Philip Alcabes discusses myths of health, disease and risk.

Censoring Science

Crof’s H5N1 blog is the place to watch for coverage of this week’s controversy over censorship of scientific findings.  A few words here about the controversy and the rush to censor science.

As Martin Enserink reports at Science Insider:

Two groups of scientists who carried out highly controversial studies with the avian influenza virus H5N1 have reluctantly agreed to strike certain details from manuscripts describing their work after having been asked to do so by a U.S. biosecurity council. The as-yet unpublished papers, which are under review at Nature and Science, will be changed to minimize the risks that they could be misused by would-be bioterrorists.

The “biosecurity council” in question is the U.S. National Science Advisory Board for Biosecurity, an arm of the NIH’s Office of Science Policy.   It has recommended censorship of research on genetic alterations of avian (H5N1) flu that might make the virus easily transmissible between humans and pathogenic as well — ingredients for a potentially serious human outbreak.

I attach little public health importance to the experimental work, carried out by Fouchier in the Netherlands and Kawaoka in the U.S.  Flu’s behavior in human populations has been notoriously difficult to predict, even with relatively advanced molecular information about viral strains.  Flu forecasters repeatedly predict bad outbreaks and even (as in 2009) devastating pandemics — which fail to materialize.

Even when it comes to the most studied flu outbreak of all, the 1918 pandemic, opinions still differ on why so many millions of people died.

This week, what concerns me is the biosecurity industry.  It seems more than ever eager to terrify people.   The Fouchier and Kawaoka experiments themselves are interesting but hardly recipes for disaster.   And yet, some voices say the research shouldn’t have been carried out in the first place.  Surprisingly, they include the respected D.A. Henderson, here much mistaken.  He editorializes this week with two coauthors for the online publication Biosecurity and Bioterrorism.

It’s not opposition to science — it’s just the biosecurity “experts” making a living.

The move to suppress publication of research results because scientific findings might tip off some chimerical evildoers is ridiculous.  Fouchier, Kawaoka, and their teams were obviously trying to contribute to the search for ways to make people safer.   That’s what most people want science to do.  Instead of urging caution, the many scientists on the NSABB should be standing up for the wide dissemination of scientific findings — not for suppressing them.  Made-up concerns over “bioterrorism” should not trump public access to scientific research.

And the NSABB scientists shouldn’t be cowed by the self-professed biosecurity “experts” at the Center for Biosecurity.

The sole raison-d’etre of the “biosecurity” business is to keep itself in business — by keeping people terrified.   It does that by continually invoking impossible scenarios that are supposed to (a) frighten the public and (b) cause the public to buy products that we don’t need or give up rights that we do need.

After being scared into thinking the 2009 H1N1 outbreak was going to be a reprise of the 1918 flu calamity and finding that it was exceptionally mild instead, surely the public is not going to be taken in by the biosecurity industry much longer.

It’s anybody’s guess as to whether the new findings about H5N1 are at all meaningful in (human) public health terms.  Which is what happens with science.  That’s why the point of suppressing the findings isn’t to make anyone safer – - it’s just to keep the biosecurity experts in business.

By Philip Alcabes | December 21st, 2011 | Categories: biosecurity, epidemics, flu, Outbreaks, public health, science | Tags: , , , | 2 comments

Childhood Obesity: NYC’s Little Lies, Big Self-Congratulation

There is very little evidence that obesity is harmful to young children.  So I have to ask why NYC’s Department of Health and Mental Hygiene feels so strongly that fat schoolchildren should be forced to slim down.  And why it’s so eager to congratulate itself today on its policing of eating behavior — see reports by WSJ, Bloomberg, CBS (with photos of fat kids!), Huffington, and many other sources.  Why would the city’s health agency lie in order to claim that its jihad against a not-very-convincing evil has been successful?

The subject is a report published by CDC today claiming that obesity among NYC schoolkids in grades K through 8 has decreased 5.5%.

The city’s health commissioner, Thomas A. Farley has been true to the shades of history’s empty-headed warriors.  Farley announced that the drop in obesity prevalence is a “turning-point in the obesity epidemic” although it “does not by any means mark the end.”

A missed photo opp:  Dr. Farley standing on top of a fat child, holding up a sign reading, “Mission Accomplished.”

Farley is zealous about controlling people’s behavior and contemptuous of facts (nobody will ever accuse him of being an intellectual, either).  He blogs about his own work for the exclusive reading pleasure of Department of Health staffers.  This allows his staff to read the Farley-esque twist on truth.  One example for now:  in October of 2010, Farley’s blog exultantly told his staff that in 2009 the department had “immunized nearly 130,000 children [against flu] in more than 1,200 schools over a few months.”  Of course, health department employees are smart — many of them knew that the 2009 H1N1 vaccine Farley was talking about was a fiasco, far too late to make a difference, and aimed at an outbreak that was more of a whimper than a bang.

What about today’s “turning point” in the obesity war?  It’s worth noting that the supposed drop in obesity among NYC schoolkids is really just a very slight (1.2%) difference in the prevalence of obesity between 2006-7 and 2010-11.

A small difference between small numbers amounts to a large percentage difference.  So the 1.2%  actual difference magically turns into the advertised 5.5% — the proportionate change.

But the false advertising gets worse

1.  The prevalence of obesity in NYC was not measured multiple times on the same group of kids (to use epidemiology jargon:  this wasn’t a panel study).  Nobody observed fat children becoming less fat.  The city simply measured obesity prevalence each year on 5- to 14-year-olds who were in the school system.  So a high proportion of the 21.9% of kids who were labeled obese in 2006-7 would have been out of the age range for the 2010-11 assessment.

Plus, lots of kids leave the NYC school system after grade school (this has to do with Bloomberg administration’s bizarre system for preventing children from attending local schools).  So, even those children who haven’t aged out of the analysis by turning 15 would be absent from the data after a few years.  And, there’s also natural immigration and emigration.

Did the 2006 fat kids get slimmer?  Nobody knows.  The 2006-7 obesity prevalence among NYC schoolkids (21.9%) can’t be compared to the 2010-11 prevalence (20.7%).  If you were forced to compare these numbers, you’d say there had been a slight change — not a 5.5% decline.  There’s the first lie.

2.  The second lie is a little more complicated.   Since there is no widely accepted functional definition for childhood obesity, children are labeled obese if their body-mass index (BMI) falls into the upper 5% of the expected distribution of weight-for-height.  This expectation is based on an old-fashioned standard.  Fair enough.  But lots of distributions shift over time — SAT scores, human height, grades awarded at Ivy League colleges, and global average temperature, to name a few.

Sometimes the reason for an overall shift of this sort isn’t hard to specify (test prep, nutritional quality, relaxation of grading standards, generalized global warming, etc.).  But the main effect causing a shift in the distribution doesn’t explain why the few people who are in the upper reaches of the distribution are so far from the mean.  To say that fewer children are now above the high-BMI cutoff than in 2006-7 therefore the tendency of children to be fat is declining is a lot like claiming that because 2011 was cooler than 2009 and 2010, global temperatures are not really going up.

(Dr. Farley, I gather that statistics aren’t your strong suit, but surely when you witnessed that snowstorm we had this past October — an outlier if there ever was one — you didn’t conclude that the climate is actually getting colder, not hotter.  So what makes you think that a very tiny decrease in the proportion of kids with high BMIs means that the city’s kids are getting slimmer?)

3.  Claiming credit.   Attributing to the health agency’s own efforts a minuscule change in the proportion of kids who are in the upper tail of the broad BMI distribution requires self-congratulation so acrobatic as to stretch credulity.

Maybe there really has been some change in the city’s children since 2006.  Or in our food supply or buying habits.  Or exercising.  But to claim that such a change both caused the tiny decline in schoolkid obesity prevalence and that it was the result of the Health Department’s efforts — the exercising and the low-fat milk and the salad bars in the school cafeterias and so forth — is to commit the fallacy that Rene Dubos outlined (in his book Mirage of Health) nearly 50 years ago:

When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail.

Is childhood obesity really a health problem?

It’s not crazy for health professionals to be concerned about body mass.  Obesity might be really bad for some people, and somewhat bad for many.

But those people are adults.  Why are health agencies like NYC’s so riled up about obesity in little children?

So far, there’s no strong evidence that obesity in younger children predicts any real harm later in life, other than being a fat adult.  With adults, several signs of impending debility are more commonly found in the obese than the non-obese, such as hardening of the arteries, fatty liver, sleep apnea, and diabetes.   And with adolescents, there’s some evidence that those who are obese develop similar warning signs.  But not younger kids.

A 2005 BMJ paper reported only social effects in adulthood (being unemployed and being without a romantic partner) of early obesity.  Similarly, one cohort study carried out in Newcastle upon Tyne found little evidence that fat children became fat adults, and no evidence for predictors of illness in adulthood among those who had been overweight as children — although other studies have shown correlations between adolescent obesity and adult problems.

For kids below age 15, the most visible problem with obesity is that it occurs most commonly among the poor and dark-skinned.  This bothers the obesity warriors.  In fact, not only is obesity more common in African- and Hispanic-American children in NYC, even the slipshod standards of today’s report on NYC schoolkids can’t be manipulated to show that obesity is declining among these children.

As with all holy wars, from the Children’s Crusade through the U.S. invasion of Iraq, the warriors aren’t really concerned about principle.  Something about somebody got under their skin.

Here’s how I answer my own question:  I guess the obesity crusaders don’t like it when the children of the wealthy look like the children of the poor.  They think that white kids on the Upper East Side aren’t supposed to look like kids who live in the Bronx.

It isn’t about health, in other words.  It isn’t even about obesity.  The “childhood obesity epidemic” is about making sure society looks the way that the health crusaders want it to look.

 

 

By Philip Alcabes | December 16th, 2011 | Categories: epidemics, obesity, public health, Uncategorized | Tags: , , , , , , | 1 comment

HIV, Contraception, and (More) Unethical Conduct by U.S. Researchers

Brava! to Caitlin Gerdts and Divya Vohra at Daily Beast for a superb, and much-needed, dissection of the flaws in this week’s heavily hyped Lancet study by Heffron et al.  The study purported to show elevated HIV risk associated with hormonal contraceptive use among women in parts of Africa (abstract here, subscription needed for full text).  The NY Times ran a front-page story, claiming that

[t]he most popular contraceptive for women in eastern and southern Africa, a hormone shot given every three months, appears to double the risk the women will become infected with H.I.V.

and almost everybody else (as diversely situated in newsworld as the Atlantic, CNN health blog, Catholic News Agency, and Voice of America) joined the NYT in failing to examine it critically.

Gerdts and Vohra add the essential context that was missed by the newsmedia:  about a half-million women die during or because of childbirth each year, almost all of them in poor countries.

At RH Reality Check, Jodi Jacobson summarizes the main cautions about the Heffron study, and points to a Guttmacher Institute white paper.  She takes into account concerns about high maternal and infant mortality in parts of Africa, the harms associated with complications of pregnancy and unsafe abortions, and, of course, the substantial possibility of vertical transmission of HIV in places where antiretroviral therapy isn’t universally available.

To claim that poor women should give more weight to the rather remote risk of acquiring a virus that might cause serious illness years down the road than to the dangers of pregnancy itself in the near term is to reduce real women to automata.  Facing dire straits they might be, but they’re supposed to be reasoning machines, programmed to engage in the AIDS industry’s preferred calculus, risk.

A quick summary of the shortcomings of the Heffron et al. research:  comparing users of hormonal contraception to nonusers, the difference in actual risk of acquiring or transmitting HIV was very small, amounting to 1 to 3 new infections per one hundred contraceptive users over and above the infection rate for nonusers.  And it’s impossible to say that these excess infections were actually attributable to the contraceptive — because the study wasn’t a clinical trial.  A great many aspects of social setting, relationships, health, and welfare of the study subjects would have been different between contraception users and nonusers, some of which would undoubtedly account for differences in rate of HIV transmission.

And since all of the subjects were in so-called discordant couples — one partner infected with HIV, the other not — it would be unusual to expect no HIV transmission at all.

Unless, of course, the subjects had been offered antiretroviral therapy, ART.  But this the researchers did not do.  They referred eligible subjects to HIV clinics.  They seem not to have checked whether people who needed ART were getting it.  They seem not to have offered ART to women who got pregnant, either.  Certainly, their Lancet article makes no report of doing so.

I wondered if this was too much to expect of researchers — so I asked the students taking my course on global AIDS and human rights.  Undergraduates, I find, generally have a clearer sense of ethics than most medical researchers.

Even the students who felt that the Heffron study was worth doing and basically sound were troubled by the researchers’ lack of curiosity as to whether HIV-infected subjects were getting the ART drugs they needed.  And most of the students thought this was a disabling ethical fault, which should have caused human subjects committees to make the researchers redesign the study.  One student pointed out that the Bill and Melinda Gates Foundation, one of the study’s funding sources, could easily afford to pay for antiretroviral therapy for all of the roughly 2,000 HIV-infected people in the study.

In the end, my students had the questions that Marcia Angell raised in her editorial in the New England Journal of Medicine in 2011 (PDF at this link angell editorial nejm 2000 ):  Don’t physician researchers have the same responsibility to study subjects that they do to their own patients?  And therefore, when their subjects lack resources to obtain effective therapy for treatable conditions, don’t the researchers have a moral obligation to make the therapies available?

Heffron et al. didn’t do this.  They watched HIV-infected people transmit HIV to their partners (the researchers provided HIV testing and counseling about avoiding transmission — but they don’t make clear whether they notified uninfected partners that they might be in harm’s way).  They did little to prevent transmission.  Notably, they didn’t offer ART to people with low CD4 counts.  Nor did they offer post-exposure prophylaxis to uninfected people who had had intercourse with an infected partner.  They just watched.

On this account, the Heffron study wasn’t only flawed — it was so questionable on ethical grounds that the Lancet should be ashamed to have published it.  And the funders — the NIH as well as the Bill & Melinda Gates foundation — censured.

 

 

By Philip Alcabes | October 9th, 2011 | Categories: AIDS, epidemics, Ethics, Physicians, public health, Risk | Tags: , , , , , , | 1 comment

Bean Counting HIV Infections

Larry Kramer told the NY Times today that there is no  AIDS policy in the U.S.  To which  Kevin Fenton, the aimless director of CDC’s AIDS efforts, replied, non-sequitur-ly, “CDC is not resting.”

The occasion was CDC’s publication in PLOS One of new figures claiming that the annual number of new HIV infections in the U.S. is only around 50,000.

And if you read the CDC’s new Fact Sheet on HIV infection, just posted, you find out that

The current level of HIV incidence in the United States is likely not sustainable. Prevention efforts in recent years have successfully averted significant increases in new HIV infections, despite the growing number of people living with HIV and AIDS who are able to transmit the virus.

CDC English is a little difficult for native speakers to interpret, but I think that the translation of “likely not sustainable” is:  “we need more money or else the incidence is going to go up.”

Now, 50,000 new HIV infections each year is bad news for 50,000 Americans.  But on a population basis, it’s not a very high number.  The HIV prevention industry will wring its hands, and perhaps Mr. Kramer will, too.  They can all grumble that after 30 years of AIDS there should be no new infections at all.   But that’s ridiculous.  A pipe dream.  HIV is a sexually transmissible infection.  And STIs can’t be eradicated — because, well, people have sex.  No matter what.  And sometimes the kind of sex that isn’t recommended by the experts. With the wrong people.  And so forth.

Really, that there are only 50,000 new infections each year is a sign of (a) the low inherent infectiousness of HIV and (b) Americans’ sharp awareness of how to protect themselves from HIV infection.   It’s not really clear that any new prevention is needed.

What is needed:  get effective treatment into more HIV-infected people.   Obviously, to slow the progression of HIV-based impairment in the individual — but also as a public health measure, to reduce the HIV carrier’s infectivity and thereby reduce the probability of transmission.  It would have medical value and public health value.  But there’s not much policy on that.

CDC officials are bean counters, not policy makers.  That’s why, Mr. Kramer, your expectations are too high.  The CDC’s job is not to do anything about AIDS.  CDC’s job was never to do anything about AIDS.  CDC’s job was, and is, and presumably will always be:  to keep CDC in business.

They’re terrific bean counters, obsessive, scrupulous, punctilious, completely absorbed in their own assumption that their data are a source of truth, committed to deciphering the supposedly unequivocal message the data send.

The message, always, is “CDC needs to do more of what it’s been doing.”

I gave the CDC a hard time in August 2008, when the agency published its estimate that there are 56,000 new HIV infections in the U.S. each year.  That seemed too high, I told the NY Times at the time.  Of course, it was useful for the CDC’s rudderless AIDS division to claim that HIV incidence was higher than everyone thought:  suddenly, lots of people were urging that HIV  prevention programs be beefed up.

Now, the agency has backpedaled. The 2006 incidence wasn’t 56,000 after all, the CDC now figures, it was only 48,000.  And anyway 56,000 is the same as 48,000, the agency now says.

Let me summarize:  Back in 2008, the CDC’s estimate supposedly showed that prevention wasn’t working, so the agency needed to do more of it.  The new estimate, which is almost the same as the old estimate, shows that prevention does work, so the agency needs to do more of it.  All CDC calculations point to the same conclusion:  keep CDC in business.

If CDC were interested in the nation’s health, more so than maintaining its meager status quo, it would be advocating for more treatment (to Donald McNeil’s credit, he makes that point in today’s NYT article).

And if CDC were interested in HIV as a public health problem, and not just in bean counting for the purposes of keeping itself in business, it would stop putting its beans into 30-year-old jars.  What’s the point of the tired “race/ethnicity” breakdown?  Does anybody know anymore how to categorize people into the ancient non-Hispanic-black/Hispanic-including-black/non-Hispanic-white codification?  Does anybody know what it means?

And the famous transmission categories, the MSM-IDU-heterosexual-other breakdown:  that was useful early on, when we weren’t sure that the modes of communication of HIV were fully known.  But that era ended in 1985.

Dear CDC:  Could you please put your beans into some useful jars?

No, it’s asking too much.  Because CDC’s aim isn’t to be useful.  It’s to keep counting beans exactly the way it knows how to count them, and put them into the same jars as always, and keep on concluding that the data — the beans — show that CDC must keep on doing exactly what it has been doing.

 

 

 

 

By Philip Alcabes | August 4th, 2011 | Categories: AIDS, epidemics, public health | Tags: , , , , | 1 comment

Cholera: Problem Solved?

Once again I’m grateful to H5N1 for bringing cholera news to my attention.   This week, epidemiologists from France have presented evidence suggesting that the Haitian cholera outbreak began when the causative bacteria were brought in by Nepalese UN troops.

In an article in the July issue of Emerging Infectious Diseases, just out, Piarroux and colleagues assert that (quoting from their abstract) “Our findings strongly suggest that contamination of the Artibonite [River] and 1 of its tributaries downstream from a military camp triggered the epidemic.”

So the mystery is solved, more or less.  The news media have taken note:  articles on the EID report have already been written by the AP, Guardian, and other sources, and are being picked up fairly widely today.

The news, based on a report ordered by UN Secretary-General Ban Ki-moon,  is being treated as an about-face on the UN’s part — because the organization, along with WHO and CDC, refused last fall to do an in-depth investigation of the origin of the outbreak.  So, according to the media’s coverage, this week’s report exposes some hypocrisy on the part of the health organizations.

That’s silly, and wrong.   I’m usually critical of WHO and CDC, but in the case of the Haitian outbreak they were completely correct to refuse to “investigate.”  As I wrote last fall, cholera isn’t a detective story, it’s a disaster.  To investigate the so-called origin of an outbreak that is as self-evidently the result of  calamitous conditions, state poverty, and helpless officialdom is to shift the blame.  Dodge the truth.

The work by Piarroux and colleagues in establishing a clear description of the origin and progress of the Haitian outbreak is impressive, often elegant, quite convincing.  But to believe, as some do, that it somehow proves that the UN and WHO are responsible for a catastrophe, or that sending foreigners into Haiti is always bad, or even that (as the authors of the EID paper say)

Putting an end to the controversy over the cholera origin could ease prevention and treatment by decreasing the distrust associated with the widespread suspicions of a cover-up of a deliberate importation of cholera

is to misunderstand public health.

The problem in Haiti is, and has been, a problem of predisposition — nature out of balance, people on the move, dire straits of all kinds (food, medicine, clean water, toilets, housing, etc.)  too tolerable to weak leaders.  Colonization by one aid group after another (UN included).  It was inevitable that cholera was going to break out.

To take the Piarroux report as definitive is to mistake the germ for the disease, mistake the outbreak for the problem, mistake the detective story for the real disaster — the real disaster being self-explanatory and not in need of “investigation”:  not enough money and not enough political will to keep the public from getting sick.

By Philip Alcabes | June 30th, 2011 | Categories: Disease, epidemics, News, Outbreaks, public health | Tags: , , , , | Comments Off

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