Burden of Proof

In the early 1980s, there was growing concern about the quality of peer review at scientific journals. So two researchers at Cornell and the University of North Dakota decided to run a little experiment to test the process.

The idea behind peer review is simple: It’s supposed to weed out bad science. Peer reviewers read over promising studies that have been submitted to a journal to help gauge whether they should be published or need changes. Ideally, reviewers are experts in fields related to the studies in question. They add helpful comments, point out problems and holes, or simply reject flawed papers that shouldn’t see the light of day.

This week, an annual meeting of the world’s most powerful global health players is taking place in Geneva. It’s called the World Health Assembly, and ministers of health, heads of state, and civil society leaders are gathered at the United Nations’ Palace of Nations to set health priorities and policies for the entire world.

At the moment, they’re focused on whether we’re prepared for future deadly disease outbreaks — a question that’s particularly urgent in the wake of the Ebola epidemic in West Africa. More than a year and 25,000 cases later, it’s clear the World Health Organization and the countries involved weren’t ready for that crisis. The world took too long to act, leading to avoidable suffering and long-term devastation.

In the wake of the police-involved deaths of black men including Michael Brown and Eric Garner last year, thousands have protested across America to turn our collective attention to the different treatment of black and white people at the hands of America’s criminal justice system.

The focus, of course, is much needed. But there’s discrimination in many other places, too. Every single day, there are many more race-related deaths that result from a quieter problem: systemic discrimination in the US health system.

The truth is this: even today, in America, white privilege works better than most medicine when it comes to staying healthy. Racial health disparities may be a more subtle killer than gun violence or murder, but they’re arguably a more violent one. They infect every part of the body, and they strike at literally every stage of life, from cradle to grave.

Baltimore or Ferguson — the site of recent riots — have life expectancies and infectious diseases rates that hover near those of the developing world. These cities can be seen as microcosms of a much larger problem. “If the statistics that are present in these communities were present in any white community in Baltimore,” Douglas Miles, a Baltimore pastor, told the New York Times, “it would be declared a state of emergency.”

Simply put, black babies don’t have a fair start. Pre-term delivery — coming into the world at less than 37 weeks — is one of the key causes of infant death in the US. These early births lead to a host of health complications, both short and long term, from vision and hearing impairment to cerebral palsy. Black women have a 43 percent higher risk than white women for delivering their babies prematurely. They are also between two and three times as likely to have babies dangerously early, in less than 32 weeks.

When it comes to nursing, black mothers are consistently less likely to breastfeed than white mothers, despite the guidelines suggesting all mothers do so because of well-documented health benefits. This gap has been explained by everything from preference to a lack of access and education about health benefits to a dearth of support for new moms. The latest data from the Centers for Disease Control and Prevention showed that hospitals in predominantly black neighborhoods also do less to promote breastfeeding than mostly white hospitals.

Dr. Oz has come under heavy criticism in recent months for promoting junk science on his widely watched television show. He’s been lambasted by experts, by fellow doctors, even by the federal government.

Now Oz is finally responding to those critics. But rather than address their complaints head on, he mostly wants to talk about ... civil liberties. “I know I have irritated some potential allies,” he wrote in Time magazine on Thursday. “No matter our disagreements, freedom of speech is the most fundamental right we have as Americans. We will not be silenced.”

There is no shortage of examples of bogus health claims by celebrities and their disastrous influence on public health and science. Over the years, famous folks have suggested that vaccines cause autism (Jenny McCarthy), that “miracle” diet supplements are the holy grail of weight loss (Mehmet Oz), and that steaming your vagina is, well, a good idea (Gwyneth Paltrow).

While their ability to influence our health choices is proven, it’s rare that celebrities use that influence for good. A notable exception is actress Angelina Jolie, who came out Tuesday as a model health communicator, writing in a New York Times op-ed about the removal of her ovaries and fallopian tubes.

Welcome to Burden of Proof, a regular column in which Julia Belluz (a journalist) and Steven Hoffman (an academic) join forces to tackle the most pressing health issues of our time — especially bugs, drugs, and pseudoscience thugs — and uncover the best science behind them. Have suggestions or comments? Email Belluz and Hoffman or Tweet us @juliaoftoronto and @shoffmania. You can see previous columns here.

Part of this new knowledge includes an overwhelming quantity of health information. It’s constantly produced, reproduced and transmitted to public audiences. Not only are we confused; even the best scientists can’t stay on top of it all. Much of it is wrong.

It’s not an overstatement to say that most of modern medicine and our health hinges on the effectiveness of antibiotics. Whenever you go to the hospital for an operation — a hip replacement, an ACL repair, heart surgery — almost without exception, doctors will give you a dose of antibiotics to prevent infection. Antibiotics also make the cesarean section, one of the single-most life-saving procedures on the planet, possible.

But there’s a scary side to antibiotics, too. More and more, bacteria have outsmarted the exact medicines meant to kill them. Some of these bacteria-fighting wonder drugs either no longer work or are expected to stop working very soon. Just consider the latest superbug outbreak at a Southern California hospital: the New York Times reported that, already, seven patients have been infected, including two who died, and almost 200 others have been exposed.

Medicine wasn’t always science-based. Much of it still isn’t. But over 100 years ago there was a paradigm-shift away from thinking about health care as a healers’ art towards a professionals’ science.

Opinion was downgraded; unbiased, experimental trials, upgraded. By the second half of the 20th century, the medical community realized that it needed to use randomized control trials — which split up a group of people by lottery and give one half a treatment and the other nothing or a placebo — to find out whether the medicines, surgeries, and other interventions doctors were using actually helped patients.

Yet, as medicine has moved closer to science, the notion that we should run high-quality experiments to figure out whether policies work hasn’t taken root in government.

In the US, former Obama and Bush officials recently estimated that only 1 percent of government spending is backed by any evidence at all. Perhaps unsurprisingly, evaluations of government-sponsored social programs found that three-quarters of them have no effect on the people they were designed to help. That’s right: the government spends trillions every year on what often amount to blind guesses.

Internationally, there’s a movement to change this state of affairs. Both the United States and United Kingdom have made substantial progress in recent years in backing up their public programs with actual research evidence. The Canadian government, meanwhile, has lagged behind. The tale of these three countries can prove instructive in how to get evidence into policy — and the obstacles that governments face in their attempts.

The grain study, like many other health studies you read about, is an excellent moment to think about one key insight that could help you live longer than whole grains (or red wine or coffee or chocolate) ever will: a study isn’t a study isn’t a study like any other.

There are literally thousands of ways to design a study. When a news story suggests, “A new scientific study has found...” or a celebrity doctor begins a sentence with, “Studies show...”, you need to ask, “What kind of studies?” Because “studies” are not equally reliable, they all have different limitations, and they should not be acted on in the same manner — or even acted on at all. Here’s a quick guide to understanding study design that will help you navigate the often bewildering world of health research.

You’ll be hearing a lot more about antimicrobial resistance in 2015 because we are literally running out of effective antibiotics.

It’s natural for bacteria and viruses to evolve and slowly resist the drugs that we invent for treating the infections they cause. But for decades, we’ve been speeding up their evolution by overusing antimicrobials when they’re not needed, by not completing prescribed courses of treatment, and by breaking infection control protocols in hospitals where these superbugs can easily spread.

In the past we’ve just invented new medications when the old ones became less effective. Unfortunately that strategy isn’t sustainable: there have been no new discoveries of distinct classes of antibacterials since 1987.

The deepening antimicrobial resistance is scary when it’s coupled with this discovery void: so much of our health depends on antibiotics that work. It’s not just wounds, sore throats, or STDs that need treating. Much of contemporary medical care relies on antibiotics to stop infection. Anyone who has gone through a cancer treatment, an organ transplant, a hip replacement, or a complicated pregnancy — who has a friend that has — benefited from these drugs. That pretty much means all of us.

Governments are finally picking up speed in trying to thwart this crisis. Several US and international responses are planned for next year. The World Health Organization will be publishing a “Global Action Plan on Antimicrobial Resistance” in May 2015. The O’Neill Review in the United Kingdom will publish its findings, building on preliminary results from last week that found antimicrobial resistance will result in at least 10 million extra deaths per year (more than projected cancer deaths) and cost the world economy up to $100 trillion by 2050. There will also be action closer to home: antimicrobial resistance will be a key part of the Obama Administration’s Global Health Security Agenda.

One of the Ebola remedies that’s gaining traction is to isolate West Africa — the hot zone — and close America off to travelers from the region. Yesterday, the calls for a travel ban escalated at a congressional hearing on the epidemic, making it seem like a political eventuality. “It needs to be solved in Africa, but until then, we should not be letting these people in, period,” said Fred Upton, member of the House Energy and Commerce oversight and investigations subcommittee.

The fear of spread is understandable, especially as an Ebola outbreak appears poised to grow closer to home. America recently recorded its first Ebola death with the passing of a Liberian visitor Thomas Duncan, and the CDC announced the first-ever cases of Ebola transmission to two of Duncan’s nurses.

As Ebola panic peaks, conspiracy theories are spreading fast. So now is the time when we need to check our irrational reactions to this horrible crisis and avoid policies that will divert scarce resources from actual remedies. And we know from past experience that airport screening and travel bans are more about quelling the public’s fears and political expediency than offering any real boost to public health security.

The best way to protect Americans is by protecting West Africans

The US government has long known about this threat. It’s one reason why the CDC spends so much time supporting public health institutions in developing countries, why the US Department of Defense invests so heavily in global disease surveillance, and why the National Institutes of Health is the most generous funder of investigator-driven global health research in the world. It’s also why the White House launched a new Global Health Security Agenda last February 2014 – before the current Ebola outbreak – to get ahead of epidemic threats like it.

But this Ebola outbreak — and the failed response — shows in the clearest way how unprepared we are for global pandemics. International institutions like the World Health Organization have been starved for cash to the point that they can’t lead effectively during crises. International laws, like the International Health Regulations which govern responses to pandemics, don’t work in practice. And the US government has often led the way – with ‘zero nominal budget growth’ and ‘no enforcement mechanisms’ as its firm position on international laws.

To date, Ebola has killed more than 3,000 people this year, the largest-ever outbreak of this disease. It’s bound to kill more. Even though the public health community knows from previous outbreaks how to contain it, we did alarmingly little to stop Ebola until very recently — and some say too late.

Nearly five months passed from the time the World Health Organization (WHO) announced that Ebola was in West Africa (March) until this crisis was declared a “public health emergency of international concern” (August).

In August, we started to see unprecedented action, political will, and resources being poured into Ebola. But this surge response only came when it seemed to be politically expedient. As you can see in the chart above, leaders woke up to Ebola when public attention on the disease peaked following the news that two Americans had been infected in Liberia, weeks after Ebola cases had already started their exponential ascent.