Jedi Mind Tricks

Let’s start with an exercise.  Think of the last 2 digits of your social security number.  Got it?  Now, at what year did Albert Einstein emigrate to the United States?

Did you guess 1933?  If so, you are the smarty pants exception to the rule.  Chances are, if your social digits are high, you guessed high, and vice versa.  This is an example of a neat behavioral economics mechanism called “anchoring,” in which our decision making processes are affected by information around us.

In the realm of public health, behavioral economics can help us make the right decisions.  We often know what’s good for us. But we can’t always do what we want to do.  I don’t want to eat a bag of leftover Smart Food by myself.  I don’t even like popcorn.  And yet I do.  As I’ve discussed before, public health sometimes helps us out of these jams by taking away opportunities for us to make mistakes.  But sometimes public health gives us the choice to decide.  Then helps us to make the right decisions. 

(One of my favorite institutions in Brunswick, ME)

One example of this help comes from Dr. Sara Bleich at Johns Hopkins.  In a wicked cool experiment, Bleich and her team posted 3 different messages about soda at neighborhood bodegas. 

“Did you know that a bottle of soda or fruit juice has about 250 calories?” 

“Did you know that a bottle of soda or fruit juice has about 10% of your daily calories?” 

“Did you know that working off a bottle of soda or fruit juice takes about 50 minutes of running?”

Do these statements do anything for you?  Which statement is a bigger deterrent for you?  I’m an easy target, but the exercise one rings most powerful to me.  (Full disclosure: Because of my terribly indiscriminate I'm-a-hungry-grad-student-diet, I'm easily shamed and susceptible to suggestions.  This usually results in buying many overpriced bananas by the cafe checkout counter.)  Bleich and her team tracked the buying behavior of adolescents in the stores over a 6 months period.  They found that the signs worked.  Looking at the 3 strategies as a whole, the odds of buying a “sugar sweetened beverage” (soda or fruit juice) decreased by 44% after they posted the signs, as compared to before.  Looking at the 3 methods separately, the exercise information was significantly associated with a decrease in purchase. 

Even if quinoa and kale aren’t a part of your regular diet, the evidence on the negative health effects of consuming too much sugar (i.e. empty calories), especially in adolescents, is weighty and obvious*.  Yet information alone can’t improve population health.  Public health relies on brilliant folks like Dr. Bleich to figure out the right tricks to employ to help us make the right decisions.

*Never an inopportune time for a DHem plug.  Thanks to Jesse for the reminder.

Welcome to the Gun Show

(My flabby gun)

After a few weeks of living in northwestern China, I thought I had gotten used to a lot of absurdity.  Like having lamb for breakfast, deer penis wine with lunch, and doctors who smoke as they examined patients.  Still, watching on the news, in a country of over a billion, the story of a man waving a knife on a street corner, felt absolutely absurd.  It took the police hours to subdue and disarm him.  This, I realized, was what it was like to live in a gun-less society. 

Here in the States, I live in a society where we can hunt, reenact historical scenes, and carry guns in self-defense.  The majority of the US, even gun owners, even NRA members, support mandatory waiting periods, registration, and other gun control regulations.  With so many editorials and statistics floating the interwebs this week, you’ve probably heard that American women account for 84% of all female firearm homicide victims in high income countries (but just under 1/3 of the population); that 6 states don’t have minimum age requirements to possess a handgun*; or that, as David Sedaris so famously wrote in the holiday classic, blind people can go hunting in Michigan and Texas.  You know our policy and enforcement failures.  So instead, let me tell you what public health (policy) is doing well:

(For a recap on why gun violence is a public health problem to begin with, start here.) 

Disarming Batterers:  A number of states actively deny individuals who have restraining orders against them from owning or buying firearms.  It’s a group that is hard for the NRA to rally around, and a 2003 study by Vigdor and Mercy suggests that the laws reduced intimate-partner homicides. 

Surveillance:  Did you know that more people die by suicide than homicides every year? The National Violent Death Reporting System, established in 2002 and run through the Centers for Disease Control & Prevention, serves as a tool for pinpointing and observing trends that helps state and local workers frame and understand where and how violence occurs so they may better prevent it.    

Research in Practice:  These numbers I spit out don’t just stay as numbers.  They’re translated into training programs for counselors, pastors, and physicians to know how to talk about and reduce violence.  Research that evaluate policies help pinpoint and effective interventions so more resources could be directed toward the ones that work, like limiting the number of guns one can purchase per month, or disarming people who have had felony convictions*.

(Standing way too close to fireworks in Baltimore)

What can you do well?  Calling members of Congress pressures them to support gun control measures, educating yourself spreads best practices, and writing a big-a$$ check helps offset NRA contributions and funds worthy programs that reduce violence.

*From David Hemenway’s Private Guns, Public Health.  Again, no funding, just a good book.  

PS. I talk about DHem a lot, but folks at Hopkins, like Daniel Webster ("DWeb") are also doing great things on guns.

Gun Rhetoric Done Right

Working on a longer gun post, in the mean time, we haven't discussed DHem in 3 weeks...

(Just like Oprah)

This is why I love David Hemenway.  He has a memorable illustration for every point.  As the author of Private Guns Public Health, DHem gets called upon by the media after every mass shooting (chatting with Tom Ashbrook this morning).  He is name checked by Nicholas Kristof here, here, here, and more.  It's the second most recent one that I want to talk about (last 4 paragraphs, for those without the attention span to read a column).  Somehow, after all these years of commenting on this same topic, he manages to be clever and novel in presenting a public health perspective.  He likens something as divisive as gun control to something as common (and funny) as dog poop.  In the process, he explains how public health successes come about.  Poop is a funny word.


Declaration of Competing Interest: No, I still don't get royalties from any of DHem's books.  I am beginning to think that I should.

Academia Done Right

I remember the first day of my Principles of Suicide Prevention course, we went around the room to talk about why we were taking the class.  Over and over again, from the 2 instructors to the students, though we were in different programs, there was the same refrain, "When I took DHem's class-," "DHem-," "DHem-."  When I got to Hopkins last fall, there it was again.  That one name everyone mentioned when they talked injury prevention, that one name that inspired them to care and see the world differently.  Except at Hopkins, it wasn't DHem.  It was Sue Baker.  She even predates DHem.

So when I saw a feature on her this Sunday, I thought: how could I not mention an article that a. features a hero in injury prevention and b. mentions the very title of this blog?

By 1973, she was teaching Hopkins’s first class in injury prevention. Baker’s decision to champion what was at the time a virtually nonexistent discipline was a mystery to some of her colleagues. One of them, a public-health professor, asked what she was working on. “The connection between alcohol and highway safety,” she replied.  “Oh,” the professor said, “is that public health?” (emphasis added)

--Robert W. Stock for the New York Times 

The world outside is raining and storming, you might as well take the time to enjoy this piece and be inspired by a woman who sees public health everywhere.  The article not only has some neat stories from the Annals of Safety History (any good student of Baker and DHem should recognize some of these), but also shows how a research career forms and grows and relates to the people and world around us.  It's that second part that makes me like the piece so much.  I don't yet know if I can talk about so many research projects without being boring.  But examples like this is exactly what I'm gearing up to do here when I grow up.

Mistakes (Don't Have to) Happen

Part of how public health works "while we were sleeping" is to take away opportunities for making the wrong decisions.  Figuring out what decisions to target isn't always easy.  Banning cars will drastically reduce the number of car accidents on the road.  But it would also prevent people from giving me rides.  Public health succeeds then, when it strikes the right balance between what's good for the individual and the public.  Here are a couple of clever examples:

Haizhu Bridge

(source: http://news.163.com/09/0826/02/5HK0I4SF00011229.html)

Maybe "clever" was too generous a term.  This wacky idea might not score an A in design, but it is reportedly successful.  If you're the officials of a crowded city with a growing bridge-jumping suicide problem, how might you combat an issue?  Making the bridge harder to jump off of is a good place to start.  The traditional approach is to put up barriers, but officials in Guangzhou had another idea: grease up the bridge with brown oils to make it difficult to climb.  Weird?  Yes. Unsightly?  Yes.   Effective in curbing the number of jumpers?  Also yes. 


Children's Aspirin*
This is one of my favorite stories of While We Were Sleeping.  In the 1940's, children's aspirin first came onto the market.  They were a commercial success.  Pink and flavored, they were attractive to children.  Some literally ate them “like candy” such that 200 children each year were dying from ingesting aspirin.  It took the work of a Duke pediatrician, Jay Arena, and the head of a small pharmaceutical company, Abe Plough, to stop these deaths.  They made the bottles more difficult for children to open.  Safety enclosures are routine for our pill caps now, but back then, no other company was willing to do so.  Plough took the risk.  “If it if it saves the life of one child," he said, "I’ll do it.”  They didn’t stop there.  Arena and Plough also worked to cut down the dose and number of tablets per bottle, so that even if all the other measures failed and a 2-year-old somehow ate an entire bottle of aspirin, the dose would not be toxic.   The child could still be safe simply because Arena and Plough adjusted the bottles. 

Policy Implication:  "It is possible to protect children without changing their or their parents' behavior.*"

*While We Were Sleeping pp 30-31, 37-39 (I swear I'll stop quoting DHem every other post.  But it's a hard habit to break.

P.S.  Those of you who like good long form non-fiction or want to read more about bridge jumpers, check out this excellent New Yorker piece on the Golden Gate Bridge.

Red Light District

(special thanks to Priscilla for inspiring this post)

Is running red lights public health?  Randy Cohen, the New York Times "Ethicist," recently justified it as ethical practice for cyclists in an opinion piece.  Since I once incurred ridicule from peasant farmers in China for forgetting how to ride a bike ("like riding a bike" my foot), I thought it best to turn this question over to 4 great public health minds for their diverse and expert perspectives.  Hit the comments below for your own take.

To start off, their glittering credentials (more complete bios available on their respective post pages):
David Hemenway: Commuter cyclist; PhD in economics, Harvard; currently a big deal in injury prevention
Oliver Hsu: Serious 'gearhead;' MS in Health Policy, HSPH; currently works in healthcare consulting
Amy Lee: Commuter cyclist; MPH in Public Health Practice, UW; currently works in clinical research

Cass Kercher: Non-cyclist, MPH in Occupational Health, Drexel; PhD student in injury prevention & policy at Hopkins

(apologies for my lack of tech savvy, they don't teach this in public health school)

David:  Ride (and run lights) safely and sensibly 

I am most concerned about safety.  In Boston I often run red lights as this turns out to make me safer—for example  if, as is common, there is a car illegally parked up ahead and I will be forced into the motorists lane, so I want to do that when there is no car behind me.  If there were a safe bike lane I would rarely run a red light.  I also, on a rare occasion, will actually use the sidewalk if it is especially dangerous on the street, and it doesn’t affect any pedestrians. ... (Read more) 
 

 Oliver: Respect the rules, or risk causing harm

I'm definitely one of those cyclists who does not run red lights and stop signs. I am an avid gearhead so that may bias my response. I get annoyed when cyclists flaunt the rules, especially, in the back roads of California where vehicle speed is much higher and there are more blind corners. The environment is more dangerous yet that there is less regard for the rules just because traffic is infrequent.  I would disagree that just because a bike is not moving as fast or is as heavy as a car that it is somehow less dangerous than a car. There is still roughly 200 pounds of rider plus bike traveling at 20 miles per hour. ... (Read more)

Cass: Our imperfect laws keep you from hitting me  

As a frequent active commuter (until very recently I didn't own a car and walked nearly everywhere I went in Philadelphia and Baltimore), I am concerned with transportation safety. On more occasions than I can count I have witness cyclists putting pedestrians and motorists at risk while they occupy a lane of travel but ignore traffic laws. Of course, I will admit to crossing the street against a light, but always in the crosswalk of a very empty intersection. ... (Read more)
 

Amy: Rules keep me in check while the right environment makes rule-following easy

I do not run red lights when I'm biking.  Although I think some lights are ridiculous to sit through (especially during rush hour when I'm breathing in car exhaust), I follow the rules because I believe that this is public health.  I am a fairly experienced biker, but I can make mistakes.  Following biking rules helps reduce the temptation for me to make a poor decision when I'm in a rush because it is habit for me to slow down and stop when I see a red light or a stop sign.  This is true for drivers, too, which is why we don't allow drivers to make illegal turns when the roads are completely clear. ... (Read more)

Their individual practices may differ, but David, Oliver, Cass, and Amy all point to the need for better bike infrastructure.  They also recognize that while traffic regulations are designed to keep cyclists from endangering themselves and others but given imperfect regulations, cyclists must also rely on individual discretion in deciding what is safest for them.

Policy Implications: Altering bike infrastructure (e.g. better lanes, more vigilant and sensible enforcement, tolerant bike culture) can improve road safety and behavior for drivers, cyclists, and pedestrians alike.

Photo credits for this post: Kent Dayton via UVM.edu (DHem), and Oliver Hsu, Jim Kercher, and Sasha Tan via facebook (Oliver, Cass, and Amy).

David: Ride (and run lights) safely and sensibly

I am most concerned about safety.  In Boston, I often run red lights as this turns out to make me safer—for example  if, as is common, there is a car illegally parked up ahead and I will be forced into the motorists lane, so I want to do that when there is no car behind me.  If there were a safe bike lane I would rarely run a red light.  I also, on a rare occasion, will actually use the sidewalk if it is especially dangerous on the street, and it doesn’t affect any pedestrians.

Running red lights for a bicyclist is like jaywalking in that both save time;  jaywalking increases pedestrian risk, while running a red light (for a bicyclist) may increase or reduce the risk of injury.  Of course, if safety is not going to be affected at all, and if other bicyclists at the intersection are running the red light, I will probably tag along.  (Note that I travel in Boston, I mostly bike to commute, and rarely go very fast.)  (Return to post)

(Photo credit: Kent Dayton via uvm.edu)

David Hemenway is sort of a big deal in injury prevention and has a PhD in economics from Harvard University, so trust him when he says that "property" is "what to serve when the Queen comes over".  He commutes to work on his bike and is who Oliver means by "DHem".

You Can't Count on Me

I graduated from college in 2007 and enjoyed 6 brief months of employment in the pre-recession era.  It was a time when the research office flowed with free food.  I especially remember one celebration (Flag Day?) when we had a tall, gorgeous cake covered in chocolate shavings and studded with fresh fruit.  As it was being cut, a giant strawberry fell onto the conference room table.  I instinctively reached for it.  Only to have my supervisor gasp and swat my hand away.  It was a compromised strawberry; I wasn’t to touch it.

I wash my hands 83 times a day, cough into my elbow, and always buckle up.  Public Health needs us to do these things for our own good and the good of others, but it can’t solely rely on our caution and wisdom.  Because I draw the line at fallen strawberries.  You might draw the line at sunscreen.  We’re all idiot snowflakes in our special ways, misjudging our risk in everyday situations.  This is why while most traffic accidents occur during the winter months, when road conditions are poor, most traffic fatalities occur during the summer months, when conditions are clear*.  We drive carefully when the roads are slick but carelessly when they are not, leading to deaths. Though 15% of all motor vehicle crashes in 2009 occurred in rain, snow, and sleet, they only accounted for 10% of traffic fatalities*.  

(when my car was totaled** on I-495 one fine May morning and spun off of the road, I was able to recover, stop the car, and avoid all those thick trees thanks to this nice patch of grass)

Thus Public Health strives to make our environments safer so that even when we make the wrong call, we and those around us are protected.  Rather than resigning road safety to the whims of individual drivers, trees can be cleared from the side of the road so that cars that spin out can be slowed down by grassy patches rather than slamming into trees.  Airbags and collapsible steering columns prevent cars from becoming death boxes once crashes occur and minimize secondary injuries.  These measures make crashes less lethal and lift the onus off of individuals but aren't always easy to come by-- they require conscientious planning and lobbying to win government and manufacturer support.  These measures are necessary and reassuring when we aren't always reliable or rational.  Because never mind the conference room table, I would have eaten that strawberry off of the carpeted hospital floor. 

Policy Implication:  Making products and the environment safer can be easier and more effective than changing human behavior.   

*From the NHTSA's Fatality Analysis Reporting System, via David Hemenway slides

**Not my fault.

What We Talk About When We Talk Public Health

I had known for years that mopeds were dangerous and helmets crucial.  I’m a public health student, specializing in health policy.  I'll be a 'health services researcher' when I grow up and these are the kinds of things we believe.  Plus, I grew up in motorcycle-dense Taipei.  I remember crowding around the safety campaign posters after school to gawk at photos of helmet-less, headless bodies.  Then again, I grew up in Taipei.  So I’ve also felt the thrill of whizzing up a mountain on the back of a motorcycle, tilting from side to side, and I know the convenience of mopeds. It wasn’t until the death of the kindest ER doc I know that these safety beliefs became real.  Afterward, my mentor made me promise that I’d never ride a moped.  He didn’t have to.  I knew it by heart by then:  Mopeds are dangerous.  Helmets are crucial.  

We are shaped by the stories close to us.  Yet public health, by its nature, looks at people from a distance, focusing  on populations rather than individuals faces.  This is useful in spotting trends and making policy recommendations, but it also means that despite solid research, public health findings often don’t seem convincing.  Sometimes, it takes a death to shake us.  Other times, a happy ending will do just fine.

While I am still learning the art of public health storytelling, Professor David Hemenway at the Harvard School of Public Health has compiled a collection of compelling public health success stories he may or may not have shamelessly shilled in multiple classes.  In it, he uses a neat concept to describe public health: it is lifesaving work that often happens behind the scenes, "while we were sleeping."  It moderates the air we breathe, the cars we drive, and the drugs we take, even as we are blissfully unaware.

In the coming weeks, months, and years, as I sharpen my public health research skillz, I hope to use this place to articulate just what exactly public health is, why you should care, and what great, non-creepy, things are happening while you're asleep.

Policy Implication: Public health protects your life in ways that are often unnoticed; better awareness of its successes/tragedies can enhance the public’s reception.

Declaration of Competing Interest  Neither While We Were Sleeping, nor DHem (as the cool kids call him), nor anything else that will be mentioned here sponsors this blog in anyway.  I just like his book, message, and the grades he gave.  My views do not represent those of any of my institutions.