By S. Todd Stolp MD

Clinicians and public health practitioners alike have lamented shortcomings in public health literacy that have contributed to poor outcomes from the COVID-19 pandemic.[1] Of course, the primary institutional solution for any weakness in literacy, including health literacy, is our educational system. Yet collaboration between clinical and public health experts and their colleagues in the educational sector to improve public health education curriculum across the country is lacking.

Public Health Literacy Defined

The definition of “health literacy” and “public health literacy” has evolved. In 2009, Freedman et al proposed to divide “health literacy” into “individual-level health literacy”- a concept which continues to be developed in the recently updated Healthy People 2030 definition – and “public health literacy.”[2] The definition of “public health literacy” as proposed by Freedman et al is “the degree to which individuals and groups can obtain, process, understand, evaluate, and act upon information needed to make public health decisions that benefit the community.”

This notion of “public health literacy” is acutely relevant to an effective public health system, partly because rigorous public health literacy strengthens the partnership between a community and local public health professionals and partly because public understanding of population health vocabulary facilitates communication. But the benefits of public health literacy go much further. A focused effort to improve school health education curriculum to advance public health literacy is exactly the prescription this country needs.

U.S. National Health Education Standards

In 2022, two different coalitions of health educators, the National Consensus for School Health Education[3] (NCSHE) and SHAPE America,[4] worked on disseminating two competing versions of new U.S. National Health Education Standards (NHES). A modern revision of the 2007 NHES poses an enormous opportunity to address shortcomings in public health literacy. In the wake of the COVID-19 pandemic and other ongoing public health challenges, updated public health education curriculum in K – 12th grades should include renewed focus on public health principles, epidemiological knowledge, statistical proficiency and must integrate public health education with other cross-cutting STEM subject matter. Clinicians and public health professionals who have worked with the public, both behind the closed doors of clinics and in the national media over the course of the COVID pandemic to convey public health messages, have been underutilized in the development of the new NHES. In addition, the release of two different versions of updated national standards is likely to create inconsistent implementation and confusion among state departments of education and those who are developing new health education curricula. A more collaborative effort is needed.

What Can Improved Public Health Literacy Accomplish?

Of course, barriers other than low health literacy, such as lack of access to healthcare and insufficient financial resources, present obstacles to health-seeking behavior that cannot be mitigated by health education. The 2020 National Academy report, Encouraging Adoption of Protective Behaviors to Mitigate the Spread of COVID-19: Strategies for Behavior Change,[5] cautions that “(t)here is not strong evidence that explaining the science of disease can directly change behavior.” But this cautionary statement ignores overwhelming evidence that a foundational understanding of the science of disease enables timely access to services, facilitates rewards for health-promoting behaviors and avoids unnecessary costs and unproven treatments.[6]  The success of historical campaigns like tobacco control were propelled by limiting access to tobacco and shifting costs of tobacco-related disease to tobacco consumers and industries, but these efforts were built on an understanding of tobacco-related disease and political will, all of which were facilitated by public health literacy. Campaigns now underway to curb firearm violence have been hobbled by limited access to public health research, but new studies will now hopefully see new strategies emerge. While it is not a panacea against future public health challenges, improved public health literacy is a critical catalyst for interventions encouraged by the National Academy report, like access to services, rewards for health promoting behaviors and financial incentives, to be effective.

In fact, an overwhelming amount of research supports the need for a foundational understanding of health science as a cornerstone for public health, for resilience to both public health emergencies and chronic diseases. Following the Dobbs Decision in 2022, education has been shown to facilitate access to contraception for those with limited options.[7] Lower health literacy scores on the Rapid Estimate of Adult Literacy in Medicine–Short Form (REALM-SF) have correlated with a variety of adverse maternal and neonatal outcomes.[8] The American Heart Association position statement Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention provides comprehensive support for health literacy in battling the country’s most common cause of death.⁸ The U.S. Surgeon General’s 2021 advisory, Confronting Health Misinformation, includes the recommendation that educators should implement “…health literacy programs….across all educational settings, including elementary, secondary, post-secondary and community settings.”[9]

Public Health Literacy and Health Equity

It is easy to feel powerless when public health workers are confronted with gaping health disparities rooted in a tangle of social, geographic, racial, ethnic and economic realities. However, one tool available to us living in a country that has not yet embraced universal health care, is a system that promises universal education. Advancing public health literacy through nationwide standards in health education is a tangible way to address health disparities, insofar as our schools are satisfactorily funded to meet those standards.

The Need for Partnership

Relying upon the expertise of specialists in the field of education is, of course, critical to the development of an effective update and implementation of public health literacy educational standards. Employing developmentally appropriate and evidence-based teaching methods in accordance with frameworks that build upon cross-cutting lessons in other STEM subject matter is vital. However, it is equally important that curriculum include insights that are foundational to public health principles. Examples might include demonstrations reflecting the additive or exponential effects of disease prevention measures taken within a population during an outbreak, or simultaneous lessons illustrating natural selection principles in action when antibiotic resistance emerges in a community. Insights that distinguish normal grief from clinical depression can be gained from studies of literature and parallels between physical and mental disabilities, thereby helping to destigmatize mental health care.

Critical thinking skills must also continue to be a focus of updated health education material. There is evidence that automated dissemination of messages during the COVID pandemic has been disproportionately used to spread misinformation compared with its use to disseminate accurate and reliable public health information.[10] While assessing resource reliability was already a recognized focus of the previous 2007 National Health Education Standards, recent elegant work conducted by public health researchers during the COVID-19 pandemic to understand effective countermeasures to mis- and disinformation campaigns has added to the evidence-base for mitigations that should be included in new educational material.[11]

We Must Not Let SDOH Become a Cliché

Which brings us to the familiar topic of the Social Determinants of Health (SDOH). There is real risk that “SDOH” will become nothing more than a cliché unless clinical and public health professionals provide the service of translating science into action. APHA testimony to Congress in 2021 on the topic of “Vaccine Hesitancy” addressed the need for clinicians and public health communities to provide information to the public, but the need to partner with educators to build primary prevention before the advent of the next public health threat was not prioritized. Numerous published essays have encouraged a new paradigm for healthcare and public health without mention of the critical role of education and public health literacy in primary prevention.[12]  In a brief evaluation report of the CDC initiative, Improving the Social Determinants of Health – Getting Further Faster, support for education was mentioned only in the context of “outdoor education” or as a secondary prevention strategy, but not as primary prevention.

Shortfalls in the U.S. healthcare workforce are expected to worsen according to projections.[13] One way to increase interest in a possible future career in healthcare or public health is to increase exposure to the opportunities and the attractive features of those occupations. By expanding student exposure to epidemiologic investigations and the “Sherlock Holmes” challenges intrinsic to public health work, early curiosities can be cultivated into career trajectories to fill vacancies in the future  workforce.

Calls to energize government and private institutions to fund and devote expertise to address public health literacy as one of the few social determinants that can be modified have been meager.[14] While “education” has been raised as a potential mitigation, tangible efforts to coordinate with private educational coalitions and government departments have not been center stage. With the 2022 release of newly proposed National Health Education Standards, it is still not too late to roll up our sleeves.

[1] The Lancet Public Health Editorial, Education: a neglected social determinant of health; Vol. 5, Issue 7 2020; e361  https://doi.org/10.1016/S2468-2667(20)30144-4

[2] Freedman D, Bess K, Tucker H et al Public Health Literacy Defined, Am J Prev Med 2009;36(5):446–451) https://pubmed.ncbi.nlm.nih.gov/19362698/

[3] National Consensus for School Health, Accessed January 31, 2023 https://www.schoolhealtheducation.org/

[4] SHAPE America, Society of Health and Physical Educators, Accessed January 31, 2023 https://www.shapeamerica.org/standards/health/

[5] National Academies of Sciences, Engineering, and Medicine. 2020. Encouraging Adoption of Protective Behaviors to Mitigate the Spread of COVID-19: Strategies for Behavior Change. Washington, DC: The National Academies Press. https://doi.org/10.17226/25881

[6] Magnani et al, Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association, Circulation. 2018;138:e48–e74. https://doi.org/10.1161/CIR.0000000000000579

[7] Nelson H, Cantor A, Jungbauer R et al Effectiveness and Harms of Contraceptive Counseling and Provision Interventions for Women Annals of Int Med, May 24, 2022 https://doi.org/10.7326/M21-4380

[8] Yee L, Silver R, Haas D et al Association of Health Literacy Among Nulliparous Individuals and Maternal and Neonatal Outcomes, JAMA Network Open. 2021;4(9):e2122576. https://doi.org/10.1001/jamanetworkopen.2021.22576

[9] Murthy, V, Surgeon General of the United States, Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment, June 24, 2021 https://www.hhs.gov/sites/default/files/surgeon-general-misinformation-advisory.pdf

[10] Ayers et al, Spread of Misinformation About Face Masks and COVID-19 by Automated Software on Facebook JAMA Internal Medicine; June 7, 2021 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2780748

[11] Vraga EK, Bode L. Addressing COVID-19 misinformation on social media preemptively and responsively. Emerg Infect Dis. 2021 February 2021 [January 4, 2021].  https://doi.org/10.3201/eid2702.203139

[12] Jonas, W and Adibe, B An Integrated Framework for Achieving National Health Goals, JAMA Health Forum. May 20, 2022;3(5):e221109. https://doi.org/10.1001/jamahealthforum.2022.1109

[13] Buntin, M Projecting the Health Care Workforce Needed in the US, JAMA Health Forum. 2022;3(8):e222430. https://doi.org/10.1001/jamahealthforum.2022.2430

[14] Butler, S What is the Outlook for Addressing Social Determinants of Health? JAMA Health Forum, 2021;2(9):e213639. https://doi.org/10.1001/jamahealthforum.2021.3639

From my perspective though, epidemiology need NOT be boring. In the interest of full disclosure, I should point out that my judgement may well be clouded by my own skewed metric for boredom, recognizing that I have engaged in a fair amount of work as an epidemiologist myself.

In teaching epidemiology to students in the primary grades, it is best to simply approach the subject matter from the standpoint of probability. Better yet, from the standpoint of gambling, assuming you have no obstacles in the form of parental permission. For me, one of the most satisfying light-bulb moments in such a classroom occurs when students recognize the difference between a health care decision made in the interest of an INDIVIDUAL and a public health decision made for a POPULATION. The gambling analogy compares the difference between the potential outcome of a day of gambling for the gambler and a day of gambling for the casino.

But even such a metaphor loses interest in young students accustomed to adrenaline levels stirred by digital entertainment in the twenty-first century. And so we introduce the “Epidemiology Machine.” This device is nothing more than a marble-rolling platform perforated with scattered holes that marbles can fall through, representing people who contract an infection. A flood of marbles (the “population”) rolls down the platform, with only a certain percent of them falling through the holes – that is, becoming infected. Modifications of the probability of falling through the holes (“becoming infected”) are then made by students sliding two different metal sheets across the platform, representing the mitigations of 1) “Vaccination and Immunity” and 2) “Masking and Physical Distancing.” As each metal sheet slides across the platform, the number of infected people (“marbles” falling through the platform) decreases. The rattling flood of marbles provides a certain level of attention-grabbing noise while students have an opportunity to learn, with guidance from the instructor, the following lessons (depending, of course, upon the appropriate developmental and educational stage of the group of students):

• Vaccinations/Natural Immunity and Masking/Physical Distancing can decrease the number of people in a population who become infected.
• Vaccinations/Natural Immunity and Masking/Physical Distancing can have more than an additive benefit when implemented at the same time and in differing proportions.
• The number of people who become infected in a population from time to time under the same circumstances can vary from trial to trial, such that the only way to get an accurate idea of the number becoming infected is to look at multiple trials and calculate an average. A true lesson in probability, and an opportunity to engage in a little applied math.
• When the mitigations of Vaccinations/Natural Immunity and Masking/Physical Distancing are employed to such a point that, ON AVERAGE, fewer than one person in a population becomes infected by one index case, an epidemic will be extinguished. This number – the number in a population infected by one person who was the initial source of infection – is called the “reproduction number.”

To confirm that the Epidemiology Machine is indeed capable of capturing the attention of students from the 4th through 8th grades (even if only for a short time) see the following photo:

And please present the case to young people that a career in health care and public health can indeed provide daily adventure and real benefits to their communities.

Models of Health Literacy Education.STS Studios

April 5, 2010

by S. Todd Stolp MD©

We have probably all heard the description of the allegorical “experiment” in which a frog dropped in hot water will immediately hop out, but a frog in a pot that is slowly heated will recline with hind legs crossed like a vacationer in a spa until succumbing to the heat.  This tale is often told to emphasize the human tendency to ignore slow-paced social change while vehemently protesting the same change imposed rapidly.  Because April 7 through 11 has been designated Public Health Week, perhaps a close look at the “Boiling Frog” experiment will provide some insights regarding the challenges facing the Public Health sector.

Through the magic of the internet, gathering further research about the poor frog in the experiment is actually quite easy.  First, it should be pointed out that, for good reason, animal rights regulations would prohibit the above “experiment” today, and children should be cautioned not to try this experiment at home.  However, it turns out that in the 1880s a future president of the American Public Health Association, Professor William Sedgwick, conducted an extensive review of the excitability of the nerves of frogs and quoted the works of Heinzmann from 1872 who had indeed conducted the above experiment with a very slow incremental increase in water temperature in an elaborate system to measure the excitability of the frog.  The conclusion was that as long as the incremental change in temperature was slow enough, the evasive muscle movements of the frog were absent.  So how does this relate to today’s Public Health challenges, and was it just chance that the reviewer of these studies was a Public Health giant?

To summarize the implications of this experiment, incremental change is ignored if it is slow enough.  Consider the incremental change that has occurred in our world over the past 50 years.  While we often complain of the dizzying rate of social change over time, it seems that each tiny change that occurs over the short term is in fact embraced.  Consider the arrival of fast food restaurants, the ability to purchase a meal for our bodies while at the same time feeding our automobiles at a convenience store, our welcome acceptance of the latest digital device at work and play and our desire for the latest technical excuse to avoid exertion.  If we are truly alarmed by the effect these changes are having on our health – and the evidence that this is true is overwhelming – why are these concerns not reflected in our consumer and citizen behavior?  Could it be the “Boiling Frog” effect?

Perhaps.  However, humans receive much more input from and have much more impact upon our environments than frogs.  We can share philosophical views, read the news, watch commercials on T.V., adjust our investments and plan our employment.  We can design our cities with a broad range of options when resources allow, choose our meals when choices are available, and select our careers when education is sufficient.  These are what are called the “determinants of health,” and play at least as important a role in our health as our access to clinical care, and helping communities to act upon these opportunities is the greatest challenge to public health.

It is interesting to note that before Heinzmann engaged in his research, an European physiologist, Friedrich Goltz, had conducted essentially the same experiment, but Goltz had conducted his research differently.  Goltz compared normal frog responses to increasing temperature to the responses of frogs with their brains removed.  In his experiment, Goltz used such a rapid change in temperature that the normal frogs actually became irritable and made escape-like movements.  The frogs that were “destitute of cerebral hemispheres” did not.  Humans, of course, have immeasurably greater cerebral capacity to understand the effects of our environment upon our behavior and audaciously pride ourselves in wielding such magnificent thinking powers.  Whether we optimize use of our cerebral resources to use our cognitive and creative skills to keep the temperature in our pot in a survivable range or leap to a new environment will be the ultimate measure of our insight and compassion.

Think back to what you learned in primary and secondary school about health. Most of us recall sex education in high school, lessons about handwashing in life skills classes, first aid and perhaps some work in a science lab with petri dishes and moldy bread. To the credit of our dedicated educational leaders, tobacco control, anti-bullying and social tolerance efforts have been expanded in recent decades. The Affordable Care Act emphasized the importance of learning the vocabulary of health insurance, to prepare the public for an obstacle course of words like “insurance premiums,” “deductibles,” and “co-insurance.” But most of what is learned is focused on personal health education. While we address learning about our own personal health needs, an even larger gap in knowledge about public health widens.

Consider the kinds of knowledge that could buttress our communities as we face the spread of the COVID-19 virus. How many understand the difference between a virus and a bacterium, and what do those differences mean to an outbreak response? What is the difference between contact, droplet and aerosol transmission of different diseases? How does the incubation period, infectious period and the presence or absence of symptoms affect the transmission of diseases? These questions pertain not only to the COVID-19 virus, but also to long-term foes like chlamydia, HIV and influenza.

In 2019 the California Department of Education adopted a revised Health Education Framework to guide K-12^th grade health education in California schools. Because California health education standards were separated from the science standards in the early 1990s, diligent efforts are required to maintain bridges between cross-cutting topics in science and health. A broad range of opportunities exist to further expand science-based insights into community health. How are the principles of natural selection at play as organisms evolve and become resistant to antibiotics? How do such principles relate to the ability of a virus like the COVID-19 virus to leap from one species to another?

It is also important to keep in perspective the maladies that will continue to have the greatest impact on public health. What is the difference between grief and depression? What powerful marketing strategies are used to promote e-cigarettes, sugar-fortified foods and drug use? How can you recognize reliable, science-based health information on traditional or social media? How have vaccines and community planning effectively changed life expectancy and quality of life in the last century? What statistics are important measures of community health, and how is our community measuring up?

Shortcomings in public health literacy lead to misguided beliefs. While humble skepticism is a welcome foundation of science, irrational skepticism about vaccine recommendations and climate change undermines our social responsibilities.

The best lessons build long-term reasoning skills to help an individual come to rational conclusions as life throws us new challenges. Advancing public health literacy through a team effort by statewide health, science and educational experts can do just that. Such a prescription represents perhaps the most effective remedy for current and future pandemics.

©March 2009

Based upon the high quality education bestowed upon us by the endless stream of crime scene investigation mysteries on television, we learn that one of the first lessons for those trying to catch crooks is to think like the criminal.  If the suspect is a sailor, stake out the marina.  Similarly, when considering how to best find the culprit in an infectious disease, it is helpful to think like the virus or bacteria in question.  What would I do if I were an STI?

Consider what characteristics can lead a germ to end up on the “Ten Most Wanted” list.  First, it is important to recognize that germs are much more likely to create an epidemic if they avoid calling attention to themselves and do not kill their host.  When an illness announces its arrival with large red spots on the face or causes life-threatening symptoms, it can hardly avoid being discovered and arrested.

Similarly, an organism that kills its host is destroying its own meal ticket.  Sometimes this strategy works, but only when the victim showers the environment with germs as the illness progresses.

Causing an infection which allows the victim to go about his or her business while being attracted to and expressing affection for others is an ideal way to guarantee success as a germ.  This is the successful strategy employed by the mononucleosis virus which is also known as the “kissing disease.”

Another germ that takes advantage of this tactic is the Chlamydia bacteria, the most commonly reported infectious disease to health departments in California.  Chlamydia is a sexually transmitted infection (STI) which usually causes very few symptoms.  Chlamydia may cause burning with urination in males or females, or crampy pain and mucous discharge from the vagina in females.  The devastating inflammation that it stirs up in the female organs is the most common cause of female infertility in the U.S.  By causing inflammation in the genital tract, Chlamydia also increases the likelihood that other infections like HIV/AIDS can be transmitted.

For a germ to be successful, it must procure a means of transportation that is dependable.  West Nile Virus found just such a transportation system in the mosquito population.  What better way to assure a trip from host to host than to hitchhike on a vehicle as readily available as mosquitoes in the summer?

The most dependable way to avoid becoming a victim of the germs that cause STIs is to abstain from sexual contact.  Conveying this message to those confused by the discovery of new attractions is, of course, the full time occupation of the parents of adolescents.  From the perspective of the STI, depending upon the gravitational forces that from time to time develop between two human beings is as reliable a method of transmission as there is.

In people who are sexually active, condoms have been shown to reduce the transmission of infection, although different studies have found that the risk of infection is diminished differently for different infectious organisms.  Also, the amount of protection afforded by condoms is very dependent upon proper condom use.  Because reading the package insert is not often a priority at the moment of passion, it is important to learn such things ahead of time.

A second way to prevent STIs from inflicting permanent damage upon the population is to test for the presence of the germs in any person who is sexually active.  This can be done at the time of a routine physical, at the time of a visit to the family planning clinic, or in response to symptoms experienced by a patient.  The test can now be done for the two most common STI germs, Chlamydia and Gonorrhea, simply by collecting a urine specimen.

Another way to protect the public from the effects of STIs is to vaccinate against the Human Papilloma Virus (HPV).  The new HPV vaccine provides protection against four strains of the HPV virus that are responsible for 70% of cervical cancer.  We screen for cancer of the cervix with the Pap Smear obtained every three years after age 21.  After 30 years of age, women should personalize their cervical cancer screening recommendations by discussing it with their health care providers.  The HPV vaccine consists of a series of three doses given after nine years of age.

The surest way to decrease the discovery of crime is to stop looking for criminals and ignore the existence of misconduct.  Infectious organisms would love for the health care system to give up on screening the population for STIs and stop encouraging the use of condoms for people who choose to be sexually active.  Unfortunately, such a course will not make these villains go away.

©July 2006

Flying over a city, it is hard to avoid comparing the pattern of highways, warehouses and agriculture below to the structure of a single overgrown organism.  Freeways, like enormous vessels, feed communities with a vital flow of traffic.  A nervous system is represented by a perplexing array of power lines and cables.  Neatly groomed fields and orchards provide nourishment.  And much like a single creature, our communities enlarge only through the increased complexity and reach of these organ systems.  The globalization of the food industry is an example of just such a system.  Worldwide food production and distribution has been anticipated for over a century as an answer to disparity and hunger.  However, the question has recently been raised whether the health of industrialized countries like the United States might be better served by relying more heavily upon food that is locally grown and processed.

Arguments supporting the use of local food sources are compelling.  Alice Waters, of Chez Panisse fame, has championed the sustainable food movement, pointing out that locally produced food often has both nutritional and culinary advantages.  Following the European model, locally baked goods and locally raised produce (so called “Slow Food”) can enrich food quality as well as community relations.

The recent notion of “Food Miles” has raised awareness of the ecological and social consequences of a globalized food industry.  Examining the catch on a glacier at the local supermarket recently revealed an eclectic mix of shrimp from the Phillipines, Mexico, China and the Gulf Coast.  While one could work up quite an appetite before locating locally harvested Tuolumne County shrimp for the dinner table, one might do better to settle for local trout.

In order  to produce food products on a scale that makes international shipping a profitable venture, systems must sometimes be employed that conflict with basic health interests.  Approximately 75% of the antibiotics used in this country are utilized by the food industry to prevent disease in densely populated herds and flocks.  As a result, a growing awareness of organic and natural husbandry practices has emerged.  Some of these safer organic techniques have been employed in locally raised turkey and beef.

It is also true that marketing ploys have made detecting the implications of such claims as “fat free,” “free range,” “cholesterol free,” and “low fat” perplexing.  It is best for a consumer to ask questions if such labels are unclear.

Many communities feature a Farmers Market during those months of the year that are conducive to locally grown produce.  No better example of the benefits of locally sourced food can be given than the displays at such Farmers Markets.  The allure of the produce at the market is so compelling that some regulars find morning cosmetic rituals refreshingly irrelevant prior to visiting the stands.  Often, social interactions with neighbors and friends are as inspiring as the opportunity to shop for fresh groceries.

Taking advantage of these local resources can provide benefits both for the health of individual local residents as well as for the health of the “community organism.”

©January 2011

One of the most palatable features of the “Law of Supply and Demand” is the intuitive notion that the value of something diminishes when you have too much of it.  This phenomenon is easily illustrated by comparing the unwasteful care focused upon a crab leg at the beginning of an all-you-can-eat crab feed compared with the attention garnered by the last crab leg of the evening.  However, in an era that is likely to be seen by our descendents as the “Information Age,” which began with access to newspapers and now at mid-stream is highlighted by the Internet, Facebook, Google, Yahoo, and cell phones smarter than NASA computers of yesteryear, it is worthwhile to remind ourselves that information, like crab meat, is at risk of being devalued by its shear plenty.

From the perspective of public health, the danger that we lose respect for information is no laughing matter.  One of the largest underground activities of public health in this country is the collection and analysis of data relating to our health.  Without this infrastructure the discovery of epidemics or the identification of risk factors that shorten life expectancy or quality of life would be delayed.  By scrutinizing this data according to stringent statistical rules, the public health system wades through a sea of potential and alleged risks in order to identify those that appear to have a causal relationship to illness and select the ones for which practical mitigating measures are available. In this way, every health care and illness prevention dollar can be spent to the greatest public benefit.  There is enormous responsibility inherent in this mission.

First, it is important that the analysis of data be done objectively.  All of the mysterious tools available to statisticians and epidemiologists – coefficients of variance, confidence intervals, t-scores, etc… – should be applied with consistency.  In accordance with a timeless scientific principle, those collecting the data should have no self-interest or pre-judgment about the conclusions of the ultimate findings, within what is humanly possible.  A positive and productive recommendation cannot justify misrepresentation of the data.

Secondly, the importance of credibility cannot be overemphasized when we are talking about the role of public health in the dissemination of information.  Recognizing what we do not know is equally as important as recognizing what we think we know.  The list of historical examples of science doing a poor job of public education and suffering a lack of public support because of it is striking.  More important, serious and unnecessary outbreaks of illness have resulted from such events.  A few examples follow.

The British Medical Journal recently published a report identifying incriminating evidence that the article published in another English journal in 1998 that fueled the anti-vaccine movement was rife with distorted data, misrepresentations and frank conflicts of interest.  These ethical lapses ultimately led to the revocation of the author’s license to practice medicine, but this has not prevented countless deaths resulting from cases of vaccine-preventable illnesses that may have been, at least in part, a result of this misinformation.

The ongoing debate regarding climate change is another example of science falling victim to passion and dogma on both sides of the debate.  While the data is absolutely convincing that unprecedented changes in certain parameters are occurring within the historical records, the interpretation and dissemination of this information needs to follow scientific guidelines, as free from political or self-centered influence as possible.

The recent release of Healthcare Acquired Infection rates for healthcare facilities throughout California is another example.  It was clear to the experts that the rates of infections due to surgical procedures at various hospitals was reported inconsistently between hospitals, under different criteria, and was largely influenced by the patient mix at various hospitals.  Naturally, hospitals receiving a large number of seriously ill patients and burn victims suffered higher infection rates.  Therefore, to the objections of certain consumer groups but in accordance with objective principles, this data was released by the California Department of Public Health with clear disclaimers.

The responsibility to handle information with great respect, of course, extends to all levels of the community.  Whether in debates involving party politics, health reform, climate change, private agencies or public health, maintaining a sense of humility about the data we wield and showing a healthy skepticism about the data we consume is a duty and skill that deserves our attention, right down to that last crab leg.

December 20, 2017

When I read the recent headline that our nation’s primary public health agency, the Centers for Disease Control and Prevention (CDC), has been “prohibited” from “using seven words in official documents used for next year’s budget,” I found myself stomping around the house in disbelief.

As clarified by the CDC director, the truth of this news is probably less provocative than the face value of that headline.  And yet, the preponderance of evidence points to an ongoing and relentless effort to undermine science and scientific principles by our political leaders.  The proverbial last straw has landed on this camel’s back.

In 1996, a federal budget bill stated that “none of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

Subsequently, Congress eliminated funding for Gun Violence Prevention Research at the CDC.  Funding declined from $2.6 million in 1996 to zero in 2014, 2015, 2016 and 2017, despite a request for $10 million for each of those four years.

This lack of funding prevented scientific research that may have helped address firearm violence in this country, like a 2009 study of suicide rates in California that was funded by local Tuolumne County dollars to identify that, over the prior decade, for every firearm-related homicide in rural parts of the state, there were approximately four firearm-related suicides.

A disrespect for science can cause politicians to blunder into the realm of pseudo-science in response to public outcry, designing legislation with good intentions but with disastrous results.

In 2001, AB 487 was approved by Governor Davis requiring physicians in California to receive 12 hours of training in pain management because of a perception “that physicians consistently fail to manage their patient’s pain appropriately” in part due to “…undertreatment and undermedication.”

The passage of this bill coincided with the release of new opiate medications by pharmaceutical companies.  The encouragement to prescribe long-acting narcotics provided by AB 487 in conjunction with savvy marketing by pharmaceutical companies helped pave the way to today’s opiate addiction crisis.

Pseudo-science and ideological convictions may even misguide us to oppose sound science.  The trail of scientific discovery is littered with the lives of scientists whose sacrifices have resulted in the eradication of smallpox, travel into space, the control of yellow fever and endless research that has either proven or disproven contemporary theories.

To ignore the practical benefits of new discoveries discounts the sacrifices of these modern explorers.  If such neglect aggravates global climate change or results in a chronically ill child contracting an unnecessary infectious disease in school, it is nothing short of tragic.

Scientists must also bear some of the blame for public skepticism.  Real science is humble.  While scientists are generally superb at describing their fields of expertise, they are often not so good at translating their knowledge to the masses.  Science has unfortunately abdicated marketing to the corporate world that stands to prosper from the sales of products and services that are the fruits of science.

Here in Tuolumne County we are trying to change that.  A program called the Exploratorium of Health Care Careers will visit every public school in the county this year.  It is also active in Calaveras County and will be starting in Merced County this spring.

The program is made possible by an intrepid group of volunteers from many scientific and educational backgrounds who are seeking to introduce local 7th, 8th and 9th graders to the wonders and rewards of careers in science and health care.

But to bring new generations into those fields we must encourage students to ask questions.  They must shed their fear of asking the “wrong” question.  We cannot do that if our leaders prohibit our best scientists from asking certain questions or “using seven words” – or for that matter even one word – in their quest to understand our world better and to improve our lives for tomorrow.

If we accept this kind of scientific censorship we degrade the quality and integrity of our science and lower the expectations of tomorrow’s scientists.

In today’s world, with all its diversity, we need to instill our youth with evidence-based and science-based reasoning, so that tomorrow all of us – from the vulnerable fetus to the transgender community – can benefit from opportunities that represent our entitlement.

©September 2008

The United States Preventive Services Task Force is assigned the task of identifying those preventive services which are recommended for the general public.  Several criteria are used to assess various preventive procedures to see if they make sense.  Such criteria include the prevalence of the illness to be prevented, the effectiveness of the detection method, the disability caused by a preventable condition, the effectiveness of disease treatment once it (or the risk of it) is detected, possible negative consequences of a preventive intervention, and finally the cost of a preventive procedure, test or treatment.

First, the public health literature is analyzed to find those health conditions which cause the greatest harm to the population.  Relevant factors include whether a condition is common, whether it leads to considerable disability, and whether it frequently leads to negative consequences or a fatal outcome if not detected.

Secondly, preventive measures to prevent associated illness are assessed to see if they are effective, accessible and safe in preventing the illness.  Immunizations, for instance, are carefully screened before they are licensed to the pharmaceutical companies to determine if they are effective in preventing the various vaccine preventable illnesses, affordable and relatively free of side effects.

Similarly, if effective treatment for the condition is not readily available, then early detection is less likely to demonstrate a benefit.   Small cell carcinoma of the lung continues to have a relatively poor prognosis, even when detected early by a chest X-ray.  This partly explains the reason why routine chest X-rays are not an effective screening test for the general population, although they may be worth considering for certain smokers.

The potential NEGATIVE effects of preventive procedures are also examined by the USPSTF to determine which tests should be recommended.  A chest X-ray does involve exposure to radiation in the form of X-rays, and this is another reason why an X-ray or CT scan is not an ideal screening test.  Also, vaccinations are carefully reviewed for safety before they are widely recommended.  Sometimes new concerns are raised about a particular vaccination after they are widely distributed to millions of people.  The newly identified risk must then be compared again to the effectiveness of the vaccine, but such an assessment should take into consideration the benefits that have already been achieved by a particular vaccine.  It was for this reason that vaccination recommendations changed after polio in the U.S. became so rare that the live oral vaccine was considered less safe than the inactivated injectable vaccine.  Therefore, a switch to the injectable vaccine was recommended.

Some tests have a high false positive rate, meaning that they incorrectly raise the possibility of the presence of an illness when in fact no illness is actually present.  If further investigation for the presence of disease is possibly dangerous, like an abdominal surgery in a patient with an elevated CA-125 blood test for ovarian cancer screening, then this risk must also be considered before suggesting the test in the first place.

Healthy debate about whether or not to participate in screening tests at Health Fairs and through programs that are offered by health systems is part of conscientious personal care.  Unfortunately, there are self-serving programs out there selling screening services for profit rather than for a benevolent interest in improving your health.  To sort through the bewildering array of solicitations that most people receive trying to sell you a preventive service, like bodily CT scans and ultrasounds for otherwise healthy individuals, your personal health care provider is your most valuable resource.  In addition, the USPSTF recommendations are easily accessed with an internet search.