Archives For public health

Recently, the Lancet posted yet another article on Obama’s Global Health Initiative. In it, the writer points out the numerous failures of the GHI. The $63 billion budget was not new money and was instead a new label for funds already budgeted elsewhere. Where GHI differed was in its goal to place all of the leadership under one organization. A central office was created, but this was shut down in July. The article then focuses its text on the tensions that arose when USAID took over as the leaders of the program. I could go on about the successes and failures of the global health initiatives, but I would prefer to focus on a more important issue. What are the GHIs? It is my belief that productive debate will arise if and only if we are adequately informed.

The Global Health Initiatives focus mainly on infectious disease and strengthening healthcare systems around the world. Prior to the Obama administration, they were many organizations (and if we are to be honest, still act as such). PEPFAR and the Global Fund to Fight AIDS focused on HIV/AIDS. The Global Fund also targeted tuberculosis and malaria. The GAVI Alliance put its efforts into immunization. The World Bank’s MAP dealt with AIDS and nutrition. These are not foci of the United States, and Obama’s plan called for a comprehensive effort similar to (and including) these programs that would combine their efforts to improve their effectiveness.

I will instead focus on the current administration’s global health initiative, without a critique. In November 2009, the goal of the GHI was to double US aid for global health to approximately $16 billion per year in 2011, establish goals for the US to assist in addressing the Millennium Development Goals, and attempt to scale up domestic health efforts. The six areas of focus included HIV, tuberculosis, malaria, reproductive health, health systems, and neglected tropical diseases. The November report made three recommendations. First, the group wished to define measurable GHI targets. These would be US-specific and would focus on the delivery of care. Second, they recommended funding be increased to $95 billion over six years, an increase from the original budget. Finally, the recommended that the GHI focus on outcomes and be people-based. Overall, the recommendations were subtle and not clearly defined, but they hinted at the theme of the GHI. The goal was to provide a comprehensive program in which the United States could better address global health initiatives. This was sold as change from the disease-specific nature of Bush’s programs to one that focused on health systems and delivery.

In July 2012, the GHI office was officially closed by the Obama administration. It was touted as a productive shift, but the reality was that this closure was due to myriad problems encountered by the program. The program lacked core leadership, and those in the developing world had troubles with knowing what defined a GHI project. While it had a huge budget, there were only four full-time employees in the office. The idea remained, but the office did not.

There is far more to this story, but that is what you should know about Obama’s GHI. It was and still is an interesting idea, but it remained an idea. What we need are solutions with better focus.

Two years ago, I wrote a piece for a public health group based upon a project based in medical school. An excerpt follows:

“In June 2009, President Barack Obama signed into law the Family Smoking Prevention and Tobacco Control Act (HR 1256). This legislation would require all tobacco products and advertising to have a graphic warning covering 50 percent of the front and back iof the package. The FDA has proposed a number of graphic designs […] The proposed designs include grotesque imagery in an attempt to dissuade smoking in the United States. According to the Center for Disease Control, smoking accounts for approximately 443,000 deaths per year in the US, including deaths from lung cancer, cardiovascular disease, COPD, and numerous other morbidities. It is thus apparent that smoking is a public health concern, and these new warning labels hope to address the concern by deterring such behavior. However, though the proposed graphic labels may be more effective than the previous Surgeon General’s Warning (a text-only message on the side of the package), these labels can be greatly improved through what will be defined as a gains-based message as opposed to the proposed loss-based message. In doing so, the labels would not only educate the public on the dangers of smoking, but it will be argued that they will encourage smoking prevention and cessation behavior. In fact, it is argued that the currently proposed labels may do more harm than good. To make this argument, three assumptions must be made. First, as hinted above, smoking is a public health concern. Second, tobacco warning labels are designed to result in human behaviors of smoking cessation and prevention. Finally, human behavior is, in some circumstances, predictable.

This is not to say that the proposed labels by the FDA or those currently being used around the world are completely ineffective. In fact, the graphic labels may be more effective than the small text-only Surgeon General’s Warning. However, there is a wide margin for improvement. The proposed labels appear to be far too grotesque. Though admittedly fear-inducing, this negative emotion will most likely lead to reactance behavior. Expect sales of slip covers to increase, along with the possibility of some smokers increasing their smoking behavior. Smoking rates may continue to decline, but the rate of this decline may not yet be optimal. Data from other countries, along with numerous experimental studies, have demonstrated that confounding factors can contribute to the decline in these countries, and grotesque imagery can result in maladaptive behavior. A truly effective label would be designed with a positive, gain-framed message. It would be designed to motivate behavioral change and encourage self-efficacy. Data from others who were able to quit can enhance subjective norms. Imagery depicting the benefits of quitting or those who were able to quit can further eliminate reactance. All of this would then be coupled with resources on quitting, such as phone numbers, web sites, and support groups. This is a war that cannot be fought with fire. As demonstrated every time a cigarette is lit, fire is only good for lighting up.”

First, I believe that this claim still holds, and my predictions, while still probably true, mean little when compared to the growing need to reform healthcare. Howevera greater concern lies in how we approach public health research. Within basic science, and especially physics, we like to break down larger systems into their components, analyze them, and search for unifying hypotheses. That is one method, but the concept is simple: Focus on the rules of a system in order to predict behavior.

Often, this concept is lost in public health research. Perusal of the literature will reveal that such concepts are hypotheses in the discussions of papers, but one sees very few examples where they are applied. In the case of tobacco warning labels, concepts in behavioral psychology may be applied to predict behavior resulting from labeling campaigns. The validity of these models remains to be seen, due to a low sample size. Nonetheless, studies were performed. Phone surveys revealed results similar to what was predicted by the theory of reactance.

Briefly, the theory of reactance predicts a cycle in human behavior. One begins with some level of (1) freedom, which is then (2) threatened. The human will (3) react, and undergo a (4) restoration of this freedom. Types of reactance include those exhibited by certain groups (trait reactance) and various threats to freedom (state reactance). These can be measured through fear, anxiety, disgust, and the like, all of which are predicted to increase with the level of reactance. The restoration of freedom is key. This is done through avoidance, acting out, or the like. In the case of smoking, this would be manifested in increased rates of smoking, a reduced desire to quit, downplay of harmful effects, and avoidance through the purchase of slip covers. A study by Dillard et al. in 2005 pointed out such concepts, and phone surveys on tobacco noted such reactions.

Another concept is message framing. There are two types of messages in this theory, gain-framed and loss-framed. A gain-framed message focuses on the benefit of performing a task, while a loss-framed message focuses on the risks associated with not performing the task. Loss-framed messages include pointing out the risks associated with not performing regular mammographies or other early detection methods of disease. Gain-framed messages include those associated with the benefits of exercise and sunscreen use. The current tobacco warning labels would be improved by avoiding reactance through the use of gain-framed messages, as was pointed out by Tamera Schneider in the Journal of Applied Psychology in 2001.

This highlights an important issue in public health and other epidemiological studies. The studies often do not cite and properly utilize the foundational psychological or basic science research. This shapes policy in a less-informed manner, sometimes leading to unforeseen negative outcomes. By increasing effective communication between the sciences and epidemiology, policy changes may become more effective