Saturday, October 09, 2004

The politics of health 

Earlier this week I had the opportunity to interview for a position interning under the senior HIV/AIDS policy analyst for the ASTHO, an organization about which I knew nothing before I read of the announcement for this very position. To prepare for the interview process, I spent a few hours here and there researching the organization, their function, endowment, and, fortunately, the administrative structure.

The ASTHO is a well-funded group of health officials that represent the upper echelon of health policy formation of every state and territory in or associated with the United States. These highest officials are rarely involved in direct interaction with the Washington office, which serves rather as a think tank where educated individuals of various backgrounds research the latest science related to the major aspects of public health, subsequently condensing the most sound information into discrete policy reccomendations. These recommendations are then funneled into the netwrok of regional health officials for use, presumably, in influencing the development (or promotion thereof) of policy that more rigidly conforms to the best science available. All things considered, this kind of work sounds amazing: pooling your scientists and social workers in the most well-connected governing cities in the world, paying them to translate research into recommendations for action, and then directing those recommendations into a readymade members-only club of the individuals who actually control policy creation and management in this country.

Unfortunately, I also learned that Fay Boozman, the Director of the Arkansas Department of Public Health, has been elected (a week ago) as the new President-Elect of the ASTHO.

Now, let me put this into some perspective, because Arkansas is an understandably ignored state when it comes to the promotion of health policy. In 1998 I, at the age of eighteen, voted in my first general election. The primary reason I so adamantly wished to vote concerned the Senatorial candidacy of Fay Boozman, and I was adamantly voting to keep him out of office, even donating a few remaining dollars of my scholarship money to his competitor, Blanche Lincoln.

Fay Boozman had previously been an opthamologist in Northwest Arkansas, where he and his brother were in private practice. Boozman would leave pamphlets in his exam rooms for patients to read while waiting for his arrival documenting his personal experience with finding Jesus ("God confronted Fay and began speaking to him very personally and deeply") and how He is ultimately the power behind all healing.

When he entered the political arena, he was not one to mince words regarding his opinions and their impact on his eye toward policy. When a journalist inquired as to the physicians feelings about abortions requested for pregnancies that result from rape, Boozman, a vehement anti-abortionist, replied that "pregnancy from sexual assault [is] rare, because of hormonal surges that result from the stress endured by a woman during a rape," a statement which has no medical support yet was mentioned again in several speeches.

Boozman lost to Blanch Lincoln, but Arkansas notoriously conservative Governor, the Reverend Mike Huckabee (who has recently provided "Choose Life" license plates), quickly appointed Boozman, a physician with no large-scale health history who only began studying in the field via correspondence courses after his appointment, to the directorship of the ADHS in spite of his outspoken history of ideology presiding over science (after rejecting Dr. Joseph Bates, a deputy state health officer who had been recommended by the State Board of Health for his public health history as the head of the state's tuberculosis control program and former chief of medical services at the John L. McClellan Memorial Veterans Administration Hospital). In fact, Boozman's appointment was very likely facilitated by his religious facility, as Governor Huckabee went on record saying that Bates' "philosophy" of public health -- views surely shared by most in the department and medical community -- didn't jibe with his own. Boozman's brother John is also a religio-conservative Congressman whose platform begins with a resounding series of lauds for gun rights (including the right to carry a concealed weapon across state lines), immigration strictures (including the designation of English as the single national language), and "values legislation" (shudder).

Once installed, the Department under Boozman's directorship was accused of, among other things, large-scale failure to comply with the Freedom of Information Act and losing a letter from federal authorities that resulted in a loss of a $725,760 grant to help AIDS patients.

I hesitantly mentioned pieces of Boozman's state and territorial history in my interview with the Association of State and Territorial Health Officials, but my qualms weren't acknowledged in the least. "Fay is great! Every time we see him he's all smiles!" was one of the more incongruous comments I received, doubly ironic in that it came from the HIV/AIDS senior policy analyst.

Today I notice that the ADH is under heavy fire for poor management. Who could have imagined.

And so, to the ASTHO I offer the best of luck with that smiling and pious ally of God and his political messengers both here in the nation's capitol and at home in the great state of Arkansas. May you not set national health policy back to Reformation-era applications of herbal poultices, bleedings, and heavy metal ingestion, as we all know nowadays that none of those treatments do a darn thing to the demons that live in your pancreaous and taint the humours.

Man, I really could have used that $15 an hour.


Tuesday, October 05, 2004

Flu immunization (and vice-presidential spanking) 

Well, before I say anything else, how fantastic was it to watch Cheney being bent over Edwards' knee and spanked repeatedly with his own words? Priceless, I say. I also saw Wonkette for a few seconds being interviewed by Tom Brokaw, but she unfortunately made herself look like such an ass that she was promptly yanked off the air (she lost me when she made an analogy using the Stay-Puft Marshmallow Man) along with some conservative male blogger who had presented some bizarre argument negating the relationship between strength of an argument and superiority in argument (it's good to be reminded from time to time that these well-known blogger 'journalists' are generally more ridiculous and ajournalistic than the general public).

In the wake of the candidates' Vice-Presidential sound-off, the group that had convened at my hosts' home inadvertently wandered into discussions of health care. As something of an insider on the subject, I made a sincere effort to quietly moderate, content to dwindle into the hiss of conversation as long as I could interject corrections or accurate statements of fact now and then. I'll admit, though, that I completely lost all tact when I was told by several people that immunizations, the influenza vaccine in particular, are an absolute waste of time and, someone went so far to assert, an absolute faux pas of an industry that is not to be trusted.


This is the very situation that public health officials so often speak of when addressing the difficulties of promoting sound public health policy to a public that, even at the most educated echelons, is content to equate localized soreness and a three-day fever (all reasonable reactions to certain immunizations) to the severity of a bout with (in the mildest of scenarios) influenza, which, I should remind you, managed to kill 25 million people during the 1918 pandemic, a statistic that even the best estimates realize probably undercuts the actual figure of deaths by half. I should also take this opportunity to remind everyone that, unlike bacterial pathogens, viral infectious diseases still have no effective chemotherapeutic agents, which means that another flu pandemic is not only possible but indeed probable.

Influenza, as well as essentially all infectious diseases, experiences occasional antigenic shifts, as ugly word that essentially describes the ability of organisms with sloppy mechanisms for genetic repair (like all viruses, for example) to occasionally produce viable new offspring with structural components that are entirely different from previously dominant strains. Changes like this aren't good things when you consider that the memory capacity of our immune systems is completely incapable of quickly adapting to a new antigenic determinant--the only way we learn, unfortunately, is by contracting the illness, developing the disease, and hoping that we don't die while our bodies furiously try to cope with yet another intensely pathogenic variety of disease-causing organism.

While trying to make this point, I was rudely and naively interrupted by the comment that influenza is much less dangerous than AIDS, not to mention that we still can't get an HIV immunization. True, very true, HIV immunization is still a decade away at best, but I'm not entirely convinced that the public would use it if it were available considering everyone's willingness to eschew a flu shot (one of the simplest actions one can take to reduce the burden of disease on national healthcare, not to mention one's personal and local well-being) without any valid reasoning. On the other hand, consider that in the United States, around 44,000 new cases of HIV are reported each year, and about 16,000 deaths in the states occurred due to HIV-related infection in 2003, with a total population of persons living with HIV in the U.S. at around one million during the same year. HIV must get special consideration, and this is clear--it one of the leading causes of death in the world today, and it exerts an amazing strain on the global healthcare infrastructure in all regards, but the U.S. has it easy by comparison, and this is an issue that most Americans tend to ignore. Almost one percent of the global population (over 37 million fucking people) are currently infected with HIV, a statistic that is grossly underrepresented here. Sub-Saharan Africa alone last year counted 2.2 million HIV-related deaths last year as compared to our 16,000, with 3 million newly infected individuals over the same period bringing the total prevalence of HIV-infection in the region up to a staggering 25 million persons.

With some simple extrapolation, it is clear that infection disease with numbers like this causes a huge strain on the finance and resource pool of an international community struggling to pay for the healthcare it needs to get a handle on diseases like HIV. While severe in its effects and rampantly pervasive, HIV infection is one of the simplest diseases, in theory, to handle, as the major routes of transmission are almost entirely preventable by doing nothing greater than modifying human behavior in at-risk populations. Simply using a rubber is enough to decelerate the spread of sexually-transmitted HIV by almost 99%, and needle exchange programs coupled with hygienic needle-use practices virtually cancels out the two major routes of HIV dissemination.

Influenza, on the other hand, is fiercely infective and virulent, meaning that it easily invades and multiplies in new hosts in addition to its ability to produce a state of profound illness. Currently the sixth leading cause of death in the United States, , influenza remains a significant cause of morbidity and mortality, especially in high-risk persons who develop serious complications (a group that includes individuals experiencing the immunosupression of HIV/AIDS). The U.S. alone can account for up to 90 million flu cases per year, bringing the annual economic cost of the flu in the U.S. up to $12 billion, additionally requiring the sacrifice of 69 million workdays and approximately 315 million days of restricted activity. if one coupes this cost with the fact that the inactivated influenza vaccine is 70% to 90% effective in healthy persons under 65 years old, one can easily see that the flu vaccine is not a laughing matter. no matter how shitty you feel for two days after yur shot, you have virtually no excuse to avoid a flu vaccination--the vaccine is at a minimum 50% to 60% effective in preventing hospitalization, and up to 80% effective in preventing death caused by the virus.

The CDC these days considers almost the entire population of the United States a 'target population' for the flu vaccine, a designation which simply means that the calculated benefit to the individual and the population at large renders any potential risk insignificant: all persons over 50 years old, any adult of child with immunosupressive conditions (including HIV/AIDS), women who will be pregnant during flu season, all children aged 6 to 23 months, and (and I cannot emphasize this enough) any person who has any interaction whatsoever with those at risk (healthcare officials, friends of healthcare officials, people with friends or family in the hospital, people who have any reason to visit a hospital even once, etc.) are all considered groups that need to be vaccinated against the flu by the CDC and WHO.

As evidence to the extreme infectivity of influenza, I add that it only takes about 320 tissue culture doses of the influenza virus to initiate infection in a human. A single human cough aerosolizes roughly 60,000 tissue culture doses, while a single sneeze spews about 110,000 tissue culture doses into the air. think about that the next time you're on a crowded plane or bus listening to the sputtering and sniffling crowds.

My words fall on deaf ears, though, as I realize that the facts are meaningless in the face of a public that simply doesn't want to feel tired for a couple of days.

All of this takes on special meaning now that the avian flu, one of the most devastating human-infecting varieties of influenza (which is normally only transmitted from certain birds to humans) has very recently demonstrated for the first time an ability to pass from person to person. I fear that a future pandemic will again be the necessary force to shake people from the easy stupor of long-term ease of health.


The New York Times has articulated a clear description of the importance of the energy density of the food we eat in relation to wait gain and/or loss, so listen up all of you who want to slim up a bit but loathe physical activity.

As you may have heard from the science-conscious in your midst, fad dieting is one of the least effective things you can do to impact your long-term physical condition, and a good deal of these diets actually impact your physiology in such a negative way that the short-term weight loss one experiences is something akin to severe intentional malnutrition (ahem, Atkins) that then decreases your future ability to moderate body weight (not to mention a host of other unpleasant attributes). In the end, it still comes down to calories, and it's the calorie or energy dense foods that we tend to overeat because they don't fill us up as well. Researchers have found that we usually eat the same weight of food every day regardless of what we eat, so the key to losing weight is to eat more water-heavy foods like soup, fruits, and vegetables.

Dr. Barbara J. Rolls, a professor of behavioral health at Penn State, says,
"People given the message to eat more fruits and vegetables lost significantly more weight than those told to eat less fat. Advice to eat more is a lot more effective than advice to eat less. Positive messages about what can be eaten are more effective than restrictive messages about what not to eat."


Monday, October 04, 2004

Mi casa es, um, el casa del alguien 

Yesterday afternoon I paid my security deposit as well as the first month's rent at my official First Place in DC. I'll be living with two girls, both older than me, both enjoyable people, but neither with much in common--I figure it will be better this way, as the more comfortable I get around people, the easier it gets to be really, really lazy, and I need to be as far away from lazy while in graduate school as I can possibly manage.

I've tentatively scheduled the move-in to take place on Wednesday, for no other reason than I'd like to have a comfortable bed and a bottle or two of good wine tomorrow night, an appropriate send-off after beginning my foray into the world of professional public health interviews, the first of which will take place in all it's khaki and sweater glory tomorrow morning at the ASTHO.

I've been so busy over the weekend that I'm now frantically trying to tie up some loose ends for my biostatistics class which meets in just under two hours. You know, it's that kind of half-assed (quarter-assed?) studying where you're not really aiming to absorb nor comprehend, but rather read over all the important details well enough to pass the quiz that begins every class, intently promising yourself that, if I can just do well on this one quiz, I promise I'll spend all day Thursday and Friday catching up. Gung-ho!


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