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Hoekelman Center October 2020 Newsletter - Vote for Health
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A Note From The Director October 2020
Director of the Hoekelman Center, Andy Aligne, M.D., M.P.H., was invited to speak on WXXI's program Connections with Evan Dawson regarding the pandemic. You can take a listen here "Coronavirus and Population Density"
What Is Epidemiology?
One of the silver linings that I hoped would come out of this disastrous epidemic was a better public understanding of epidemiology, but that doesn’t seem to be panning out, as this recent quote from The New York Times illustrates,
“But observational studies can show only correlations, not cause and effect.” (NYT 9/1/2020)
A variation on the above sentence appears pretty much every week in the science section. I understand why they say this: because there are all these studies where one thing is associated with another, but it doesn’t mean that the first caused the second. A basic lesson in science is that simple correlation by itself is not sufficient proof of causation. True enough. If several people play their birthdays and win the Lotto, that doesn’t prove that playing your birthday is a sure-fire way to win the Lotto. But that truism doesn't justify the logic leap to implying that observational epidemiologic studies can't provide actionable evidence of causality, or that only randomized trials can do that.
Epidemiology, generally speaking, is about looking at the big picture of entire communities. It tries to answer questions like How do we prevent epidemics? Going back to the work of pioneers like Florence Nightingale, epidemiologic studies led to public health and hygiene interventions that enormously increased life expectancy by decreasing deaths from infectious diseases.
Since then, epidemiology has saved more millions of lives by uncovering the preventable causes of non-infectious diseases. For example, it was epidemiologic studies that established that cigarette smoking was the main underlying cause of the global lung cancer pandemic. It was epidemiologic studies that determined that belly-sleeping was the cause of the SIDS epidemic and then established that Back to Sleep was an effective solution. I could go on.
In terms of the current COVID catastrophe, there are lessons from the epidemiology of previous pandemics that could be helpful. For example, I had the opportunity to be on the radio recently because WXXI’s Connections did a show on the impact of population density on COVID, and I talked about how the real issue is overcrowding, not population density. I wrote a research article about this in the American Journal of Public Health regarding the 1918 flu. The distinction matters for health policy because it’s not cities or tall buildings that are the problem so much as homes, workplaces or any locations where too many people are packed in together. As a recent article in The Atlantic pointed out, the common theme around the world in outbreaks that have been driving the pandemic is “the three Cs”: crowds in closed spaces in close contact. Nations that have been using this understanding to fight the pandemic have been more successful in controlling the contagion than those that haven’t.
If we ever figure out what made the COVID-19 pandemic as severe as it is and how to keep similar future pandemics from occurring in the first place, observational epidemiology will probably play a role in that. Epidemiology is an amazing science that saves lives. Respect.
P.S. For more info on epidemiology, the Hoekelman Center has a number of books on the topic and the CDC has great online resources.
A Note From The Director January 2020
Pictured above: Children from the Cyclopedia Program created from a CARE Project by Cappy Collins, MD, in the Rochester Review Magazine January/February 2013
The Social Determinants of Health (SDoH)
What Should We Do About Them, and How Does One Teach That?
As I write this, a Viewpoint in JAMA points out that there’s some confusion about SDoH (Silverstein, NAS). A huge focus lately has been on “screening for SDoH” in the medical setting, but there’s not a ton of evidence for this approach and even some concern that it could do more harm than good (Davidson). So what’s the problem with SDoH “screening”?...
First of all, it doesn’t always work very well for accurately identifying social risks. Why not? There are multiple potential reasons:
- People might be afraid to reveal that they don’t have enough to eat, for example, because they worry that they could wind up getting their children taken away.
- People are used to the conditions they’re used to and might have a different definition of “normal.”
- A few years ago, CARE residents Francis Coyne and Andy Peckham along with some medical students, and in consultation with Dr. Arvin Garg the leading expert on the WECARE survey tool-did a project on SDoH screening. They found that even when people did reveal social risks, they often didn’t want any assistance because they expected their problems to be temporary.
- The questions can be stigmatizing, especially if only administered in high risk populations.
- Even when people answer accurately and ask for help, it’s not obvious how to connect them to resources or that these resources will be effective for resolving their problems and improving health outcomes.
- The doctor’s time could already be stretched pretty thin. Adding one more list of tasks to the clinical encounter would just make it more rushed.
- Investing in SDoH screening could divert attention and resources from preventive community-level action.
So what’s the solution? I would propose that if health professionals are to become effective partners in addressing SDoH then they first need a basic understanding of evidence-based community-health. And that’s what we’ve been teaching in CARE track for all these years!
To deliver that education, we go beyond the walls of the hospital or doctor’s office and partner with community-based organizations and individuals. This was the insight of Anne E. Dyson, a pediatrician and philanthropist who founded the Dyson Initiative to promote this type of training. At this 20th Annual Dyson Day we salute her vision and celebrate it by looking at the success we’ve had with almost 200 participants in the CARE track.
Our special guest speakers for Dyson Day this year are Dr. Sara Horstmann and Dr. Cappy Collins who will be talking about their wonderful CARE projects and how they have continued to use what they learned in CARE to keep doing and teaching community health and advocacy.
- Addressing Social Determinants to Improve Population Health, The Balance Between Clinical Care and Public Health. Michael Silverstein, MD, MPH, Heather E. Hsu, MD, MPH. https://jamanetwork.com/journals/jama/fullarticle/2757035
- National Academies of Sciences, Engineering, and Medicine 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Washington, DC: The National Academies Press. https://doi.org/10.17226/25467.
- Screening for Social Determinants of Health, The Known and Unknown. Katrina W. Davidson, PhD, MASc, Thomas McGinn, MD, MPH. https://www.ncbi.nlm.nih.gov/pubmed/31465095
A Note From The Director October 2019
Pictured above: Dr. Aligne pointing at a plaque which commemorates the site in the University of Rochester where the HIB vaccine was invented "leading to the eradication of the Haemophilus Influenza Type b disease in children."
Opioids and "Antivaxxers"
There is a strong case for childhood vaccines like the Hib shot, which was invented here in Rochester, and prevents deadly epiglottitis and meningitis. Nevertheless, according to the medical literature, when pediatricians take the time to give information to vaccine-hesitant parents, it doesn’t seem to accomplish much in terms of changing minds but it does tend to increase burnout among the doctors. So what to do?
In my course on project planning, I often say, “Don’t reinvent the wheel or the Hindenburg!” What I mean by that is to resist the urge to rush into action. Instead, I want folks to start by looking stuff up so they can do what works best, or at least avoid repeating proven mistakes. When the literature does not provide specific solutions, we need to fall back on general principles.
Going back to Aristotle, the three key components of persuasive argument are Ethos (credibility with the audience), Pathos (emotional connection) and Logos (facts and such)—in that order. Using this framework, if we want to understand a breakdown in communication between pediatricians and parents, we shouldn’t start by looking at vaccine handouts, or even with sad stories about sick children. We should start by looking for any reasons the public might distrust the medical establishment.
Unfortunately, a casual glance at the daily news yields plenty of reasons. As I write this today, the headlines are about new research showing how red meat is not actually bad for you. Apparently, the nutrition experts telling us that red meat causes deadly heart attacks have been basing their recommendations on very weak evidence. The news article didn’t go over the actual evidence; it just quoted doctors going back and forth over how misguided their opponents are. All the average reader could conclude is that many of the experts are wrong—one way or the other.
Even more disturbing is the ongoing saga of the opioid crisis that has been dominating the news for weeks. This manufactured epidemic caused hundreds of thousands of deaths and millions of severely disrupted lives. I recently read the book American Overdose, and what that makes clear is that the responsibility for this disaster goes way beyond the Sackler family and Big Pharma. The list includes many doctors, including medical school professors and leaders of organized medicine, the FDA, hospitals, pharmacies, drug distributors, etc.
Given current realities like the opioid crisis, being suspicious of the medical establishment is not a sign of paranoia. So what can well-meaning pediatricians do in this context to have credibility with “anti-vaxxers”? I think we start by listening. It turns out when one listens to “anti-vaccine” parents that many of the things doctors think they know about them are not true. There are many varieties of “anti-vaxxers.” Some accept vaccination in general, but want fewer total vaccines or a more spaced out schedule. In general they are not categorically against all vaccines. I have taken the time to listen in person to some of the national leaders of the movement, and these are moms who had their children vaccinated. They believe that their children then got sick because of the vaccines. Worried mothers of sick children are who I was trained to listen to. They say they are doing advocacy to protect other children from what happened to theirs. As a public health scientist, I do not put much weight in personal anecdotes as evidence of causality, but as a pediatrician, I can understand their concern.
For Tyler’s visit to the Mennonites near Penn Yan, he collaborated with Sara Christensen Deputy Director of the Yates County Public Health Department, who gathered questions ahead of time from local parents. The discussion was organized around answering those questions first. Then, the floor was opened for other queries and comments from the audience. The panelists did not just come to lecture. Afterwards, parents came up to thank Tyler and his colleagues. Did this one outreach effort succeed in correcting everyone’s misconceptions about “anti-vaxxers” as well as those about vaccines? Not likely. Did it succeed in building trust that both sides want what’s best for children? I think so.
- Strategies intended to address vaccine hesitancy: Review of published reviews. Eve Dubé
- Lessons Learned From the Opioid Epidemic. Joshua M. Sharfstein, MD, Yngvild Olsen, MD, MPH
- The New York Times, We’re Ignoring the Biggest Cause of the Measles Crisis by Jennifer Lighter Sept 22, 2019
- The New York Times, The Rise of the Anti-Vax Home Schoolers,Ginia Bellafante, September 15, 2019
A Note From The Director June 2019
Drs. Andy Aligne and Andy Sherman in Senegal.
Is There a Right Way To Do & Teach Global Health?
Global aid in general and global health education in particular are areas of controversy, as detailed in books like "Great Escape" by Angus Deaton and "Hoping to Help" by Judith Lasker. Some people argue that people in poor countries would be better off if we just left them alone. I think this is a dangerously wrong-headed idea. While some aid programs are wasteful or even harmful, that doesn't mean that they all are.
Netlife grew out of Dr. Andy Sherman’s experiences as a Peace Corps Volunteer. While living in a small village in Senegal, he got to know children who would go on to die of malaria. This motivated him to found a non-profit to facilitate distribution of insecticide-treated bed nets. These have been shown to have a huge impact on malaria mortality, but nets were very underutilized when he began this work. Through medical school, residency, fellowship, private practice and parenthood, he has kept going back to Senegal to maintain relationships and keep the good work going. Nowadays, net distributions are done routinely by the Senegalese government, but Netlife has continued to look into how things can be improved.
Recently, Netlife conducted a survey that revealed that people needed more nets than World Health Organization (WHO) guidelines recommended. Observations and interviews discovered several reasons for this, including the harsh rural conditions, which caused the nets to wear out faster than predicted. Local people were also sleeping outside regularly at night because of the extreme heat, and that issue was getting worse with global warming. Sleeping outside meant they were unprotected by nets. This was new information that was not in the malaria literature at the time. For a previous project, Netlife sponsored a contest to come up with a practical solution for hanging up mosquito nets outside. Winners got prizes like a cow or a goat. One of the winning teams came up with a wire and rubber contraption that can be made with locally available materials and is easily used.
On our 2019 trip, we went back to help distribute hundreds of these kits along with nets for outside use, and we made a video and posters to help teach others how to hang up the nets outdoors. All of this work is done in partnership with local health workers, doctors, nurses, Peace Corps Volunteers, village chiefs, etc. Everything we do is with very low overhead. We visit the villages by bicycle-not air conditioned SUVs- and pay for all of our own travel expenses. The residents and students who come with us get to watch Dr. Sherman demonstrate his mastery of community relationship building and cross-cultural communication.
We will be getting feedback on the impact of our novel outdoor use of nets from the regularly collected malaria statistics. I go on these trips to help with the scientific evaluation of the project but also because they do me a tremendous amount of good. Hearing all the little children in the village come to “give me five” and say hello while I’m trying to find a spot where my phone works (They have cell service now!), helping the team overcome some of the many obstacles inherent in this kind of work, completing long bike rides – all of those are good antidotes to burnout. And then there is the fact that everywhere we went, people thanked us profusely for helping them to fight malaria, which for them is a real and terrible danger. They all know people who have suffered or died from this disease. One municipal official told us his job is to promote economic development but he can’t do that when malaria makes people too sick to work.
Long-lasting insecticide treated nets work to prevent malaria and save lives. We know we are moving the needle in one of the world’s malaria hot spots. And as explained in historian Randall Packard’s brilliant book “The Making of a Tropical Disease” controlling malaria in places like Senegal can be particularly important for “shrinking the map” and perhaps eventually eliminating one of the world’s major killers. Netlife’s approach is community-level, preventive/upstream, evidence-based, locally sustainable with longitudinal relationships and high return on investment with measurable impact.
I believe that there are many right ways to do and teach global health. The Netlife experience is just one of those, but one example is enough to disprove the nihilistic notion that nothing works.
- Andrew Aligne, M.D., M.P.H., Director of the Hoekelman Center
Disclaimer: The views expressed on this page do not reflect those of the University of Rochester Medical Center.