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.

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?

National Initiative to Stop Teen Dating Violence

The Robert Wood Johnson Foundation (RWJF) just announced that Blue Shield of California Foundation and the Family Violence Prevention Fund will join with RWJF to help communities combat and control teen dating violence. The initiative called Start Strong targets kids aged 11 to 14 and the budget is big -- $18 million. However, this budget will be divided between 11 communities in the country.
If this sounds somewhat familiar it may be because you read my Society & Health post a few months back on the Teen Dating Violence Forum that was held by the Boston Public Health Commission (remember the Rihanna/Chris Brown event that put dating and intimate partner violence in the fore front of everyone's minds?).
Boston will be one of the communities funded for this initiative. And boy do we need it! I think every shooting and stabbing I hear about in this city (and I hear about it way too much...) is either gang-related or a case of intimate partner violence. I know...I should be scientific about this, but you can check out the stats at the BPHC website if you are interested.
The leadership of Start Strong in Boston seem up to the challenge before them. I am excited to see what kind of impact it has on the city and among young people. Maybe it will affect the same kids who hit me with an egg while I was riding home from work this week. (I had to throw that in there...true story.)

A Question of Sustainable Screening

This month my first first-author publication was published in the Journal of Women's Health! I am extremely excited as it was the product of a two-year effort and became a really insightful article with the help of some really intelligent colleagues and collaborators. While I want to share with you highlights from the article, I'd also like to share some reflections on what I learned through the process.

The article examined what factors predict mammography re-screening (in the past 2 years) among Latinas living in California. This paper began as a study of all Latinas, but by the final iteration it focused on Latinas had at least one mammogram. Here are some of the major findings and considerations:

• Multiple factors influence mammography screening; those screened were older (60+ years), more educated, had health insurance, and reported having a 'usual source of care'.
• The most common reasons for not having a recent mammogram were cost, inconvenience, and lack of knowledge.
• Latinas who interviewed in Spanish were more likely to have been recently screened than those who interviewed in English (suggesting language might not be such a barrier to preventive health care use once access is attained).
• Increasing access to mammography screenings (both by reducing the cost and increasing the convenience) will likely improve re-screening among Latinas.

This was an incredible learning experience; one that I am so thankful to have had prior to graduate school and dissertation defenses. Nonetheless, there are a few key 'lessons learned' that I'd like to share. I hope these will serve as a reminder for myself and provide some comfort to others who will likely endure the same challenges and frustrations.

1. Listen. Embrace opportunities to invite in others to be a part of the publication process. I was so grateful to connect with collaborators at the CA Department of Public Health who were running mammography screening programs. It gave us a lot more confidence in our understanding of the problem and the interpretation of our data. 
2. Persist. Publishing this article was  a roller coaster ride. At first you think that your idea is the greatest one yet. Then, either through reviewers' comments or constructive criticism, you begin to doubt. It takes courage to work through the tough issues that need to be dealt with to improve the paper.
3. Revise! As focused as I thought the paper was when we began, there was way too much in there for a 2500 word article. Revisions focused the paper and resulted from thoughtful critique from reviewers and coauthors.
4. Relax. Once you submit that article there is no point in checking the website every day to see if the status of the article has changed (I never did that...). Enjoy the waiting because once you get the manuscript back your next few weeks are shot.

I am looking forward to working on some more publications, but I'm excited to have this blog so I can discuss public health issues that interest me any time. 

If you could publish in any area -- magazine, newspaper, journal -- what would you write about?

Health Care Reform Needed Now

By now you must have noticed that I am enamored with Nicholas Kristof. His latest column "Franklin Delano Obama" in the New York Times is fantastic. He examines three common arguments against health care reform proposals:

1. "We have the best health care in the world, and you want to create a socialized bureaucracy?"
2. "You want to wait months for a necessary operation, as in Canada?"
3. "You really want higher taxes to pay for this, stifling the economy and undermining our long-term competitiveness?"

The economic crisis highlights the fundamental problem of insurer-based system that requires (or nearly requires) employment. Each day people are losing their jobs and with it their health insurance.

Yet, health insurance alone is not going to solve America's poor health or its obesity epidemic. As Kristof explains, the health of Americans is embarrassingly low despite our technological advances and per-capita health care spending. Our health "care" system must move away from its treatment-focus and adopt policies and programs that invest heavily in prevention and is balanced throughout the prevention-treatment continuum.

Should Prevention Trump Treatment?

I remember when I first started thinking about entering the field of public health. One of my major concerns was whether I needed to become a doctor in order to be respected and influential in the field. I was grateful for the advice I received from faculty (mostly doctors and nurses) at school that the path to clinical practice should not be done if you aren't passionate about becoming a clinician! While that may seem obvious, I think my concern was getting at something much deeper than that -- the enormous tension in public health to work within the health care system (a medical-driven, treatment intensive environment) and to work without it. 

The public health approach to health promotion is fundamentally about prevention. Its goal is to collaborate with multiple sectors to create environments where people can make healthy choices, to develop policies that protect peoples health, and to disseminate new finds and raise awareness about health damaging practices and products. 

Conversely, a clinical approach to health is to screen, identify, and treat disease. These clinical activities are vital and important to improve health of individuals. Ask anyone with high blood pressure, diabetes, or cancer, and they will agree that medicine plays an important role in helping them live their healthiest life possible. 

Sometimes people forget that clinical medicine and public health practice must be work in tandem. For example, when HIV/AIDS work began, there were many who wanted to prevent the spread of HIV/AIDS, but forgot the need to improve access to treatment for those already affected. Expanding access to antiretroviral therapy is now a major part of HIV/AIDS activities. 

The era of public health as a competency only for those in clinical medicine has past. What remains is a (growing?) tension between a growing number of public health professionals with no clinical training who reject the treatment-oriented focus of health work in this country and clinicians who believe that advancements within the health care system will be vital to improving the health of our nation. While both may believe that prevention is necessary, it is unclear whether -- when it really it comes down to it -- both believe that money spent on prevention is worth more than money spent on treatment. 

Our health care system is broken. Training more OB-GYN and orthopedic surgeons is not going to fix it. We need to create incentives for family physicians, primary care practitioners, and midwives. We need to invest more in prevention, in early life care, in parenting support, and healthy community initiatives to reduce violence and increase social capital. 

What does this tension mean for public health? Will it promote dialogue and lead to sustainable change or will it prevent us from accomplishing all that needs to be done to turn our health care system into a health promotion system?

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.

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 Intelihealth.com 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.

Defining "Risk": Statins and Heart Disease

The front page of CNN.com today read "Study: Cholesterol drugs can help low-risk patients." This is a perfect example of the medicalization of health. Rather than advocating high-risk prevention strategies for those at higher risk of developing disease, we now have "medical creep"  -- where even moderate risk of heart disease makes someone a good candidate for medical intervention. 

Dr. W. Douglas Weaver, president of the American College of Cardiology was quoted as saying, "This takes prevention to a whole new level, because it applies to patients who we now wouldn't have any evidence to treat." 

This is great news for Big Pharma -- not mainstream America. Note: cholesterol lowering drugs like AstraZeneca's Crestor (used in the study cited and funder of the research) or Lipitor by Pfizer are laden with awful side effects: headache, diarrhea, muscle pain and even depression, insomnia, and ulcers. Who needs that?

What is the alternative to pharmaceutical intervention? Hmmm...let me think...a healthier diet, regular exercise, and quitting smoking. And the side effects of such a drastic lifestyle change?  Side effects may include lowered risk of diabetes, stroke, cancer, and depression. 

While the choice of pill or persistence may seem obvious to me, the barriers to sustainable lifestyle change are great. Choosing persistence may seem more expensive or too restrictive (who is to say I can't eat another slice of mom's apple pie?). But the truth is we all have the power to make change in our life that will improve our health. The result may be 10 more years of healthy life or 10 more days. How do you measure the worth of your days and years?

My choice: a healthier lifestyle.  I will leave the statins for those who truly need them.