"Hashtag Activism"- Is It Working For Public Health?

Last year on Facebook, my timeline was suddenly filled with status updates of just one word.  Red. Black. White.  "What is this?" I thought to myself.  It turned out that it was a breast cancer awareness campaign.  Facebook users were listing their bra colors to help prevent breast cancer.  And there are tons of these public health campaigns all over social networking sites.  "Like" our Facebook page to prevent cancer!  "Re tweet" this message to prevent heart disease!  For those of you familiar with my blog, you'll remember that I think "raising awareness" is the most counter-productive phrase used in our work.  It is not specific enough to measure for change and (on its own) it will not change health behaviors.  

So I thought of my frustration with these campaigns as I read a great article in the New York Times this week called, "Hashtag Activism, and Its Limits".  David Carr writes eloquently about the ease of supporting a variety of causes:

"If you “like” something, does that mean you care about it?  It’s an important distinction in an age when you can accumulate social currency on Facebook or Twitter just by hitting the “like” or “favorite” button.

The ongoing referendum on the Web often seems more like a kind of collective digital graffiti than a measure of engagement: I saw this thing, it spoke to me for at least one second, and here is my mark to prove it".

I like that David brings up the question of engagement here.  Many of these public health campaigns on social media just strive for "likes" on Facebook or "hits" on a website or "re tweets" on Twitter.  And not that they mean nothing, but those measures are just the tip of the iceberg in measuring audience engagement.  And audience engagement (beyond "raising awareness") is what could actually lead to public health activism, knowledge change, and ultimately behavior change. Leslie Lewis gives a great overview of Return on Engagement (ROE) on her blog "digital.good".  According to Leslie, ROE measures tend to be more qualitative and measure message reach and spread.  In addition to "likes", ROE also measures things like brand/campaign awareness, comments, shares, and returning visitors. 

I certainly do not think that all public health campaigns delivered via social media are ineffective.  On the contrary, I think that social media is an incredibly powerful tool for public health.  David Carr makes similar comments later in his article.  Challenging his initial skepticism of web activism, he lists several recent "campaigns" that have been quite effective (e.g., the reversal of Susan G. Komen de-funding Planned Parenthood).

However, to use social media effectively in public health, we must be strategic and we must evaluate.  

Some sample questions that I ask program planners:

• What is the goal of the campaign?  (e.g., to drive traffic to your website; increase hotline calls; increase specific behaviors like breast self examination?).
• How will the campaign activities (logically) lead to the desired goal/outcome?
• Are your goals/outcomes measurable?
• Have you thought about evaluation before launching the campaign?
• Besides the ideas listed above, how are you measuring "audience engagement"?

 
 What other questions should we be asking?

Onward

In upcoming posts, I plan to pursue two main themes.  The first is a more comprehensive exploration of what determines eating behavior in humans, the neurobiology behind it, and the real world implications of this research.  The reward and palatability value of food are major factors, but there are others, and I've spent enough time focusing on them for the time being.  Also, the discussions revolving around food reward seem to be devolving into something that resembles team sports, and I've had my fill.

The second topic I'm going to touch on is human evolutionary history, including amazing recent insights from the field of human genetics.  These findings have implications for the nutrition and health of modern humans. 

I look forward to exploring these topics, and others, with all of you in the coming months.

Recent Media Appearances

Men's Health interviewed and quoted me in an article titled "Reprogram Your Metabolism", written by Lou Schuler.  Part of the article was related to the food reward concept.  I'm glad to see the idea gradually reaching the mainstream. 

Boing Boing recently covered an article by Dr. Hisham Ziauddeen and colleagues in Nature Reviews Neuroscience that questioned the idea that common obesity represents food addiction-- an idea that I often encounter in my reading.  Maggie Koerth-Baker asked me if I wanted to respond.  I sent her a response explaining that I agree with the authors' conclusions and I also doubt obesity is food addiction per se, as I have explained in the past, although a subset of obese people can be addicted to food.  I explained that the conclusions of the paper are consistent with the idea that food reward influences fat mass.  You can find my explanation here.

Food Reward: Approaching a Scientific Consensus

Review papers provide a bird's-eye view of a field from the perspective of experts.  Recent review papers show that many obesity researchers are converging on a model for the development of obesity that includes excessive food reward*, in addition to other factors such as physical inactivity, behavioral traits, and alterations in the function of the hypothalamus (a key brain region for the regulation of body fatness).  Take for example the four new review papers I posted recently by obesity and reward researchers:
Read more »

The Vaccine War: Public Health vs. The Media

A few weeks ago, I had the pleasure of speaking with Laurie Edwards, a writer and blogger who examines chronic illness, healthcare, life balance, public health history, and everything in between.  Among other topics, we talked about the role of social media and mainstream media in the vaccine debate.

So I thought of that conversation as I watched last night's re-run of PBS Frontline's special "The Vaccine War" (originally aired April 27, 2010).  I highly encourage advocates on both sides of the issue to check it out.

The piece was quite balanced with interviews on all sides.  For example, we heard from vaccine advocate Dr. Paul Offit, bioethicist Dr. Arthur Caplan, anti-vaccine advocate parents in Ashland, OR (with one of the lowest vaccine rates in the country),  Jenny McCarthy and her colleagues at Generation Rescue who continue to argue for evidence of the link between vaccines and autism, and from parents of a girl who almost died at 6 weeks from whooping cough.

It explored possible contributors to the fear of vaccines and/or the lowering vaccination rates:

• 1998 Lancet article by Dr. Andrew Wakefield that linked autism to childhood vaccines (*This article has since been retracted and MANY U.S. and International epidemiological studies have found no scientific evidence of a causal link)

• A new generation of parents that are too young to know the devastating effects of vaccine-preventable diseases like polio.  One interviewee used a term that I really like- "Community Recollection".  As Community Recollection of these diseases disappears, we can become complacent.

• A false sense of security because many of these diseases are not seen frequently in the United States.  However, we forget that with the ease of air travel, borders are almost non-existent.  For example, the piece followed an outbreak of measles in San Diego that started when a non-vaccinated 7 year old from the US contracted it while vacationing in Switzerland and brought it home to classmates.

• The Internet.  While it also offers many positive benefits regarding healthcare (e.g., access to information/publications; online support groups and connections with a "community" of individuals with similar diagnoses)- it also has its potential downfalls.
• It can keep controversy alive- even after it has been disproven (e.g., the Wakefield article)
• False or unproven information can go viral and it is hard to retract!  They use the example of the youtube video of Desiree Jennings (a 25 year-old Washington Redskins cheerleader) that claimed that a flu shot caused her debilitating muscle disorder.  

So how can Public Health compete with the Media and the Internet?

• Let's not compete.  Let's collaborate.  Let's learn (either through our own capacity or collaboration) to effectively communicate public health information online.  Our biggest audience (the public) is not usually reading our peer reviewed journals or attending our annual conferences.  This is already starting to happen.  Public health organizations have active Facebook and twitter accounts, blogs, videos.  Let's keep going.  And let's train our public health colleagues/students in health communication.

• Let's remember to share the spotlight with celebrities and other spokespeople that have influence over the public.  Like it or not, the way people get their health information and make decisions is changing.  They do not just agree with doctors or scientists.  I almost always see these debates featuring Public Health (scientist speaking in jargon) vs. Celebrity/Parent with moving emotional story about their child being injured by a vaccine.  That is hard to compete with!  Believe it or not (because we seem to only hear from Jenny McCarthy), there are also pro-vaccine celebrities.  Jennifer Garner and Kristi Yamaguchi have been flu vaccine advocates.  Jennifer Lopez and Keri Russell have been pertussis vaccine advocates.  Let's make sure the public knows that. 

• Let's think about the framing and marketing of vaccination messages.  When the HPV vaccine is framed as a Cancer Vaccine for both boys and girls...versus an STD Vaccine for just girls/young women it is perceived very differently by the public.

Tell me what you think:

• What can we do to change the current "Community Recollection" about vaccinations?
• Other suggestions regarding how public health can collaborate with the media/internet sites to communicate more effectively with the public?

Speaking at AHS12

I'll be giving a 40 minute presentation at the Ancestral Health Symposium this summer titled "Digestive Health, Inflammation and the Metabolic Syndrome".  Here's the abstract:

The “metabolic syndrome” is a cluster of health problems including abdominal obesity, insulin resistance, low-grade inflammation, high blood pressure and blood lipid abnormalities that currently affects one third of American adults.  It is the quintessential modern metabolic disorder and a major risk factor for diabetes, heart disease and certain cancers.  This talk will explore emerging links between diet, gut flora, digestive health and the development of the metabolic syndrome.  The audience will learn about factors that may help maintain digestive and metabolic health for themselves and the next generation.

Excessive fat mass is an important contributor to the metabolic syndrome, but at the same level of body fatness, some people are metabolically normal while others are extremely impaired.  Even among obese people, most of whom have the metabolic syndrome, about 20 percent are metabolically normal, with normal fasting insulin and insulin sensitivity, normal blood pressure, normal circulating inflammatory markers, and normal blood lipids.

What determines this?  Emerging research suggests that one factor is digestive health, including the bacterial ecosystem inside each person's digestive tract, and the integrity of the gut barrier.  I'll review some of this research in my talk, and leave the audience with actionable information for maintaining gastrointestinal and metabolic health.  Most of this information will not have been covered on this blog.

The Ancestral Health Symposium will be from August 9-12 at Harvard Law School in Boston, presented in conjunction with the Harvard Food Law society.  Tickets are currently available-- get them before they sell out!  Last year, they went fast.

See you there!

HEADING WEST

In the hinterland of life

west of the coast

by 25km of traffic

dense as dust we must

confront the size

of the problem.

My brown shoe

has lost its shine

and the sole worn -

singular or plural, urban,

ethnic, aged or rural,

alcohol-obliviated,

club-dominated,

fast-food saturated,

Diet Coke burpurated:

is it any wonder?

Map 241, F13 marks

the Mt Druitt of my soul,

suburbs built without amenities:

instead, misunderstandings,

sensitivities offended,

little attention to child care,

concrete poured and walls built

in haste against imaginary winds:

letters posted from here

and there give clues,

random roads and rusted gates:

public transport is bad.

Qsymia (formerly Qnexa), the Latest Obesity Drug

There are very few obesity drugs currently approved for use in the US-- not because effective drugs don't exist, but because the FDA has judged that the side effects of existing drugs are unacceptable. 

Although ultimately I believe the most satisfying resolution to the obesity epidemic will not come from drugs, drugs offer us a window into the biological processes that underlie obesity and fat loss.  Along those lines, here's a quote from a review paper on obesity drugs that I think is particularly enlightening (1):
Read more »

Words for a new year*

For last year’s words belong to last year’s language

    And next year’s words await another voice …

So I find words I never thought to speak

In streets I never thought I should revisit...

                                                         -T.S. Eliot Little Gidding

2011 was a year of continued discussion in Australia about the future of our health system, with movement towards more decentralised hospital care, the establishment of larger more formal primary care entities, and new interest in the efficiency of the way in which we spend the health dollar.  While the debate has been hot at times, it has not been anywhere near as bitter as that in the US over Obamacare.  Words have been chosen here with restraint even when discussions have been tense. 

But in the US, the polarised politics and the words used on each side of the political debate in general and in discussing the health reform proposals in particular are bitter indeed, contributing to, if not creating, a highly flammable social environment.

In Tucson, Arizona, at 10:11 am on January 8, 2011, a young man intruded upon a small group waiting to talk to their congress representative at a suburban Safeway supermarket.  He came up very close and shot Gabrielle Giffords, 40, a Democrat congressional representative holding the meeting, in the head. He then shot and killed six others and injured 13 before being disarmed by two by-standers. 

Through superb surgical care and intensive rehab, Ms Giffords is now walking with assistance and speaking in halting words. Revisiting ‘streets I never thought I should revisit’ on the Sunday evening of the anniversary of the shooting, she ‘led a crowd in the Pledge of Allegiance, her words ringing out across a cold Tucson night in a rare public appearance at a candlelight vigil. She limped to the podium, and (astronaut) husband Mark Kelly helped lift her left hand over her heart. After months of intensive speech therapy, Giffords recited the pledge with the audience, head held high and a smile on her face as she punched each word.’ the Huffington Post reported. She has now reappeared in Congress and attended President Barack Obama’s 2012 State of the Union address but has indicated that she will leave Congress shortly for more rehab.

On May 18^th, Giffords had further surgery at Memorial Hospital, Houston, to replace the half of her skull that had been removed at the time of the shooting to allow brain swelling to occur without pressure on deeper brain centres.  Her surgeons used a custom-built plastic replacement, fashioned using CT imaging of the cranium on the opposite side.  Her husband, astronaut Mark Kelly was that morning docking the space shuttle Endeavour with the International Space Station. All up, the sun had risen on a hi-tech day in America.

The assailant, Jared Lee Loughner, has pleaded not guilty to 49 charges. He was assessed as incompetent to stand trial because of a mental problem, said to be bipolar disorder in several reports and  schizophrenia in others. He is now ‘forcibly medicated at a Missouri prison facility in an effort to make him mentally ready for trial.’ I wonder what he will choose as his words for this year.

Much thought and discussion, and some contrition, occurred at the time of the shooting about the virulence of political debate in the US and whether this had indirectly led to the attempted assassination of Giffords. She narrowly won re-election in November 2010 against a Tea Party candidate who virulently opposed her support for Obamacare.

Tom Zoellner, who worked on Giffords’ 2010 campaign, in a book about the event and its causes, argues that the killings were a product of ‘spiteful politics, a broken mental health system, wide-open gun laws and suburban alienation. A number of malevolent factors came together … I think it is flat-out wrong to say that Jared Loughner came from nowhere.’ 

Press reports said that Pima County Sheriff Clarence Dupnik blamed the vitriolic political rhetoric that has consumed the country, much of it centered in Arizona. "When you look at unbalanced people, how they respond to the vitriol that comes out of certain mouths about tearing down the government. The anger, the hatred, the bigotry that goes on in this country is getting to be outrageous," he said. "And unfortunately, Arizona, I think, has become the capital. We have become the Mecca for prejudice and bigotry."


Giffords had said previously. "For example, we're on Sarah Palin's targeted (mid-term election) list, but the thing is, the way that she has it depicted has the crosshairs of a gun sight over our district. When people do that, they have to realize that there are consequences to that action."  The media said that “Republican challenger Jesse Kelly held fundraisers where he urged supporters to help remove Giffords from office by joining him to shoot a fully loaded M-16 rifle. Kelly is a former Marine who served in Iraq and was pictured on his website in military gear holding his automatic weapon and promoting the event.”


"I don't see the connection," between the fundraisers featuring weapons and Saturday's shooting, said John Ellinwood, Kelly's spokesman. "I don't know this (Loughner) person; we cannot find any records that he was associated with the campaign in any way. I just don't see the connection.”


What relevance do these events in the US have to us in Australia?  Fortunately the acrimony and bitterness of American debate about health care have not infected our discussions.  But whatever one’s view about the causes of the Giffords disaster, ‘last year’s words’ and deeds about health reform and political life more generally in the US might serve as a lesson for us in our search for the voice that will lead to continued health reform in Australia. No health reform should be countenanced that does not endorse the values that underpin civilised living. While the dominating influence of the news cycle and political sound bites is felt everywhere, discussions about health care should surely have a distinctive, humane quality to them.  


The values of civility are obvious in any intensive clinical setting whether saving the life of Gabrielle Giffords or attending to the needs of the mentally ill.  Sometimes that is where they stop, not informing our policy thinking and our management. We do not say much about why we are seeking to improve the health system beyond the rhetoric of shortening waiting lists and creating more beds.  We have learnt phrases like “activity–based funding” without specifying the purpose and outcome of the activity. We stop short of telling the grand story of social achievement through health care. The extent to which these humane values are transmissible to today’s and tomorrow’s generations of health care professionals is in question.  But we can be reassured by the huge numbers of young people seeking meaningful careers in medicine and other health professions.  They get it.


The new words that we need to support changes in healthcare this year are ones that tell that story of health care, why we do it, why we pour money into it, why people spend their lives in it, not building monuments but providing care and giving service, a story that does not shy from compassion, concern, help, support, love and sacrifice.


There’s a new story to be told - or maybe an old one using words that have accumulated dust.    

*Published in RADIUS March 12