When the HPV Vaccine first came out, I produced a story for the Women’s International News Gathering Service about pros and cons of the vaccine.  A recent article in the NYT summarizes recent evidence published in JAMA about the vaccine’s safety.  The basic take-home message from CDC and FDA was that the vaccine is safe.  As summarized by the NYT, the counter argument suggested that the vaccine might not be as essential if girls receive routine pap-screening throughout their adult lives:

From the NYT: “There are not a huge number of side effects here, that’s fairly certain,” said the editorial writer, Dr. Charlotte Haug, an infectious disease expert from Norway, about the vaccine. “But you are giving this to perfectly healthy young girls, so even a rare thing may be too much of a risk.

“I wouldn’t accept much risk of side effects at all in an 11-year-old girl, because if she gets screened when she’s older, she’ll never get cervical cancer,” Dr. Haug said in an interview. “You don’t have to die from cervical cancer if you have access to health care.”  (NYT, August 18, 2009)

That’s all well and good if you live in Norway (or any other place where girls, women and the rest of society have good access to health care), so here’s hoping that Obama and the rest of our government can bring us up to modern standards and provide adequate care for all.

The US Preventative Services Task Force concluded last week that men over 75 years old should no longer be screened for prostate cancer. Furthermore, they conclude that “the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.”

As I have written before, while we in the US like to get as much care as possible, there are situations when more care isn’t necessarily better, and that in many cases, patient factors should help decide the course of treatment. Prostate cancer screening is a prime example of a situation in which screening can lead to a whole host of uncomfortable and potentially life altering consequences (e.g. invasive procedures, impotence), and may or may not lead to a longer life.

While there are certainly many situations in which the best treatments are clear and effective, in cases where the relationship between cause and effect, and treatment and health, are murkier, more may not be better, and in fact may be worse.

A recent article in the New York Times reported results from an APA study that concluded that abortion does not cause mental illness. The full title of the article is “Abortion Does Not Cause Mental Illness, Panel Says.” Maybe I am being paranoid, but somehow that title calls the results into question (as in, “a panel claims this, but we’re still not sure”). However, in the brief summary, the author points out that these results are the same as results from a large scale review of evidence in 1990. So, why are we continuing to ask this question? Is it because conservative forces are hoping that we’ll find something that gives credence to the idea that women shouldn’t have control over their own bodies? Given that this finding has been replicated in two large studies now, for my money, I’d rather invest in exploring mental health consequences of issues that have less to do with partisan politics and more to do with actual risk.

There are direct relationships between where you fall in the socioeconomic hierarchy and your health. There are also relationships between whether you are a man or a woman, and where you fall on this hierarchy. Lastly, there are relationships between gender and health. How do gender and socioeconomic status interact to give some people a better shot at a healthy life? The attached files are from a talk I gave on this topic, as well as a reference list to accompany the slides. Please feel free to email or post with questions.

SES, Gender and Health (Slides)

SES, Gender and Health (Outline and Biblio)

In two recent conversations with David Hemenway, I learned about how to get more bang for our buck in keeping people safer, and about a cool statistical insight that helps explain things ranging from why your classes are larger than “average” to why its hard to reduce the number of cars on the road.

Listen to the audio:

Public Health Success Stories

Why Your Classes are Larger than Average

Recent work by Bob Kaplan and Dominick Frosch suggests that when patients and doctors work together to make decisions, everyone wins.  More…

The US House of Representatives recently passed a bill that would require health insurance companies to cover mental illness.  Apparently, health insurance companies are none too pleased about the prospect of having to provide this coverage (for example, see NYT coverage).

This type of controversy really gets my blood boiling.  Consider the following questions raised:

“Is an ailment a legitimate disease if you can’t test for it? A culture tells the doctor the patient has strep throat. But if a patient says, ‘‘Doctor, I feel hopeless,’’ is that enough to justify a diagnosis of depression and health benefits to pay for treatment? How many therapy sessions are enough? If mental illness never ends, which is typically the case, how do you set a standard for coverage equal to that for physical ailments, many of which do end?”

First of all, many “physical” illnesses also lack a hard and fast test– there is no test to tell the doctor if you have a cold, or in many cases why some people have lower back pain, but in those cases, we expect treatment.  Second, psychiatric diagnosis does not stem from one complaint alone (e.g. “I feel hopeless”), but rather requires a systematic review of patient history, current symptoms, and other factors, just like going to the doctor for physical illness.  Third, while many mental illnesses are chronic, so are cardiovascular disease and cancer, but few people would suggest that just because a disease is chronic, insurance should not be required to cover it. Furthermore, treatment can vastly improve the lives of patients, and make them more functional and productive members of society.

Mental health and physical health are linked, and many so-called mental illnesses have distinct biological bases (genetic, neural).   If anything, I would argue that the fact that we do not understand the biological bases of mental illness provides justification to invest more in research and give more attention to treatment.  Furthermore, I would venture to guess that if we provided adequate mental health services to those in need, we might actually reduce the overall burden of healthcare costs (countries that provide universal health coverage to their citizens often cover mental health as well, because it is the smart thing to do).  As noted by the NYT: “a 2006 study in The New England Journal of Medicine, examining the costs associated with a parity program put into place by President Bill Clinton for all federal employees, found that it actually didn’t increase the use or the cost of mental health services.” 

In the long run, the United States needs to think about prioritizing the health of the population.  This means covering those who need coverage, and it means considering the person as a whole. 

Three separate teams of researchers have discovered the same set of genes that increase risk of addiction and lung cancer in smokers.  This is an exciting discovery.  When explained at the New York Times, the conclusion was:

“The genetic variations, which encode nicotine receptors on cells, could eventually help explain some of the mysteries of chain smoking, nicotine addiction and lung cancer that cannot be chalked up to environmental factors, brain biology and statistics, experts said. ”

Similarly, one researcher commenting on the finding suggested: “This is really telling us that the vulnerability to smoking and how much you smoke is clearly biologically based” (psychiatry professor Dr. Laura Bierut of Washington University in St. Louis, a genetics and smoking expert who did not take part in the studies).

However, what both of these sources do not comment on is the fact that more and more evidence suggests that biology AND the environment interact to create health, disease, dispositions.  Certain genetic variations may lead to riskier profiles, given a stressful environment, but in some cases, the same genes that are riskiest under threatening conditions can also be most protective under nurturing conditions.   Following this type of exciting discovery, in my view, what will be even more exciting is to understand the way(s) that the genes identified interact with both the physical and social environment to allow some people with those genes to avoid smoking all together, some to become addicted immediately, and some to fall in between.  To say that genes will explain the “mysteries of chain smoking, nicotine addiction and lung cancer that cannot be chalked up to environmental factors, brain biology and statistics” is to miss the most exciting part of the story– the interactions between all of these factors.

Almost every morning on NPR there is talk of a recession.  Are we headed for a recession?  What will happen if there is a recession?  Are the markets going to fall even further?  What are people thinking about the economic stimulus packages that the government is proposing to avoid a recession?

In a recent talk about her work on risky families,  Shelley Taylor mentioned offhand that this work makes her think about recession in a new way– financial stress can place a major burden on families, which may lead to less supportive environments for children.  Is a pending recession a risk factor for depression and other health problems when children born today grow up?

One of the major findings of Taylor’s work is that the early childhood environment really matters.  The question is no longer about nature versus nurture, but rather about the interaction between an individual’s genes and his or her environment.  For example, in the case of the serotonin transporter gene, having two copies of the short allele, in combination with a negative early family environment, confers increased risk for depression and other problems.  In the context of a rich and nurturant early family environment, however, individuals with the short-short combination may actually do the best.  Researchers have conceptualized this in terms of “sensitivity to the social environment” (individuas with the short-short combo are highly sensitive to the social environment, whereas individuals with long-short or long-long may be less sensitive to the social environment and do pretty well either way).  Another good example is the MAOA gene– individuals who are low in MAOA, and who grow up in abusive contexts tend to have much higher probability of showing aggressive behavior (including violent arrests) than individuals who have high levels of MAOA or who grow up in supportive environments (see: Caspi, McClay, Moffitt, Taylor, & Craig: Role of genotype in the cycle of violence in maltreated Children.  Science. 2002).

Back to the question of a recession and its potential impact on children being born now, we don’t have data supporting or refuting this claim, but I have been thinking about the types of markers that might be able to address this type of question.  There is tons of evidence that socioeconomic status plays a major role in health, morbidity and mortality, but what does this mean for people when their financial position changes?   Will a recession now lead to more depression and health problems 20 years down the line?  Will the threat and stress of a potential recession have similar effects?

Natasha Jategaonkar who is a project manager for the Framework Convention Alliance told me a little bit about the world’s first public health treaty. In this excerpt from our conversation, Nat comments on the role of tobacco advertising in relation to the treaty. Listen to Nat here.