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Mr Epidemiology

No, I'm not a skin doctor

Income inequality and determinants of health in the US

A series published in The Lancet recently investigated the effect of income inequality on the health of Americans. While incomes for those in the top have grown, extreme poverty has also grown in the US. In fact, more than 1.6 million households in the US survive on less than $2 per day; a number double that of the 1990s. The cycle is not likely to be broken either, barring major social change. Differences in aspects ranging from zoning laws, access and quality of education, and inheritance laws continue these inequalities through generations, making it more difficult to rise out of poverty.

Photo by Thomas Hawk (click to see more)

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A coffee, a donut, and a defibrillator

By Leonard Bentley from Iden, East Sussex, UK - Iden, CC BY-SA 2.0
By Leonard Bentley from Iden, East Sussex, UK – Iden, CC BY-SA 2.0

When someone has a heart attack, every minute counts. The American Heart Institute guidelines say that for every minute, the chances of a victim surviving decrease by 7 to 10 percent. To help save lives, Automated External Defibrillators (AEDs) have become more and more ubiquitous, and now can be found in many different locations, including coffee shops, banks, malls, and sports complexes. When placing these devices though, a few issues need to be considered, including hours of operation, proximity of other AEDs, and being in high-traffic areas. To help inform these decisions, researchers from the University of Toronto recently conducted a very interesting study.

Using data on cardiac arrests that occurred outside of hospitals in Toronto from January 2007 to December 2015, they were able to place them on a map. They then identified businesses and municipal offices with at least 20 locations from sources such as the Yellow Pages, along with their hours of operation and geographic coordinates. For each site, they mapped the number of cardiac arrests that occurred within 100 m to identify which locations would be able to save the most lives. As a final test of these locations, they then looked at how the locations fared over time; determining if the locations relatively stable or if the AEDs have to be moved every year to continue to be effective.

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A better name for “non-communicable diseases”

I came across an interesting read last week in The Lancet. In it, Drs Allen and Feigl make an interesting case for changing how we refer to non-communicable diseases

The global health community does not spend much time on branding, which perhaps explains why existing classifications for the three largest groups of diseases are both outdated and counterproductive. The first Global Burden of Disease study described infectious diseases, non-communicable diseases (NCDs), and injuries. This grouping reflected a predominantly infectious disease burden in low-income and middle-income countries, which has since tilted towards NCDs. A name that is a longwinded non-definition, and that only tells us what this group of diseases is not, is not befitting of a group of diseases that now constitute the world’s largest killer.
(emphasis mine)

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2017: What can we expect?

Following up from the end of last year, I thought it would be fun to predict what I think the next 12 months will have in store for us. So lets get to it!

1. Repeal of the Affordable Care Act

President Trump has already made it clear that this is one of his first priorities when he assumes office. The groundwork was already laid with the combination of the Senate passing a budget measure that was supported by Congress, and this week Trump issued an executive order to start rolling back the ACA. Now, the ACA is not without fault as we’ve discussed before; premiums have increased for many users, and the lack of true, universal coverage means many who don’t need coverage would rather pay the penalty than enrol. But repealing it without a replacement could be a disaster for many Americans. The Washington Post estimates that the repeal will kill more than 43,000 annually (based on this study in the NEJM). The impacts will be felt beyond the healthcare system though, with evidence from California suggesting that such a move could affect everyone involved with the health industry ranging from hospitals, food, and transportation services that all work together to provide patient care. Estimates from this study suggest up to 209,000 people would lose their jobs, and it would cost California over $20 billion dollars. It remains to be seen what replacement is offered, but the transition between the two is one that needs to navigated delicately.

 

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2016: A Year in Review

Thanks to all our old and new Public Health Perspectives readers for your support over the year. Your tweets, Facebook comments, and feedback are all really appreciated. Lets wrap up the year by reviewing our most popular stories of 2016.

April 2016: Perhaps there is a drug that can prolong your life. It’s called money

What makes New York different to other US cities? | Photo credit Kah-Wai Lin
What makes New York different to other US cities? | Photo credit Kah-Wai Lin

“A wise man once said that “mo’ money, mo’ problems” (Wallace, 1997). However, despite increases in supposed problems, one of the major benefits is increased life expectancy.

New research published in JAMA last week examined how big a difference earning more money makes in life expectancy, as well as how this changes by geographic location across the United States. Researchers collected tax records from 1.4 billion individuals from 1999 to 2014 aged 40 to 76. Of these, around 4 million men died, compared to 2.7 million women (mortality rates of 596.3 and 375.1 per 100 000 respectively). They examined these data to look at what predicted life expectancy at age 40, after adjusting for race and ethnicity.”

 

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The only way to save Obamacare is to expand it

The Affordable Care Act was a landmark piece of legislation for the United States. While most other G-20 countries already have some form of universal healthcare (either through a single payer system, or mandatory insurance coverage), the US was one of the few countries that did not have one. Arguably, however, it didn’t go far enough, and therein lies its biggest problem.

One of the key provisions in Obamacare was that insurers could not deny coverage based on pre-existing conditions. This was a hugely important for those with serious or chronic illnesses, who would normally be denied coverage. For example, diabetes can cost someone approximately $7900 a year in direct medical expenses, which is a hefty sum if you don’t have insurance coverage. Obamacare mandating that these individuals, and others with similar conditions, have to be able to purchase coverage, is an excellent step forward. However, the business of insurance relies on those who enrol but do not require services subsidising those who enrol and do. In terms of healthcare, this would be low risk people paying and not using services, ensuring high-risk individuals are able to access services. As you can imagine, there is very little incentive for low risk individuals to enrol; a phenomena known as “adverse selection.”

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Basic Income: From an idea to reality

Our current way of dealing with poverty is inefficient at best, with mountains of forms, paperwork, weighed down by bureaucracy and procedures. At worst, it’s stigmatising and judgemental, keeping people in poverty rather than giving them opportunities to break free and elevate themselves out of poverty. One possible solution is providing individuals with a Basic Income (click link for my previous post on the subject).

A selling point for Basic Income is that it can save the government money. By streamlining select government services into one agency, it can reduce inefficiency. In fact, this is something that people on both sides of the political spectrum can agree on – both those who want small government and those who want the government to support our most vulnerable citizens. One example is in Ontario, where a recently published report titled “Finding a Better Way: A Basic Income Pilot Project for Ontario” by Hugh Segal reported that a basic income guarantee would replace Ontario Works and the Ontario Disability Support Program, giving everyone an income of $1320 a month, with an extra $500 for those with a disability. This would effectively replace those two programs with one larger, more comprehensive program that doesn’t require the same intensive oversight and monitoring.

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Which diseases do we get to “fight”?

About two weeks ago, the Hospital for Sick Children, also known as SickKids, launched their new ad campaign. For those who aren’t from Canada, SickKids is based in Toronto, Ontario, is the second largest children’s hospital in the world, and does some truly amazing and inspiring work. I highly recommend watching the ad, as the messaging and production quality is absolutely amazing. The imagery and symbolism is strong, and shows these children as fighters who will vanquish their foes. It shares more in common in terms of tone and imagery with NBA and NFL commercials than typical hospital advertisements.

I have mixed feelings on this ad campaign. On the one hand, it is meant to provide a strong, motivational message to children undergoing treatment, and to help raise funds for the SickKids Foundation. In this, it is wildly successful, with an ad that has been viewed almost half a million times (as of this writing), and one that has sparked lots of discussion. However, while the ad is motivational and empowering, it is not without fault.

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How can one person completely change the results of a survey?

In public health, we rely heavily on samples, as measuring everyone you are interested is often impractical. However, this requires a lot of thought and development in order to avoid unintentionally biasing your sample, as was the case for the USC Dornslife/LA Times Daybreak poll.

Last week, a story came out about how one 19-year old black man in Illinois was single-handedly changing the standings of the US Presidential election. This was based on the results from the USC Dornsife/Los Angeles Times Daybreak, a survey of voter attitudes on “a wide range of political, policy, social and cultural issues.” In this survey, Donald Trump has generally held the lead, until last week, when Hillary Clinton came out in front. Interestingly, this is markedly different than most other national polls, that have shown Clinton is generally ahead, or a much closer contest than that poll would have you believe. So what happened?

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