Category Archives: Guest blog

Contagions, content, and confusion in the digital age of health information

SeymourHeadshotGuest blogger: Brittany Seymour, DDS, MPH

Sixteen years ago, a study alleged an association between the MMR vaccine and autism. The authors disclosed in their publication that they could not claim a causal link, and the paper was eventually found to be faulty and was retracted. Nonetheless, flaws and all, the information was made visible and still today, anti-vaccine sentiments continue to rekindle the paper’s alarming claims, plus additional concerns. Anxious parents persistently echo one another’s worries through blogs, video-sharing websites, and other social media platforms, which too often contradict scientific consensus and current knowledge. A small but mighty group of doubting individuals are dismantling decades of life-saving research and successful health policy.

Disturbingly, content errors and false information tend to linger, even following subsequent correction. Particularly in the face of highly charged and emotional topics, individuals can become even more unwilling to revise their beliefs. When virtually anyone anywhere can publish anything online, people have little difficulty finding support to back any belief, creating a digital “corrupted information environment” one blog, share, and tweet at a time. We are entering an age of digital pandemics: rapid spread of misguided and incomplete online health information that has resulted in unsubstantiated confusion around some of public health’s greatest achievements, such as vaccines, contraception, and fluoridated drinking water.

We are witnessing an accentuated Kruger and Dunning effect, namely that unskilled people are also unaware that they are unskilled. Individuals are crafting convincing and persuasive arguments riddled with empirical citations and links to scientific studies. However, they ultimately lack the sophisticated skillset required for deeper interpretation of their own sources within the context of the larger issue. Without formal expertise, they are unable to move from the basic stages of knowledge, comprehension, and even application to advanced strategies for accurate analysis, synthesis and evaluation of the subtle yet significant complexities embedded in the scientific method. Put simply, a clever compilation from Google does not qualify one as a health expert any more than possession of a fine camera makes one a photographer.

These shortcomings go unnoticed while their confidence motivates readers to action. Ultimately, they are unable to recognize the larger harm their social media “publications” are causing in the absence of information porters such as the peer-review process or expert consensus. Now that over half of adults turn to the internet for health information, including using social networking sites, the hosts of these digital pandemics are becoming easily accessible and their content is proving contagious. Conversely, the most competent experts often underestimate their own competence, the “burden of expertise;” in part because scientific competence requires open acknowledgment of limitations in order to discover accurate truths. But on a public forum, citing any limitation, even as a requisite for the scientific process, attracts the naysayers who predictably share it across the web without context, and thus without accurate meaning. When searching #fluoride on Twitter for example, we discover, at surface level, an evenly matched digital Clash of the Titans: the proficient yet restrained domain expert versus the unskilled but vociferous lay person touting content that is masquerading as science but is actually nothing more than shallow advocacy. It’s no wonder the public has become confused and distrustful.

Clearly, social media is an expanding worldwide phenomenon. Yet, little is known about the precise mechanisms at play at the interface of social media and high-level global health strategies. Why does some content “go viral” when others don’t? Key findings include factors like an innate desire to share, emotion, storytelling, and public access- aspects that are perfectly ripe for success across social media. Yet, these aspects are also in direct conflict with the gold standard for acquiring, conveying, and applying scientific knowledge: objectivity, avoidance of conclusions based on anecdotal accounts, and publication in private peer-reviewed journals.

Despite its shortcomings, social media can provide public health experts with answers that once were private yet now are public: individuals, along with sharing misinformation, are also sharing their most intimate sentiments about that information.  In the past, interviews and conversations would have been necessary to uncover the numerous and highly nuanced reasons why individuals oppose particular public health interventions. Today, on the very websites publishing information that infuriate the experts also exist literally thousands of personal concerns made public for all to see, and minus researcher bias. The public nature of social media is perhaps our utmost barrier to information accuracy and yet a tremendous untapped resource for public health research, innovation, and intervention.

Brittany Seymour is an Instructor on Global Health at the Harvard School of Dental Medicine’s Department of Oral Health Policy and Epidemiology and the Inaugural Harvard Global Health Institute Fellow. Her research includes interdisciplinary global health curriculum development and pedagogy, capacity strengthening for oral health delivery systems in resource-challenged regions, and digital information transfer and impacts on health.

An emerging threat of “digital pandemics”- lessons learned from the anti-vaccine movement

SeymourHeadshotGuest blogger: Brittany Seymour, DDS, MPH

During the 20th century alone, the world experienced a larger gain in life expectancy than in all the previously accumulated history of humankind. This triumph has been dubbed one of the greatest achievements in global health and is largely attributed to the 20th century success of vaccines. However, a digital assault (one that began with autism but has ballooned to numerous other concerns) regarding the safety and importance of vaccines has permeated the Internet. Anti-vaccine sentiments, derived from this study – now retracted – perpetuated by celebrities such as Jenny McCarthy and Kristin Cavallari, and other concerned citizens, have gone viral. A “digital pandemic” is underway, and like a game of telephone, the truth has morphed, facts were lost in translation, and the story of vaccines today boggles the mind. Public acceptance and trust in their safety and utility has waned. Regions of the world, including the United States, are experiencing their worst disease outbreaks in nearly two generations (IOW since the invention of the associated vaccines), and many of these are attributed to exemptions from the recommended vaccine schedule. As rotavirus vaccine inventor (and recipient of death threats due to his pro-vaccine work) Paul Offit describes it, every story has a hero, victim, and villain; in this story gone viral, Jenny McCarthy is the hero, the children the victims, which leaves one role for public health experts: the villain.

More recently, is public health at the forefront of yet another digital assault, susceptible once again to the label of villain? Last month, a study with known limitations was released naming fluoride as one of six newly identified developmental toxins in children. Ironically, this followed the American Dental Association’s announcement only two weeks prior that it has changed its longstanding guidelines for the use of fluoride in young children, recommending an increase in fluoride exposure before the age of two years old, as compared to the former recommendations. Yet, within a matter of hours from the release of the study, the story of fluoride as a new threat to normal child development created a flood of posts on Twitter (just search #fluoride) and was covered in popular media news stories for CNN,USA Today, Forbes, and Time. These news sources alone generated over 54,000 views and shares over social media by the end of the weekend. Does fluoride share the same vulnerabilities as vaccines?

To many public health experts, these stories trigger bewildering thoughts. How is it possible that such misguided health information can spread so far so fast, painting public health experts as villains? Is there a way we can reverse our role in this story and emerge the heroes? Lessons learned from the vaccine story provide insights into an emerging threat of digital pandemics and the power of social media as the medium. Public health is encountering an unfamiliar menace, a rising global pandemic of rapid and unrestricted information transfer.

In today’s global society undergoing tremendous technological advances, new and emerging media modalities are greatly affecting health by influencing policy decisions, direction of philanthropic aid, and individual health behaviors. No doubt, due to the power of handheld technology and online social networking,social media and “citizen journalist”have played a role in propagating potential detriment to what is revered as one of public health’s greatest triumphs (vaccines). Thomas Patterson explains that information accuracy is becoming obscured, “The internet is at once a gold mine of solid content and a hellhole of misinformation.” As Nicco Mele illustrates, the internet makes David the new Goliath, where citizens are capitalizing on the power of social media’s velocity and reach, disarming the traditional gatekeepers of information quality.

Even when presented with corrective information, it’s no wonder the public continues to be confused, and concerned, about potential dangers of our intentional public health interventions. But what triggers a digital pandemic, and where is the threshold between an outbreak of bad health information versus a true online pandemic wrought with content persuasion? In a world of expanding voices sharing health information online through social media, how can we ensure that the cream still rises to the top and the public is making health decisions based on the most accurate information possible?These are the big “opportunity” questions we as public health experts need to be addressing under our responsibility to keep today’s citizens, their children, and our societies healthy.

Brittany Seymour is an Instructor on Global Health at the Harvard School of Dental Medicine’s Department of Oral Health Policy and Epidemiology and the Inaugural Harvard Global Health Institute Fellow. Her research includes interdisciplinary global health curriculum development and pedagogy, capacity strengthening for oral health delivery systems in resource-challenged regions, and digital information transfer and impacts on health.

How will a trade agreement – the TPP — impact global health?

Guest post by Mary Anne Mercer, Senior MCH Advisor for Health Alliance International and the IH Section’s liaison with the Trade and Health Forum. Mary Anne spoke at a recent activist rally in Seattle on January 31st about public health concerns related to the TPP.

Only six months ago, when the TPP, or the Trans-Pacific Partnership, was brought up in discussions, even well-informed activists generally gave blank stares.  TP what?  But in recent weeks it’s been the subject of increasing news coverage, along with exposure to the so-called fast track authority bill that would grant President Obama authority to sign the agreement without prior Congressional review.  Although extensive negotiations on the TPP have been going on in secret over the past several years, as information about the TPP becomes better known, activist groups around the world have organized to oppose it. Just what is the TPP, and why do we care about it?

The Trans-Pacific Partnership is a “trade” deal (but encompassing many other areas of corporate rights) among 12 countries of the Pacific Rim, including the United States. Official discussions are held behind closed doors without public information or input, and without input from our elected representatives in Congress, so little is known about the specific terms of the agreement.  However, WikiLeaks has published two chapters over the past few months detailing regulations concerning intellectual property and the environment. We have good reason to expect that the TPP will ratchet up terms that are prominent in existing trade agreements that have been signed between individual countries. So although only the negotiating committees, which include about 600 diplomats and corporate representatives, know the exact terms of the deal, we have substantial cause for concern.

National and international groups concerned about global health have voiced opposition to many terms of the agreement, believing that they would affect the health and quality of life of people around the world if enacted.  Some of the main health-related concerns about the TPP include:

  • Restrictions on individual countries’ abilities to pass and enforce laws protecting public health. Through a mechanism known as Investor-State Dispute resolution, corporations would be entitled to sue sovereign governments for passing laws that ‘restrict trade’ – even public health measures such as restricting tobacco advertising on cigarette packaging, which the Australian and other governments are now facing.
  • Intellectual property laws that would set up barriers to accessing generic medicines and other health commodities (including AIDS drugs), thus dramatically increasing their costs. By extending the already lengthy duration of patents and other corporate protections, Big Pharma will have an even stronger hold on the economic gains to be made from health problems around the world.
  • Detrimental effects on equity, including the distribution of income and other resources.  There is good evidence 20 years after NAFTA that poverty and inequality have increased in Mexico and wages in the US have stagnated.  The promises of NAFTA have not been kept.

But the TPP is far from a done deal.  Many progressive groups, including a number of labor, environmental and community organizations, as well as APHA’s Trade and Health Forum, are working to oppose the TPP and the Fast Track bill.

Sen. Harry Reid, Majority Leader in the U.S. Senate, recently indicated that he is not interested in having the Senate vote on legislation granting Fast Track Authority this year. There is no question that Reid’s decision is a result of mobilization of voters across the country. We need to continue to educate and inform as many people as possible about the content of the TPP and the negative impact it would have on jobs, the environment, and on public health in the US and globally.

Motivating and Retaining Community Health Workers: The 2011 Annual CBPHC-WG workshop

By: Dr. Paul Freeman

Prior to the recent APHA Annual Meeting, the CBPHC-WG held a day long workshop focusing on Community Health Workers. There were over 110 attendees including presenters and organizers. This was the largest workshop our group has held in the 13 years we have been conducting these workshops. It was a great feeling to see APHA functioning at its best in providing a venue where those from MCHIP, CORE group, academics, members of other NGOs, not-for-profit and for-profit organizations and consultants could share their views in an open, mutually respectful environment and learn from each other. This year JSI personnel, under the leadership of Mary Carnell, worked in partnership with Working Group members in all stages of workshop planning and implementation. The work of Agnes Guyon (who lead the workshop), Sandee Minovi and Kimberley Farnham, all from JSI, and our own Sandy Hoar, Vina Hulamm, Melissa Freeman, Laura and David Paragon, Tonio Martinez and Larry Casazza were outstanding.

Leban Tsuma MCHIP leading. Photo credit: Paul Freeman.

Our norms were: use of an evidence-based approach, the right for all participants to be heard and for their viewpoints to be respected. At this time, renewed attention is being given to the role of CHWs with recognition becoming more widespread now that the Millennium Development Goals, especially those for women and children, cannot be met without community involvement.  The 8 large group presentations and 16 small group discussion sessions covered well a wide range of perspectives on CHW motivation, retention and performance. I am sure some participants were being exposed to different points of view from their own for the first time.

Samuel Yalew, Urban Health Extension Project/JSI (Ethiopia) leading. Photo credit: Paul Freeman.

I would especially like to highlight the area of internal motivation of CHWs. Through Pink’s book “Drive” many of us are becoming acquainted with the “modern” approach to the importance of autonomy, mastery and purpose in motivation. Yet several NGO presentations, such as those by Tom Davis of Care Groups and Connie Gates of Jamkhed, demonstrated that these elements have already been addressed by NGOs for decades as appropriate to local circumstances.

Sarah Shannon from Hesperian facilitating. Photo credit: Paul Freeman

Melissa and I will prepare a report of the workshop to be disseminated early next year. There were many lessons to learn from conducting this workshop that should remain with the International Health Section for years to come. One of the key lessons was that with enough goodwill and cooperation from individual members – things work best with at least 8 volunteers for such an event – memorable events can be implemented by the Section. With enough “hands” each contributing a relatively small amount, things go much more smoothly than if all sit back waiting for a few to do all the work.

Paul Freeman is a physician with advanced training in tropical disease control and general public health, health personnel education, and health program management and evaluation. He has over two and a half decades of experience in capacity building and the design, planning, implementation, monitoring and evaluation of primary health care, child survival and malaria control programs in developing countries and for deprived rural indigenous populations in developed countries. He is a Clinical Assistant Professor at the University of Washington School of Global Health and the Chair-Elect of the International Health Section.

Strengthening of Public Health Associations (SOPHA) Evaluation

By: Dr. Paul Freeman

For 25 years the Canadian Public Health Association, with support from the American Public Health Association, has been facilitating ongoing processes to establish and/or strengthen Public Health Associations in developing countries. In November 2011, SOPHA has organized a mission to evaluate its program through field visits to three countries currently receiving assistance and through the results of a questionnaire answered in 5 other country partner Associations. Omar Khan and I were part of this evaluation process through field visits to Nicaragua, Mozambique and Congo Brazzaville. I accompanied Drs Henri Delatour and Deo Sekimpi to the Congo. It was inspiring to see how enthusiastic the members of the local Public Health Association – L’Association Congolese Pour La Santé Publique et Communautaire (ACSPC) – were. In the midst of poverty they devoted a lot of their own time to establish their association and to conduct ongoing activities that established the credibility of their organization with the community and government.

We huddle to discuss Public Health Association business. Photo credit: Paul Freeman.

The SOPHA program has resulted in both individual and group capacity strengthening and knowledge sharing.  Formal training was given in key aspects of strategic planning and project planning, implementation, monitoring and evaluation. SOPHA support of participation in international conferences and networking improved the profile of the organization and led to learning through sharing. In 2008 and 2010 ACSPC organized scientific conferences where different stakeholders participated. ACSPC members have built both personal and institutional capacity by attended many international meetings.  ACSPC also collaborated with municipal and national health authorities, thus contributing to strengthening the health system at those levels.  The projects contributed to public health capacity building across many health programs, such as sanitation, immunization, road safety, TB control, HIV/AIDS control and malaria control.

They appreciate what can be achieved through association. Photo credit: Paul Freeman.

Institutional capacities were adequately strengthened and they are sufficient to ensure sustainability in the short term, but better fund raising activities are needed for the mid to long term. The ACSPC staff were trained on results based management (RBM) tools which were applied in the development of project plans.   New knowledge was applied in financial management to prepare annual, midterm and final financial reports to CPHA, and strategic planning was used to prepare the strategic plan 2012-2016. Funding is not sufficient; the association is using the skills and tools acquired with the SOPHA program to look for other donors and prepare projects.

Supplying latrines and clean water to schools, a typical project. Photo credit: Paul Freeman

There were several key lessons learned. SOPHA capacity building contributes to increase the confidence and the credibility of the association. Advocacy needs to be undertaken to increase the involvement of other health professionals (doctors, nurses) and government officials in the association and develop their interest for public health issues. The main challenge and issue for project implementation was that the multi-disciplinary and multi-sectoral dimension of public health is not yet understood by many stakeholders and decision makers and, partly as a consequence of this, there are few doctors, nurses, or government (Ministry of Health and local health authority) members in ACSPC.

We talked for hours, often by gaslight in small rooms – their offices – in just adequate private housing, that we reached through dirt streets awash with water from recent rain. It was heartening to see what had been achieved and how these pioneer members, with only a few trained health professionals amongst their numbers, had established and barely kept afloat, their own Public Health Associations. Perhaps we could establish links with them for solidarity and to support their growing skill and knowledge base.

Paul Freeman is a physician with advanced training in tropical disease control and general public health, health personnel education, and health program management and evaluation. He has over two and a half decades of experience in capacity building and the design, planning, implementation, monitoring and evaluation of primary health care, child survival and malaria control programs in developing countries and for deprived rural indigenous populations in developed countries. He is a Clinical Assistant Professor at the University of Washington School of Global Health and the Chair-Elect of the International Health Section.

The Business of Benevolence

by Dr. Sosena Kebede

The Global Fund (an international financing organization that pools resources to fight against the top three leading infectious diseases in the world: AIDS, TB and Malaria, to date has committed $22.4 billion) just announced that, due to the current financial crisis, it is canceling round 11 of grant renewals for recipient countries. Most of the recipient countries are in the sub-Saharan Africa and the United States has been the single largest donor (traditionally about 33% of all donations through the GF come from the US) since the organization’s inception in 2002.

My initial reaction on hearing this news mirrors that of most of my colleagues in global health – let’s do something, anything; this can be catastrophic and may mean winding the clock back to when hundreds with HIV were perishing because they didn’t have access to drugs. Other thoughts that flash through my head include: What does this mean to governments of poor nations, NGOs, other donor agencies, pharmaceutical companies, health care workers in poor nations, business people, rich people with the disease, or poor people with the disease?  Will this mean drug rationing? Will this give rise to drug resistance if some treatments are stopped due to lack of funding? Will this mean a lucrative business for someone out there who will stand to gain big when resources shrink, and the rich will find a way to get access?  Speculations, speculations.

Some, all or none of the feared may come to pass. However, the more I think about it, the more I am bothered by the commentary this issue makes rather than the potential outcome, however grim it may (or may not) end up being.

It is deeply saddening to face the fact that the very livelihood of millions of poor people can often depend on the benevolence of the rich. Our world is changing fast; emerging economies are flexing their muscles and contending with Western powers for influence in poor countries. Yet, millions of the world’s poor will have no say on how this phenomenon called globalization will affect their lives. Poor nations have also been below the radar detection when debates rage all over the world about the global mess that years of fiscal irresponsibility and corporate greed has brought. For millions of the world’s poor, our new world order and the concept of globalization, the shift in power/wealth etc., whether good or bad, might as well be happening in another planet for all they have any part in it. Unfortunately, their lack of participation in the process does not shield them from the consequences – they stand to lose the most having no means or power for self-determination.

Poverty, health and human rights are inextricably intertwined. We can’t truly advocate for global health equity when the world continues to have millions of voiceless people and people will not have a voice unless they are economically empowered. The business of benevolence, however generous and much needed it may be, is only a temporary measure for the poor that merely affirms to us our implicit sense of moral superiority.

Sosena Kebede, MD, MPH is an assistant professor of medicine in the department of medicine at Johns Hopkins University in Baltimore, MD. She is also an associate faculty at the Johns Hopkins Bloomberg School of Medicine in the department of International Health. Her work in global health focuses on health systems strengthening works such as directing a hospital management training program in Ethiopia for Yale University as well as doing consultancy work for the World Bank. Her professional memberships include being a section counsilor for APHA’s international health advocacy and policy committee, as well as member of the advisory board for the international Association in Technology, Education and Development.

Putting Students to Work Writing APHA Policy Papers

By: Dr. Amy Hagopian 

University of Washington faculty members in the Department of Global Health have found opportunities to do double duty as teachers and APHA activists.  For two years, faculty have assigned students to write APHA position papers on important policy areas, while at the same time offering valuable learning opportunities for students.  In the last couple of years, students have written four policy papers approved by APHA’s Governing Council:

  1. Transporting nuclear waste (20107)
  2. Cleaning up the Hanford nuclear reservation (20105)
  3. Improving housing for farmworkers (adopted in 2011, not yet given a number)
  4. Creating citizenship opportunities for undocumented workers in the U.S. (number pending, adopted in 2011).

Students have also written two additional policy proposals for submission in 2012:

  1. Reducing non-point pollution run-off into coastal waters
  2. Modernizing the Clean Water Act to improve its ability to address modern point-source water pollution hazards

Now two UW faculty members, inspired by the “Occupy” movement and the brief statement of support for it adopted by the governing council at the annual meeting in DC this year, have invited two students to work on a new policy.  Faculty members Stephen Bezruchka and Amy Hagopian will work with UW graduate students Valerie Pacino and Nathan Furukawa to write a position paper on the health hazards of income inequality, but within and between nations.

Authors of the position paper are inspired by populist movements, including the ones that preceded Occupy protests–especially the Arab Spring actions in Tunisia, Egypt, Libya, and beyond.  These efforts used narratives on income inequality, wealth inequality and social inequality to spur direct action.

We invite International Health section members with ideas about how to contribute to these position statements, or who can refer us to literature citations, to be in touch. Please contact Dr. Amy Hagopian (hagopian [dot] amy [at] gmail [dot] com) for more information.