The Moore Tornado Reminds Us That "Sheltering" Is A Community-Level Concern

As the news of the Moore, Oklahoma tornado flooded in on Monday, the images were terrifying.  Over and over, Meteorologists kept saying- "it would be very hard to survive this storm above ground".  And then we heard that basements and safe rooms are not common in Moore.  Safe rooms being structures that are reinforced to withstand 200+ MPH winds.

So how can that be?  How can a town situated in an area of the country ripe with tornado activity be without basements and safe rooms?

Well- as with most public health challenges, the answers are complex:

Environmental:  The soil in the state is comprised mostly of clay.  The bedrock is mostly limestone.  Both absorb water and become unreliable foundations for a basement.

Urban Sprawl:  As The Atlantic points out, "One reason tornadoes prove so deadly now is that, given the spread of the suburbs, their funnels simply stand a better chance of touching down where people are".  Therefore, instead of striking farmland, these tornadoes are striking homes and schools and shopping centers- many without sufficient sheltering options.

Cost: Various estimates have been given over the past two days, but NBC News reports that individual home safe rooms can cost $8,000-$10,000 to construct.  There is a lottery to receive state assistance for these costs.  The most recent lottery selected 500 homeowners...out of 16,000 applications.  The city of Moore recently applied for $2 Million in federal aid to help build safe rooms in an additional 800 homes.  City officials report that the program was delayed because FEMA standards were a "constantly changing target".

There are additional cost challenges at the community-level.  NBC News reported that it would cost $1.4 Million to construct safe rooms in each school.

Access:  The City of Moore has no community (or "public") tornado shelters.  On their website, they attribute this to two reasons:  (1) People take less risk by sheltering in place and (2) There is no public building in Moore that is suitable for a shelter.

With hindsight being 20/20, it is heartbreaking  to read the following statement on their site:

"Statistically, there is only about a 1-2% chance of a tornado - of any size - striking Moore on any particular day during the spring. But of all tornadoes that do strike us (again, not very many historically), there's only a less than 1% chance of it being as strong and violent as what we experienced on May 3rd [1999]".  

Interestingly, "May 3rd" (as it is often abbreviated), shined a light on the need to shift from individual (family) shelters only to community-level ones.  Shortly after that storm, FEMA released design and construction guidance for community safe rooms.  Many communities, such as nearby Tushka, OK, have constructed such rooms very successfully.

In public health, we assess health needs and change the conversation from individual-level to community-level solutions.  We need that frame of mind to improve emergency preparedness planning for tornadoes.  As Megan Garber writes for The Atlantic:

"The old, Wizard of Oz-style model of sheltering -- every farm with its cellar -- is slowly giving way, in the age of suburban sprawl, to large shelters meant to house large groups of people".    

"Sheltering, in other words, is moving from an individual concern to a collective one". 


Tell Me What You Think:

• What are some solutions to the challenges (environmental, cost, access) listed above?
• What is your reaction to the shift from individual to community-level shelters?

BREATHE DEEPLY AND SAY ‘NINETY-NINE’*

On July 4^th 2014, the Medical Journal of Australia will celebrate its centenary, so we are about to turn 99! 

Whatever the outcome of the federal election on September 14^th, new national policies for the financing, governance, quality and scope of publicly funded medical and hospital care will soon be under construction. 

For these policies to work well, the new government will need the participation of those who will implement them, including, quite obviously, the medical profession.  For participation to be at its best, the profession needs access to the information that underpins high quality professional performance.  Throughout its 99 years, the Journal has helped communicate that information amongst the profession and beyond.

The Journal has always played this role. My historian colleague Milton Lewis points out that in doing so it has continued a tradition dating back even further – to colonial days. The first Australian journal was born in Sydney as early as 1846. Lacking adequate support, it soon ceased publication. But the better organised Victorian profession (has anything changed?!) was able to establish a quarterly journal, the Australian Medical Journal, in 1856.

The Australian Medical Journal continued to be published in Melbourne for over five decades until along with the younger, Sydney-based, Australasian Medical Gazette, it was replaced by the national publication, the Medical Journal of Australia.¹ Throughout this time, the other significant source of intra-professional unity (and an effective political player at both State and federal levels) was the British Medical Association, the first Australian branch of which was set up in Victoria in 1879 and the second in NSW the next year.¹ Its successor, the Australian Medical Association, operates the Journal.

The Journalhas contributed to the development of medical care and health by providing a place where research and clinical observation is published, where thoughtful opinions based upon experience and evidence from the sciences and practice are offered, where concerns – ethical, political and legal – about health and health care are raised, life’s passage is marked (most often with obituaries), successes celebrated, courage and outstanding professional service recognised. The wit and wisdom of correspondents have entertained and stimulated and the Journal has been a strong component of the professionalisation of medicine in Australia.

The Journal has regularly changed its format and livery but its central purposes have remained largely intact.  Now it is also available online, on mobile phones, laptops and (non-medicinal) tablets anywhere, anytime, as it joins the dance of the Internet. The dynamism that is challenging print media more generally extends its challenge to the Journal.  New business models to sustain it are essential and work continues to develop them. But for a near centenarian it has shown remarkable flexibility, optimism and athleticism!  If only we could all do as well at 99!

This is an excellent moment for the Journal to promote and strengthen the publication of research especially that which assesses clinical effectiveness and new ways of organising and providing care.  Policy-makers, managers and clinical practitioners are hungry for evidence to help them decide. 

As McKeon and colleagues in their review of health and medical research in Australia noted, we spend comparatively little on health care research and development in Australia.² They call for a substantial increase in R&D investment (to 3-4% of government health expenditures) to address the problem of expenditure on health and hospital care, which is rising faster than our willingness to pay.² The Journal is here to publish and disseminate such research.

Medical journals depend heavily on voluntary contributions from doctors and other health service professionals, research workers, patients, politicians, health service managers and experts with an involvement in health and medicine from diverse fields of interest and work.  Without the altruism of colleagues presenting their ideas for others to read and examine critically, there would be no journals.  It is the desire to share insights for the benefit of patients that features strongly among the reasons that include professional advancement why contributors write papers, commentaries, case studies and reviews.  A love of the profession leads others to submit material that sustains the spirit, by way of personal stories, art, poetry or letters.

This is a rich background against which to plan for the future.  The Journal takes those gifts, these contributions given to it in the past and sees them as markers of its heritage and future strength.  They explain why we are optimistic and why we look forward to your company when we celebrate our 100^th in July 2014!

*Previously published in MJA

1.Lewis M, MacLeod R. Medical Politics and the Professionalisation of Medicine in New South Wales, 1850-1901. Journal of Australian Studies 1988; 2: 69-82.

2. Mckeon Report. Strategic Review of Health and Medical Research. Final report Feb 2013. http://www.mckeonreview.org.au/downloads/Strategic_Review_of_Health_and_Medical_Research_Feb_2013-Final_Report.pdf(accessed April 2013).

Angelina Jolie's "Medical Choice" Dominates the Internet

I woke up this morning to the quintessential Pop Health story.  Angelina Jolie published an op-ed called "My Medical Choice" in the New York Times.  She talks about undergoing a preventative double mastectomy in February 2013 after genetic testing revealed that she carried the BRCA1 gene.

As I inventoried her column and the online chatter today, I worried that I missed the boat!  Dozens of bloggers and news outlets wrote about her op-ed within hours of its posting...what else could I add to the conversation?

With so many posts for readers to sift through- many of which focus on very specific issues (e.g., the efficacy of preventative mastectomies)- I decided to add to the conversation by cataloging the public health implications being discussed:

Angelina as a "champion" for breast cancer prevention: will her celebrity status help or hurt the cause?:  Most of the articles and comments that I read in response to her op-ed were overwhelmingly positive.  This is exemplified by an open letter on KevinMD.com written by Dr. James Salwitz.  He praises Angelina for her bravery and leadership in the battle against breast cancer.  He goes on to state, "Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years".  On the flip side, a few writers/commenters raised the concern that Angelina's influential status in conjunction with her decision to have surgery could cause women to panic about their own breast cancer risks.  For example, David Kroll writes for Forbes, "For all the bravery of Ms. Jolie and the positive groundswell that her op-ed generates, I also want to be sure that women with breast cancer - women who are already scared - do not feel the extra burden that they’re not doing enough if they don’t consider a double mastectomy".

I thought that Linda Holmes (of NPR's pop culture blog) did a really nice job of reconciling Angelina's role as both "celebrity" and "champion" in her post called "Why Angelina Jolie's Op-Ed Matters".

Legal and Policy Issues:  BRCA Genetic Testing:  On April 15, 2013, the Supreme Court heard oral arguments challenging Myriad Genetics' patents on "the breast cancer genes".  As a side note: I do not remember hearing about this story last month- perhaps because the Boston Marathon bombings also took place on April 15th?  The concern is that such patents inhibit scientific advancements, keep testing costs high- and therefore limit access to the testing.  Angelina alludes to this in her op-ed when she reveals that the BRCA1 and BRCA2 testing costs approximately $3,000 in the U.S.  Sarah Kliff from The Washington Post notes that this testing "is about to get significantly less expensive: The Affordable Care Act included the genetic test among the preventive services that insurers are required to cover without any cost sharing".

Health Communication- Risk Perception:  Nancy Shute wrote an interesting piece for NPR entitled, "Angelina Jolie and the Rise of Preventative Mastectomies".  She interviews Dr. Todd Tuttle, who raises concerns about women overestimating their risk of breast cancer (in the other breast after being diagnosed on one side) and choosing more invasive treatment like mastectomy when not medically necessary.  Shute also discusses some potential contributors to the increases in risk perception and preventative mastectomy. For example, she mentions advancements in breast surgeries/reconstructions and the "hyper-awareness" of breast cancer resulting from ubiquitous pink ribbon campaigns.  Many of these contributors were discussed two weeks ago in the must-read The New York Times Magazine article "Our Feel Good War on Breast Cancer" by Peggy Orenstein.

Reviewing the Evidence Base for Recommending BRCA Testing or Preventative Mastectomies:  Many articles focused on reviewing what we know about the effectiveness of (1) BRCA testing for predicting cancer and (2) mastectomies for preventing cancer death.  Several articles linked to the CDC feature, "When is BRCA Genetic Testing for Breast and Ovarian Cancer Appropriate"?  Sarah Kliff discusses why "Most Women Probably Shouldn't Get the Cancer Screening Angelina Jolie Did".  NPR linked to a 2010 Journal of the American Medical Association (JAMA) article that provided the "clearest evidence yet that women carrying the BRCA1 and BRCA2 genes should consider preventive surgery because they are at a very high risk for breast and ovarian cancers."

With so many articles and blogs to sift through, I could probably keep going.  But I'd like to stop and hear from you:

• What other public health implications could result from Angelina Jolie's disclosure in today's New York Times?
• How do you think her disclosure could impact the issues I've raised above- risk perception, policy decisions, etc?
• I've linked to some of the articles that I read today- are there others that you would recommend to me and Pop Health readers?

"Call the Midwife": Public Health in the 1950s and Today

Are other people in love with "Call the Midwife" like I am?  I started watching last year during a break between Downton Abbey seasons.  The show follows the lives and work of nurse/midwives working in the Poplar community of east London in the 1950s.  The community has a high poverty rate and limited resources.  The series is based on the memoirs of Jennifer Worth, who like the main character Jenny Lee, became a midwife at the age of 22.

Season 2 of Call the Midwife (airing in the U.S. March 31-May 19, 2013) has been packed with public health issues.  I have been struck by how many of the highlighted issues still challenge us today:

• Season 2, Episode 1: Jenny Lee begins to care for a young mother named Molly, pregnant with her second baby.  In the course of their visits, Jenny realizes that Molly is a victim of domestic violence.  In one especially poignant scene, Jenny soothes and encourages Molly via a conversation held through the family's mail slot. Molly has been ordered by her husband not to let Jenny in the house.

Domestic violence (or intimate partner violence- abuse by a current/former partner or spouse) is still a problem today.  The Centers for Disease Control & Prevention (CDC) estimates that it affects millions of Americans.  This violence has long-term economic and health consequences for individuals, families, and communities.  The CDC offers many resources focused on public health's role in the prevention of intimate partner violence.

• Season 2, Episode 5: Jenny Lee provides prenatal care to Nora, a mother of 8, living in poverty.  The family of 10 crowds into a 2 room flat.  When Nora finds out that she is pregnant again, she is desperate to end the pregnancy.  With the family's financial situation, she feels that it is impossible for her family to take care of another child.  Jenny confronts Nora after seeing evidence of self harm.  Jenny reminds her that there is only one way to terminate a pregnancy (abortion), but it is illegal.  Nora risks her life seeking the services of a local woman who performs abortions.

Abortion remains a hotly debated public health issue in the U.S. both at the state and federal level.  This episode of "Call the Midwife" is a grim reminder of what can happen when women do not have access to safe, legal abortions.

• Season 2, Episode 6:  After diagnosing several late-stage Tuberculosis (TB) infections in Poplar, the community physician (Dr. Turner) advocates for a screening program in the form of an x-ray van.  Dr. Turner and Sister Bernadette (a nun/midwife) make a wonderful public health argument for the resources they need.  They cite the risk factors, specifically poverty in their community, noting that families may have up to 12 people in one apartment.  The close living quarters increase the chance of spreading this infectious disease.  In fact, we meet one family in the episode that lost 6 children to TB.  As a public health professional, it was fascinating to see the promotional materials that the clinicians created to recruit people for the screening.  They papered local bars with flyers and set a large sign outside the van reading, "Stop. 2 minutes may save your life. Get a chest x-ray".

Infectious diseases and their screening, treatment, and vaccination remain key public health issues in the U.S. and around the world.  Many infectious diseases like measles or chickenpox can be prevented by vaccines.  Over the past 15 years, there has been much discussion between the public and public health communities about the safety of vaccines for children.  In January 2013, the Institute of Medicine released a report reaffirming that the current childhood vaccine schedule is safe.  In fact, they report that "vaccines are one of the safest public health options available".

Tell Me What You Think:

• What have been your favorite episodes of "Call the Midwife"?
• What other public health issues are portrayed in the 1950s that still challenge us today?

The Neurobiology of the Obesity Epidemic

I recently read an interesting review paper by Dr. Edmund T. Rolls titled "Taste, olfactory and food texture reward processing in the brain and the control of appetite" that I'll discuss in this post (1).  Dr. Rolls is a prolific neuroscience researcher at Oxford who focuses on "the brain mechanisms of perception, memory, emotion and feeding, and thus of perceptual, memory, emotional and appetite disorders."  His website is here.

The first half of the paper is technical and discusses some of Dr. Rolls' findings on how specific brain areas process sensory and reward information, and how individual neurons can integrate multiple sensory signals during this process.  I recommend reading it if you have the background and interest, but I'm not going to cover it here.  The second half of the paper is an attempt to explain the obesity epidemic based on what he knows about the brain and other aspects of human biology.

Read more »

Speaking at AHS13

The 2013 Ancestral Health Symposium will be held in Atlanta, GA, August 14-17.  Last year was a great conference, and I look forward to more informative talks and networking.  Tickets go fast, so reserve yours now if you plan to attend!

This year, I'll be speaking on insulin and obesity.  My talk will be titled "Insulin and Obesity: Reconciling Conflicting Evidence".  In this talk, I'll present the evidence for and against the idea that elevated insulin contributes to the development of obesity.  One hypothesis states that elevated insulin contributes to obesity, while the other states that elevated insulin is caused by obesity and does not contribute to it.  Both sides of the debate present evidence that appears compelling, and it often seems like each side is talking past the other rather than trying to incorporate all of the evidence into a larger, more powerful model.

There's a lot evidence that can be brought to bear on this question, but much of it hasn't reached the public yet.  I'll explore a broad swath of evidence from clinical case studies, observational studies, controlled trials, animal research, physiology, and cell biology to test the two competing hypotheses and outline a model that can explain all of the seemingly conflicting data.  Much of this information hasn't appeared on this blog.  My goal is to put together a talk that will be informative to a researcher but also accessible to an informed layperson.

On a separate note, my AHS12 talk "Digestive Health, Inflammation and the Metabolic Syndrome" has not been posted online because the video recording of my talk has mysteriously disappeared.  I think many WHS readers would be interested in the talk, since it covers research on the important and interdependent influence of gut health, inflammation, and psychological stress on the metabolic syndrome (the quintessential modern metabolic disorder).  I'm going to try to find time to make a narrated slideshow so I can post it on YouTube.

Kudos to The New York Times Magazine for Examining the "Feel-Good War" on Breast Cancer!

In last week's The New York Times Magazine, Peggy Orenstein wrote an article called "Our Feel-Good War on Breast Cancer".  The piece is lengthy but well researched, insightful, and well worth the reading time.

Peggy, a breast cancer survivor herself, hits every key public health issue- cancer screenings, treatment options, "awareness" raising, message framing, funding, and research.  As someone who has been critical of "awareness" raising, I was happy to see the issue discussed front and center.  For me, her interview with Dr. Gayle Sulik (Sociologist and Founder of the Breast Cancer Consortium) was the most striking.  A key quote from Dr. Sulik (I added the bolding):

“You have to look at the agenda for each program involved.  If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”

Peggy also tackles the issue that is an ongoing challenge in public health and medicine:  screening.  Screenings are tests that look for diseases before you have symptoms.  Ideally, screening will identify diseases early when they are easier to treat and have better outcomes.  For breast cancer, the key screening test is a mammogram (x-ray of the breasts).  However (as Peggy points out), we seldom hear about the research that demonstrates limited effectiveness of mammograms for reducing cancer death.  This is not the research cited in the communication materials from advocacy organizations.  We also tend not to hear about the negative side effects of screening large segments of the population.  There can be false positive tests: which subject the patient to unnecessary medical intervention and emotional distress.  There can also be over-treatment for the detected cancer, even if it turns out to be a non-aggressive tumor.

When I was working in suicide prevention, one of the best articles I read was "Screening as an Approach for Adolescent Suicide Prevention" by Dr. Juan Pena and Dr. Eric Caine.  The authors dedicate a section of the paper to key decisions and tasks to resolve before implementing a screening program.  While the public health issue and screening tests are different, I believe many of their decision points are generalizable to almost any health issue.  The table presenting these decisions and tasks is a great reminder to public health professionals and clinicians that recommending and undertaking a screening program should be strategic and the decision should be re-visited regularly.  For example, the authors highlight:

• Key Decision:  Population and Setting- Is the screening program consistent with the target population's community or cultural values?
• Key Decision:  Screening Instrument- What will be the false positives and false negatives rates in the population to be screened?  Are these rates acceptable?
• Key Decision:  Staffing and Referral Network- Are there effective treatments available for the types of conditions being screened for?
• Key Decision:  Quality Assurance- How will the screening program be monitored to ensure that protocols are followed?
• Key Decision:  Legal and Ethical Issues- Has sufficient informed consent been given to parents and youth about risks, benefits, and limits of screening?

Going back to the "Feel-Good War" article:  I like that Peggy did not just point out all the flaws in our current breast cancer screening and treatment systems.  Instead, she invited her interviewees to recommend potential improvements.  Some ideas were noted in two key areas:

• Message Re-Framing:  Rather than offering blanket assurances that “mammograms save lives,” advocacy groups might try a more realistic campaign tag line. The researcher Gilbert Welch has suggested this message, “Mammography has both benefits and harms — that’s why it’s a personal decision.”

• Funding Re-Distribution:  Peggy asked scientists and advocates how some of that "awareness" money could be spent differently. She highlights the February recommendations of a Congressional panel (made up of advocates, scientists and government officials) that called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities. 

Tell Me What You Think:

• What do you think about the "pink culture" or awareness raising around breast cancer?  Will it effectively lead us to our goal of prevention?
• In addition to message re-framing and funding re-distribution, what else would you recommend to help improve the approach to breast cancer prevention, screening, and treatment?