Taxing Our Way to Health

Philadelphia has taxed sugary beverages for just over a year, but regulations and taxes like this are popping up all over the world.

In Chile, policy makers have won one of the biggest battles against powerful sugar, junk food, and soda lobbies. Corporations are prohibited from using cartoon characters in advertising, cannot play commercials during children’s programming, and schools have strict guidelines about what kinds of food can be sold on campus and during the school day. They also have a high tax on soda and will be enacting stricter guidelines for advertising in the next two years.

Cereal boxes scrubbed of their cartoon mascots, from

From the NYT article:

Until the late 1980s, malnutrition was widespread among poor Chileans, especially children. Today, three-quarters of adults are overweight or obese, according to the country’s health ministry. Officials have been particularly alarmed by childhood obesity rates that are among the world’s highest, with over half of 6-year-old children overweight or obese.

In 2016, the medical costs of obesity reached $800 million, or 2.4 percent of all health care spending, a figure that analysts say will reach nearly 4 percent in 2030.

Such sobering statistics helped rally a coalition of elected officials, scientists and public health advocates who overcame fierce opposition from food companies and their allies in government.

“It was a hard-fought guerrilla war,” said Senator Guido Girardi, vice president of the Chilean senate and a doctor who first proposed the regulations in 2007. “People have a right to know what these food companies are putting in this trash, and with this legislation, I think Chile has made a huge contribution to humanity.”

Other countries, are of course, facing similar struggles. I know soda taxes are unpopular and controversial (I work right by City Hall in Philadelphia and was subject to blaring truck horns of soda distributers protesting the soda tax before it was passed) but I think they’re a really interesting and important tool in the fight for better nutrition and fair advertising. That said, I think there are lots of legitimate reasons why people feel icky about soda taxes! While I’m generally in favor of them, it does feel not great that the tax burden of these increase falls disproportionately with low-income shoppers while there aren’t significant efforts to make healthy food more affordable and accessible.

Other articles of interest:

How Big Business Got Brazil Hooked on Junk Food – 9.16.17 from the New York Times

Congress Could Cut Soda and Candy from SNAP, but Big Sugar is Pushing Back – 8.28.17 from Civil Eats

Links Roundup: Racial Disparities in Maternal Mortality

Higher rates of maternal death among Black women in the US have been evident in research for a long time but have lately gotten a lot more mainstream coverage. The increase in coverage is important to raising awareness and implementing changes in health care that would improve outcomes, but it has unfortunately come out of tragic deaths and near misses among new mothers, including Erica Garner and Shalon Irving.

 Serena Williams’ Birthing Experience Highlights The Danger Of Being Black And Postpartum (1.10.18 via Essence) Serena Williams, one of the greatest athletes of all time, experienced a near-fatal blood clot shortly after giving birth. Her own knowledge and self-advocacy helped clue medical professionals in to save her life.

Black mothers are dying: the toll of racism on maternal health (1.11.18 via STAT) This is an op-ed, so it doesn’t go quite as depth as some of the other articles I’m linking, but I think it’s a good one because it gives an overview of many of the factors that contribute to the racial disparity in maternal deaths, from preventative care and the policies that dictate accessibility, to institutional racism in medical professions.

Too many black women like Erica Garner are dying in America’s maternal mortality crisis (1.10.18 via Vox) Activist Erica Garner died within months of giving birth. Her death, particularly in light of her anti-racist activism, highlights the relationship between experience of racism and poor health outcomes for women of color. Vox writes:

Research has shown that a number of factors, including poor access to pre- and postnatal care, chronic stress, and the effects of racism, and inadequate medical treatment in the years preceding childbirth are all likely to play a role in a black woman’s likelihood to suffer life-threatening complications in the months that come before and after childbirth.

These issues might appear to suggest that the disparity between black women and white women dying from pregnancy-related causes is due to economic differences, but research has found that black women in higher economic brackets are still more likely than white women to die from pregnancy- and childbirth-related problems.

How Hospitals are Failing Black Mothers (12.27.17 via ProPublica) This is a really fascinating analysis by ProPublica (an organization that does really fascinating, in-depth reporting, support them!) into the differences in outcomes of maternal hemorrhage at hospitals in New York, Florida and Illinois. They found “that women who hemorrhage at disproportionately black-serving hospitals are far more likely to wind up with severe complications, from hysterectomies, which are more directly related to hemorrhage, to pulmonary embolisms, which can be indirectly related. When we looked at data for only the most healthy women, and for white women at black-serving hospitals, the pattern persisted.”

Nothing Protects Black Women from Dying in Pregnancy and Childbirth (12.7.17 via ProPublica and NPR) This is one you should sit down for and grab a box of tissues. Shalon Irving, a 36 year old CDC epidemiologist studying structural inequality and its relationship with poor health outcomes, died weeks after giving birth in 2017. There’s no pull quote I can find that really captures it, you really should just read the whole thing.


Get a Flu Shot!

It seems like everywhere I go right now, people are talking about the flu. There are definitely years where it seems like it takes out more people than others, but it does actually seem to be pretty bad this year. Regarding flu deaths this year, the CDC says:

The proportion of deaths attributed to pneumonia and influenza (P&I) was 6.7% for the week ending December 16, 2017 (week 50). This percentage is below the epidemic threshold of 6.9% for week 50 in the National Center for Health Statistics (NCHS) Mortality Surveillance System.

A 0.2 difference between the actual proportion of deaths and the epidemic threshold seems pretty small.

Even if you never get the flu and feel like the 15 minutes of hanging around at Walgreens is a waste of time, your immunocompromised friends, family, coworkers, and public transportation sharers will appreciate your having a shot.

Evidence is a Downer – But We Need It

In a season 6 episode of Parks and Recreation, City Councilwoman Leslie Knope decides to champion adding fluoride to the drinking water to prevent endemic cavities. Leslie, in her usual way, provides ample evidence in large binders supporting her position and expects everyone to join her side. However, her rival on City Council, a corrupt dentist, starts sowing uncertainty in the fluoride plan. He goes on a local news show and calls it a dangerous chemical, and when that doesn’t work to sway opinion, recruits the local candy company, Sweetums, to take over the city water system and replace the water supply with basically… gatorade.

What’s Leslie to do? Arguing against the sugary tap water is nearly futile because no one wants to listen to the evidence-based science she has supporting fluoride-treated water. In the end, Leslie reads the ingredients of the sugar-water to the town in a monotone, while her co-worker, Tom Haverford, introduces a re-branded fluoride as T-Dazzle, “which makes your teeth stronger and … starts a party in your mouth.” Constituents swayed to the newly-sexy fluoride and against the newly-boring sugar-water, Leslie wins.

So what does this have to do with public health?

Well, evidence is not so sexy in the real-world, either. Often the people who are tasked with creating laws about health (politicians) are not experts on health and ill-equipped to understand research about best practices in health policy.

A study on barriers and facilitators to use of evidence-backed research for policymakers found that many policymakers, particularly state politicians who are part-time, have little time and few resources to actual research issues that they’re making laws about. On top of that, many were unable to critically analyze research and tell what sources were reliable or not. One particular quote that hurt me to read was:

One official observed that in assessing the effectiveness of a new medical procedure, “I just did exactly what…everyone…is hoping I’m not. I talked to my brother-in-law and I Googled it” (Jewell & Bero, 2008, p. 184). (Emphasis mine.)

This is really bad for the rest of us – who have to live with hasty and ill-informed decisions made by politicians! In health sciences, evidence-based medicine is when specific decisions about the best available evidence are made to influence decisions for patients. Research is being done all the time to find out what the best types of therapy are for certain populations, or what screenings should be done for certain types of cancer, or what helps people stick to a diet or exercise plan. This information is useful, but can sit on a shelf unless medical professionals adopt it and communicate it to their patients, and in the legal realm, if policymakers don’t care to understand the latest and best available information, they’re not able to make informed decisions on what kind of legislation is going to bring the most benefit.

Making evidence easy to understand and accessible is important. We probably don’t have to go to T-Dazzle lengths to communicate benefit, but taking into consideration confirmation bias and general antipathy toward evidence and preference toward the familiar is important for making your case. As most people who have had arguments with a political opposite have experienced, throwing facts at someone usually does little to change their mind. We need evidence, but we need to push for better ways to communicate it so it can reach the people who need to hear it.

Pop Public Health: “The Pill”

Country legend Loretta Lynn married at 15 and had 4 children before age 20. (And a few years later had twins!) Her musical success in the 1950s and 60s was a triumph for women, who had few country icons. Many of Lynn’s most successful songs discussed her family life, motherhood, and being a real country woman. “The Pill,” recorded in 1972 and released in 1975, blasted conversation about birth control in rural communities into the mainstream.

Oral contraceptives, known as “The Pill” have not been available for that long. The 1965 Supreme Court case, Griswold v. Connecticut, decided that married couples had a right to use the pill to prevent contraception and Eisenstadt v. Baird decided that single people had a right to use the pill in 1972.

In ‘The Pill,” Lynn proudly sings in the chorus: “This old maternity dress I’ve got / Is goin’ in the garbage / The clothes I’m wearin’ from now on / Won’t take up so much yardage / Miniskirts, hot pants and a few little fancy frills /Yeah I’m makin’ up for all those years /Since I’ve got the pill.” In total, she sings that she’s “got the pill” 7 times in a song that’s just about two and a half minutes.

When Lynn’s label released “The Pill” in 1975, it immediately caused controversy and many country radio stations refused to play it. A 1975 People magazine article noted:

From his pulpit, a preacher in West Liberty, Ky. recently denounced country singer Loretta Lynn and her new song The Pill. The effect was to send much of the congregation scurrying out to buy the record. More than 60 radio stations from Boston to Tulsa have banned the song, but through word of mouth and the FM underground The Pill is selling 15,000 copies a week. For Loretta Lynn, the most honored woman in country music, it is her biggest hit ever.

Lynn’s response to critics of her song was as frank and cavalier as the lyrics: “If I’d had the pill back when I was havin’ babies I’d have taken ’em like popcorn. The pill is good for people. I wouldn’t trade my kids for anyone’s. But I wouldn’t necessarily have had six and I sure would have spaced ’em better.

Lynn later stated in an interview with Playgirl that she’d spoken with several rural doctors who told her that “The Pill” had been especially helpful in communicating the benefits of oral contraceptives to women in rural communities.

Mainstream acceptance of contraception was and is still a huge issue for people of reproductive age. Just last week, The Trump administration “moved to expand the rights of employers to deny women insurance coverage for contraception.” The 55 million women who had the right to copay-free birth control are now at risk of employers using personal religious beliefs to deny access to contraceptives. Without insurance, birth control pills can cost $50 per month, a birth control implant can cost up to $800, and intrauterine devices can cost up to $1000. Certainly all of these are less expensive than pregnancy, giving birth, or raising a child, but the cost of preventing pregnancy can be significant enough that women may not be able to afford reliable methods of contraceptives.

Sexually active people of all ages, religions, and race are all very likely to use or have used contraceptive methods to prevent unintended pregnancy. It’s unfortunate that the current political administration is attempting to curtail access to reliable and safe contraceptive methods. (Call your senator!!) It seems like, in 2017, we could also use a few new popular songs about birth control, right?

A Prescribed Epidemic

Prescription opioids (aka painkillers) like morphine, OxyContin, Percocet, and Vicodin (to name just a few) peaked in 2012, with 81.3 prescriptions per 100 persons. The rate of prescriptions has since fallen, but the United States still represents 80% of world opioid prescriptions (via 2015 data), and has high rates of opioid prescriptions among people under the age of 65 (i.e. the population that is younger and should be healthier). This problem of prescription is deeply embedded in how the United States (fails to) regulate the pharmaceutical industry:

Unlike most of the developed world, the United States puts minimal constraints on aggressive marketing by pharmaceutical companies, whether the target is patients, prescribers, or medical and scientific societies. U.S. pharmaceutical manufacturers have been highly successful at promoting prescription opioids in this lightly regulated, profit-driven health-care environment.

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Opioid abuse is rampant, and is frequently cited as one of the “gateway” drugs to heroin . Opioids are highly addictive drugs because they target parts of the brain that are susceptible to feeling pleasure. Since opioids are more intense than the natural endorphins that humans produce, users of pharmaceutical opioids or illegal opioid drugs (like heroin) feel pulled to chase the high, continue using opioids (and use in increasing amounts), and may become addicted.

Prescriptions for opioids have fallen since an all-time high in 2012, but are still above CDC recommendations. Additionally, length of prescription was found to have actually increased between 2006 and 2015, meaning patients are exposed to the affects of prescription opioids for longer periods, against CDC recommendations. Prescriptions are also doled out unevenly, and a CDC report found that  “the places with the largest number of prescriptions filled tended to have more white residents and higher rates of poverty and unemployment…” See the maps below. On left, rates of opioid prescriptions by state in 2012, on the right, poverty rate by state in 2013. States with higher rates of poverty also have higher rates of opioid prescription.

Just about this time last year, Last Week Tonight did a segment on opioid prescriptions that highlighted the role of aggressive marketing from pharmaceutical companies to influence doctors’ prescriptions of opioid painkillers. [Note: There are some things I find grating in the format of Last Week Tonight but I think this does really quality work at communicating the history of opioid marketing and prescription in the US.] In sum – big pharma played fast and loose with marketing, many doctors fell for it, and now we have huge rates of opioid abuse.

It takes time to change trends in medical practices. It took time for the prescription rates to reach the 2012 highs! So it tracks that it’s going to take some time, even with increased surveillance, research, and awareness before doctors really change opinions about what pain management strategies should look like.

Most articles that I see in local news focus on the opioid epidemic in population health – through interviews with people affected by the opioid crisis and investigations into the areas where opioid addiction is most prevalent. I think many of these articles are great, but they do obscure the macro-level issue of how opioids have come to saturate the medical industry. Fortunately, now more attention is being paid to the source: big pharma. 

41 States of Investigate Pharmaceutical Companies over Opioids (9.19.17 via NPR) – A coalition of state attorneys general have come together to investigate potential impropriety in pharmaceutical companies’ role in the opioid crisis.

“Our subpoenas and letters seek to uncover whether or not there was deception involved, if manufacturers misled doctors and patients about the efficacy and addictive power of these drugs,” New York Attorney General Eric Schneiderman said during his press conference announcing the investigation. “We will examine their marketing practices both to the medical community and the public.”

Are Pharmaceutical Companies to Blame for the Opioid Epidemic? (7.2.17 via The Atlantic) – “Big Tobacco” faced lawsuits in the pursuit of improved public health and has been required to make changes – this article examines the legal possibility of states attorneys general pursuing these cases.

With the tobacco-industry lawsuits, customers were using the product as instructed and got sick. With opioids it’s a different story: Customers are not using the pills as directed, and so it is harder to blame the pharmaceutical companies for the effects of that misuse, according to Lars Noah, a professor of law at the University of Florida. In addition, doctors, not consumers, were the ones targeted by the aggressive marketing campaigns undertaken by pharmaceutical companies, so it can be difficult to link consumer deaths with aggressive marketing.

Whether suits against pharmaceutical companies will be successful is to be determined – already cities and states that have been hit hard by the opioid crisis have taken steps to sue pharmaceutical companies, and it’s possible that in the next year or so we could see court decisions go one way or another. I’m definitely interested to see what happens — but hopeful that this increased attention on the issue of opioid prescriptions will ultimately result in better treatment for those facing addiction and helpful changes made in medical care to prevent exacerbating an already unfortunate epidemic.


Health in a Natural Disaster – How to Help Puerto Rico

Hurricanes Harvey, Irma, and Maria have come and gone, but the destruction of these gigantic weather events remain and will remain through the visible infrastructure damage and the threats to human health.

Breaches at water treatment plants and flooded toxic waste sites in Houston pose hazards to people cleaning up and rebuilding their homes. Water-damaged structures are likely to grow mold, hospitals and medical professionals face closures or running out of resources for those in need of care.

In Puerto Rico, where the electrical grid was nearly wiped out from Hurricane Maria, hospitals are relying on gas-powered generators.  I think it’s really hard, particularly in the areas of US unaffected by these large storms, to imagine the wide-scale damage that has been done. We are very disconnected from the mechanisms that make life comfortable and in some cases, possible. Electricity is something I really rarely think about, same with gas lines, access to fuel, water and food. Cutting off any one of these things would make life more difficult, but dealing nearly all of those things being cut off or made extremely inaccessible that on top of needing specialized medical care (anything from refilling prescriptions, to receiving chemotherapy, to access to a doctor to check out a persistent cough) and needing to rebuild or find a new home are extremely overwhelming. Puerto Rico is facing months of rebuilding efforts to

If you have the means to do so, I encourage you to donate to relief efforts in Puerto Rico. Despite being a US Territory, they are really not receiving enough aid to respond to the magnitude of damage that was done. The longer Puerto Rico goes without an adequate response to Hurricane Maria (and Irma) – the more dire the health of its residents will become.

Money is particularly useful. In-kind items, unless specifically asked for, need to be sorted, inspected, transported and ultimately may be trashed if not useful (clothing donations frequently end up being on the garbage end of donations). If you can donate money, these are some organizations that are doing direct work in Puerto Rico that are particularly focused on health:


What is Reproductive Coercion?

Reproductive Coercion is getting some surprise attention this week after actors Nikki Reed and Ian Somerhalder went on Dr Berlin’s Informed Pregnancy Podcast and related their pregnancy story with a few red flags. (Note: Dr. Berlin is a prenatal chiropractor, chiropractors are not medical doctors.)

I’ve linked the podcast so you can listen for yourself (the section in question is within the first 8 minutes) as well as a Jezebel article that includes a partial transcript, but basically, Reed says Somerhalder knew way before she did that he definitely wanted children, after they were married Somerhalder wanted to have children around the same time his best friends’ did, and then one night on vacation with aforementioned best friends, he popped Reeds’ birth control pills out one by one into the toilet while their friends filmed it and Reed was “freaking out.” Somerhalder ends the story by admitting really he was the one who decided to get pregnant, rather than his earlier use of “we.”

Is this reproductive coercion? And what is reproductive coercion anyway?

Reproductive Coercion (RC) is a type of intimate partner violence where one partner seeks to limit or control the other partner’s ability to make choices about their reproductive health. RC is a spectrum of behaviors, which can range from pregnancy promoting behaviors like tampering with birth control, sexual assault, and preventing someone from seeking an abortion if they want one, to behaviors that attempt to pressure, control, or harm a pregnant person with the aim of ending the pregnancy against their will.

When you listen to the actual audio, it seems as if they’re trying to make this into a cute, jokey story, but I can’t shake the red-flag-feeling. Reed’s response on twitter, shortly after media outlets started picking up on the story on Friday, characterizes the controversy as something the media has blown out of proportion, while most fan replies to her tweets are encouraging and insist that they knew it was lighthearted.

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Here’s the thing – the narrative was their own. There are many times that a controversy over how something was reported in a profile of a celebrity – which come from much longer interviews that are condensed for publication and may only feature select quotes, but this came from a podcast where Reed and Somerhalder were speaking openly and unedited. The multiple journalists and outlets that picked up on the podcast (a podcast which I imagine rarely makes national headlines) raised the red flag over Somerhalder’s description of tossing her birth control in the toilet while Reed was upset, and that Reed asks about the video that was taken and wonders if she was too drunk to remember. These elements are alarming facts, and I when I listened to the actual audio the way they were told didn’t make me feel any better. Maybe they didn’t tell the story in an artful way, but these are tactics that are part of the spectrum of behaviors known as RC.

Reed and Somerhalder later put out a joint statement addressing the allegations of reproductive coercion:

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Celebrities are very often not experts on the topics they become associated with. This is true. However, it is a rare moment in pop culture that a relatively little-known public health problem is gaining some attention, which is ultimately a good place to start a conversation.

Mapping Abortion Access

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This visual representation of abortion access in the USA from The Pudding is really fantastic and informative –albeit depressing.

Since 1973, abortion has been legal (up to the third trimester of pregnancy) following the Supreme Court decision in Roe v. Wade that asserted that pregnancy termination is part of a pregnant person’s right to privacy. Prior to Roe v. Wade, death due to unsafe, illegal abortion accounted for a significant percentage of maternal deaths. Access to safe and legal abortion dramatically reduced maternal deaths and abortion is now one of the safest surgical procedures (safer than giving birth!)

The maps that The Pudding put together (a site I’d never heard of before but I love “visual essays” so goodbye to all of my free time) are really great because they help visualize the specific barriers that people seeking abortion face both in clinic location (the above screenshot) and availability of services according to location and gestation (below screenshot).

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Abortion is legal, but what is legality without access?

In the spring semester, I worked on a group project for a class about abortion access in Pennsylvania, and we plotted clinics that offer abortion services on a map. It becomes abundantly clear, when looking at the map, that the 20 or so providers are clustered in mainly urban areas. But people live in those in-between areas too! Population density is greater in those urban areas, but when you look at 2010 Census data, you can see that there are huge areas of the state where physical access is severely restricted. And these plots don’t even get into the specific restrictions each clinic may have on what types of services they offer.

As The Pudding explains, TRAP (Targeted Regulations of Abortion Providers) laws frequently limit access to abortion by instituting arbitrary rules for “safety,” but are actually medically unnecessary, political moves. It is expensive and time consuming to fight them. (If you’re interested in this – I recommend watching the documentary Trapped.)

Abortion access is an issue I care about a lot, but I think it’s really important to have these kinds of visual representations of data and access because it can succinctly and clearly translate these complicated issues. So check out the maps that The Pudding put together

Climate Change, Hurricanes, and Humans

This Vox video is a really helpful primer on the impact of climate change on weather events. On top of that, Houston is located in a wetland area that has largely been paved over in the last few years, decreasing drainage opportunities. Where water might go naturally into the ground, it’s now sitting on top of tar and the city has filled up like a bathtub.

People are suffering in Houston because of climate change. It is stressful and difficult to deal with homes that have been destroyed, on top of physical risks to health like increased diseases, insects, and injuries.

If you’re looking for places to donate, I urge you to think more locally than large, national relief organizations . Here are links to some people and organizations that will really benefit from any donation, small or large.