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.

©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.