Tuesday, November 30, 2004

Pork Hall of Fame: Let's Rock

NYT reports today that Congress's new omnibus spending bill has made major cuts in the National Science Foundation (you know the folks that helped bring us browsers, Google and some other things less important like bioinformatics, mathematical research, etc.). The budget is down $105 million from last year and $272 million less than even President (Creation) Science requested.

But not all the news was bad. Congress did find money for the Rock and Roll Hall of Fame, the Alabama Sports Hall of Fame in Birmingham, the Country Music Hall of Fame in Nashville and bathhouses in Hot Springs, Ark., among other worthwhile projects. Some of this will take up the slack left by the cuts at NSF, a major funder of science education in the US. For example,
Todd C. Mesek, a spokesman for the Rock and Roll Hall of Fame, which is receiving $350,000, said the money would be well spent on education programs to teach children about language, the mathematics of music and geography ("cities where rock and roll was fostered"). Some of the money, Mr. Meek said, will be used for "toddler rock," a music therapy program.
Hey, I'm only passing on the information.

Update: From today's Christian Science Monitor:
Despite a surge in pork, Congress is sending President Bush the leanest nondefense spending bill in nearly a decade. Overall nondefense spending dropped to $401.8 billion - the first aggregate decline since 1995. Affordable housing programs in the Department of Housing and Urban Development took a $378 million hit. The Environmental Protection Agency faces a $278 million reduction from 2004, mainly affecting state and local water projects.
At the same time, in addition to the Hall of Fame items noted above,
lawmakers found $1 million for the B.B. King Museum in Indianola, Miss.; $250,000 to repair a gymnasium in Caribou, Maine; and $250,000 for a new firetruck for Tijeras, N.M.
The record 13,000 "pork" projects were estimated to cost a total of "at least" $24 billion in FY 2005, not exactly a tunafish sandwich.

Surgical Strike in Falluja

A report by Miles Schuman in The Nation, dated November 24, gives new meaning to the term "surgical strike." US forces reportedly killed "scores of patients" and health care workers in a bombing raid on a health center in the early hours of November 9:
Although the US military has dismissed accounts of the health center bombing as "unsubstantiated," in fact they are credible and come from multiple sources. Dr. Sami al-Jumaili described how US warplanes bombed the Central Health Centre in which he was working at 5:30 am on November 9. The clinic had been treating many of the city's sick and wounded after US forces took over the main hospital at the start of the invasion. According to Dr. al-Jumaili, US warplanes dropped three bombs on the clinic, where approximately sixty patients--many of whom had serious injuries from US aerial bombings and attacks--were being treated.

Dr. al-Jumaili reports that thirty-five patients were killed in the airstrike, including two girls and three boys under the age of 10. In addition, he said, fifteen medics, four nurses and five health support staff were killed, among them health aides Sami Omar and Omar Mahmoud, nurses Ali Amini and Omar Ahmed, and physicians Muhammad Abbas, Hamid Rabia, Saluan al-Kubaissy and Mustafa Sheriff.

Schuman appropriately includes the names of the health care workers: real people doing work like ours. Besides destroying the health center, the strike leveled an adjoining warehouse where medical supplies were stored.

James Ross of Human Rights Watch was quoted as saying
the onus would be on the US government to demonstrate that the hospital was being used for military purposes and that its response was proportionate. Even if there were snipers there, it would never justify destroying a hospital.
This is only for starters. Read the whole article. It'll make you retch.

Update: More bad casualty news here (via DailyKos). See also Iraq Veterans Against the War and Iraq Coalition Casualty Count links on the left sidebar for depressing updates.

Open Access, Open Sesame

The whole point of publishing a blog is for others to see it. For that they need open access to it. You would think that would be the whole point about science, too: Open Access. Unfortunately that is not how scientific publishing has worked until recently. Even now the vast majority of scientific papers aren't accessible unless you have priviliges at a library that carries the journal or you have a subscription. That is beginning to change and this post is to alert readers to an extremely significant trend in scientific publishing.

In the interests of full disclosure, I am a co-Editor-in-Chief of an Open Access journal. I don't make a penny from it although the publisher does (more on the publisher's business model, below). I spend a lot of time and effort arranging for peer-review, counseling authors and doing all the other things good editors do because I believe strongly in the principle that good and reliable science should be available without charge to any one on this planet (and in this case, has an internet connection and a browser). This is especially true for the majority of work in this country supported by tax-payer's money through NIH.

In the medical field Open Access works like this. If you do a PubMed search on a particular subject (e.g., influenza A H5N1), the search engine returns a list of citations meeting the search criteria. If an article is in an Open Access journal there will be a button next to the cite to download the full text of the article in .pdf format. That's good for the searcher who gets the paper immediately without barriers of place, time or money, and good for the scientist who has a large stake in his or her work being noticed, cited and used by other scientists.

Many people don't realize that scientists don't get paid for their contributions to scientific journals and may actually have to pay "page charges" (often amounting to $50 - $100 per page). The publisher's subscription fee is solely for marketing and distribution. But with the internet we don't need publishers for distribution. We can distribute for free. Open Access journals do just that as on-line publications.

So how do the publishers make money? Open Access publishers have switched the business model from having the reader pay to having the author pay. Good for readers. What about for authors? Does it prevent some from publishing? That depends on how much it is and if there are easy ways to pay for it. Some, like the recently launched Public Library of Science (PLoS) charge a hefty $1500/paper. Others, like the 100+ journals published by the leading Open Access publisher BioMed Central charge in the neighborhood of $600/paper (varying with journal; a few are in the $1000 or more range). In the BioMedCentral case, however, there is a novel twist: they allow institutions to beome "members." There are currently more than 450 subscribing institutions in 38 countries (complete list here), including most of the major research universities in the US (143 total). If you are a faculty at one of the subscribing institutions there is no charge to publish at all and there are special provisions to allow Editors limited processing charge waivers for scientists in developing countries or students without other means. But even if your institution is not a member, most national research funders (including NIH) allow scientists to put a processing charge on their grants. So many universities now belong to this effort, however, that this is becoming increasingly unnecessary.

There are other advantages to Open Access besides immediate access. Publication is almost always faster while still maintaining rigorous peer review. Large supplementary datasets or appendices, colored photos or diagrams and long papers are all easily accomodated without any extra charge. The full text of each article is immediately and permanently archived in the National Library of Medicine's full-text archive, PubMed Central, as well as repositories in Germany, France and The Netherlands. Thus even if a journal ceases publishing, its papers are archived for however long these national repositories last (forever is a long time).

What about intellectual property rights? Here is the BMC model (link for attribution). Although other journals might differ, this is probably typical (although admittedly I have not investigated this). The author retains copyright but:

Anyone is free:

  • to copy, distribute, and display the work;
  • to make derivative works;
  • to make commercial use of the work;

Under the following conditions: Attribution

  • the original author must be given credit;
  • for any reuse or distribution, it must be made clear to others what the license terms of this work are;
  • any of these conditions can be waived if the authors gives permission.

Statutory fair use and other rights are in no way affected by the above.

PLoS and BioMedCentral are not the only Open Access publishers. Many other journals have gone Open Access on their own, including all the journals from Oxford University Press; the British Medical Journal (kudos); and Environmental Health Perspectives, the major journal in the environmental health field (I note that this happened after an Open Access rival, Environmental Health, started publishing. It is hard to know whether that influenced EHP's decision, but it was certainly welcomed and past due).

Open Access is a significant development in scientific publishing. Here is the current link page from BioMedCentral (link for attribution) for other tools for free access to medical literature:


Dedicated to the promotion of free access to medical journals over the Internet, the site carries listings of free full-text journals.

Health InterNetwork

The Health InterNetwork was launched by the Secretary General of the United Nations and is led by the World Health Organization to bridge the "digital divide" in health. It aims to ensure that health information and the technologies to deliver it are widely available and effectively used by health personnel professionals, researchers, scientists, and policy makers.

Public Library of Science

A non-profit organization of scientists committed to making the world's scientific and medical literature freely accessible to scientists and to the public around the world.

PubMed Central

A digital archive of life sciences journal literature with free and unrestricted access.


The Scientific Electronic Library Online - SciELO is an electronic library covering a selected collection of Brazilian scientific journals.


SPARC is an alliance of universities, research libraries, and organizations built as a constructive response to market dysfunctions in the scholary communication system. These dysfunctions have reduced dissemination of scholarship and crippled libraries. SPARC serves as a catalyst for action, helping to create systems that expand information dissemination and use in a networked digital environment while responding to the needs of scholars and academe.
Update: A helpful reader, Peter Suber, whose blog is devoted to the Open Access Movement, has provided a number of extremely useful links for those interested in this important development. Of particular interest is the third link on the NIH open access plan which would require depositing a paper funded by NIH in the PubMed Central free access repository within 6 months of publication. This reasonable (too reasonable? why 6 months? I paid for it with my tax money, I should see it immediately) is being vigorously opposed by some scholarly societies whose income relies on their journal subscriptions and several major medical journals who make a great deal of money selling reprints of clinical trials to drug companies who send them free to doctors. Anyway, here are the links from Peter (above opinions are my own):
Open Access Overview
(my introduction to OA for those who are new to the concept)

SPARC Open Access Newsletter
(my newsletter, published monthly)

FAQ on the NIH open-access plan

Timeline of the open access movement

What you can do to help the cause of open access

Monday, November 29, 2004

Influenza and leadership

This post is ostensibly about avian influenza A (H5N1). It's really about how we are going to cope without effective public health leadership. Avian flu is a freight train coming our way. Whether or not it hits us will just be a matter of dumb luck one way or another and is probably out of our control by now. How badly we are hurt if we are hit isn't. But it isn't just a matter of an effective plan or manufacturing a vaccine, although both are part of it. As much as anything it is about a public health system that is leaderless, uninspired and dispirited. I plan to devote several later posts to this issue, but first, bird flu.

Last week's dire predictions concerning a potential avian flu pandemic made the newswires but surprisingly little impact on the major blogs. There are some notable exceptions (DemFromCT on Daily Kos covered it nicely) and one of the major public health blogs as well (Public Health Press). The (excellent) blog Infected Hands calls attention to a report suggesting that intradermal injection of vaccine might require less inciting antigen and hence stretch supplies further as well as make administration easier and faster, although this remains to be seen.

But one post, by Melanie on American Street, deserves additional comment. In "Waiting for a Protein to shift" she takes issue with reporting that suggested the global death toll would be 7 million (a number also reported here). She notes,
This [referring to a Reuters news article] is very sloppy reporting. First, the Spanish Flu pandemic of 1918 killed 50 million people. The population of the planet was a fraction of what it is now, about 1.8 billion. The lethality (mortality) rate of the 1918 virus was between 2-5%. By contrast, 75% of the people who have contracted this year's Avian virus (that can be identified, always a sketchy business this early) have died. That's a stunning rate. The 1918 pandemic did its lethal business in a mere 8 weeks [not quite true; Ed.]. Given how much more mobile the world is now, it is chilling to contemplate how much damage this year's bug could do in next to no time.


The Reuters writer, then, took at face value the 7 million deaths from a possible Avian flu pandemic from the "expert" with which he spoke. In 1918, more than half of the world's population was infected by the flu. Actual numbers of deaths by this Avian flu would be catastrophic. So, the tone of this article, while a little hysterical, actually understates the amount of danger that this potential represents.

In earlier bulletins, WHO was already calling for public health authorities all over the world to begin to prepare for vaccinating their entire populations. If this bug is as bad as it looks, that's not an outrageous demand. Unfortunately, the earliest estimate for the vaccine to begin to be available is March, and I think that even if we put all of the vaccine makers in the world to the task of manufacturing it, we'll have a little difficulty cranking out 5 billion doses in time to do a lot of good.

Right now, our defensive strategy is to hope that the mutation doesn't occur before we are ready for it. I'm not liking those odds.
I think Melanie makes a good point about the low-ball estimate for mortality (which regrettably I repeated). There is still no agreement on how many people died in the 1918 pandemic (estimates range from 20 million to 100 million over three separate waves and 18 months). Just in the last few days WHO personnel have given numbers that range from very conservative (2 - 7 million) to 20 - 50 million to 100 million (quoted here and here). But even the largest of these numbers seems too low if one accepts WHO's global infection figure of 30% together with most estimates of case fatality (which for the handful of H5N1 cases so far is over 70%). If 30% of the world's population of 6.4 billion is infected and there is a 30% mortality that is almost 600 million deaths. A mortality of 10 million would only be a mortality of 0.5%. Note that a 30% global incidence is not impossible. These numbers are all over the place and obviously no one really knows. But there are sound reasons to fear the high end, although even the low end is catastrophic.

What to do? Success on a vaccine is one way to slow and ameliorate these huge numbers. But in another report from WHO (as reported in the British Medical Journal today ) it is recognized that the "market" doesn't work for vaccines, something we have clearly seen with this season's flu debacle in the US (full report, Priority Medicines for Europe and the World Project can be found here). As Melanie notes, it isn't feasible to produce and vaccinate the entire globe, but the production of some "herd immunity" in the population can slow and blunt the spread of the disease, buying precious time to make adjustments to cope with a pandemic. At the moment there is essentially no native immunity to H5N1. Even vaccinating 30% of the population would be a tremendous help, but would also be a tremendous task.

And such a successful vaccination program isn't likely to happen, but even if it did there would still be hell to pay. One response is essentially nihilist. In the nuclear freeze movement of blessed memory we used to have a poster giving the steps to take to protect yourself against a nuclear attack. It ended with sitting down, putting your head between your knees and kissing your ass good-bye. That kind of response won't happen because we are hardwired to try to survive. But it would be nice to have some vision other than as a bit part in a post-apocalypse reality show.

I don't see much that our public health officials are doing to plausibly prepare for this. We go through an endless cycle of "needs assessments," contingency plans and appropriations that never find their way to the street level. Most knowledgeable people don't believe we are in much better position to cope with an emergency than we were a few years ago. We have no more surge capacity in our hospitals than before. Even a slightly worse flu season than usual overwhelms them. And there will be a serious shortage of nurses and other care givers, not to mention undertakers. It isn't as if this hasn't happened before. It has. But we aren't really in better shape. There is neither the political will, the political vision, nor the political public health leadership. We are drawing up plans on paper on how to get to the life boats when the ship hits the iceberg. Even if that works in an orderly way (and there isn't enough room for everyone), there is precious little thought what to do when we are set adrift.

So what am I saying? In an earlier post (Vioxx: What would Gandhi do?) I suggested we adopt a "constructive program" and do our own planning, constructing and implementing on a small local scale. We don't need CDC or Tommy Thompson to think about how to use hotels or motels for surge capacity (each room has a bathroom), begin to organize volunteer retired nurses and doctors (our neighbors) in case of an emergency, start talking to the mortuaries about what they will do, inquire again and again at our community hospitals about adequate supplies of respirators (including pediatric sizes since this virus seems to have a predilection for children). I know some of these things are (allegedly) being done by state health departments. But my (up close) observation is that with staffing shortages, turf battles and a stunning narrowness of vision, most of it isn't happening and the plans on paper will be out the window in the first 24 hours after a true emergency is recognized.

I would love to be wrong about this. Convince me.

Sunday, November 28, 2004

An Environmental Crime

The London Times reports on the truly stunning deterioration of civil society that the US occupation has produced. By almost any definition of environmental health this is an environmental catastrophe (imagine if it were caused by a toxic release). Via Juan Cole:
The London Times reports that nearly 700 persons die under suspicious circumstances (most of them from bullet wounds) every month in Baghdad. These are not, at least mainly, victims of the guerrilla war. They are mostly victims of crime or revenge. I figure that as 8400 murders a year in a city of 5 million, or 168 per 100,000 per annum. The highest murder rate in the US for 2003 was 45.8 per 100,000, in Washington, DC, with Detroit coming in second. That is, Baghdad is nearly four times as dangerous as the most dangerous American cities, more than a year and a half after the fall of Saddam. The US has by its stupid mistakes deprived Baghdad's residents of the basic right to personal security. It is true that Saddam's secret police used to dump bodies at the morgue, of course. But all the polls show that Baghdadis feel themselves substantially worse off in personal security now, and no wonder.
Original London Times article here.

Vioxx: What would Gandhi do?

An interesting report from AP (here via CNN) tells how 12 states have by-passed FDA judgment and decided for themselves which drugs are safe and effective and therefore which they are willing to shell out their portion of the billions of dollars spent on prescription drugs by federal and state governments. Using information from the scientific literature the twelve state cooperative venture, called the Drug Effectiveness Review Project, recommended to its members that Vioxx be considered for reimbursement removal two years ago. Washington and Oregon did so in early 2002. Missouri took another tack:
Missouri applied the Vioxx warning to a computer program that in fewer than three seconds judges whether the state should pay for prescriptions, said George Oestreich, the program director.

After that, when a pharmacist tapped in prescription information, the computer program knew to block payment for Vioxx if the patient had a history of cardiovascular disease or if the prescribed dose was higher than 25 milligrams and was to be taken longer than five days.

In those cases, an electronic message would flash the answer back to the pharmacy: Missouri won't pay.
Seems like a constructive program. Which brings me to Gandhi.

Many people think of Gandhi as the exemplar of passive resistance. But as Jonathan Schell writes in a book I strongly recommend, The Unconquerable World: Power, Nonviolence, and the Will of the People (Metropolitan/Owl, 2003 and available on Amazon here), Gandhi was anything but passive. His philosophy was quintessentially one of action. In addition to his better known strategy of active non-cooperation, he was an ardent advocate of what he called "the constructive program." If the goal is the betterment of India, why not proceed to it directly? As Schell writes,
Why not pick up a broom and sweep a latrine--as Gandhi in fact did at the first Congress [Party] meeting he attended, in 1915....He frequently suggested, indeed, that the constructive program was as effective a path to political power as noncooperation. Political power, he wrote, would in fact increase in "exact proportion" to success in the constructive effort. (pp 140-141).
Gandhi's goal was not seizure of political power per se but the objectives that political power can help achieve: ending untouchability, cleaning latrines, improving the diet of Indian villagers, improving the lot of Indian women, making peace between Muslims and Hindus (as summarized by Schell, p. 142).

It is something to think about. Obsessing about the recent election loss should not obscure the possibility that in many areas of public health we can advance our own "constructive program" without waiting for the Messiah of 2008 and his/her Congressional Apostles. There is much interesting discussion about "framing" issues. Fine. Probably important, maybe essential. But let's not forget that we can sweep some latrines now and provide support for those who have been doing so for a long time. Since the latrines have been filling with crap faster than we have been removing it, perhaps it's time to start thinking and implementing new and better ways to sweep, whether it be the state, local or neighborhood levels.

Saturday, November 27, 2004

Surgeon General's Warning

This letter to the Editor of The Stabroek News in Georgetown, Guyana was entitled: Travel to US should come with health warning. Indeed.
Saturday, November 27th 2004
Dear Editor,

I think travel to the USA should now, like a packet of cigarettes, come with a health warning. The security measures recently introduced regarding travel to, and within, the USA are so stressful that it is hard to see a mad rush for holidays in America. I recently returned from a short vacation and am still recovering from the stress and anxiety involved.

First of all, the travel agents' briefing about 'homeland security' came as a surprise. These included leaving one's suitcases unlocked, not having beverages in suitcases, keeping film in hand luggage, etc. Airline security people are empowered to break suitcase locks, inspect and dispose of goods they consider 'suspicious', and there would be no compensation for loss or damage. Airlines now accept no responsibility for such actions. This is all part of 'homeland security'. I wonder how travellers' insurance companies feel about that. I felt uneasy about leaving my suitcase unlocked - anyone could put anything inside an unlocked case. How would the owner be able to prove that he/she had nothing to do with it?

On our plane (American-based airline), at the end of the captain's 'welcome aboard' speech, we were requested to report any 'suspicious behaviour'. On arrival at the US airport, we were fingerprinted (both index fingers), then photographed full-face. Our vacation involved changing planes at four airports - San Francisco, Las Vegas, Los Angeles and Hawaii. At each one of them we were required to divest ourselves of jackets, trinkets, wristwatches, shoes, and these, together with carry-on luggage, were placed in trays for conveyor belt electronic scrutiny. We had to have a photo ID (normally our passport) at the ready. Very boring and exhausting. I suppose we were lucky not to have our back and front 'curvy bits' cupped and squeezed, to ensure we were not hiding non-metallic explosives, as some American passengers recently experienced and complained about.

{remainder of letter snipped}
Update: The letter writer is obviously naive about the dangers in foreign countries, possibly believing that the indigenous peoples are harmless and picturesque. Shortly after posting the above letter, I ran across this irrefutable evidence that the public health measures indicated are necessary. Representative John Hostettler (Republican, Indiana 8th District), with a prior conviction as a recipient of the Christian of the Year Award, was detained again when he tried to bring a loaded 9 mm Glock aboard a plane in Louisville, KY. (Via up2date on dKos).

The Next Big Thing

With retail season upon us, everyone is wondering what will be The Next Big Thing. The answer might have been anounced at a meeting of ministers from 13 Asian countries held over the last two days while Americans were chowing down on a Thanksgiving bird. Yes, it's H5N1 bird influenza and as many as 30% of the entire world might get this gift that keeps on giving. According to WHO, as many as 7 million might even be thrilled to death.

Haven't heard that WHO just announced it expects H5N1 to cause the next big flu pandemic? Maybe that's because US health officials have been taken up with even more important health issues. For example, the US Surgeon General wants us to trade family medical information at the dinner table so everyone is aware how their genes will doom them to serious disease (see post, The Surgeon General as Appetite Suppressant). Meanwhile the Director of CDC was busy explaining why she and her agency overstated the health impacts of obesity (see post below). In neither case was there any time for our nation's public health "leaders" to mention we are facing a threat that requires a change in farming practices, animal husbandry procedures, strengthening the public health system and the proper and timely provision of vaccines. Especially not the proper and timely provision of vaccines.

Influenza pandemics come around every 20 or 30 years, so we are due for one, as WHO pointed out at the meeting. Pandemics are caused when the influenza virus changes sufficiently that there is essentially no native immunity from past infection. And as far as anyone knows, humans have never been afflicted with an H5N1 virus before. It'll go through the world's population like a hot knife through butter.

The H5N1 influenza A virus has mainly affected birds, which are subject to many other influenza A viruses that don't seem to affect humans, although a few human cases have been reported in people in close contact with infected birds for some strains (H5N1, H9N2 and H7N7). In the three dozen or so cases where H5N1 has made the jump from birds to humans it has had a frightful 70% mortality, akin to Ebola and much higher than SARS. Human cases of H5N1 seem to occur unusually often in children. The real worry is that H5N1 will continue an already evident genetic shift and become adapted to person-to-person transmission. Already it has had an unprecedented geographic spread in birds and been found in tigers and domesticated cats. A likely scenario would be co-infection in pigs, often kept in close contact with humans in Asia. Pigs can also harbor human influenza A, which could allow a subsequent genetic recombination between the avian and human viruses with the worst features of each: extreme virulence and transmissibility between people.

Any protection must come from solid public health and other infrastructures to provide implementable contingency plans for dealing with transport and trade if the disease starts to spread, support for better agricultural practices, especially in the poorest nations and the stockpiling of affordable anti-influenza medication. Timely surveillance and warning and the ability to implement preventive and care-giving measures are needed not just locally, but globally. Too bad it's called influenza A. Maybe if we could rename it al-Qaeda we could find enough resources to bring "health democracy" to the rest of the world (giving new meaning to getting a "shot" from the US).

What about a vaccine? Two American companies are working on it, although nothing is expected during this year's flu season. With any luck we'll make it through without an H5N1 pandemic--this year. But what about next year or the year after? Two companies? Sounds familiar. Will they have exclusive licenses? Or will they distribute their technology globally, so that world public health authorities can set up half-a-dozen or a dozen production facilities with associated distribution networks throughout the world?

Oh well, not to worry. I'm sure our nation's public health leaders are doing their best. And they can't do everything (that's why they are urging us to take care of ourselves, after all). They have taken significant steps already, just announcing they are letting a contract to manufacture 75 million doses of vaccine. And at a bargain price: $877.5 million. Of course, it's a vaccine against anthrax, a non-contagious disease that only killed a handful of Americans when it got out of a government facility. But it's a matter of priorities and it's a start. First things first.

News reports about the Bangkok meeting with various slants can be found at AP via Newsday, CBC, The Standard of Hong Kong, The Nation and Reuter's Health. CBC has an "in depth" with a Canadian perspective and useful background on avian influenza viruses in general. So far no notice of the Bangkok meeting on the CDC site. WHO has a press release that adds nothing and is less helpful than the news stories, linked above.

Friday, November 26, 2004

Powell and Gerberding: Administration Aqueducts

The resignation of Colin Powell as Secretary of State has brought a mixed reaction from progressives. dKos and Atrios are glad to see him go. The estimable Juan Cole of Informed Comment saw him as an important moderating force, as did The Washington Note (Steve Clemons). I confess to being in the former category. Colin Powell was not only duplicitous with the public (assuming he had private reservations, which if he didn't, makes additional reasons to be glad he's gone) but he carried (a lot of) water for the Administration. He was always the "good soldier." Some see that as a virtue. Few of them would cut the German General Staff any slack for the same thing. Yes, I know, comparisons of Bush with Hitler are odious. Even I don't believe Bush is a Hitler. But that fact just underscores my point. Disagreeing with Bush can get you ostracized, marginalized or fired. Disagreeing with Hitler got you dead or in a concentration camp. Okay, enough said. This blog is about public health, right?

Which brings me to Julie Gerberding, current Director of CDC. An infectious disease/HIV specialist who came to CDC in 1998, Gerberding was Acting Director of the National Center for Infectious Diseases during the anthrax attack of 2001. To say that CDC did not distinguish itself in that episode would be an understatement. For one thing, it propagated inaccurate information on the dose needed to infect, continually maintaining that number was in excess of 10,000 spores when the available science indicated it was far smaller. A seminal paper by Meselson et al. in 1994 suggested that as few as 9 spores might be sufficient to infect 2% of those exposed. It turns out that it was about 2% of the Brentwood mail facility that contracted inhalational anthrax from spores of weaponized anthrax contained in loosely sealed postal envelopes. If they had understood that so few spores might produce serious or lethal disease when a large population was exposed as at the mail facility, CDC might have accorded them the same kind of exposure assessment (nasal swabs) they did Congressional staffers and treated them prophylactically with cipro. Not only did NCID (under Gerberding's direction) miss the boat, but CDC leadership allowed itself to be cowed by, and subordinated, to the criminal justice system (in this case the FBI) in handling a public health crisis and in communicating with the public.

To be fair, there are some important ways that Gerberding is an improvement as CDC Director Apparently she learned important lessons about public communication from that debacle. She herself, in contrast to her former boss, the former Surgeon General or the low-wattage Secretary of HHS Tommy Thompson, is an impressive and articulate communicator. She doesn't go beyond the science, which she represents reasonably accurately, and she doesn't try to spin it. Her performance in the SARS episode was good and was what we should expect from a public health official at that level. So what's my complaint?

Same as Colin Powell. She seems to have carried a lot of water for the Bush Administration. CDC, a once proud and effective public health agency, has itself become marginalized and morale is at an all time low according to long-time employees. Again to be fair, one told me he thought she was doing her best within the Administration in private to fight for public health. Shades of Colin Powell. At that level, fighting for public health has to be done publicly and you have to be prepared to lose your job. Being fired over public health priorities would in itself be a valuable contribution. She isn't going to be out on the street living in a Kelvinator box. She'll have an easy time landing an academic or other position.

Moreover, much of the loss of agency morale is said to be traced to poor management. Gerberding has put in place a wholesale reorganization of CDC that has disconcerted and upset many. Leaving aside its virtues as an organization chart (and there is much to criticize here), she did it by fiat with little or no preparation within Congress or the agency. Major changes like this, which must have been in the works for awhile, need a great deal of attention to getting everyone onboard, and if, in that process, modifications need to be made, they can be. I am told that none of that was done.

The latest agency dust-up is the admission that a much bally-hooed CDC paper in JAMA with Gerberding's name on it was inaccurate (PubMed abstract of paper here). The paper made news because it said that obesity was poised to overtake cigarette smoking as the major cause of ill health in this country The gist of the JAMA paper was that the biggest causes of disease in the US are "modifiable behavioral risk factors" (read "life-style"):
These findings, along with escalating health care costs and aging population, argue persuasively that the need to establish a more preventive orientation in the US health care and public health systems has become more urgent.
The burden of this "preventive orientation" will fall on individuals to change how they live. Apparently the role of the fast food industry, agribusiness, the automobile culture or urban design is not part of CDC mandate.

Gerberding is not only failing to fight publicly for her agency (which has had budget woes) but is actively promoting the Administration's emphasis on self-reliance as a "preventive measure." She is not only carrying water for this Administration. She is a one-person aqueduct.

What's the Point?

Now that I have a few posts under my belt, it is time to ask the pertinent question: Why? I have been perusing some of the writings on the subject. If you are interested in a single source to start, I would recommend a slim volume by Rebecca Blood, The Weblog Handbook (you can find it on Amazon here).

There seem to be two parts to this:
  • personal to the maintainer (for the moment, that's me)
  • focus/objective
These two are related, but let's separate them for discussion purposes.

There is a reasonable commitment related to maintaining a blog. Whether the maintainer is a person or a group/community, it has to have a point of view or opinions you feel worthwhile enough to share with others. If you don't want to share them you may as well keep a private journal. And if the opinions are essentially conventional wisdom there is no need to share them. They are already available. In addition, since most "writing is thinking" committing opinions to writing helps clarify them, refine them and, for others, making explicit and explaining them and possibly persuading some in the audience.

But all the advice I see on this subject emphasizes that the level of commitment is such that tailoring posts to "build an audience" or appeal to as many people as possible is a bad strategy. Blog editors express themselves by what they write and (importantly) by what they link to. The personality of a blog (as opposed to an electronic magazine, say) is directly related to what the links are and the voice that is used to put them in context. But just collecting a bunch of "public health" links (of which there are probably hundreds or thousands of candidates, daily) isn't either that interesting or that useful. Anyone can use a free news aggregator like NetNewsWire for the Mac or SharpReader for Windows for this purpose. So to make this work you need to link to and comment on things that truly interest you or the community. Without that, I think the effort is eventually doomed. With it, it will evolve and prosper. The Weblog Handbook quotes Cyril Connolly as saying, "Better to write for yourself and have no public than to write for the public and have no self." Seems like good political, as well as personal, advice. Are you listening John Kerry and DNC?

As regards focus/objective, it is already narrowed down quite a bit to public health concerns, not a family journal, election politics or food, to take common examples of blog subjects. But that still leaves a lot of territory and prompts the original question, "To what effect?"

Here are some functions I think a blog can fulfill:
  • Filter information from the web and elsewhere pertinent to our point of view and of use and interest to the public health community;
  • Provide context for that information;
  • Provide alternate points of view (challenging the conventional wisdom or the unspoken assumptions that get in the way of finding "out of the box" solutions);
  • Encourage argument, examination and evaluation of important issues for the purpose of fashioning a coherent point of view that can be framed and efficiently and effectively communicated;
  • Accrue an audience specifically interested and attuned to that point of view, which may be small, but if coordinated can exert significant influence and leadership.
These are advance ruminations, made without much experience doing this (although with more hours than I care to admit reading other blogs). I expect that if I continue things will evolve and (I hope) mature.

So having done my due diligence of reflection, I'll return to trying this out some more. I hope to post later in the day.

Thursday, November 25, 2004

Surgeon General as Appetite Suppressant

The United States Surgeon General has a new approach to the obesity epidemic specially for Thanksgiving. As reported in today's Chicago Sun Times, he suggests you discuss Uncle Frank's colon cancer at the dinner table:

It's not just Thanksgiving today.
U.S. Surgeon General Richard Carmona is declaring today also is the first annual National Family History Day.
As extended families gather today, it's a perfect time to compile medical histories, Carmona said. Show it to your doctor and keep a copy for your records, updating when necessary.
In the future, genetic tests likely will pinpoint your risk for common diseases, but in the meantime, the best predictive tool is a family history. However, doctors often don't have time to ask about family histories, and even when they do, patients often are vague on the details.
In the future, genetic tests likely will pinpoint your risk for common diseases, but in the meantime, the best predictive tool is a family history. However, doctors often don't have time to ask about family histories, and even when they do, patients often are vague on the details.
You can't change your genes, of course. But if your family history indicates you are susceptible to a given disease, you can take steps to prevent it, or at least detect it early with screening tests such as mammograms and colonoscopies.

Lovely. Last time I checked, none of the "steps to prevent it" actually prevented any disease. If you are lucky maybe they will prevent an earlier death or decrease or disability. Or maybe they'll just increase the length of your illness by telling you about it sooner and you'll die at the same time anyway (the evidence for the efficacy of many screening tests is questionable; for some of the difficulties involved, see here, here and here).

We know that many diseases are truly preventable by removing their causes. To the extent that those causes are environmental or occupational the "fixes" lie in political action. In the meantime, my advice is to relax with your family and friends, enjoy the day and worry about your weight some other time. Yes, obesity is a problem in this country. But holidays and family gatherings are special and come infrequently. Tomorrow you can return to a proper diet (which in my lexicon, means "everything in moderation").