Safety Done Not-Good-Enough

This piece from Deadspin has all the words that I didn't even know I wanted to say:

What could change [skateboarding's anti-helmet] culture? ESPN, for one, given that their X Games broadcasts make them the de facto biggest supporter of competitive skating. Simply requiring riders to be helmeted would not just prevent scary moments like Hatchell's but also finally do more than pay lip service to safety in the shadow of the Caleb Moore tragedy. And it's not like every skater opposes helmets; sometimes, the moment itself provides a platform for promoting helmet use.  --Timothy Burke of Deadspin.com

When it comes to changing the safety culture, Public Health can make decisions for people.  Public Health can help people make the right decisions.  And private businesses can work with Public Health to make that happen.

We have seat belts and air bags, for example, because after a long fight, the automobile manufacturers agreed to install them in every vehicle.  The same principle could go for helmets.  ESPN's X Games could prevent injuries and save lives by mandating helmet use.  It could be the leader in the movement. It has the clout.  So far, ESPN has chosen not to exercise its great power.  ESPN would not make a good Spider Man.

O-Aren't-You-Glad Part 2: Even Gladder

(Previously: I visited a Chinese medicine lab and Oregon had Medicaid lottery...)

(Traveler Tip: Have One of These on Hand)

Wandering down the streets of Taipei one morning, Ashley, Baby Syd, and I popped into a random traditional medicine practice so Nurse Practitioner Ashley could check out what Chinese medicine was all about. In my travels, I'd observed that though Taiwanese people were friendly to begin with, having an adorable white baby on hand guaranteed premier service everywhere.  Except there.  The doctor seemed bored by our presence.  Given Ashley's father's collection of Australian aboriginal remedies for snake bites, we asked what he'd prescribe for snake bites.  It was then that his attitude turned from curmudgeon to contempt, as if we asked if his medicine was magic.  "If a snake bites you, go to a hospital.  Why would you ask for for traditional medicine then?" He replied (quite sensibly).  "You'd want to remove the venom.  Call 119 and go to a hospital for that."

Two weeks ago, I left you in suspense with the outcome of the Oregon Medicaid study.  Here goes: About two years after eligible adults were randomly chosen to enroll in Medicaid or not, the people with Medicaid coverage went to their doctors more (and in turn, had more tests done) than people without.  They also spent less money on healthcare and were less likely to be bankrupt by illness.  Medicaid bought peace of mind.  Enrollees reported higher quality of life and were less likely to have depression.  They were also more likely to take their diabetes medications.  Read here for one enrollee’s experience.  Those were the good bits. 

However, when it came to health outcomes, the Medicaid group wasn’t significantly different from those without.  What are we to make of this?  Is Medicaid any good?

One way to look at this is to say that people without insurance, like their Medicaid counterparts, know to go to the hospital for snake bites.  When it comes to the big illnesses, people find a way of getting medical care.  Doing so comes at a greater financial and emotional cost without Medicaid.  Another perspective is to question the effectiveness of our healthcare system, and the quality of doctors that Medicaid patients (and indeed, all patients) see.  The enrollees are going to the doctors but the doctors aren't delivering.   A third perspective is to say that maybe two years aren’t long enough to observe health differences, perhaps we’ll see an effect in a few more years.  I think all three are at work.

The Oregon study reiterates the importance of having health insurance.  Saving people from depression and bankruptcy are not small feats.  Yet it also remind us of the work cut out for Public Health.  It doesn't stop at policies that enable healthcare access.  Improving healthcare quality, and in turn the population's health, is much trickier.  Good thing I’ve chosen to explore it for my doctoral thesis.  

Education Done Right

These kids are killing me.  I know I promised Oregon Pt. 2.  But these kids.

First, they sing about Hot Cheetos and Takis*.  (Favorite lines:  I'm on point like an elbow/
Hands red like Elmo/Ma mama said 'have you had enough,?'/I look and said, "no, ma'am.")  And now this:

My Bike:  (Favorite lines: No games bro/I don't need no drama/'cause I'm trying make change like Obama/bow)  Could they be any more awesome?  Children.  Rapping.  About riding their bikes.  They're exercising, yes, but they're also just children playing and having fun (with really good flow).  But where are your helmets, kids!?



Khaki Pants: (Favorite lines: But they ain't go no flavor/they like some celery/ but swag ain't what you wear/ swag is a mentality; also: I'm snappin' like the back of your hat/this is a track you can call it burrito/ 'cause it's a wrap)



The public health in this one is more undeniable (though I love the celery dis, because celeries are gross).  These kids are rapping about school dress codes.  The video is filled with images of children being joyous in schools-- dancing, reading, rapping.  That's how school should always be.

Also public health?  The grown ups behind this.  Huge, huge props to the YMCA-sponsored Beats and Rhyme program teaching children to write, work together, and enjoy themselves.  I cannot stop smiling.

*At first I was just going to link it, because I wanted you to see the new videos.  But this is too good not to include:

Questionable nutritious value aside, Hot Cheetos are, admittedly, one of my favorite things.  It comes right after the song in the List of My Affections.  And right before this excellent GrantLand analysis of Hot Cheetos and Takis.

O-Aren't-You Glad For Insurance?

(From top left: Mysterious liquids, pharmacy certifications, the lab's "sink," and a tub filled with:
packs of antibiotics, a carton of cigarettes, and hangover pills, on the lab counter)

A rusty cleaver.  A faucet-less sink.  And colorful, new blister-packs of house-made hangover pills.  The herbal medicine lab was a fascinating mixture of tradition and innovation, of regulations and disorder.  In college, I spent 2 months living in the remote Chinese province of Ningxia.  One of the highlights of the trip was a visit to an old friend of my grandfather and a practitioner of traditional medicine (followed by an awesome lunch with “deer penis wine”).  He remarked that unlike western pharmacology, he didn’t know how each of the ingredients he prescribed broke down and functioned. He just knew that certain combinations worked.  His proof was in the people who got better.

In many ways, Public Health views having health insurance and going to the doctor in the same way.  We think insurance is good and people should have them.  Ditto primary care physicians.  We observe that people with them have better health outcomes than people who don’t.  But we’re not sure why.  Does insurance get you better doctors?  Is it the peace of mind?  The old pharmacist could compare the results of 2 equally sick people, one with herbal treatment and one without, to see whether his treatments work.  But Public Health can’t easily do that.  People with insurance are different from people without.  People without insurance tend to be younger, sicker, and have lower-income than people with insurance*.  So comparing the 2 groups is like comparing apples and oranges.  If only we could grab 2 similarly orange people without insurance and say, “you get insurance and you don’t,” and wait to see what happens.
If only.

The brilliant and articulate Dr. Kate Baicker from Harvard (who I’ve mentioned here) found a way.  She and her team seized upon a natural experiment from the state of Oregon.  In 2008, Oregon realized that it could afford to take on an extra 10,000 people in its Medicaid program (public health insurance for low-income people).  The need was much greater than 10,000.  So Oregon held a lottery. This way, the people who were randomly selected would be similarly orange to those who weren't.  Baicker et al tracked both groups over time and looked at their health, their use of health services, and how much they spent on healthcare—setting up a way to analyze the ‘effect’ of having Medicaid.  This is an important feat because the ACA is about to expand many Medicaid programs. It’d be good to know if these resources are being put to good use. 

So, how’d it go?  Oh look, we’ve run out of room again.  You’ll have to check back next week.  (If the suspense is really killing you, this has been all over the news: see here, here, and here).

*From the Kaiser Family Foundation: a wicked good resource on health policy basics.

Marathon Monday

I don't have words yet.

The Colbert Report
Get More: Colbert Report Full Episodes,Indecision Political Humor,Video Archive

Stephen Colbert (above) had the perfect words for what transpired on Marathon Monday.  I am not there yet.  I have not been able to stop watching the news long enough to step away and to reflect.  Boston was, and is, my city.  It's the city of my friends and my family and their friends and family.  The Back Bay was my neighborhood.  That was my library, where I still owe $7.10 in late fees.

A lot of other people- more eloquent, more articulate, more heroic- have had words.  Amidst the sea of commentary, I'm especially grateful for 3 writer-reporters who highlight our medical and emergency response infrastructures-- the public health components that allow healthcare workers to focus on the very individual acts of saving lives, one person at a time:

"Why Boston Hospitals Were Ready."  Atul Gawande for The New Yorker.

"Doctors Saved Lives, If Not Legs, In Boston." Gina Kolata, Jere Longman, and Mary Pilon of The New York Times.  

"Emergency Planning Saved Lives in Boston Marathon Bombings."  Kari Nijiiri for New England Public Radio

Jedi Mind Tricks

Let’s start with an exercise.  Think of the last 2 digits of your social security number.  Got it?  Now, at what year did Albert Einstein emigrate to the United States?

Did you guess 1933?  If so, you are the smarty pants exception to the rule.  Chances are, if your social digits are high, you guessed high, and vice versa.  This is an example of a neat behavioral economics mechanism called “anchoring,” in which our decision making processes are affected by information around us.

In the realm of public health, behavioral economics can help us make the right decisions.  We often know what’s good for us. But we can’t always do what we want to do.  I don’t want to eat a bag of leftover Smart Food by myself.  I don’t even like popcorn.  And yet I do.  As I’ve discussed before, public health sometimes helps us out of these jams by taking away opportunities for us to make mistakes.  But sometimes public health gives us the choice to decide.  Then helps us to make the right decisions. 

(One of my favorite institutions in Brunswick, ME)

One example of this help comes from Dr. Sara Bleich at Johns Hopkins.  In a wicked cool experiment, Bleich and her team posted 3 different messages about soda at neighborhood bodegas. 

“Did you know that a bottle of soda or fruit juice has about 250 calories?” 

“Did you know that a bottle of soda or fruit juice has about 10% of your daily calories?” 

“Did you know that working off a bottle of soda or fruit juice takes about 50 minutes of running?”

Do these statements do anything for you?  Which statement is a bigger deterrent for you?  I’m an easy target, but the exercise one rings most powerful to me.  (Full disclosure: Because of my terribly indiscriminate I'm-a-hungry-grad-student-diet, I'm easily shamed and susceptible to suggestions.  This usually results in buying many overpriced bananas by the cafe checkout counter.)  Bleich and her team tracked the buying behavior of adolescents in the stores over a 6 months period.  They found that the signs worked.  Looking at the 3 strategies as a whole, the odds of buying a “sugar sweetened beverage” (soda or fruit juice) decreased by 44% after they posted the signs, as compared to before.  Looking at the 3 methods separately, the exercise information was significantly associated with a decrease in purchase. 

Even if quinoa and kale aren’t a part of your regular diet, the evidence on the negative health effects of consuming too much sugar (i.e. empty calories), especially in adolescents, is weighty and obvious*.  Yet information alone can’t improve population health.  Public health relies on brilliant folks like Dr. Bleich to figure out the right tricks to employ to help us make the right decisions.

*Never an inopportune time for a DHem plug.  Thanks to Jesse for the reminder.

ObamaCare at Year Three

With the exception of my uncle, who asks me about the health benefits of red wine (to get me to condone his drinking), people tend to only ask me one public health question: What do you think of ObamaCare? 

The Patient Protection Affordable Care Act (formerly known as PPACA, now known more commonly as the ACA, Health Care Reform, or ObamaCare) celebrates its 3rd birthday this week. As someone who majored in sociology at Bowdoin College, it’s been thrilling to have people take interest in what I study. I love talking about Health Care Reform.

(Pictured:  Found the knife and sticks in my room at my parents' house.  I think I wanted to whittle my own spear in middle school.)

I think of it like my little Swiss Army knife: a knife blade, a screwdriver, a nail file, a pair of scissors, a toothpick, and tweezer in one.  I’ve carried one around for years, though not the same one.   Most days, I forget that I have one— hence the many, many knives I’ve donated to the TSA.  And that time at nerd camp when I had to turn it in as "contraband."  But every once in awhile, when a package arrives or a Swedish bookshelf needs assembling, this little tool becomes very handy (see also MacGyver, Angus).  The ACA works the same way.  It doesn’t affect my life most days.  My relationships with my doctor and insurance company have not changed much in 3 years, nor the price I pay for these things.  But as I already know from the experience of my family and friends, it will be very handy when I need it.

If this analogy all sounds a lot like how we think of health insurance, it makes sense.  The main focus of the ACA was coverage expansion.  It was about allowing young adults to stay on their parents’ health insurance, about closing the ~$3000 coverage gap on medications for elderly people, helping people find and purchase insurance, and much more.  For more details, the Kaiser Family Foundation has the full deets on what’s in the ACA in both short and long form.

Though it can get you out of all sorts of jams, the Swiss Army knife is no panacea.  The little blade can cut through cardboard boxes, but it can’t chop down trees.  It’d be silly to expect it to.  Similarly, though the ACA has provisions that encourage efficiency, it won’t drastically reduce healthcare costs or trim our obesity rates.   And yes, there are bits that anger this group but pleases another, like the changes in how we pay some doctors, limits to how much insurance companies spend on non-medical expenses, and increase Medicare taxes for high-income earners.  Yet for the most part and for most people, the ACA hasn't and won’t affect your insurance status or fees.  It’ll just be there when you need help.