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Protecting public health from private guns

This past weekend, an unspeakable act of violence was committed against a group of innocent Americans at a grocery store in Tucson, AZ.  The incident has sparked off another series of debates regarding gun control and finger-pointing about who is to blame for this particular incident.  While this act of terrorism deserves all of the media attention it is currently receiving, it is important to realize that firearms are responsible for tens of thousands of deaths every year in the United States, most of which do not make national headlines.  Firearm injuries are an important public health problem in the United States and therefore this incident should also be viewed as our failure to implement the best evidence-based policies that we know can help save lives.



My advisor during my masters at the Harvard School of Public Health, David Hemenway, is perhaps the world's leading expert on the public health approach to reducing mortality and morbidity from firearms.  He has authored an excellent book on this topic "Private Guns, Public Health" - which I would encourage anyone interested in public health to read, not just those interested in firearm injury prevention.

I quote from the preface to this book:

"...motor vehicles and firearms are the leading agents of injury death in the United States, with vehicles first and guns a close second. But while motor vehicles are used by almost everyone, every day, throughout the country and are crucial for our standard of living, the same is not true of firearms."

Firearms are nearly as lethal are motor vehicles, yet unlike the automotive industry - which we are constantly regulating to become safer and safer (e.g. speed limits, seat belts, side impact air bags, and  rear object detection sensors) and limiting who can drive a car (e.g. minimum driving regulations, license refusals for DUIs) and how (e.g. under the influence, while texting) - government has not nearly done as good of a job applying these public health principles to the firearm industry.  This past weekend, we learned (again?) why these policies are important.



Also from David Hemenway's book preface:

"It is shameful that tens of thousands of Americans die needlessly from guns each year while our gun policy is driven more by rhetoric than scientific information."

Hear, hear.  Let's not wait for the next shooting spree before we wake up to the importance of firearm injury prevention policies to protect the public health.

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Can an ART a day keep the doctor away?

Interesting results of a trial that looked at the Pre-Exposure Prophylaxis (PrEP) - essentially uninfected people taking a drug prophylactically - on new infections from HIV were released earlier today in the New England Journal of Medicine.  Roughly 2500 male and transgender men who have sex with men (high risk uninfected) in the Americas, South Africa, and Thailand were randomized to receive a once daily combination pill of emtricitabine and tenofovir disoproxil fumarate (FTC–TDF).  After about a year and a half, about 100 people developed new infections from the virus but the treatment group experienced a roughly 44% decreased risk of new infection.  This is pretty exciting news, as there is a clearly the need for new effective methods to prevent HIV.

I know it is coming...so I'll weigh in on this question.  So if this works, why not just distribute the drugs to everyone in highly affected countries?  While exciting news, I think there are a number of drawbacks of that might prevent this approach from being more widely adopted at the general population level.  

First, these are heavy drugs, the trial itself found relatively high levels of adherence problems, and I am not an expert in this but I've always had the impression that most ART drugs are not the kind of thing people want to be taking unless the alternative (death) is severe.  

Second, we need to consider the whether this represents a good use of resources. This trial was conducted in a very high risk population and even then the risk reduction was only about half.  Depending on how costly these drugs would be, plus the associated medical costs of ensuring some medical follow-up of people taking these drugs, it might not be cost-effective relative to other prevention strategies in the general population.  

Third, we must also consider drug resistance.  Although no drug resistance was detected among those patients who developed HIV during the trial, resistance to these particular medicines can be developed and could potentially have widespread effects on overall usefulness of ART medicines.

Fourth, we must also consider the behavioral effect of these drugs on patients.  The overall trial would have picked up short-term behavior effects (e.g. if people think they are protected they may engage in more or more risky sexual behavior) but we should worry about is the more long term effects of this intervention on behavior, say over time or outside of a trial setting.  Depending on how large this effects might be, it could undermine the overall effectiveness of the strategy.

Finally, PrEP is not a magic bullet.  There are other ways of becoming infected that are unlikely to be affected by this drug (e.g. injections) and the reduction was far from complete.  Plus, unlike other prevention methods (e.g. condoms) it does little to protect against other STIs.  

But of course anything that helps in preventing this horrible disease, even a bit,  is very good news.

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Posted in health

Presidential Hopefuls and Global Health

In a recent article in the Lancet, author Nellie Bristol reviews the differences in the presidential campaign platforms of John McCain and Barack Obama. As a disenfranchised immigrant in the United States, I tend to remain relatively oblivious on US politics, in particular during presidential campaigns. In Canada, national elections are frequently called out of the blue and are over in less time than it takes a beaver to build a new dam. Perhaps they'll show some ads during hockey night in Canada, but it rarely captivates national attention as it does in the United States. Here, it seems like there is always someone campaigning for something. I frequently get asked at dinner parties what my thoughts are on the US health care policy, and I feel like such a sham when I have to rely on the few sound bites I have heard discussed among classmates.

However, I must admit that I have caught a bit of the Obamamania going around. I have always felt a bit of disappointment on US foreign policy, in particular as it pertains to global health issues. Obama does appear to be the leading candidate on this front: he seems to understand that going at it alone will not solve the problem and that he seems more eager to accept views more popular in Europe and other donors on issues relating to sexuality and pharmaceutical procurement. What I am perhaps most excited about is a view that Obama seems to share that tackling global health does not equal tackling HIV/AIDS in an emergency response framework. Health systems needs to be strengthened before any progress can be made on global health. These types of improvements are not going to come overnight and they are not going to be nearly as sexy as simply putting millions of people on treatment. Long-term support to countries will be required.

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Reproductive Health Redux

I am currently reading Fatal Misconception: The Struggle to Control World Population by Matthew Connelly. I would recommend this book to anyone interested in population control but also to anyone interested in global public health in general because not only does the book provide an overview of global movements to control population, but because I think there are a lot of parallels between the historical movements outlined in this book and the current movement to control HIV/AIDS.

The book provides a detailed account of how governmental and non-governmental actors interacted throughout the 20th century on the topic of population control. I thought it was fascinating how different groups, for example environmentalists and eugenicists, came together to back the same cause due to their realization that a certain outcome would be beneficial to all of their interests.

However, it was the challenges of implementation that most interested me. When population control programs were being rolled out throughout the developing world, the initiatives were oftentimes driven by the agendas of Foundations and Governments of Western countries. The impact of these initiatives on the recipient countries themselves was often given little forethought. There was a concern that there would not be enough domestic resources available to carry out all of the necessary interventions (e.g. sterilizations, IUD insertions) and therefore additional financial incentives were frequently given to these workers to meet the objectives of the population control initiatives, forcing them to abandon their other responsibilities.

I won't spoil the ending for anyone who wants to read this, but the book basically tells the story of a movement that despite is power and influence, fails to deliver on its overall promises, largely due to a failure of implementation. I think HIV/AIDS should take a few lessons from this experience. Thanks to Matthew Connelly for this excellent contribution.

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