Philip Alcabes discusses myths of health, disease and risk.

The Health Department at Work

I was pleased to receive a phone call from the NYC Department of Health and Mental Hygiene  and to be selected to participate in a “health survey.”  The questions offered a fascinating insight into the agency’s preoccupations — and what sorts of impropriety obsess its leadership nowadays.

It’s reassuring that the Department wants to be able to estimate how many New Yorkers lack health insurance and, separately, lack a regular health-care provider, and asked questions about those things.  And I was impressed that the survey designers thought to ask whether, the last time I sought help for a medical problem, it took a long time to get an appointment.

And then came some predictable How Are We Doing? questions:  Have I had a flu immunization in the past 12 months? (No, thank you, I’m not convinced that it works…  Okay, I didn’t say that, the survey taker seemed young and too earnest for serious critique, so I just said “No.”)  At least two doses of hepatitis B vaccine at some time in the past?  When did I last have a colonoscopy?

But there was the question about whether I have used oxocodone or hydrocodone (OxyContin or Vicodin) without a prescription, or outside of the prescribed dosage.  The Department has just announced a new campaign to stop people from using pain killers too much.

There was the question about whether I’m exposed to cigarette smoke in my household.

There was a question on whether my household has a disaster plan.  No, we don’t.  We have a couple of flashlights, some water, and a bottle of scotch.  Will that do?  We’re grown-ups, we don’t have pets or little children to look after.  We’ll work something out.

(But I didn’t say that to my earnest interviewer, either.  I have a feeling they don’t find whiskey to be humorous, over there at the health department.  In fact, they had some very specific questions about alcohol consumption, amount and frequency.)

There were questions about how often I exercise vigorously.  How often I exercise moderately.  How often I exercise lightly.  How long I engage in said exercise when I do do it.  Very interested in exercise, our health department.

There was the question as to how many servings of fruit or vegetables I ate yesterday.

And then, onward to mayor Mike Bloomberg’s white whale:  sugar-sweetened beverages!  Mayor Mike is going to ban serving soda or other sweet beverages in large sizes — and he’s not asking for a new law (which might not pass), just a go-ahead from the city’s eleven-person Board of Health, all appointed by the mayor, chaired by the city’s cheerleader for “healthy lifestyles,” health commissioner Thomas Farley.   A restaurant trade association, the Center for Consumer Freedom, responded to news of the mayor’s intention with an amusing ad in today’s NYT, portraying Bloomberg as The Nanny.

The survey questions:  How often do I drink soda or bottled iced tea?  What about beverages to which I add sugar myself, like tea or coffee?

And, now that we were deep into the zone of health officials’ self-stimulation:  how many (a) women and (b) men had I had sex with in the past year?  Did I use condoms?  And, had I used the Internet to meet a sex partner in the past 12 months?

So much for health.  Now we know what haunts the dreams of the self-righteous mayor and his bluenose health commissioner:

Pain relief.

Fat people.

Vigorous exercise.

Pleasurable foods.

 Sex.

Reading this list, you would have to be forgiven for thinking that these men, Bloomberg and Farley, have been living in a monastery since, say, the 14th century.  In fact, if they were really clergymen instead of officials, they would leave us alone about how we eat and sweat and screw.  At least in between sermons.

But thanks for calling.

 

 

 

Life Expectancy Goes Up but Risk-reduction lectures Continue

Bravo! to Rob Lyons at Spiked. Since it’s now apparent that life expectancy has increased almost everywhere and is at historic high levels in much of the developed world, Lyons asks the logical question:  why is the public health system still scolding everyone about what people eat and how fat the average person is?

A paper by David Leon in this month’s International Journal of Epidemiology showed the dramatic increase in life expectancy — the median age at death, that is.  It has reached over 85 years for women in Japan, but it’s high even in countries where longevity was relatively low a generation ago.  Cheeringly, US life expectancy at birth is now 78 years; in the UK it’s 80.  And it’s even higher in some countries of western continental Europe.  Here are the graphs for different parts of the world from Leon’s paper, showing trends since 1970:

Life expectancy since 1970

Lyons has gone after the anti-obesity crusaders before (as well as related topics at his smart blog on contemporary food confusion, Panic On A Plate).  Now, he’s particularly disturbed by the sermonizing about eating. “You can’t even have a pie and a pint without someone telling you it will kill you, it seems,” Lyons writes at Spiked.

And, really, it’s even worse than that — because it’s not just eating that’s the subject of the lecturing.  It might be true that you will live longer if you give up smoking, cut your salt intake, drop your BMI down to 24.99, exercise four times per week for at least 20 minutes each time, get immunized against flu and human papillomavirus, drink in moderation, and take naps.  But unfortunately there’s not a bit of evidence that any of that — apart from the decline in smoking — has contributed to increasing longevity.

And of course, even with smoking cessation, there’s no telling whether it would make any difference to you — only on average.

So why are the public health messages so far away from what really matters — basically, prenatal care, postnatal care, and wealth (with its concomitant, standard of living)?  Well, there’s a puzzle.

What’s the point of having an industry whose main aim is to make sure that people are constantly in fear that they are doing something that will kill them — even as it becomes apparent that most of what people do is only making us live longer?   Lyons calls it Good News Omission Mentality Syndrome (GNOMES).

I ask you:  could it have something to do with control?  And the desire to sell products?

Mitochondrial Dysfunction: Biologizing Autistic Behavior

Marx famously opined that social phenomena — world-historic events, he called them — occur first as tragedy, then as farce.  That was in 1852.

Today, it would be closer to the truth to say that tragedy only counts if it can be diagnosed.   And diagnosis only counts if it’s biological.

That’s been the story of  the conversation about autistic children, and the implication of so-called mitochondrial dysfunction.

Deficiencies of energy metabolism have been rumored in association with the autistic picture for a while now, and emerged in the Hannah Poling case a few years ago.  They were given a boost by a small European case series (abstract here, PDF here) published in 2005 in Developmental Medicine and Child Neurology.  (The authors of the article gave their paper the deceptive title “Mitochondrial dysfunction in autism spectrum disorders:  a population-based study,” even though the research involved no population at all, just 11 kids.  But business is business.)

Another boost came this week with the publication in JAMA of a methodologically careful study of  energy metabolism in 10 California children diagnosed with autism, contrasted with 10 children drawn from a well-matched sample of comparable control children.   The new study found reduced oxidative activity in mitochondria — the tiny energy-chain entities inside cells that produce chemically based, biologically derived power for the cells’ functions.  The reduced oxidative activity was present in most of the 10 autistic children, and they showed a much-altered mean energy metabolism on several different measures.

Thus, altered energy metabolism at the cellular level has been documented in a small handful of children diagnosed with autism.  It seems not to be present in all children with autistic diagnoses.  It might be a result of autistic behavior rather than a cause, or a bystander phenomenon of some kind.  Or it might be a feature that hastens diagnosis (in the ones who have the unusual metabolic pattern, it has not been shown to precede the diagnosis) without actually playing any predisposing role.  Indeed, the authors of the JAMA paper remark that the

mitochondrial dysfunction observed in this preliminary study performed with children presenting with full syndrome autism may or may not indicate an etiological role.

But this minor and still untested finding on mitochondrial energetics, still not of any self-evident significance regarding the cause of autistic behavior, has created a major stir.  Medscape weighed in.  Business Week ran a story written by HealthDay reporter Jenifer Goodwin.  And it’s no surprise that the story has been front page news at the autism blogs, like Age of Autism and Autism Speaks.

So it seems safe to say that we’re looking at the third coming of a fact.

That some children engage with the world differently than do most kids was the first discovery, an old discovery (some think the 18th-century Wild Child of Aveyron was autistic).  It was codified in 1910 when  the psychiatrist Eugen Bleuler labeled one of the varieties of childhood schizophrenia “autistic.”  Identification.

Next came diagnosis — beginning with Hans Asperger in 1938 and Leo Kanner in 1943.   In the grip of modernity, slow acquisition of words, quirky communication, fixity of focus, failure to multitask, preoccupation with parts rather than wholes, and so on, are no longer signs of diabolical possession, thankfully.  But neither do they signal a broadened sense of what human experience is like.  They’re just signs of disease.

Diagnosis has allowed all sorts of theories to summon support:  about parenting, about the toxic environment, about thimerosal in vaccines, or about immunization itself.  Autism is the diagnosis that lets people express their misgivings about modernity.

Now we’re seeing the beginning of step 3:  biologization.

If autism is to stand up to 21st-century modernity, it has to have a biological basis.  Otherwise it will go the way of the obsolete disorders of old, like neurasthenia, hysteria, or frigidity.  The research on mitochondrial dysfunction in California won’t be the last or the only big-dollar expenditure aimed at finding a biochemical basis for the diagnosis of autism.   And there’ll be DNA studies, too.

The sad thing is that the only good way for troubled parents to get services for their children is to have the kids diagnosed, and to help to get them labeled as biologically off-kilter (Autism Speaks was one of the sponsors of the study just published in JAMA).  Get them labeled as dysfunctional, to use the term of art.

There’s no percentage in betting on need, or social disadvantage, or just plain poverty as an impetus to free up funds and services.  The need doesn’t count if there’s no dysfunction.   Your event doesn’t count as world-historic without a biological basis now.  First as tragedy, then as diagnosis, then as biology…

Autism, ADHD, obesity, addiction — each time our society is confronted with a problem it can’t solve or an irritation it can’t salve, we feed the problem into the medical establishment’s diagnosis mill.  Then we turn it over to the biologists to put some science on it.

Once the problem has a name and a diagnosis and a biological mishap to it — then we can see it.

Public Health: Childhood is a Dangerous Place

Is there a Department of Scare Creation at Case Western?  This week, we have research reported by their Dr. Scott Frank and colleagues: “Hyper-texting and Hyper-networking Pose New Health Risks for Teens.”  Frank says,

The startling results of this study suggest that when left unchecked texting and other widely popular methods of staying connected can have dangerous health effects on teenagers.

(Aside to Dr. Frank:  C’mon, doc.  Do you not know that “hyper text” is already a term in wide usage? Do you know how sometimes there are underlined words, most often in blue, that, if you click on them with your mouse then you are magically transported to another website?  That’s it.  Do you realize that any teens who aren’t already laughing at you for your transparently hysterical research agenda have cause to snicker over your misuse of contemporary language?  But back to my point…)

The subject of a press release by the American Public Health Association, the study claims that teens who text  more than 120 times a day are, compared to light texters:

  • 41% more likely to have used illicit drugs
  • Nearly 3.5 times more likely to have had sex
  • 90% more likely to report having had four or more sexual partners

The results were based on a survey of over 4,000 high school students in the midwest.

The paper, presented at the annual meeting of the APHA, is yet another indicator of the association’s redirection — from promoting social reform to becoming the Popular Front for the Promotion of Family Values.   The news media complied with the APHA’s mongering by publicizing Frank et al.’s findings, for instance here, and so did the usually serious WebMD.

Research like this is meant to say both “childhood is deadly” and “children are dangerous.”  Teenagers have sex, it says, and you grownups shouldn’t take that lightly.

The connection of teen sex and teen drug use to cell phones, iPhones, or the Internet appeals to people who think there is something new, and terrifying, about modernity.  As Carl Phillips notes over at ep-ology, it’s a way of saying “Beware the scary new technology!  It is causing teens to interact.”

Of course, there’s also a race, class, and sex angle:  The study reported that excessive texting (along with what the authors call “hyper-networking,” meaning excessive use of social network sites) is more common among girls, racial minorities, and kids whose parents have less education. One more reason to be suspicious of the poor and the dark-of-skin, says the Popular Front.

Especially, the APHA wants us to beware of girls.  The public health industry — the folks who reminded your grandparents that female sexual desire spreads disease with posters like this one, from the ’40s:

US Government VD Poster, ca. 1940

Source: U. of Minnesota, Social Welfare History Archives

… now tell us to watch out for girls who text.

Mike Stobbe at AP, covering the report, did a (typically) good job of looking deeper into the question.  About half of kids between the ages of 8 and 18 text each day, and the ones who do average 118 texts per day. While texting while driving is a really bad idea, texting about sex isn’t uncommon (Stobbe points out).  Unlike texting while driving, nobody dies from it.

Public heath shouldn’t be a matter of, as the Frank report put it, wake-up calls for parents.   Childhood really is dangerous in some places (Somalia, Congo, and Haiti come to mind, in case physician-researchers currently obsessed with sex amongst American teenagers are looking for something useful to do with their medical skills).  But it isn’t in America.   Sex, even between teenagers, really isn’t very scary.   There are a lot of things we adults could do to make the country and the world less miserable, but spying on our kids isn’t among them.

Anti-Tobacco Crusaders

It’s hard to understand why the public health industry is so irrational about tobacco use.  Yes, it’s dangerous  to inhale the fumes of burning tobacco.  Smoking can be very bad for people.  But why vilify tobacco use in all its forms?

The anti-tobacco crusade is a modern-day version of Revivalist religious fervor.  It sure isn’t science.  And it isn’t about protecting people’s health.

The CDC estimates that 442,000 Americans die from tobacco smoking each year.  These estimates are slippery; they’re based on a fairly loose definition of what it means to die “from” a behavior — but let’s agree that a lot of people die sooner than they otherwise would because they smoke cigarettes.

Alternative ways of self-administering nicotine allow users to avoid the disastrously harmful drug-delivery device, the cigarette.  You’d think that Big Public Health, 45 years into a campaign to get people to stop smoking, would be promoting all sorts of safe methods of nicotine delivery.

That’s not what happens.  Instead, the industry pours anathema on light cigarettes, smokeless tobacco, and other safer-than-cigarettes products.

The latest sermon is an article in this month’s The Nation’s Health — the newsletter of the American Public Health Association (APHA, which has turned into the High Synod of Public Health Religion).  The article  claims that “New Types of Smokeless Tobacco Present Growing Risks for Youth.”

The title is a double rhetorical turn now (alas) typical of APHA:  (1) your kids are going to die, and (2) the “risk” to them is increasing.  The piece would seem silly if the author, named Kim Krisberg, weren’t so serious.  After all, it isn’t kids who die from smoking, and the risk of smoking-related death isn’t increasing at all.  But we’re not in the realm of truth here.

Since Big Public Health isn’t dealing in truth when it comes to tobacco, evidence isn’t part of the story.   The head of the Campaign for Tobacco-Free Kids can say “the time to stop the spread of dangerous products is before they become the fad of today,” insouciantly sidestepping the fact that smokeless tobacco products aren’t dangerous.  Brad Rodu’s invaluable website Tobacco Truth explains — see Brad’s June 16th post, for instance.  Or go to this page at the excellent resource TobaccoHarmReduction, or see this article published in Cancer Epidemiology, Biomarkers & Prevention in 2004.

The public health industry’s animus for tobacco leads it to label as harmful something that is really a boon to public health — the increasing use of products that provide nicotine without burning tobacco.  Surely it’s better to have people chewing nicotine-containing products that won’t harm them than to allow them to continue smoking tobacco in order to get a nicotine dose.

Moralistic fervor makes you stupid.  Stupid enough to write, as two physicians with FDA’s Center for Tobacco Products did,

As state and local communities across the United States adopt indoor clean-air laws that restrict smoking in public areas and workplaces, the tobacco industry seems increasingly focused on the development and introduction of novel smokeless tobacco products

… as if the tobacco industry were magically making Americans who would otherwise stop smoking suddenly crave smokeless tobacco — and as if that would be bad for them.  Drs. Deyton and Cruz, you should know better.

But Matthew Myer with Tobacco-Free Kids isn’t unintelligent.  Nor, I assume, are Deyton and Cruz.  And I can’t imagine they really want people to suffer.

Still, do they really think that safe non-smoked tobacco products are going to bewitch our kids?  Do they believe that apocalypse comes in a package of smokeless tobacco?

Are they just so obsessed with battling tobacco companies that they’ve lost sight of the aim of public health, i.e., to reduce suffering?

Or is it simpler?  Has the public health industry’s big-money anti-tobacco campaign allowed too many people to make too good a living by saying stupid things about tobacco?

The cigarette manufacturers have been scurrilous, dastardly, and sometimes appallingly inured to the misery and death their products have hastened.  Maybe they deserve the Myerses of the world.

But the public health industry could be a lot more focused on helping people to live less painful lives, and less obsessed with its private demons.

As Carl V. Phillips suggests in a post this week, the FDA will have to break with the public health industry’s moralism if people who use nicotine are going to protect themselves from cigarettes.

If the FDA can’t overcome Big Public Health’s obsession with satanic tobacco rituals, re-introduce truth into the discussion, and re-focus on making real people’s lives less miserable, the zealots are going to turn stupidity into bad policy.