Thursday, January 22, 2009

Take Our Beef, Or Else!

The week before leaving office, former President Bush approved a 300% tariff hike on Roquefort cheese. The news caught my attention while riding the T. Dramatically, the Metro article suggested that in retaliation the EU may raise the tariff for US imports of Coca-Cola. While this seems a bit far-feteched, I had to wonder 'Why? Why did our government decide to place such an enormous tax on Roquefort, the infamous moldy, sheep's milk, inimitable creation?'  

Well, according to reports in Time, Huffington Post, and the UK's Guardian this political decision was made to punish the European Union (EU) for their refusal to import meat raised with artificial hormones and antibiotics, a restriction that dates back to 1989. Take that EU or more specifically, the French district of Lozeyron! No longer will Americans enjoy your delectable cheese because you refuse to import our potentially toxic meats! I mean really?! What may be the effect of such tariffs -- recipes left unfulfilled? Wisconsin (i.e., domestic) alternatives embraced? Roquefort-lover riots in protest?

This short announcement caught my eye because it sheds light on the huge influence that the meat industry has on US policy -- both domestic and international. The EU ban on beef imports was due to the untraditional methods used to raise the cattle (i.e., use of antibiotics and hormones to help the cows grow fatter, faster on a  corn, rather than grass-based,  diet). In fact, the International Trade Commission published a 2008 report on the current state of US beef exports, which details which countries and regions are not importing US beef and why.  

Anyway, it was an interesting story I had to share. For more on US Food Policy and developments in "BigAg" check out this US Food Policy blog out of Tufts University. It is a great blog!

Wednesday, January 21, 2009

Sex Trafficking: An Introduction

Human trafficking is an absolute evil. It destroys families, inflicts unimaginable pain and suffering on its victims, and is a practice that needs to be prevented. Sex trafficking is particularly malicious as it primarily coerces young girls -- as young as 4 -- into a world that they could never imagine. In this world, these children's bodies are no longer under their own control -- it is abused, misused, mutilated. The physical and emotional toll of sex work can weaken even the greatest of spirits. 

Several articles by Nicholas Kristof and Josh Ruxin have really opened my eyes to the challenges, controversies, and monstrous tactics used to subdue and control girls who have been trafficked for sex work. Ruxin, a public health professional and aid worker who has been living in Rwanda for the past few years, writes in Kristof's blog pretty regularly -- his latest piece, "Asia is Not Alone: Sex Tourism in Mombasa" is an honest account of Ruxin's return to Mombasa, Kenya, and his shock at the extent of sex work and child prostitution in the city. 

Kristof, an Op-Ed contributor to the New York Times, recently reported on his trip to brothels in Cambodia and the horrors he saw inflicted in a young, rebellious, child sex worker named Long Pross. The article titled, "If This Isn't Slavery, What Is?" is a brilliant, heart-wrenching piece. Thankfully, there are places like the Somaly Mam Foundation in Cambodia that help to fight sexual slavery, and others like it in centers of trafficking around the world. In addition to providing treatment, recovery, and alternative work opportunities for girls trafficked into sex work -- a great challenge in itself -- there is an enormous need to prevent this practice in the first place. 

International Justice Mission is an organization committed to bringing justice in circumstances of slavery and human trafficking in countries with incredibly dysfunctional judicial and policing systems. The New Yorker published an article on the work of IJM's founder, Gary Haugen,  onJanuary 19, 2009, titled "The Enforcer: A Christian Lawyer's Global Crusade". I see the work of IJM as providing rescue to those currently enslaved world-wide as well as creating a message of caution for those who would seek to control and destroy the lives of others. Perhaps this will help prevent future abuse in these communities.

But there is more that can and must be done: 
  • to identify the roots of trafficking -- the social and historical conditions, cultural and familial values, and a lack of awareness of trafficking tactics
  • to breakdown the pathways through which trafficking comes to be -- the lack of political will, the absence of strong justice systems
  • To recognize of the problem of demand -- that sex trafficking is driven by issues of male sexuality, gender supremacy, power, and control. 
The US has committed millions of dollars over the past 10 years to combat human trafficking.  In December, 2008 the US reauthorized the "Trafficking Victims Protection Reauthorization Act, HR7311. Additionally, advocacy efforts to implore President Obama to make anti-trafficking efforts in the US a priority are under way (you can sign and electronically send a letter to President Obama here at the IJM website). The number of sex workers in the US is unknown, government sources estimated it to be around 15,000 in 2004 according to a 2007 article on the issue.

There are so many other resources on sex trafficking available online through any Google search. However, more research is needed, especially as the practice grows and expands to new regions. I am privileged to be a part of some trafficking work that is going on at Harvard School of Public Health. We hope to better understand the conditions from which these girls are trafficked, how they enter sex work, their living and work conditions, and how these impact their health and well-being. This work aims to inform service providers and other organizations who are working to prevent sexual slavery worldwide. Here is an example of some of the work our research team is doing.

Much more on this topic to come!

Thursday, January 15, 2009

Public Health Competition: Get in on it!

The Robert Wood Johnson Foundation, a leading funder of innovative public health research and programs has just announced a new competition: Designing for Better Health. The RWJF Pioneer Portfolio along with Ashoka's Changemakers are seeking individuals and groups that provide "nudges" (a.k.a. small steps) toward better health. According to the guidelines, submissions should be currently implemented and demonstrating success -- i.e., this is not a place just to throw out a great idea. If you have a great idea, get moving and enter!

Entries must be submitted by April 1, 2009, and will be judged by a panel of 3 judges who will narrow the submissions to 12 finalists. Three winners will be selected by the global Changemakers community by vote and win $5,000.

Tuesday, January 13, 2009

Mouthwash: Friend or Foe?

There is something about that tingling, burning sensation of Listerine that always keeps me coming back. I just don't "feel" like that other stuff is working. However, according to a recent study published in the Dental Journal of Australia using mouthwash containing large amounts of alcohol is associated with greater risk for developing oral cancer.

A possible link between mouthwash use and oral cancer was brought to my attention while riding the T Tuesday morning by Metro. I did a quick PubMed search and found several articles -- even REVIEW articles -- on the issue that date back to 1991. This is not a new idea, however this finding is quite controversial. I decided to review 3 articles on the subject (I was limited by those journals subscribed to by HSPH at this point).

 The first article, a 1996 review in the American Journal of Epidemiology, proposed a spurious (non-causal) association between mouthwash use and oropharyngeal cancer. The authors (one of whom worked for Procter and Gamble; the work was sponsored by a Pfizer company) argued that alcohol and tobacco use likely accounted for the association between mouthwash use and oral cancer. For example, consider that smokers are more likely than nonsmokers to use mouthwash to eliminate their bad breath, and that smoking is strongly associated with oral cancer -- it is. While it may seem that mouthwash was linked to cancer, really it may have just been the tobacco use.

In 2003, an article was written and published in the Journal of the American Dental Association (this study was also financially supported by a Pfizer company) to review the literature examining the mouthwash-oral cancer relationship. Nine studies were considered - six showed no association between mouthwash use and oral cancer, and three showed a positive association. In addition, this article re-analyzed data from a large population-based National Cancer Institute study with nearly 1500 cases and a similar number of controls. The re-analysis showed that mouthwash had the same moderate effect on both "true"/mucosal and "pseudo"/nonmucosal cases of oral cancer; whereas other known risk factors (alcohol and tobacco use) for mucosal type oral cancer were quite strongly and predictably related to "true" cases, but not to the "pseudo" cases.  Of course, confidence intervals are not presented.

These two studies with their industry backing leave me wanting...let's hope #3 wraps things up.

I can make this quick. The final article was published online (2008) ahead of the Oral Oncology print yet featured no new evidence since the 2003 review. The author suggested there is no epidemiological evidence that mouthwash causes oral cancer.

Summing It Up:
  •  None of these studies address issues of reverse causation. It is likely (think about it...) that the onset of oral health issues (cancer, lesions, etc) result in greater use of mouthwash, and not the other way around.
  • Studies do not differentiate between alcohol-based and other mouthwash types, weakening the claim that it is the alcohol-based mouthwashes that are the culprit.
  • There is no clear relationship between quantity or frequency of mouthwash use and greater risk of oral cancers.
  • More rigorous studies are needed to suggest that the relationship is not a result of recall bias, under-estimation of tobacco or alcohol use, and other potential confounders.
I'll stick with my mouthwash of choice -- for now. Of course, if you are really interested in oral health issues check out the source articles for yourself!

PS. If someone can send me that Australian journal article I'd love to take a look!

Update: So I took a look at the Australian Dental Association article, which suggested that there is sufficient evidence to implicate high-alcohol content mouthwashes in the development of oral cancer. However, the studies they cited were not recently published, leading me to believe that the evidence upon which they base their claims are the same ones that these previous lit reviews reject. It is possible that high-alcohol containing mouthwash is dangerous for certain vulnerable groups. However, more rigorous scientific evidence should be produced to support that hypothesis.

Friday, January 9, 2009

Changes to WIC Nutrition Standards: Which State is Next?

Even if you have never received WIC assistance, you have most likely heard of the government program if you worked as a cashier in a grocery store. WIC is the name given to the government food program for low-income pregnant women and young mothers called the Special Supplemental Nutrition Program for Women, Infants, and Children. 

The program was created in 1974. It provides vouchers for foods considered to provide for the nutrition needs of nursing/pregnant women and their baby or infant under age 5.  For example, white bread, whole milk, and cheese are commonly bought WIC items. However, as nutrition science has evolved, those in the field of public health and policy realized that WIC was promoting many foods that were likely contributing to obesity and overweight. 

In 2005 the Institute of Medicine (IOM) and other agencies began writing reports on changes in dietary patterns among women using WIC, as well as changes in what is known to provide adequate nutritional benefits without creating other potential health problems  such as overweight, diabetes, digestive problems, etc. (As an aside, the recommendations of the IOM are in a book called WIC Food Packages that can be found here, but appallingly costs $36.  An 8-page brief report can be found in pdf, here.).

Numerous recommendations were given by the IOM committee including 
  • increasing the vouchers for fresh fruits and vegetables
  • reducing cheese vouchers from 4 lbs/month to 1 lb/month
  • offering only whole grain breads, rice, and cereals to certain food packages
  • allowing the purchase of jarred baby foods
  • restricting the amount of juice that can be bought.
Nearly a full four years later (read January 2009), Delaware and New York have been among the first to adopt new WIC nutrition standards. New York, rather than using the IOM report standards, chose to adopt dietary guidelines set forth by the CDC. Among the changes for WIC recipients are ability to purchase whole grain breads and cereals, canned or dried beans, and jarred baby foods, as well as cash value checks for buying fresh fruits and vegetables. According to a Robert Wood Johnson Foundation announcement, WIC will begin changing its nutrition standards to align more closely with federal dietary recommendations in - RWJF says October 2010, but the Food and Nutrition Service website shows an implementation date of October 2009.

This is a great success for public health; it is a change that will affect millions of lives not just in the short term, but also in terms of long-term health outcomes. It is another example of persistence and hard work paying off. Now the question is -- how will States adopt the new standards? Will there be uniform change? And will there be regular evaluation and updating of nutrition standards, or will these last another 30-40 years?

Thursday, January 8, 2009

Appetite for Profit: An Introduction to the Food Industry

We've heard of Big Tobacco and Big Pharma -- what about Big Food? How much have consumers, politicians, and even public health professionals considered the co-optation of "healthy food" by mega-food corporations such as McDonalds, Kraft, and General Mills? There are many examples of how these companies or their spokespersons have tried and mostly succeeded in preventing healthier foods and drinks in schools, destroyed legislation to increase consumer access to nutrition information, and sent the message that physical exercise, not diet is what is making American obese. 

Appetite for Profit: How the food industry undermines our health and how to fight back is an excellent book by public health lawyer and advocate, Michele Simon. For anyone interested in gaining an expert perspective (I'm not saying it is unbiased - per se) in this issue this is a must read. People interested in childhood obesity and advertising to children may also find this book to be quite insightful.

The most useful sections of the book are found in the appendices. For example, who is the Center for Consumer Freedom? The name sounds good - I'm a consumer and I'm all for freedom! A brief glance at the appendix or a turn to one of the many pages in her book that references the CCF one will note that this "freedom" applies first and foremost to the restaurant industry. One ought be wary of many of the organizations involved in food advertising, lobbying, legislation, and policy. Many are not what they appear to be.

In addition to helping us identify industry-backed "objective" organizations, Simon also presents cogent arguments against several of the "myths" propagated by Big Food. For instance, why restaurant nutrition labeling won't put local restaurants (or industry leaders) out of business, how such tactics (point of sale nutrition information) can help consumers chose healthier options, and how schools (and more importantly, students) can thrive without soda and sports drinks sold in school.

This book renewed my passion for creating a healthier environment where we all have the ability to choose to live and eat well. My next task: understanding the Farm Bill. I have heard so much about this important piece of legislation that has an enormous amount of influence over what I find at the grocery store, where it is from, and how much it costs. 

What are your thoughts?

Tuesday, January 6, 2009

It Takes Two: Gardasil Not Just for Girls

There has been much debate over Merck's release of Gardasil, a vaccine shown to protect against certain types of human papilloma virus (HPV), even those that can cause cervical cancer (CDC) The vaccine was shown to be most effective in young girls (aged 12-15) and seemed to lose its efficacy when given to women in their 20s. Vaccination of young girls, however, was resisted by most of the usual suspects (even claims that it would increase sexual activity among those vaccinated or encourage early onset of sexual activity), but thoughtful consideration of long-term effects should be considered before getting vaccinated.

But the question, "why only vaccinate girls?" continued to linger. Recently CNBC announced that Merck decided to seek FDA approval for use in boys, as well. FDA approval could be a great step in reducing HPV disease and transmission of genital warts - though it is definitely only one tool to protect against STDs. 

Unfortunately, Gardasil is extremely costly, $360-$375 for the entire series. Not all insurance covers this vaccine. Additionally, it requires 3 shots, multiple doctor visits. Without a regular source of care, it could be difficult to ensure that teens get the entire vaccination series. Additionally, this vaccine does not protect against the most common sexually transmitted diseases: chlamydia, gonorrhea, and herpes. Thus, wise discretion of sexual partners, regular STD screenings, and consistent use of condoms are important for anyone engaging in sexual activity. 

This is an interesting development worth keeping an eye on.

Friday, January 2, 2009

Prevention First in 2009

For a good long time medicine was concerned with just that -- medicine. I am talking about the new pills, technology, and techniques that have served to prolong life and cure disease. I believe that health, however, is about 10% medicine (maybe 20% if you include vaccination...) and 90% disease prevention. 

I was attempting to look up Boston health statistics when I came across a posting of "10 New Year's Resolutions for Good Health" on the Boston Public Health Commission website. These 10 tips were written by Dr. Harvey B. Simon, an affiliate with Harvard Medical School. As a physician, I expected his resolutions to encourage getting mammograms, taking an aspirin a day for those over 50, and focusing on the medical and health services aspects of health. I was so wrong! A full NINE of the resolutions were specifically preventive behaviors aimed at reducing one's risk of getting disease in the first place. This included suggestions such as:
  • avoid tobacco
  • eat right
  • protect yourself from infection (using vaccinations and preventing STD transmission)
  • wear bike helmets, seat belts, and install child safety seats
  • reduce stress
Now, I can appreciate the openness of his resolutions, which allows people to adapt them to their own circumstances (in fact, a more detailed list can be found at the Aetna website). However, to incorporate these into our lives would definitely require more specific, measurable goals. For instance, rather than "avoid environmental hazards" I would suggest a resolution that says "Have home tested for lead paint and other toxins by April 1 , if found replace with hazard-free alternatives by August 1." That way you have a specific action to take and a deadline to achieve it by. 

What can you do to most improve your health this coming year? Is it to cut back on smoking or alcohol consumption? Drink more tea and less coffee? Go for a 2-3 mile walk or a long bike ride a few times a week? Wear a condom or use another form of STD protection every time you have sex? Go to the doctor for an annual check-up (even though you may feel perfectly fine!)? 

We all can do more for our physical and mental health. Now is the time.