Cold Spaghetti

It’s dense, y’all.  So here’s the first dose.

It’s about race and health in public health research.

The U.S. is a multi-racial, multi-ethnic society, so we use race as a variable in all of our research.  We do this partially because of the fact that racial differences persist in virtually every area of health interest, and partially because of convention – we publish statistics stratified by race, we control for race in research models, and we exclude individuals from analysis on the basis of race.  What we (‘we,’ meaning me and my colleagues of health researchers… if I might take that presumptuous leap of status) don’t do is stop to question whether race is really an appropriate construct – what it means, what it really differentiates, and what it ultimately suggests.

This is really important because the use of race in public health research is very problematic.  The idea is that using race categories controls for some sort of undisclosed differences in population genetics… or in fancier talk, the epidemiologic assumption is that there is a genotypic difference that is being controlled.  But in reality, researchers aren’t in the practice of, say, taking gene frequency measures in their participants.  And more to the point: they aren’t even in the practice of defining the criteria for assigning a person in one racial category to another.

Well, if you’re still with me, you might be asking about the standard.  Because, surely, our medical researchers have come up with some hard and fast rule about the biologic concept of race in medicine.

Nope.

And as much as population geneticists will jump up and down screaming about things like ‘continental racial categories’ and the higher incidence of genetically-related disease in certain groups (say, sickle cell) – the bottom line?  All our genome work has us coming back again and again to say that genetically, we’re all pretty much the same.

Richard Cooper (an MD and Epidemiologist at Loyola Med School in Chicago) is sort of the Master and Commander of this discourse and I’d be remiss to try and restate what he says so darn clearly:

Racial differences reflect different social environments, not different genes, even where two groups live side by side, as do blacks and whites in the United States.  Race does not mark in any important way for genetic traits; rather, it demonstrates beyond question the paramount role of the social causes.  We have much more to learn from that paradigm, rather than the one offered by ethnogenetics.

In short, when we’re studying race, we’re really not studying genotypic differences – we’re studying phenotypic differences.  (e.g.: the differences that result in our environments, not our genetics.)
Okay then, but public health uses race all the time and finds all sorts of interesting results.  What does all that mean??

For one, it means that the results might be screwy.  The majority of public health research occurs statistically: where a model full of complex and overwhelming Greek letters spell out a variety of things (the independent variables) that predict what happens to an outcome (the dependent variable).  Race is most often used as a dummy, or binary, variable – meaning that you are either black or white – so the lack of conceptual clarity about what in the world each of those categories means leaves a great deal of room for error… if you aren’t controlling for something very clearly within your model, it means that your variable is open to error.  It could be measuring the effects of other things in your model, including things in the error term.  This means it could be “endogenous,” which, in public health research, is a Really. Bad. Thing.  Suggesting that using race as a binary variable presents a problem of endogeneity to statistical models is sort of like saying that that ‘vegetarian’ gravy your Mom has been feeding you for all your 20 years of vegetarianism is actually made from 6 different animals.  It ruins everything you’ve ever done with it and colors your ability to use it in the future.  It’s better to just not know.  Or to ignore the reality.  Or!  To reinvent it!

Like, for example, saying that race doesn’t really mean what we think it means.  Let’s get real, you say, we know that race is all messy!  So when we’re talking about race disparities in health, we’re actually measuring other things… you know, like socioeconomic status, discrimination, cultural factors, stuff like this that we know have a racial component.

That’s all fine and good, I answer, but public health models shouldn’t be proxy for anything not clearly defined.  That’s not good science.  It’s more logic to argue that if race is a proxy for other factors, then we need to find better ways of measuring those other factors.  If we’re going to intervene effectively, we need to clearly understand what is going on.

Let me give an example.  Let’s say that you are a health researcher and you’re studying prenatal care utilization.  You’ve got a great regression model controlling for a variety of factors and your results show a statistically significant coefficient for the race binary variable (that the mean number of visits is higher for whites than for blacks, even when you’re controlling for things like income, age, insurance status, etc.)  You might fall into the trap of reporting (as is embarrassingly common in published research) that “race is a significant determinant of prenatal care utilization.”  Think about that for a minute.  The color of one’s skin has nothing to do with how many times someone sees the doctor.  How the world around someone reacts to them due to the color of their skin (or other individual factors) may very well impact how many times they attend a prenatal visit… but that is not what the model is measuring, nor what the data is suggesting!

Further, if you go along that route, you may filter that finding down to medical and public health practice.  It may be unintentional or even unrealized, but your intervention could be focused on race, trying to address whatever it is about being black that means you go to the doctor less.  You may not even think to see what is going on with the doctor, or the clinic, or the system because you’re so focused on intervening in on that race factor… and you’d be missing the point.

Public health science needs better conceptual precision about the measurement of race, period.  At the very least, the lesson here is that we need to be clear on what we’re measuring and how we’re interpreting it.

“Mommy, can you get me something to read while I sit on the toilet?”

“You need something to read?”

“Yes.”

“Like, a magazine?”

“No.  A book.  Can you get the one in your bedroom that is about ducks?”

—

Before you go to snap judgments…

That Little Man, the one who wants to read about ducks while sitting on the throne, has silently endured an ear infection so bad that the pressure burst through the membrane of his ear drum and started leaking fluid out of his ear.  I noticed the dried fluid when we came home from his Christmas party Friday morning and within 30 seconds, had the doctor’s office on the phone.  Any thoughts on how painful it must be to have your ear filled with pussy fluid* with pressure so strong that it breaks through an organ?  (Okay, so probably that membrane isn’t an organ.  But wow, shouldn’t this at least be memorable in the short-term?  Cause an ‘ouch,’ maybe?)  I found photographic evidence of it from earlier that morning, from photos I took during the holiday party:

So, just to be clear: men who like to read about ducks on the can are tough.  T-O-U-G-H.

Oh, did I mention?  He wore a red flashing Rudolph nose from the party all afternoon, including through the entire trip to the doctor’s office — thoroughly mortifying the two teenage boys that he sat beside in the waiting room — and delighting everyone that saw him.  You know, while his little 5-year old head was leaking pussy fluid*.

That’s my guy.  Keepin’ it real.

(Last photo by Paul, who took the photo.  Photo by Paul showing Will wearing the stocking on his head, taken by Paul, who took the photo.  Just in case: that last photo?  Paul took it.  Thanks, Paul!)

* Meagan kindly noted my use of the phrase “pussy fluid” (not once, but TWICE) in this post and though it would totally be the right thing to, um, watch my phrase-ology, I just can’t bring myself to change it.  I just can’t stop laughing at myself.

My favorite is the stick figure shaking his little butt.  Which little one do you like best?  (Video after the jump.)

12 STIs of Christmas

And here’s the public health response on this Soapbox Saturday….

From a public health perspective, fear of something is not a very effective tool to influence behavior change.  But I still find this little public health message cute and informative… mostly because it reminds that condoms protect from more than HIV.  Perhaps it is good campaign to direct at pharmaceuticals?  It does a good job of showing how ridiculous it is that we ONLY have the condom to protect against these infections, which is pretty worthless when you consider the amount of people who choose to have sex without condoms because they want to get pregnant (or live in a pronatalist culture), or are forced to do so, whether by threat, coercion, or obligation.

If anyone says ‘abstaining’ as an option, I may just hurl, or cry.  We’re not taking about American upper middle class teenagers, first of all, and second, the entirety of sexual and reproductive health doesn’t revolve around them and their perceived needs.  Sexuality as a ‘choice’ exists in only a few spaces.  In reality, many have very little choice on how their sexuality gets expressed: culture, tradition, expectations, power, money, obligation, and poverty are much more present factors than any individual behavior ‘choice.’  Which is why the condom, a method that must be negotiated between a couple, is so ineffective as a comprehensive tool.  It’s all we’ve got and at least it works when it’s used correctly, but it’s hardly the answer we need.

Santa?  Are you listening?  Here is what I would like for Christmas: A viable method of protection for sexual partners to use that prevents STIs that is NOT the condom.  Can you get your elves on that?  Our pharmaceuticals are just not heading the message.

This is a wonderful video clip from the fantastic PBS series “Unnatural Causes… is inequality making us sick?” One of the episodes, “Becoming American” was screened last night at the Ashe Cultural Center. I was one of the panelists that took questions about health inequalities at a community forum last night after the screening.

The website for the series is an incredible resource for anyone interested in income, race, immigration, housing, and the myriad of issues that influence our health. In particular, I liked the suggestions to how individuals can make strides in their own communities toward improving health. As a country, we showed we are ready for change… here are some suggestions on how we can start in our own backyards.

Research has shown that health is more than healthcare, behaviors, and genes—that the social
conditions in which we are born, live and work actually get under the skin as surely as germs
and viruses do. What can we do to help reframe the nation’s debate over health and to address
the root causes of our devastating socio-economic and racial health inequities?

Here are a few ideas you can use to get started and encourage others to become
involved in working towards health equity:

• Identify and connect people interested in the root causes of health inequities.
• Organize a “brown bag” screening to discuss how social conditions—where we
are born, live, work and play—impact health.
• Form a committee to identify assets, programs, or initiatives within your
organization where you can use the series to educate, organize or advocate for
health equity.
• Screen and discuss the series with PTAs, book clubs, neighborhood associations,
churches, tenants groups, racial justice groups, and trade unions.
• Identify three existing struggles in your community that can improve health equity,
e.g., land use, a living wage, paid sick leave, affordable housing mandates, toxic
clean-ups, lead paint removal, etc. How can you become a partner?
• Conduct an audit of health threats and health promoters in your neighborhood.
• Identify and build strategic partnerships with community-based organizations and
organizations in other sectors; link health outcomes to housing, education,
employment, political power and other arenas.
• Form a community-wide health equity coalition.
• Ask your public health department to conduct a Health Impact Assessment (HIA)
on proposed development projects and government initiatives and ordinances.
• Provide local media with facts and resources so they can incorporate a health
equity lens in their reporting; help them identify a message point person to provide
quotes, analysis and additional information.
• Broaden the discussion: look for opportunities to submit op ed articles, letters to
the editor, call in to radio talk shows, and form discussion groups.
• Organize a policy forum to brief officials in government agencies about the social
determinants of health inequities.

Paul came with me to the event last night (he was impressed that I managed to only use the phrase ‘epidemiologic assumption’ once) and regretted not having a video camera there. That can only mean that at some point in the evening, I picked my nose or something.

In lieu of my comments from last night, I’m listing a few of my thoughts based on the screening, the questions panelists were asked, and my comments…

— We should be very concerned about the mental health of the Latino youth in New Orleans. Statistically, their risks of mental illness far outweighs any other group in the city — and the risk factors we know to trigger illness in this group exist for them here in spades.

— What can we do, as a community, to create public, multiracial spaces?

— How can we advocate for better city transportation?

— What can be done to attract health researchers back to New Orleans?

All of these things are on the radars of the many community activists and organizations that are working to rebuild a better community here… but as anyone who works in community organizing and nonprofits understands, the strides made are more likely baby steps.  Can massive overhauling really occur?

Here is one community project that I think is great example of a fantastic step: The Hollygrove Market.  We have not been able to pick up the weekend box, but just knowing it is there for us and available in a neighborhood where food markets are scarce, makes me feel that maybe it is possible to create a healthy city in the midst of poverty and destruction?

After numerous failed attempts to upload it in whole to Google video, Paul shrugged his shoulders, chopped it in half, and put it up on youtube.  The second part overlaps a little with the first, I’m told.

Feedback is that it was a good interview.  I’ve sort of tried to see it once, but I’ve learned something… the agony of listening to myself speak is nothing when compared to the gripping torture of having to WATCH myself WHILE I speak.

Part One:

Part Two:

The “Greater New Orleans” interview airs tomorrow on WLAE channel 12 at 7 and 9:30 (and I think again at 2:30am?)  I feel certain that Paul will pull it from TiVo and put it online to ensure maximum embarrassment on my part; my parents pay him well to keep me tortured in this regard.

We met a candidate for public office today. Briefly, but we met. I shook her hand, took her flyer, and engaged in 3 seconds of conversation where she politely complimented our family, street, and neighbors. She seemed like a perfectly nice, pleasantly scattered lady who would make a very good neighbor. Just the type to swap recipes, seek out for child-rearing advice, or ask to watch the house while you go out of town.

Public office? Well. Maybe not.

It’s not about the issue of the first and last names being the same, really. And it’s not anything about her, personally. It’s not because her circa-1995 web-page has more typos than some of the worst college freshman papers I’ve ever read. And not because I’m completely perplexed about what that “post graduate degree in Health Care Administration” means (do you mean an MPH? that’s a graduate degree… so do you mean another doctoral degree, in addition to the PhD and MD that it says she already has from LSU?)

No, it’s not about any of those things (although each concerning in their own way). The reason that she’s unfit for Senate is because of seriously whack things like her thoughts on how to improve health care in Louisiana. This is her “healthcare plan,” in its entirety, from start to finish:

Creating effectiveness within our Healthcare system, electronic data capture, standardization of insurance forms, electronic submission, “smart cards” to help both providers and patients with demographic and eligibility data, utilizing the quality care organizations in our state to identify at risk groups, i.e. diabetes and enhance intervention programs.

It’s ridiculous on many levels. One of them is the shocking realization that this mess of a run-on sentence was written by such a highly decorated scholar. Yet another comes out of actually trying to understand what she is saying (which takes some work) and realizing how alarming it is to think that it came from someone working in medicine. (As an ophthalmologist. In private practice. Apparently, that is what you do when you have at least two, and possibly three, major terminal degrees.)

What I want to run away with here is the “card” system mentioned in the tangled web above. This, along with her gag-worthy proposal (mentioned randomly on her neighborhood flyer) of making Charity run both private and public clinics “to make it financially independent,” speaks to a larger issue within healthcare. Namely, that health inequalities (which are extreme, more on this in a moment) has lines of color and privilege — and that this system works for those in the privileged group and they want to keep it that way.

A card system would facilitate that process a little faster. Mr. and Mrs. WealthyWhites present their card and are ushered to the private facility where they have no wait time, spend plenty of time with their doctors, and walk away with oodles of ultra-thorough tests and procedures. Mr. and Mrs. PoorPersonOfColor present their card — whoops! underinsured? or uninsured!? sorry, it’s this way for you — and off they go into the crowded masses to wait (a long time) for misdiagnosis, extended morbidity, and early mortality. If this all seems crass, I assure you, it’s not. I’m speaking right out of the science. A lot of it.

Take for example some very basic measures within black-white disparities. Here’s one. The ratio of black to white infant mortality was greater at the close of the 20th century than at any other point in the preceding 100 years — and that the last 50 years saw a 90% increase in that disparity (1.6 in 1950 to 2.5 in 2000). How about mortality from coronary heart disease, cancer, diabetes, and cirrhosis of the liver? All of these (black:white ratios of mortality) were larger in the late 1990s than in 1950*.

And yes, those diligent public health folk have run themselves ragged trying to find reasons to explain the widening gap in disparities. Focusing on infant mortality, one thing that is clear is that a key to reducing infant mortality disparity means reducing the similarly widening gap between whites and blacks regarding low birth weight and very low birth weight babies. In an effort to get at birth weight, public health folk have studied it from a number of vantages… Maybe it’s more preterm births! More multiple pregnancies! Whites have more access to abortions! Access to medical care! Personal habits! Genetics!… All of these theories are discussed, studied, and dissected widely in the literature. Yet:

“The etiology of black-white disparities in low birth weight is complex and is not explained entirely by demographic risk factors such as maternal age, education, or income (8). Factors that might contribute to the disparity include racial differences in maternal medical conditions, stress, lack of social support, bacterial vaginosis, previous preterm delivery, and maternal health experiences that might be unique to black women (9).”

In other words, we have no idea what causes these health disparities. But we do know (almost by process of elimination) that it isn’t anything that we can measure well. These days, best science is suggesting to us that those “other” things: stuff like “stress” and “health experiences… unique to black women” could be the culprit. Darn those difficult to quantify, endogenous little factors!

Personally, I see a “smart card” that can quickly streamline the haves from the have-nots to be a “unique experience” — one that might be “stressful”. It might also fit into a pattern of how things tend to sort out in a racially divisive environment. Like how they might fall out between public and private schools. Or hospitals. Or ophthalmologist offices.

But I digress. Actually, pregnant women can get health care in this country. It doesn’t make an impact on closing disparity, but at least it’s something. (I shudder to think of what it would look like if there was no WIC.) An even brighter note: as of last May, in Louisiana, women don’t even have to show documentation to get prenatal care. (I know, I couldn’t believe it passed, either! Hoorah!) But as of this morning, it’s a bummer for their kids.

But back to those disparities. That pesky infant mortality. So what are we doing to work on it? What cutting-edge research is happening to better understand and solve the problem? Well, earlier in the year, the American Journal of Public Health published a study on just that. Here’s what they found:

“Ninety-seven percent of grants were for developing new technologies, which could reduce child mortality by 22%. This reduction is one third of what could be achieved if existing technologies were fully utilized. There is a serious discrepancy between current research and the research needed to save children’s lives. In addition to increased research on the efficacy of treatment, there is an even greater need for increased research on delivery and use of technology.”

In other words, putting more layers of technology on to the very real and very great health challenges that face us does not solve any problems. (So, even if the aforementioned “smart card” is a completely altruistic method of making the life of a hospital benefits coordinator — or an over-indulged ophthalmologist who doesn’t want to mess with clients who can’t pay — easier, it’s a waste of money that will have no impact on health outcomes.) Further, we have got what we need at our finger tips — we just need to figure out how to get it used appropriately.

So, sorry, MM. I can’t give you my vote.

I’m stopping here. Coming soon: the universal health care rant.

—

*Check out the MMWR article for some of these stats. Also see David Williams’ Race, SES, and Health, Ann NY Acad Sci, 1993; 896, 173-188.