difference between what is good for you and what is "better" for you...relative to something that is really "bad" for you. Come on, "Cocoa Puffs" do not provide any of the health benefits of cacao and there is no fruit in Froot Loops.

Other questions I have: What must companies do to get the "Smart Choices" label? And why are there such generous guidelines for what products qualify? Since when and who exactly decided that Coco Puffs and Froot Loops (in addition to many other similar products, I presume) are actually smart choices? This statement in the article is telling...

Ten companies have signed up for the Smart Choices program so far, including Kellogg’s, Kraft Foods, ConAgra Foods, Unilever, General Mills, PepsiCo and Tyson Foods. Companies that participate pay up to $100,000 a year to the program, with the fee based on total sales of its products that bear the seal.

Recently, I read that if it requires a label it probably isn't that good for you. Here's to simple criteria. In general, stick to foods that don't require a label to tell you that it is a smart choice.

Health Reform Update: Congress Resumes

What has happened to health reform? 

If you are like me, you are wondering if this "deep sigh" of health reform silence will turn into a coma or a comeback. Will health reform get its much needed second-wind? The New York Times today reported that President Obama hopes to create momentum in Congress for health care reform as senators and representatives return from their roller-coaster of an August recess. Obama will be focusing his speech on bipartisan points of agreement (though it may be up for debate whether any really exist). Here are a few that the article notes:

• Regulation of health insurance companies to eliminate denials in coverage based on medical history or current condition.
• Creation of federal subsidies to make insurance affordable to financially vulnerable, low-income populations.

...Did anyone else notice that this is a fairly short list?

It's no surprise that the Times reporters began comparing this speech to the one given by Bill Clinton 16 years ago. 

On a much brighter note I get to follow this story as it develops over the next few months -- mandated Times reading courtesy of my reporting on politics and policies class. Boy, am I excited!!

Web Resources

Thank you for checking out my favorite web resources for the latest public health information. Just a reminder that this is a work in progress. I would LOVE your feedback. Suggestions?

US Health Care

• Kaiser Family Foundation (health reform, medicaid/care, media, state policy)
• American Public Health Association (health care reform, advocacy)

Food & Nutrition

• Center for Science in the Public Interest (advocacy, health and nutrition)
• California Center for Public Health Advocacy (research, advocacy, obesity, policy)
• Harvard Nutrition Source (nutrition, diet)

Gender-based Violence

• Harvard Humanitarian Initiative (humanitarian assistance, research)
• Family Violence Prevention Fund (family and intimate partner violence)

Social Determinants of Health

• Robert Wood Johnson Foundation (disparities, health reform, childhood obesity)
• The Urban Institute (economic and social policy)

Global Health

• Global Health Council (global health, information dissemination)

NYC Ads Target Sugar-Sweetened Drinks

This is the most eye-catching public health campaign ad that I have seen in a long time that does not have to do with violence. While it specifies cutting back on sodas in the text, the liquid resembles sugar-laden iced team more than Coca-Cola and could apply to a wide range of beverages.

In fact, you can check out the entire ad campaign at the New York City Department of Health website, which shows a series of three ads: one with a bottle of Coke being poured, one using Gatorade, and one with the Snapple (of course, these bottles are not actually branded as such...). You can comment on the posters at the nycHealthy blog here.

The ad was first brought to my attention by Dr. Oz (known for his frequent guest appearances on Oprah) on Twitter who asks whether the ads are "too much?"

Too much of what? The truth?

I love this edgy ad campaign that pushes the boundaries and wakes up America to the food traps that are destroying our health and costing us millions, even billions of dollars health care bills for preventable illness. Sugar-sweetened beverages are low-hanging fruit with lots of empirical evidence to support their limited consumption. I wonder whether this campaign will be extended to other States and regions, as well.

Way to go NY City Department of Health!!

One Year of a Public Health Blog!

August came and went so quickly that I hardly even realized that there is an anniversary to celebrate -- one year of Veritas Health, my beloved public health blog. I started Veritas Health because I could not find anything on the web like it. Individuals just didn't seem to be writing about their public health experiences or ideas on the web! Now I not only have a public health blog, but am Co-Editor at the new HSPH Connection blog and have a Twitter account (which is in dire need of followers...)!

More recently I have noticed a flurry of internet public health activity. Departments of Public Health have Twitter accounts and even CEOs of large hospitals have their own blog. This public health and new media thing is really beginning to catch on.

Nonetheless, it would be inaccurate ignore that Veritas Health was also a way for me to chronicle my own public health journey. One that is far from complete. This week I begin my second year at Harvard School of Public Health. I am excited to be taking classes in communication (*hopefully*) and financial management at the Kennedy School of Government and Harvard School of Education, as well. I look forward to broadening my graduate school horizon and learning from professors and students not immersed in public health themselves.

I hope my readers will be patient with me as school ramps up, it is likely that posts will become a bit more infrequent (though I promise to still regularly post...whatever that may mean). I have lots of ideas and a Veritas Health New Year's resolution list to achieve!
Happy Anniversary Veritas Health.

An Eating Local Challenge @ TastyKate

I have decided to commit to increasing my consumption of locally grown/raised foods during my last year at HSPH (Harvard School of Public Health). It was difficult to decide whether to initiate this using Veritas Health or my food blog, TastyKate, but finally decided that TastyKate was a better venue. Check out my first post here.

There are many barriers to healthy eating that we, in public health, are always throwing around. Healthy food is too expensive. It's not available. It takes to much time to make. I'm going to try to put some of those theories to the test.

I hope that you will follow along. This will certainly be an adventure.

Can Chemicals in Drinking Water Be Safe?

How about an article in today's New York Times:

Debating Just How Much Week Killer is Safe in Your Water Glass

It would be impossible to eliminate all chemicals and microbes from drinking water, right? Rather than elimination, the EPA often sets standards of "allowable" levels of chemicals and microbes in the water supply. For example, a chemical used to kill weeds, atrazine, has been considered safe when the yearly average does not exceed 3 parts per billion and the daily dose remains under 297 parts per billion.

New evidence suggests that atrazine may be particularly harmful for the babies' development. While still in the womb, dosages exceeding just 1 part per billion were associated with low birth weight and birth defects (if you find this article please pass it along!). In animal studies, atrazine exposure has been associated with development of cancer. Epidemiological studies suggest that there may be increased rates of some cancers, including prostrate cancer among people with close contact with atrazine, as well.

The most recent EPA document on the health concerns of atrazine (dated October 31, 2003) states that

"the Agency does not find any results among the available [epidemiological] studies that would lead us to conclude that a potential cancer risk is likely from exposure to atrazine."

This statement is echoed in their July 2009 Status Update.

It seems like common sense to assume that any chemical that kills weeds would be safe to consume, and that the fetus of a pregnant woman may be particularly vulnerable to such exposures. To determine a cause-effect relationship here is extremely difficult, however. This is because the most convincing way to "determine" causality is to conduct a randomized-controlled trial, which would require subjecting some women (pregnant women?) to be randomly assigned to receive potentially dangerous dosages of atrazine.

The UK has banned atrazine because of how easily it contaminates groundwater. What is keeping the US from doing the same? Is there a safer alternative? Or has our dependence on industrialized farming found yet another cause for public health concern?

My Public Health Passion: Round 2

Day by day I am getting closer to identifying what makes me spring out of my chair, telling each and every person I meet the latest offense against our nation's health. Some days it is fast food commercials. I get so angry over them because I know they work! For example, I craved Dunkin Donuts for about two weeks before finally giving in and getting a Boston kreme donut (240 calories, 9 g fat, 13 g sugar - and no nutritional value). It wasn't that good. And one day I will surely give in to my McMocha temptation because of those darn commercials and advertising everywhere -- not to mention all the coupons!

Someone please tell me WHY is it so difficult to put our heads together and come up with the best freakin' spinach and beets commercial that would knock even KFC's socks off? How can we get our kids, teens, and adults craving colorful kale and blueberries, rather than Coco Puffs and Poptarts? Does Popeye need to make a comeback?

Also, while I don't like to characterize myself as particularly "political," I was taught early on in my public health studies that there is no public health without politics. Given this reality, I have often been extremely fired up by the lies and deception of headline-headed politicos who would rather communicate falsehoods and create fear-mongering than present the facts to their constituents in a thoughtful way (think: health reform). I think politics often produces fear. Fear paralyzes progress. This is why it takes so much time to achieve so little systemic change. We must move beyond a dialogue of fear, in order to debate the true issues at hand. In health care reform this means covering the uninsured and reducing health care costs. This could be done in SO MANY different ways (though I would argue that a cooperative is not going to be one of them), using evidence-based solutions.

So what is next? It's time for the job search to begin! I have decided that I definitely want a job doing some sort of communication. This could be to policymakers, public audiences, or public health professionals. It will likely involve the communication of rigorous research or its implementation (I didn't take all those methods/epidemiology courses for nothing!). The forum could lend itself to me expressing my opinion on a specific topic (sort of like I do on this blog -- but a bit more focused) or I could serve as the go-between for the researchers and the programmers/policymakers. My ideal organization will deal head-on with social and environmental aspects of public health (neighborhoods, built environment, marketing/advertising, schools) and will probably work in the area of nutrition/obesity, food policy, or healthy lifestyles (diet and exercise).

While my aims are still quite broad, I like broad. I've always been more of a "well-rounded" individual than an expert in any one thing. Eventually that is likely to change, but for now I need to embrace it. There will be a place for me, out there...somewhere. If I am lucky it will be in Menlo Park or Palo Alto.

Racial Disparities in Boston Swine Flu

Health status differs by race and ethnicity. This is not news to people working in the health arena, in fact an entire department of the Boston Public Health Commission is focused on reducing racial health disparities. Often such inequities in health are assumed to be a result of genetic differences or differences in income or socioeconomic position. However, social and environmental factors are also an important consideration.



The latest racial health disparity to reach the front page of the Boston Globe is the increased prevalence of swine (H1N1) flu cases among African Americans and Hispanics in Boston. Stephen Smith of the BG reported that H1N1 cases are clustered in neighborhoods with a high proportion of residents of these racial and ethnic backgrounds.


Dorchester, Roxbury, and East Boston were particularly hit hard this Spring and Fall by the swine flu. Why might this be the case? The two theories presented in the BG report include:

1. Crowded living conditions -- densely populated areas may precipitate the conditions needed for person-to-person transmission of the virus.
2. The composition of the local public schools -- the over-affected neighborhoods have a large Hispanic and immigrant school-aged population may have facilitated the spread of the virus in these communities.

These two theories represent the major challenge of social epidemiology. Are health differences a result of the people? or the place?

If the increased prevalence of H1N1 among African Americans and Hispanics is due to the people, then changes to living conditions would have no effect on the residents' health. If the increased prevalence is due to living conditions, then why try to change individuals' knowledge or behaviors? Activities targeting people would have no impact.

Likely the reason for increased risk of swine flu among these racial/ethnic groups is a combination of the two. Hispanics may be more likely to have recently traveled to or been in contact with someone who was in a high-prevalence area (such as Mexico City) or those most affected may have less knowledge of flu prevention activities. On the other hand, housing conditions and other neighborhood characteristics (lack of health care/vaccine access, less penetration of media messaging on how to prevent flu, etc) may have resulted in the heightened risk.

These hypotheses are even more complicated since residents in the over-affected Boston neighborhoods are also at higher risk for a variety of health issues that could compromise their immune systems, increasing their susceptibility to more severe cases of the H1N1 virus. Are those other health issues due to the people? Or the place?

The answer to that question has important implications for the type of prevention programs and actions that will be taken in the coming months to prepare for flu season. Would you try to change individuals' behaviors and raise awareness? Or would you tackle the social and built environment?

Resource constraints make it difficult, if not impossible, to attack every issue from all sides - which would you prioritize and why?

Gluten-Free = Wallet Woes

After a few months living in California I was struck by the number of food allergies and intolerances of my friends, colleagues, and their families. Gluten-free, lactose-free, peanut-free, pit-free...the list goes on and on. I don't believe that these diseases are just more 'common' in people living in the Bay Area, rather I think it is more likely that doctors (and patients) are probably more aware of food allergy signs and symptoms and thus more apt to screen for and diagnose these problems. In a highly educated, wealthy area like the Penninsula (i.e. Silicon Valley) this makes sense.

The peanut allergy epidemic (I'm not sure that it would officially be characterized as such....) that led to pretzels in airplanes and banning of peanut products in some schools surely raised America's awareness about some food allergy issues. Lactose intolerance has been around for a long time and is fairly well-known. Although many Americans suffer through stomachache after stomachache unwilling to believe that glass of milk or bowl of ice cream could be the culprit. Celiac disease, an extreme form of gluten intolerance is another story.

This week the New York Times ran an article on Celiac disease entitled 'The Expense of Eating with Celiac Disease'. Celiac disease (CD) is an immune disorder triggered by eating products containing gluten (a protein found in most of America's staple grains: wheat, rye, and barley). Even products that you might not have these grains as a primary ingredient may contain traces of it that can trigger extreme pain and health problems for someone with CD.

While the number of Americans with CD is fairly small, a recent epidemiological study in Gastroenterology shows that the disease is more common now than in the 1950s. Lack of diagnosis and treatment of CD also seems to increase the risk of premature death (nearly 4 times!). Though few people are diagnosed with full out CD, many more likely suffer from gluten sensitivities (or intolerance) that might not reach clinical or immunological proportions. Avoiding gluten for the gluten-sensitive can result in greater energy and stamina, fewer digestive problems, and an overall feeling of wellness.

Nonetheless, dealing with health conditions related to food allergies and intolerances, including CD is not covered by health insurance in the US. This is because, as the NY Times article points out, there is no pill or prescription to treat it. The regimen: a strict, allergy-free diet. For those that can't have gluten this means avoiding many cheap, inexpensive, American staples. It means eating more 'whole foods' (fruits, vegetables, meats, legumes, etc). If you think I'm kidding, go to the grocery store and compare the price of a bag of brown rice flour to a bag of wheat flour.

Apparently in Britain, those with CD are afforded insurance coverage (albeit through their government plan) to help offset the added cost of a gluten-free diet.

I think these lifestyle changes are often overlooked by health insurance companies because they don't fit the pharmaceutical quick fix framework. However, I hope that there is good debate over how these types of real-world issues related to a diagnosable, medical condition can be subsidized and included in an insurance plan (even if its through that pre-taxed flexible spending account that you can use to buy over-the-counter drugs and copays).

• For more information on how to eat gluten-free on a budget read the NY Times article.
• For more on the article in Gastroenterology read the following review in Science Daily.
• For recipes and cooking tips/ideas check out one of my favorite food blogs: Karina's Kitchen (aka the gluten free goddess).

Reuters Picks of Trafficking Story in SE Asia

After months of hard work compiling data for the United Nations Development Programme our final report on the intersection of HIV/AIDs and sex trafficking was presented in Bali (see my previous post on this international conference). Reuters picked up the story and published it in its AlertNet section on Wednesday.

Trafficking is a public health concern and HIV/AIDs illustrates one of the major ways that trafficking may contribute to infectious disease spread rapidly throughout a population. Our study entitled, "Sex trafficking and STI/HIV in Southeast Asia: Connections between sexual exploitation, violence and sexual risk," looks at the relationship between sex trafficking and sexually transmitted infections (STI) and HIV in Malaysia, Indonesia, and Thailand.

The Silverman lab at Harvard School of Public Health is currently working on more publications on the topic, with the hopes of disseminating our findings in influential (i.e. widely read) public health journals. We need to raise awareness about the horrific practices and trauma experienced by these women and girls, and we need to better understand how to prevent and protect women from trafficking of any kind.

For more on this topic check out the website of Not for Sale a great non-profit organizations committed to fighting human trafficking world wide.

When Kids Lack Calcium and Vitamin D...

...feed them Trix and Lucky Charms?!

The commercial begins with two cute kids in the frame. One is trying to figure out the other's height with measuring tape; they are playing in a large kitchen. Then the fact, which is something to the effect of

"Did you know: not enough kids are getting enough calcium and vitamin D in their diet."

So what does the ad suggest? Feed your kids more vegetables (dark green leafy vegetables are a good source of calcium and salmon or tuna are excellent sources of vitamin D)? Encourage your kids to play outside during the day (sunlight is the best way to help your body produce its own vitamin D reserves)? No...

It's General Mills (GM) to the rescue! The sugar laden cereals they manufacture have added calcium and vitamin D. Didn't you know? And your kids may be fussy over collard greens or baked salmon and they love video games so much that you would be interrupting their valuable screen time to take them outside...so just feed them their favorite cereals. I'm not dissing all cereals, though I do wonder how they became such a staple in the American diet. It's just that I could think of a million things to market to increase kids intake of calcium and vitamin D, and Trix (it's for kids!) is NOT one of them.

Not to mention the fact that the universal companion to cereal (i.e. milk) has 30% of the daily recommended amount of calcium and 25% of the daily amount of vitamin D.

We've heard about the benefits of calcium a million times. But why is vitamin D so important? Vitamin D has been shown to promote bone strength and muscle growth (oh...you thought that was the calcium?). It may even protect against some common cancers.

The Harvard School of Public Health Nutrition Source suggests that most adults take a vitamin D supplement (especially those in colder, northern climates). I actually just bought some vitamin D3 (1,000 IU) at the health food store today. I plan on having it on those days when I just don't get to exercise outside (winter...brr...). I'm not sure that I would give that much (400 IU/day is recommended for children).

Back to the commercial...

It aired on the Food Network around 6:30pm today, at least that is when I saw it. Will the marketing tactic work? Without communicating alternative, natural sources of calcium and vitamin D it just might.

The Ugly Truth: We Already Ration Health Care

Save Dick Cheney or protect 180,000 kids against measles? ...interesting question...

The debate about rationing health care and reducing choice is somewhat misleading, if you ask me. We already ration health care based on our health insurance (the more expensive, the better the coverage) and our employers decide what doctors we can see and what benefits we have by deciding which insurance companies employees can use.

A recent article by social entrepreneur Jonathon Lewis really drove this home for me today. He wrote in his blog,

"Rationing healthcare is what health systems do. No scheme, no government, no insurer, no individual (save perhaps the über-rich) has unlimited money to buy all the healthcare everyone wants."

He contrasted the health care services received by former Vice President Dick Cheney (after years of smoking he suffered four heart attacks since age 35!) with those that would have been received by an uninsured domestic worker (those low-wage earning house keepers and landscapers the wealthy so often "employ"). Morever, he asks,

"Would you deny the Vice President, a former heavy smoker, his quadruple bypass surgery (estimated cost: $45,000.00) to pay for inoculating 180,000 children against measles (estimated cost: 25 cents per child)?"

Well, would you?

There is no use denying the fact that increasing health care services for the poor and underserved will likely draw resources away from the services provided to the top tier of society. Do I think this would have a major impact on the health of the rich? No. Such a change would only serve to improve the health outcomes of our nation as a whole. The gains to be made by making health care affordable and available to all Americans will be better for population health than small, nearly unattainable medical care services to the most well-off.

Medical care services, in general, have only led to modest gains in population health. Water, sanitation, immunizations, and environmental modifications have led to many of the greatest population health improvements in our global history. We must spend more effort and money on disease prevention (innoculating those kids with measles is a good start; preventing youth from smoking is another). Treatment will always provide great tradeoffs for societal well-being because of the enormous economic cost.