public health


You Hate Leaf Blowers, Your Neighbor Uses Them: How One Town Seeks Middle Ground

(GBaile/Wikimedia Commons)

(CBaile/Wikimedia Commons)

About five years ago, Jamie Banks noticed that the whine of gas-powered leaf blowers around her home in Lincoln, Massachusetts, had grown from an occasional burst of nearby noise to a frequent, high-decibel din that could last for hours, several days a week.

She would wake up to the engine roar, she says, step outside and observe landscape workers wielding four or five blowers, raising a 30-foot-high miasma of dust that commuters would skirt as they walked to the nearby train station in the town center.

“At my home it had become a 360-degrees surround-sound situation,” she said. “It was ubiquitous.” And it was all year round, Banks added, the machines used not just for leaves but to clear parking lots and driveways, gutters and planting beds. Even to blast snow off roofs.

A health care researcher with a Ph.D, Banks began looking into the health effects of the fine dust, exhaust pollution and noise caused by leaf blowers, and found causes for concern — including a clear recommendation against using gas-powered leaf blowers and lawn equipment from the American Lung Association.

In 2012, Banks teamed up with Robin Wilkerson, a Lincoln garden designer who worried not just about the noise and dust and carbon footprint of leaf blowers, but also about their impact on the land.

“People were scouring their land of valuable organic matter,” Willkerson said, and then often replacing it with dyed mulch from Louisiana. “It just seemed like lunacy.”

Something needed to be done, they both decided.

At this point in the story, which has played out in many towns and cities around the country, a big fight ensues. Residents who hate the blowers try to get the machines banned. Landscapers, landlords and homeowners who use the blowers fight back. The neighbor-vs.-neighbor battles often grow heated, as they have recently in the big Boston suburbs of Newton and Brookline.

And often, the attempts to regulate lose. Some California towns banned leaf blowers back when they were new in the 1990s, but blower use has been growing enormously, and relatively few towns have blocked them or successfully enforced limits.

In New England, where leaf-peeping season is now routinely followed by leaf-blowing season, no town has passed an outright ban, though a few have imposed restrictions.

First-World Problems

First-world problems, you might say. And you might be correct. Lincoln, a gorgeous New England hamlet of old stone walls along winding, wooded lanes, is one of the richest towns in the U.S., with median annual household incomes topping $100,000. The leaf blower issue naturally tends to arise in affluent suburbs where people can afford landscapers and increasingly seek a manicured look.

But it can surface just about anywhere there are trees and blowers, and it doesn’t seem trivial if it’s happening where you live or (try to) work.

No less a literary personage than James Fallows of The Atlantic, who has become very vocally active against leaf blowers, argues that the issue speaks to big concepts about collective versus private life. A trenchant New Yorker article on the mother of all leaf blower regulation fights in California found that it became “a referendum on what it means to be a neighbor.”

As Banks and Wilkerson learned more about the battles over bans around the country, they decided to pursue a more positive path in Lincoln.

They started in 2012 by forming a citizen group, Quiet Lincoln, to spread word about the issue. The next year, in 2013, they asked their fellow citizens at Lincoln’s Town Meeting to approve a study panel. And thus, the Lincoln Leaf Blower Study Committee was formed.

No landscaping companies joined, but the panel did include members from the Department of Public Works, which uses blowers, and the Rural Land Foundation — which owns a small collection of stores and offices in the town known as the “mall,” and employs landscapers to maintain it — along with residents.

The committee surveyed the town to get a sense of people’s feeling about leaf blowers, and found that 46 percent of respondents were bothered by the noise and 37 percent by the dust and air pollution.

“We recognized the importance of education if we were to get town support around this issue,” Banks said. “This is a problem that affects some individuals and not others, so it’s very hard to get broad-based support.” Continue reading

Exploring The Link Between Chronic Pain And Suicide

By Judy Foreman

This week’s grim report about rising suicide and overall death rates among white, middle-aged Americans contains a slim silver lining. Here it is:

The new analysis by two Princeton economists, Anne Case and Angus Deaton, suggests that chronic pain — and the opioids used to treat it — may be a key driver of the rising deaths. While the “noisy” opioid epidemic has garnered near-daily headlines across the country for several years now, the equally horrible but silent epidemic of chronic pain has not yet broken through into the nation’s consciousness. Maybe things are beginning to change.

Many people still don’t realize it, but 100 million American adults live with chronic pain, many of them with pain so bad it wrecks their work, their families, their mental health and their lives.

There are no hard data on how many people with chronic pain die by suicide every year. But there are inferences. The suicide rate among people with chronic pain is known to be roughly twice that for people without chronic pain.

(jennifer durban/Flickr)

(jennifer durban/Flickr)

Since there are 41,149 suicides every year in the U.S., according to the National Center for Health Statistics,  it’s possible that roughly half of these suicides are driven by pain. Not proven fact, but plausible hypothesis. This would suggest that perhaps up to 20,000 Americans a year with chronic pain kill themselves, which would be more than the government’s tally of 16,235 deaths from prescription opioids every year.  According to a CDC spokeswoman:

In 2013, there were 8,257 deaths that involved heroin and 16,235 deaths that involved prescription opioids. These categories are not mutually exclusive: if a decedent had both a prescription opioid as well as heroin listed on their death certificate, their death is counted in both the heroin as well as the prescription opioid death categories.

The truth, of course, is devilishly difficult to figure out with any certainty. Many people in severe, chronic pain have, and should have, opioids available. But unless they leave a suicide note it’s virtually impossible to tell if they overdose on purpose or accidentally. That’s in stark contrast to a pain patient who ends his or her life using a gun. That’s clearly a suicide, with or without a note.

In the course of researching my 2014 book on chronic pain, I heard many grisly stories. One Salt Lake City truck driver I interviewed would be dead today if his wife hadn’t walked in on him with a gun in his mouth. He had been in severe headache pain and after many visits to the ER, was repeatedly dismissed as a drug seeker, even without a medical workup. (Eventually, he was diagnosed with two brain aneurysms, bulging weak spots in a blood vessel). Continue reading

Beyond Medicine: The Road From Health Insurance To Health

By Katherine Gergen Barnett, M.D., and Lauren Taylor, MPH, M.Div

Now that as many as 6.4 million low- and middle-income Americans across 34 states have health insurance as a result of the Affordable Care Act, it’s worth asking this question: When does health insurance turn into actual health?

It’s a legitimate question because the impact of health insurance on health has been shown to be less impressive than we might wish. At least one study out of Massachusetts, for instance, has demonstrated reductions in mortality associated with insurance status, while other studies out of Oregon show only modest reductions in mental health disease burden. So how much health have we really gained nationwide from the ACA’s insurance expansion? It remains to be seen.

In the meantime, it may be time to turn our collective attention to a slightly different question: Where else in Americans’ lives might we find more substantive ways to improve health?

The Blue Cross Blue Shield of Massachusetts Foundation recently released a report which might help answer some of these questions. Researchers, led by Elizabeth H. Bradley, Ph.D., of the Yale School of Public Health, reviewed available literature on the health improvements and cost reductions associated with interventions beyond the scope of traditional medical care. The authors point to the strong evidence that increased investment in selected social services — housing support, nutritional assistance, case management for low-income families, children with asthma and seniors — as well as various models of partnership between health care and social services can offer substantial health benefits and reduce health care costs for targeted populations.

 In other words, the research demonstrates that when these interventions are targeted at high-cost, high-need patients, the results can make a huge difference in people’s lives, and also save the system money.

As a longtime primary care physician working in an urban hospital, my patients (often underserved families) confirm this empirical evidence. Here’s just one example:

The mother of a family has been coming to me for years. Her body and medical chart are riddled with multiple diagnoses: high blood pressure, chronic pain, anxiety, depression, high sugars and obesity, for which she takes numerous medications. Her life was chaotic — homeless with two young girls, a constant state of fighting in shelters, hyper vigilance for her girls’ safety and a state of depression that was only getting darker. Her girls also started getting their care through me and though they were more resilient in this state of constant flux and stress, their own lives were slowly falling apart in the long shadows of their mother’s mental illness. As a physician, it was hard to know where to start to get this family back to better health. As a mother myself and a public health advocate, I knew I had to start with the mother and her primary concerns.

And so in every visit we addressed her housing issues — filling out form after form, making calls and writing letters — alongside her other medical issues. Last year, she came in elated. She finally had secured housing. The next several visits were a flurry of pictures — new bedrooms and her smiling girls. But far beyond the pictures, there was a transformation. My patient started seeing a therapist again, taking her psychiatric medications, exercising and taking better care of her body. Her daughters also came to see me in the months that followed and it was if they were plants in the sun, finally growing back into their girlhoods. The oldest was just starting to dream about college. And though I am not naïve enough to think that their secure housing will make their health consistently good, it shifted the landscape entirely. Enough that they were able to start taking care of their lives and each other.

Continue reading


Vomiting Up Brunch? Your Angry Tweet May Save Others From Food Poisoning

When you're in this position, you likely don't want to call health officials and report food poisoning. (Irina Souiki/Flickr)

When you’re in this position, you likely don’t want to call health officials and report food poisoning. (Irina Souiki/Flickr)

By Chelsea Rice

One of the last warm Saturdays in September, my boyfriend and I planned to celebrate his birthday at a Cambridge restaurant that friends had praised as their favorite brunch spot. The food tasted great: We shared a plate of oysters to start, and he enjoyed eggs Benedict for his main course while I opted for a breakfast take on the classic BLT sandwich, mainly because it was served on a croissant, a buttery weakness of mine.

But upon arrival back home…our brunch backfired.

I ran out to pick up the birthday cake. When I returned, I found the birthday boy almost paralyzed by stomach pain, feverish and violently ill. While he spent the rest of his birthday in a migratory pattern between the bathroom and bedroom, I waited to see if I would get sick and searched online to learn how to report the food poisoning.

Turns out that here in the Boston environs, residents call a special number at the Boston Public Health Commission. It connects with a public health nurse who asks questions about symptoms, what you ate over the past few days, and where you ate it. On that memorable day, I shouted this option into the bathroom at my sick partner, but he was so nauseous he could barely talk to me. Reliving what he had eaten in the past 48 hours was the last thing he wanted to do.

As a health journalist, I know it’s important to report food poisoning — one in six Americans gets it every year. But as a consumer, filing a public health report can be an intimidating and impersonal process for a very personal — and vulnerable — experience.

We told all our friends and canceled the rest of the festivities, vowing never to return to the scene of the crime, but I still wondered: Were we selfish? Could we have helped others with our story? Have other diners had a similar experience at that restaurant?

According to the restaurant’s worst reviews on Yelp, the list is long. (I’m not naming it to give it the benefit of the doubt — maybe it was having an off day? — but the picture is grim.) The worst reviews include bugs in the plates, under-cooked proteins and foreign objects that broke a tooth. There are even a few that reported diners getting sick after eating there. And those are just the brave few who posted. I was alarmed that this restaurant still had a line and a reservations list with complaints like that. There’s no way a health department could ignore claims like these, I thought, if they were written up in an official report.

Little did I know, there’s a new bridge between social media and public health that is finally crossing that divide.

In 2011, a research group out of Boston Children’s Hospital published a study using extracted, keyword-related Yelp reviews, showing that the ingredients people described in their reviews about food-borne illness matched up with relevant ingredients that the CDC reported were involved in food-borne outbreaks for that time.

An excerpt from HealthMap's tool to track tweets related to foodborne illness (Courtesy of HealthMap)

An excerpt from HealthMap’s tool to track tweets related to foodborne illness (Courtesy of HealthMap)

Now, that team is taking their work to help cities across the country address and more accurately monitor food-borne illness with HealthMap Foodborne Illness, part of a larger social media disease-tracking initiative based at Boston Children’s.

“When someone talks about diarrhea on Twitter they are really looking for people to care, and that’s really what it’s all about.”

– Dr. John Brownstein

Dr. Elaine Nsoesie and Dr. John Brownstein, who co-founded the project, are working with New York City, Chicago, St. Louis and other major cities to customize their foodborne disease tracking tool for each city’s needs.

“It’s hard to make people come to you,” said Brownstein. “People aren’t engaged necessarily in public health.” But if you can tap in to their online voices, he said, “you can actually get a huge amount of information that would not come from another vehicle.”

In Chicago, the city’s public health department monitors Twitter in a social media tracking initiative that HealthMap customized for them called FoodborneChicago. The tool filters tweets that are geocoded to a specified area through a system that recognizes key words related to food poisoning. Think “sick,” “food,” “vomiting,” “diarrhea,” “poisoning” and various combinations like “restaurant made me sick” or “vomiting after that lunch.”

A public health official can monitor the filtered tweets live, and sort them into “relevant” (ambulance icon), “questionable” (question mark) and “irrelevant” (trash can), as in the image above. Continue reading

WHO Says Processed Meat Causes Cancer, So Should We Stop Eating It Altogether?

Is this the end of bacon, hot dogs and corned beef on rye? (Didriks/Flickr)

Is this the end of bacon, hot dogs and corned beef on rye? (Didriks/Flickr)

Is this the end of bacon, hot dogs and corned beef on rye?

How should consumers react to news from the World Health Organization that these and other processed meats can cause cancer, and that red meat, including beef, pork, veal and lamb, are “probably carcinogenic to humans” too? Should we abstain completely now that the WHO’s International Agency for Research on Cancer (IARC) put processed meat in the same cancer-risk category as tobacco and asbestos?

Here’s the bottom line risk, from the IARC news release: “The experts concluded that each 50 gram portion of processed meat eaten daily increases the risk of colorectal cancer by 18%.”

Processed meats have previously been inked to a range of illnesses, from heart disease to diabetes and cancer. But even with this big news from the WHO, many nutrition and public health experts said that reducing consumption of such meats is key, not eliminating them altogether.

Frank Hu, a professor of nutrition and epidemiology at the Harvard School of Public Health, says there’s no need for everyone to suddenly become vegetarian or vegan. But, he said in an interview, he hopes the WHO announcement will spark real dietary change.

He made three points:

1. The WHO Announcement Is Big 

“I think the WHO announcement is very significant from a public health point of view because processed red meats have already been linked to type 2 diabetes, cardiovascular disease and other chronic disease, and this provides convincing evidence that consuming processed meats, like bacon, sausage, hot dogs, is linked to an increased risk of colorectal cancer in particular. Cutting back on red meat and processed meat reduces risk of diabetes and cardiovascular disease, but also reduces the risk of cancer. Improving your diet can actually be beneficial for reducing your cancer risk.”

2. You Don’t Need To Quit

“I’m not a vegetarian. This doesn’t mean everyone should become a vegetarian or vegan. Processed red meat should be consumed as little as possible — once or twice a week should not be a major problem. For unprocessed red meat, consumption should be moderate, but that’s hard to quantify; maybe every other day. We’re not talking about banning hot dogs, sausages or bacon, but we should change our dietary pattern from a meat-based diet to a more plant-based diet. That’s not really a new message. This message will hopefully raise more awareness. Hopefully it will motivate people to change their eating patterns.”

3. Change The Food Environment

“Certainly the risk accumulates as the amount increases, and if you can stay away from it completely that would be good. But occasional consumption of processed red meat isn’t going to create significant health problems … There are so many chemicals and ingredients in processed red meats — preservatives, nitrates, high sodium, saturated fats — it’s difficult to pinpoint exactly which chemicals cause cancer. From a public health point of view, it’s not necessary to know which chemicals are precisely responsible for the increased risk. Here the message is similar to tobacco, even though we may not know precisely which chemical cause the cancer, we can take actions to reduce the cancer risk by cutting back … It’s also important for the government to improve the food environment. There’s so much junk food in the food system.” Continue reading

Report: Dietary Supplements Send Thousands To The ER Annually

Dietary supplements can make you sick.

That’s the quick takeaway from a new report, published in The New England Journal of Medicine, that might make you think twice about the supplements.

Researchers at the Centers for Disease Control and Prevention conclude that about 23,000 emergency department visits each year in the United States can be attributed to “adverse events” due to dietary supplements. “Such visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults,” the study says.

Researchers analyzed data on dietary supplement-related emergency department visits over a 10-year period, from Jan. 1, 2004, through Dec. 31, 2013, from 63 hospitals. Of the more than 23,000 ER visits, researchers report that 2,154 patients were then hospitalized for further treatment. (The new analysis did not include patients who may have died en route to the hospital.)

The backdrop to all this is that supplement sales are dramatically on the rise:

The estimated number of supplement products increased from 4,000 in
1994 to more than 55,000 in 2012 (the most recent year for which data are publicly available), and approximately half of all adults in the United States report having used at least one dietary supplement in the past month. In 2007, out-of-pocket expenditures for herbal or complementary nutritional products reached $14.8 billion, one third of the out-of-pocket expenditures for prescription drugs.

I asked the study’s lead author, Dr. Andrew Geller with the CDC, what consumers should make of the study. Here’s what he said, via email:

People may not realize that dietary supplements can cause any adverse effects, but each year thousands of people are treated in emergency departments for symptoms attributed to dietary supplements.

Young adults taking products to lose weight or increase energy should keep in mind that some of these products can have effects on their heart, and they should not take these products in excess. If you have a heart condition, talk to your doctor before starting a weight loss or energy supplement.

Older adults should be mindful of possible choking or other swallowing problems from taking supplements. They should avoid taking several pills at once, avoid extra large pills or capsules, and swallow supplements with plenty of water or other fluid. Tell your physician you are having difficulty swallowing pills and ask him/her or your pharmacist for other options or if you can cut the supplement in half.

Patients should always tell their doctors if they are taking dietary supplements, and which ones.

All medicines and dietary supplements should be stored up, away and out of sight of young children.

Pieter Cohen — an internist at Cambridge Health Alliance and asistant professor at Harvard Medical School who studies dietary supplements and has been critical of the federal law governing them — said the new study may trigger some long-needed changes.

“This study is the most important research published since the passage of DSHEA [the Dietary Supplement Health and Education Act of 1994] and sends a clear message: Not only does the regulatory framework make no sense, it’s posing imminent threats to the public’s health,” Cohen says. “The publication of this new CDC study will hopefully be a watershed in regulating supplements in the U.S.”

He adds that the current regulations “are based on the premise that all supplement ingredients are safe.” But, he says, “with the new CDC study we learn that these products are anything but safe. In fact, the CDC found that supplements lead to tens of thousands of emergency room visits and thousands of hospitalizations each year.” Continue reading

How I Was Seduced By Cigarettes, And What Set Me Free

By David C. Holzman
Guest Contributor

More than half a century has passed since Luther Terry released the landmark U.S. surgeon general’s report on smoking and health.

Since then, smoking in the U.S. has declined dramatically. Nonetheless, roughly 50 million Americans still smoke.

Tobacco’s ‘Fantastic Voyage’

If anyone should have been immune to taking up smoking, it was me.

As a prepubescent child, I absorbed the lessons about the importance of living healthily that my parents instilled. At age 10, I got them to quit smoking after the first surgeon general report came out — although I’m sure they would have done it on their own, if not quite as quickly. Early on in my writing career, I wrote a “fantastic voyage” article about all the carcinogens in tobacco, where they went in the body, and what nefarious things they did when they got there. Little did I ever suspect I would become briefly but definitely addicted.

The germ of the habit occurred when I was medical writer for Insight Magazine. Dennis, the head copy editor, smoked like a chimney.

The author, smoking at his sister's wedding in June 1991 (Photo illustration courtesy of the author)

The author, smoking at his sister’s wedding in June 1991 (Photo illustration courtesy of the author)

“How’s that cigarette?” I’d tease him every morning when I arrived at work. “Not long enough!” he’d say. Or, “Not as good as the first one.” It became our way of bonding.

One day he said, “You want to try it?”

Curious, I took a puff. It gave a powerful kick, like a turbocharger. But it was not something I felt I needed.

But one Sunday, a few years later, I needed it. I’d gone to the car races at Summit Point, West Virginia, with my friend, Don, a former racer, and his wife Eva, who smoked. I’d slept little the week before, and D.C., where I lived at the time, was being its usual oppressively hot, humid summer self. By mid-afternoon I’d gotten so sleepy that I was getting ready to curl up in the back of my car and snooze. Then I remembered Dennis’ cigarette. I asked Eva if I could finish one of hers. A couple of puffs, and I was wide awake, once again enjoying being with my friends.

My FDA Cigarette

Around this time, I was working for daily biotech news publication, regularly covering meetings of the Advisory Committee to the head of the Food and Drug Administration. These meetings were boring. They took place in a windowless room of the incredibly ugly, mid-’50s institutional style Parklawn building. As soon as they started, off went the lights, and on went the Powerpoints.

At that point, no matter how much coffee I’d had, my head would start to sag.

So the next time I had to cover one of these meetings, I bummed a cigarette. I took several puffs, and then tossed it. This time, I remained painlessly alert after the lights went out.

I took to bumming cigarettes while I waited for the FDA meetings to start, and ultimately I bought my own pack. Continue reading

Prevention Expert: What I Wish You Knew About Not Falling Down

(Courtesy of the CDC)

(Courtesy of the CDC)

By Dr. Audrey M. Provenzano
Guest contributor

One word comes to mind when I think about Mr. H: grit.

I met him while he was in the hospital with pneumonia, the latest in a long string of hospitalizations after he broke his hip in a fall. I would see him in the halls with the physical therapist, gripping his walker, utterly absorbed in the work of lifting each foot and placing it back down.

Every morning on rounds, Mr. H would joke with us: “You’re going to throw me outta this place today, right, doc? Don’t pass go, just go home!” But beneath his humor lurked true sorrow, anger and frustration over his loss of independence. Before his fall, Mr. H had never stayed overnight in the hospital; he took only a few medicines for high blood pressure, and lived alone with his cat — a simple life he lost in a second, and yearned each day to get back.

Many of us harbor secret fears about growing older, and what many of us fear most is the loss of independence, a tragic and terrifying possibility. I’d suggest a very specific focus for those fears: falls. The most common but least talked-about reason that older adults like Mr. H lose their independence is falling down.

Here is what I most wish everyone knew about falls: They are are common, they can be devastating and, most importantly, falls are preventable.

Falls are common

Incredibly common. Thirty percent of adults over 65 fall each year. Because falls happen all the time, we don’t think about how dangerous they are. Unfortunately, one in five falls results in serious injuries, including broken bones.

Falls can be devastating

Mr. H’s story is the story of hundreds of thousands of older adults. A fall may lead to surgery, and sometimes that leads to complications, like pneumonia. Some older adults in this situation regain enough function to go back home; sadly, many do not, and one in three is still living in a nursing home a year later.

Even worse, these types of injuries often lead to declining health overall, and 20 percent of older adults who break a hip die within one year from the medical complications that frequently attend such devastating injuries.

Falls can be prevented

How? Six key recommendations, backed by the CDC, some obvious, some less so: Continue reading

CDC: One-Third Of Children With ADHD Diagnosed With The Disorder Before Age 6

(Vivian Chen/Flickr)

(Vivian Chen/Flickr)

One-third of children diagnosed with ADHD were diagnosed young — before the age of 6 — according to a new national survey from the U.S. Centers for Disease Control and Prevention.

Earlier, the CDC found that based on parental reports, 1 in 10 school-aged children, or 6.4 million kids in the U.S., have received a diagnosis of ADHD, a condition marked by symptoms including difficulty staying focused and paying attention, out of control behavior and over-activity or impulsivity.

The percentage of children diagnosed with ADHD has increased steadily since the late 1990s and jumped 42 percent from 2003-2004 to 2011-2012, the CDC says. Last year, concerns flared when a report found that thousands of toddlers are being medicated for ADHD outside of established pediatric practice guidelines.

In the current analysis, also based on parental reporting, and using data drawn from the 2014 National Survey of the Diagnosis and Treatment of Attention-Deficit/Hyperactivity Disorder and Tourette Syndrome, the CDC also found:

•The median age at which children with ADHD were first diagnosed with the disorder was 7 years old

•The majority of children (53.1%) were first diagnosed by a primary care physician

•Children diagnosed before age 6 were more likely to have been diagnosed by a psychiatrist

•Children diagnosed at age 6 or older were more likely to have been diagnosed by a psychologist

•Among children diagnosed with ADHD, the initial concern about a child’s behavior was most commonly expressed by a family member (64.7%)

•Someone from school or daycare first expressed concern for about one-third of children later diagnosed with ADHD (30.1%)

•For approximately one out of five children (18.1%), only family members provided information to the child’s doctor during the ADHD assessment

What are we — parents, educators, doctors — to make of all this? In particular, what does it mean that so many very young kids are being diagnosed with an attention disorder? (Has anyone ever encountered a 4- or 5-year-old child who is not hyperactive, impulsive and inattentive??)

I asked two doctors — a pediatrician and a psychiatrist — for their impressions of the CDC report. Both agreed that we seem to have two problems when it comes to ADHD: over-diagnosing and under-diagnosing. Here, lightly edited, are their responses.

First, the pediatrician:

James M. Perrin, MD, is a professor of pediatrics at Harvard Medical School and associate chair of MassGeneral Hospital for Children. Dr. Perrin is also the immediate past president of the American Academy of Pediatrics and chaired the 1990s committee that wrote the first practice guidelines for ADHD (and he was on the committee for the 2011 revision).

RZ: How difficult is it to diagnose ADHD in children under 6 years old?

JP: In the pediatric community, we have worked over last 15 years to train general pediatricians to make diagnoses of ADHD reliably and follow very clear, specific guidelines on how to do so. In 2011, the AAP revised its practice guidelines for ADHD and included the opportunity to diagnose children ages 4 and 5 years old.

At the same time we recognize it’s very hard to do that well in that age group…because a lot of children are inattentive at 4 — you don’t expect them to work hard and read a Hardy boys book for an hour and half. Five is often impulsive, active, so it’s not unusual to have symptoms that children with ADHD would also have at age 4, 5. So, it’s not easy.

We did say [in the guidelines] pretty clearly that you shouldn’t make the diagnoses without significant impairment of normal behavior. What we mean by that is a child whose symptoms impair her ability to play with other children, or whose behavior is so out of control that it’s dangerous, for instance she runs out in front of cars, or has many accidents, that’s when the symptoms become impairing. Continue reading

Personalized Medicine Distracts From Public Health, 2 Scholars Argue

Personalized medicine is all the rage. President Obama mentioned it in his State of The Union address this year and launched a multimillion-dollar initiative to push a personalized medicine agenda forward. The head of the National Institutes of Health has made it a priority. And really, what’s not to like about the general concept of medicine that’s personalized (it’s also called “precision medicine”) —  an approach that analyzes an individual’s genetics to make medical decisions about diagnosing and treating disease.

Well, two public health scholars argue in the New England Journal of Medicine that the current high-profile fawning over personalized medicine may be a “mistake” that diverts resources away from other public health efforts that could benefit far more people.

Ronald Bayer, Ph.D., a professor at Columbia University’s Mailman School of Public Health, and Dr. Sandro Galea, dean of the Boston University School of Public Health, write in the journal that the great enthusiasm around personalized medicine “derives from the assumption that precision medicine will contribute to clinical practice and thereby advance the health of the public.” But, they note, that may not be the case:

We suggest, however, that this enthusiasm is premature. “What is needed now” is quite different if one views the world from the perspective of the broad pattern of morbidity and mortality, if one is concerned about why the United States has sunk to the bottom of the list of comparable countries in terms of disease experience and life expectancy, or if one is troubled by the steep social gradient that characterizes who becomes sick and who dies. The burgeoning precision-medicine agenda is largely silent on these issues, focusing instead on detecting and curing disease at the individual level…

Without minimizing the possible gains to clinical care from greater realization of precision medicine’s promise, we worry that an unstinting focus on precision medicine by trusted spokespeople for health is a mistake — and a distraction from the goal of producing a healthier population.

I spoke with Dr. Galea about why he and Bayer targeted personalized medicine, in particular. Here, lightly edited, is what he said:

Personalized medicine has become this rallying cry around resource allocation in the health sciences. The president mentioned in the State of the Union. There is a White House precision medicine initiative, and it has dominated much of the NIH agenda…so it seems important to address it directly…

Nobody is arguing that precision medicine does’t have potential, but the number of people who you could point to who have actually benefited from it are very small. And so we are investing in potential — which is fine — but it’s a matter of calibrating our investment. Instead of investing in a untried, untested approach, we should be investing in things that we know make a difference…

We know that macroeconomic taxation on unhealthy substances, on alcohol, for example, can save thousands of lives, early childhood education can make an enormous difference, efforts to increase and improve vaccination rates, efforts to mitigate cycles of violence, one could go on and on….these could improve the lives of hundreds and thousands of people…

Our commentary was a call for a recalibration…I think there’s a feeling in the scientific community that the precision medicine agenda is becoming the overwhelming direction in which we are headed and that we would benefit from discussion and debate and a more careful calibration of the questions we ask and where we invest our resources.

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