That Movie Magic

In the late 1980s, the term “designated driver” began popping up all over pop culture.  The bar in Cheers had a poster and on L.A. Law, Harry Hamlin asked a bartender to call his designated driver.  This was the work of Dr. Jay Winsten of the Harvard Alcohol Project.  Using movie magic for good, he asked Hollywood studios and TV networks to spread the word on designated drivers.  The point wasn’t to change behavior over night but to bring the idea into public consciousness and shape social norms. 

As someone who grew up in the 1980s, I can attest to the success of the campaign.  What was new back then is now a given among my friends today.  As someone who has never owned a car (or a suit— despite my age, I’m barely a grown up), I have ridden shotgun countless times while generous friends drove.  Consequently, I’ve gotten to observe the driving patterns of many conscientious, risk-averse, public-health minded friends— who always buckle up, would never drive drunk, and would otherwise never put our lives at risk.  That is, except for one thing: futzing with the damn smartphone (aka “distracted driving). 

We’ve read the risks.  Signed Oprah’s pledge like Sandra Bullock.  And cried through super sad PSAs.  Yet we stubbornly assume that we are safer, smarter, and luckier drivers than others and whip out phones to send messages, find that one song, and check Facebook when we think traffic is slow. Many states are enacting distracted driving laws to deter phone use, though the policies haven’t stopped many of us.  We need Winsten's movie magic to change social norms.  He is working on replicating his campaign with distracted driving.  Until it becomes widespread though, I offer 3 personal tips to reduce distracted driving:

•  “Look, Ma, No Hands!”  Bossing someone around is more fun anyway.  Take advantage of bluetooth technology (or even Siri) to make calls and navigate via verbal cues rather than fumble with the phone.
•  Cede/Commandeer Control.  As a driver, let whoever rides shotty co-pilot.  As a rider, I offer my phone and navigation skillz so the driver can focus on well, driving. 
•  I Don’t Want To Die Today. As a rider, when I feel particularly uncomfortable with how much a driver is looking down on the phone, I shout “Eyes on the prize!” or other variants.  It’s usually funny enough that I don’t get kicked out immediately, yet alerts the driver to the issue.

Unlike Winsten’s campaign, my suggestions are not quite public health. They are one-on-one interventions whose successes I have personally witnessed.  But until policy initiatives catch up, I hope you’ll give these a try.

Read more: On Jay Winsten, on distracted driving, on Eyes on the Prize.

O-Aren't-You Glad For Insurance?

(From top left: Mysterious liquids, pharmacy certifications, the lab's "sink," and a tub filled with:
packs of antibiotics, a carton of cigarettes, and hangover pills, on the lab counter)

A rusty cleaver.  A faucet-less sink.  And colorful, new blister-packs of house-made hangover pills.  The herbal medicine lab was a fascinating mixture of tradition and innovation, of regulations and disorder.  In college, I spent 2 months living in the remote Chinese province of Ningxia.  One of the highlights of the trip was a visit to an old friend of my grandfather and a practitioner of traditional medicine (followed by an awesome lunch with “deer penis wine”).  He remarked that unlike western pharmacology, he didn’t know how each of the ingredients he prescribed broke down and functioned. He just knew that certain combinations worked.  His proof was in the people who got better.

In many ways, Public Health views having health insurance and going to the doctor in the same way.  We think insurance is good and people should have them.  Ditto primary care physicians.  We observe that people with them have better health outcomes than people who don’t.  But we’re not sure why.  Does insurance get you better doctors?  Is it the peace of mind?  The old pharmacist could compare the results of 2 equally sick people, one with herbal treatment and one without, to see whether his treatments work.  But Public Health can’t easily do that.  People with insurance are different from people without.  People without insurance tend to be younger, sicker, and have lower-income than people with insurance*.  So comparing the 2 groups is like comparing apples and oranges.  If only we could grab 2 similarly orange people without insurance and say, “you get insurance and you don’t,” and wait to see what happens.
If only.

The brilliant and articulate Dr. Kate Baicker from Harvard (who I’ve mentioned here) found a way.  She and her team seized upon a natural experiment from the state of Oregon.  In 2008, Oregon realized that it could afford to take on an extra 10,000 people in its Medicaid program (public health insurance for low-income people).  The need was much greater than 10,000.  So Oregon held a lottery. This way, the people who were randomly selected would be similarly orange to those who weren't.  Baicker et al tracked both groups over time and looked at their health, their use of health services, and how much they spent on healthcare—setting up a way to analyze the ‘effect’ of having Medicaid.  This is an important feat because the ACA is about to expand many Medicaid programs. It’d be good to know if these resources are being put to good use. 

So, how’d it go?  Oh look, we’ve run out of room again.  You’ll have to check back next week.  (If the suspense is really killing you, this has been all over the news: see here, here, and here).

*From the Kaiser Family Foundation: a wicked good resource on health policy basics.

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.

The Nerve of Public Health

My mother never grounded me, never said “because I said so,” and never counted to 10.  She didn’t even count to 3.  She just said “1.”  Her authority was absolute.  I obeyed because the consequences of not doing so were frighteningly unthinkable.  Fortunately for you and me, we do not live under my mother’s roof (Father does, but by choice).  We live in a land where we are free to question authority and wonder: Where does Public Health get the nerve to tell us what to do?

Apparently, it comes from the Constitution, the one that begins with “We the People.”  Here are three main sources of public health power:*

Commerce Clause The Federal Government only has the powers given to it by the Constitution (“enumerated powers”).  This includes the power to spend money, tax, and regulate interstate commerce.  Much of what the Government governs, from marijuana cultivation to guns in schools, draws its authority from the Commerce Clause**.  It’s what gives the Food & Drug Administration (FDA) the authority to set standards for the foods and drugs we consume and protect us from faulty protects.  The latitudes and limits of the clause were central in the debate surrounding the Supreme Court’s decision to uphold the insurance mandate of the Affordable Care Act.  This and other challenges to Congress’s authority have limited the interpretation of the clause to existing interstate economic activities with direct and substantial economic impact.

Police Powers Unlike the Federal Government, which is limited to the powers named in the constitution, States get all the powers that aren’t enumerated.  The authority for States to enforce quarantines in disease outbreaks, evacuations in emergencies, and for public schools to require vaccinations comes from the 10^th Amendment, which gives States “powers not delegated to the United States by the Constitution” to protect and promote public health, safety, welfare, and morals".  The only catch is that the actions are necessary, reasonable, and don’t interfere with individual rights.  States can delegate these powers to local districts.  That’s why Public Health regulations on safety look different in different states and towns. 

Individual Rights The Federal and State government may have lots of power, but so do you.  Though there is no individual right to healthcare in the US, as there is in many countries, people do have the right to demand as well as resist some public health actions.  Individuals are guaranteed the right to due process as well as certain civil rights and liberties.  These rights can be used to challenge government overreach in the name of public health (e.g. quarantines without reason) as well as push the government to make healthcare more accessible.  The right to medical interpreters, for example, comes from the Civil Rights Act of 1964.

Policy Implications: I trust you can piece this together on your own.

*All un-cited wisdom comes from class notes from Michelle Mello’s Public Health Law— the only Health Policy course I could not ace/ace-minus (no grudges; Prof. Mello is wicked badass).  All mis-cited wisdom comes from me.

**Both have been challenged, with different outcomes.

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.

YoungerCare, RomneyCare, and ObamaCare

(Mark and Ash; Photo credit: Julie Aleman via Facebook)

Mark and Ash  are not the faces of the uninsured.  With degrees in engineering, business, public policy, nursing, and public health, they are the faces of the exhaustively educated and eminently employable.  Their story of scrambling for coverage then, reveals just how unaffordable healthcare is without insurance, and how close uninsurance can hit.

Shortly after their dual graduations from Harvard in 2010, the Youngers found themselves in a pickle.  Before they moved halfway across the world for Mark’s new job, they needed 6-months in California to tidy up affairs—mastering hot yoga (M); not-mastering embroidery (A); and most importantly, gestating (A).  Though they were young, healthy, and had a job in hand—3 markers of being low-risk insurers like in their beneficiaries— Ash’s pregnancy was considered a “pre-existing condition” and cause for denial even if she was previously insured.  They did not qualify for Medicaid.  And though ObamaCare promises an end to coverage denials like these, the clause does not kick in until 2014.

Public Health cares about insurance because it is a gateway to healthcare in the US.  It provides ease of mind, encourages healthy behavior, and mitigates the consequences of disease when they occur.  Insurance may not guarantee good care, but it is the first step toward care.  Given the high value of coverage, insurers are wary of people with pre-existing conditions because they’re so expensive: women who are preggers are almost guaranteed to have physician visits, tests, and a hospitalizations.  All those things cost money.  

(Offspring #1 and Offspring #2; Photo credit: Ashley Younger via Facebook)

 Lucky for Mark and Ash, though Californian insurers weren’t accommodating, Massachusetts guarantees coverage regardless of pre-existing conditions.  Massachusetts insurers could afford to do this because of the “individual mandate” put in place by RomneyCare ‘06.  By requiring everyone in the state to have insurance, the mandate widened the pool of people sharing risk, lowering the cost of covering expensive people.  ObamaCare works with a similar mechanism that is not yet in effect.  As for what RomneyCare ’12 will bring, Governor Romney has threatened to repeal all of ObamaCare.  He has also promised to cover those with pre-existing conditions provided that they have continuous coverage, but has provides few additional details on how his plan would cover such individuals (see this guide to pre-existing conditions for more info).

Mark and Ash never expected to be uninsured.  And thanks to RomneyCare ’06 (which was a model of ObamaCare), they didn’t have to be.  Rather than worry about how they’d pay for the birth of Offspring #2  (which came to over $30K for a “nothing fancy,” straightforward delivery), they could focus on other things, like how Duke + Harvard left them so poorly prepared for simple games like Boggle. 

Policy Implication:  The individual mandate is one solution to expanding coverage while avoiding adverse selection.