Andrew Hyde's blog

County by County Life Expectancy: How Many Americas are There?

Andrew Hyde — Thu, 15 May 2008 11:24:20 -0700

Over the past couple of weeks Josh Eveleth and I have answered journalists’ enquiries from many different pockets of the United States about the recently published paper by Majid Ezzati and colleagues. The research, which analyzes mortality data for every county in every US state over four decades, finds a steady increase in mortality inequality across counties between 1983 and 1999.

It provoked an intense debate and discussion nationally, but also at a very local level (the local discussions are particularly interesting for someone whose travels in America have not gone much further than visiting the PLoS San Francisco office and whose experience of Vineland is the Thomas Pynchon novel rather than the New Jersey counties covered by the Vineland Daily Journal).

For example, by making the supporting datasets (and figures and video files) that demonstrate the changes in life expectancy county by county freely available in PLoS Medicine, the Roanoke Times was able to report statistics for Pulaski and Radford counties in Virginia. (An alarming finding from the study – as the New Scientist reported – is that there has been a decline in life expectancy in some of the poorest sections of the population, primarily among women in the Southern States). On a national level, the paper was on the cover of the New York Times Week in Review with former Democratic Vice Presidential Nominee John Edwards commenting that the findings demonstrate how "the wealth and income disparity effectively infiltrates all parts of people’s lives." Edwards was asked to comment because of his national campaign to end poverty in America by 2036.

Worth listening to are the interviews on NPR's Science Friday show and the shorter broadcast on Voice of America. As Ezzati makes clear in both of them, on average life expectancy has risen for American men and women since the 1960s, but is from the 1980s that the troubling geographical disparities have worsened and some counties have experienced stagnation and even a decline. This kind of worsening of life expectancy for segments of the population is not something usually associated with developed high-income countries - in the Voice of America interview, Ezzati observes it that this worsening is something that happened after the fall of the Soviet Union when the health and social networks in Eastern Europe collapsed.

In an online interview with the Washington Post Ezzati fields questions and theories about the trends from readers in the West and the East of the country, from San Francisco, California to Eastern Shore, Maryland. He illustrates the point that this worsening of life expectancy is a phenomenon occurring in the United States and not Europe by referring to the Human Mortality Database. This is a project set up by researchers at the University of California, Berkeley and at the Max Planck Institute for Demographic Research in Rostock, Germany, to provide historical mortality data for many countries.

The Economist and the Wall Street Journal (which embedded one of our video files in the blog to complement the story) focused on the impact that diseases linked to smoking or obesity, such as lung cancer and diabetes, have had on life expectancy. ABC News quoted Ezzati to demonstrate that these negative trends have affected women particularly: "one out of five American women have had their health either getting worse or at best not getting better."

The study is a troubling but fascinating reminder of how huge the United States is and how wide the disparities within it are. Whilst John Edwards spoke of "two Americas" in the 2004 Presidential election campaign, a 2005 PLoS Medicine paper by Majid Ezzati and colleagues established "eight Americas" in terms of mortality disparities across race and counties. In the Voice of America interview, Ezzati says he hopes the new study raises awareness about health care in America and prompts monitoring of those being left behind in order to understand what kind of policies and interventions can reverse the decline in life expectancy.

Trackback URL for this post:

http://www.plos.org/cms/trackback/353

Prozac and Placebos: Review of a Media Maelstrom

Andrew Hyde — Thu, 6 Mar 2008 12:08:30 -0800

Last week we had the interesting experience of watching how a PLoS Medicine meta-analysis of anti-depressant drug trials generated a furore in the media. It featured on the front page of four UK national newspapers (the Guardian, the Telegraph, the Independent and the Times), was the leading item on the BBC News and prompted stories in Time, the Wall Street Journal and the Economist.

The paper not only posed questions about the benefits of antidepressants, it revealed how many clinical trial results do not see the light of day. But whilst the issues relating to it continue to be debated – a discussion leads the Guardian Science Weekly Podcast this week– some of the headlines in the media maelstrom misrepresented the study.

Irving Kirsch and colleagues used Freedom of Information legislation in the United States (see the methods section) to get access to both published and unpublished clinical trials of several SSRI/SNRI antidepressants, including fluoxetine (Prozac), that had been submitted to the Food and Drug Administration for approval. Analyzing the full dataset, which included studies of varying duration and quality, the researchers found no clinically significant difference between a patient’s response to the placebo and these antidepressants for most depressed people. Their analysis did find clinically relevant effects for a subset of the most severely depressed patients.

The headlines started appearing at 1am GMT on Tuesday 26th, as soon as the embargo ended. The front page of the Independent (“Antidepressant drugs don’t work – official study”), the Guardian (“Prozac, used by 40 million people, does not work”) and the Times (“Depression drugs don’t work, finds data review”) all opted for an outright statement that antidepressants don’t work. But the study does not show that antidepressants do not work. Rather, the evidence reviewed in this analysis did not show these antidepressants to produce enough of a beneficial effect over the placebo to be termed clinically significant. Language Log, a linguistics blog, gives an account of how some journalists got tangled up in their own sentences when trying to describe the results. (Thanks to Rebecca Walton for pointing this one out).

Time Magazine opted for a slightly different presentation (“Antidepressants Hardly Help”), pointing out that there is a difference between “statistical significance” and “clinical significance." The article quotes the authors directly to say that only those “at the upper end of the very severely depressed category” get a clinically significant benefit. It also makes reference to the Hamilton Depression Rating Scale: the tool used by UK authorities to determine clinical significance.

The interview on the BBC Radio 4 Today programme touched upon the crucial issues in the space of five minutes. It features a debate between Irving Kirsch and Richard Tiner of the Association of British Pharmaceutical Industry. Irving Kirsch summarizes the results of the study, before they dispute whether or not NICE (National Institute for Health and Clinical Excellence), the body guiding clinicians in the UK, could get access to all of the information that they needed. This item makes the point - missing from some of the other coverage - that people taking antidepressants should not change their behavior on the basis of this report or the headlines. If worried, they should consult their doctor.

So some of the headlines were off the mark, but one good thing that can come out of the coverage is a re-ignition of the debate in the media about the importance of having access to all clinical trials data – not just the positive results pushed for publication by pharmaceutical companies.

In Bad Science, Ben Goldacre also sees the real importance of the study lies in the “fascinating story of buried data.” Noting that the authors had to use the Freedom of Information Act to get all the data from the FDA, he says the fact that “medical academics should need to use that kind of legislation to obtain information about trials on pills which are prescribed to millions of people is absurd.” The Independent ran an article to explain publication bias to a wider audience. In her Comment is Free piece, Sarah Boseley asks whether we can trust that the licensing authorities have all the data they need to approve drugs.

In comparison with the wall to wall headlines the study got in the UK, there was less coverage in the United States. Although the study was covered in North America (Fox News linked to the paper and CTV covered it in Canada, amongst others), of the major American papers we only found that the Wall Street Journal has original coverage. As Washington Monthly remarked (with bloggers theorizing), this is interesting considering that the study uses clinical trials data from the Food and Drug Administration, the licensing authority in the United States.

Pulse reports that NICE are to consider unpublished data on antidepressants before their guidance on depression is published later this year, so the ramifications of the study are set to continue. In the light of the PLoS Medicine study the Guardian returned to the earlier story that the UK government plans to train additional therapists to combat the difficulties that patients have in accessing non-pharmaceutical forms of therapy for depression.

Hopefully some informed debate about drugs and depression in general can come out of all of this coverage. Read some of the reader responses that we’ve received - in particular the compelling response by Jeanne Lenzer and Shanon Brownlee, which does a good job of suming up the most important implications of the study. They write:

“The take home message of Kirsch’s analysis is that it is difficult if not impossible to come to conclusions about the relative merits and risk of medications when only parts (usually positive parts) of the data are available. The problem of publication bias is so powerful that it has certainly distorted interventions besides antidepressants – a problem we discuss in our commentary in this week’s BMJ".

Trackback URL for this post:

http://www.plos.org/cms/trackback/335

Prozac and Placebos

from Greg Laden's Blog on Thu, 2008-03-06 16:12

Late last month, I put up a quick post, New-generation antidepressants do not produce clinically significant improvements in depression, that addressed a PLoS published metastudy of interest. I was careful to use the phrasing from the paper as the titl...

No Such Thing as a Free Lunch (or Gift or Sample)

Andrew Hyde — Mon, 11 Feb 2008 09:45:59 -0800

Are the staggering amounts spent by drug companies on marketing justified by their innovation in drug development? Not according to a Policy Forum in PLoS Medicine which has stimulated a great deal of debate across blogs and news sites over the past couple of weeks.

The analysis by Marc-Andre Gagnon and Joel Lexchin dispels the image promoted by the pharmaceutical industry that it is "research-driven, innovative, and life-saving." The data they obtained from IMS (a market research company that surveys pharmaceutical companies for information on drug promotion) and CAM (who survey doctors instead of firms) demonstrates the extent to which the industry is actually driven by marketing. They find that for 2004 nearly twice as much was spent on promotional activities than on research and development.

That's US $61,000 spent on promotion per physician in the United States, as Howard Brody of the University of Texas Medical Branch exclaimed in his blog before reflecting upon the lack of transparency in the industry. As ABC Television News reported, Gagnon and Lexchin suggest that there are other promotional revenues that won't have been captured by the market research data. (These include the ghostwriting of articles in medical journals by drug company employees, the subject of a PLoS Medicine essay last September).

Concern about direct to consumer advertising of drugs was prominent in the Consumerist – an influential consumer affairs blog – which clocked up over 50 comments in response to the paper. In Canada, CBC News made reference to the practice known as detailing (drug reps visiting doctors to persuade them to promote specific drugs, as described in a previous PLoS Medicine Policy Forum). However, Gagnon and Lexchin go on to say that the extent of detailing could be underestimated by the IMS data which obtains its figures direct from the industry. Readers of the Sci Guy blog of the Houston Chronicle expressed concern about how physicians can be compromised by gifts and drug samples, prompting a post from No Free Lunch, an organization dedicated to convincing physicians that such gifts represent a conflict of interest.

A statement from PhRMA (Pharmaceutical Research and Manufacturers of America (PhRMA) – quoting its own figures to counter the analysis – was in the Peterborough Examiner. (For those of you in the UK, that's Peterborough, Ontario not Peterborough, Cambridgeshire).

Fittingly, for authors who took the opportunity of publishing a French translation of the abstract with their the study, media coverage also came in Le Figaro. For those of you adept in other languages, you can read the coverage in Italy (La Repubblica), Argentina (Clarin) and Germany (Der Spiegel).

Trackback URL for this post:

http://www.plos.org/cms/trackback/322

Fearsome foursome factors of longevity

Andrew Hyde — Fri, 11 Jan 2008 10:51:58 -0800

Following the recent blog that related a PLoS paper to end of year excess, this week a PLoS Medicine study evaluating the combined impact of four healthy forms of behaviour was devoured by journalists keen to remind us to stick to New Year resolutions. This was certainly the approach of the New Scientist who let their readers know that no matter how “fat or unhealthy you already are" the conclusions of the study by Kay-Tee Khaw and colleagues are important. Conducted amongst 20,000 participants in the UK, the study found that those who are non-smokers, take exercise, have a moderate alcohol intake and eat five servings of fruit and vegetables a day live on average an additional fourteen years of life compared with people who adopt none of these behaviours.

The BBC were also quick to report on the paper – even reproducing one of the figures – and by midday on Tuesday it had jumped to the most viewed article and the one that was emailed most to friends. Interviewed on the BBC Television News Nick Wareham, one of the authors of the paper, stressed that even small changes in behaviour can have a significant impact on the health of populations. Elsewhere in the UK, the paper was picked up by the Guardian and the Telegraph.

“Isn’t it all quite obvious?” asked a comment responding to the Daily Mail article about the research. Whilst there is overwhelming evidence that individual aspects of lifestyle – such as smoking and diet – affect health and longevity, the study Kay-Tee Khaw and colleagues quantified the combined impact of four, an approach that is not usually taken. The research forms part of the European Prospective Investigation into Cancer and Nutrition (EPIC): conducted across ten European countries, it is the largest investigation into diet and health ever undertaken. Certainly scepticism amongst the general public is one of the many factors that makes the translation of research into public health policy complex – the subject of our editorial – and this was also evident on the other side of the Atlantic in response to coverage by the Washington Post and Chicago Tribune amongst others. “With all these good habits, there's still a chance you'll be killed while out on a hiking trail” was one of the cheerful comments replying to the San Francisco Chronicle’s article. Those hoping for an immediate extension to their lifespan were disappointed by Dr. Kim Mulvihill, a columnist for CBS, who helpfully pointed out that people who adopt these four behaviours do not “automatically gain 14 years.” “The 14 years is an average across the population of what's theoretically possible” realized Tim Armstrong for CBC in Canada. Down Under, the paper was covered in the Sydney Morning Herald and the Australian.

One of the key things about the paper as made evident in the methods section – in contrast to the usual confusing barrage of information from medical journals, government reports and the popular media – was the use of simple health indicators to score participants in the questionnaire for the study. The authors state that an analysis of how the combined health behaviours affect quality of life is also needed (although the four factors are not thought to rule out watching the cricket and drinking a beer, which will leave one public health expert interviewed for the Age in Melbourne relieved). Nevertheless, the results of the study do suggest that these four achievable lifestyle changes could have a marked improvement on the health of middle-aged and older people, which is particularly important given the ageing population in the UK and other European countries.

You can respond to the freely available article through our reader response system.

Trackback URL for this post:

http://www.plos.org/cms/trackback/307

Interview with Sheri Weiser: Effect of Food Insecurity on HIV/AIDS

Andrew Hyde — Thu, 1 Nov 2007 05:19:05 -0700

Sheri Weiser, corresponding author of a study in PLoS Medicine on the link between food insecurity and high risk sexual behaviour, featured in the PLoS collection on poverty, has been interviewed by the Kaiser Family Foundation about her research.

The interview provides an excellent overview of the study, which concludes that for women in Botswana and Swaziland food insecurity is strongly associated with the likelihood of engaging in unprotected sex, the exchange of sex for food or other resources, and lack of control in their sexual relations.

Sheri Weiser explains that factors such as socioeconomic status and education cannot in themselves account for the results:

“Overall what we are talking about here [are] people who had to make impossible choices. They had to make trade offs for instance… between dying now from starvation and potentially dying later from HIV and income and education just don’t adequately capture those complexities.”

Whilst these issues are most salient in Africa, the continent with the highest prevalence of HIV and malnutrition, Sheri Weiser argues they have resonance across the world:

“We’re talking about pretty much anywhere where women are dependent on men for food and resources and where women lack power in society and their relationships. We’re even seeing some similar patterns in some very preliminary work that we’re doing amongst homeless and marginally housed individuals in the US.”

The tendency of the West to focus efforts on the individual through educational and information campaigns has arguably neglected the structural problems (such as poverty and food insecurity) that put people at risk of HIV. The study suggests that hunger alleviation and the fight against AIDS cannot be considered independently. Sheri Weiser concludes the interview by arguing that vast scaling up in the funding to alleviate hunger is needed; the partnering of sustainable hunger relief and AIDS organisations is essential; and that an understanding of underpinnings of gender discrimination in sub-Saharan Africa and elsewhere is requried in order to change the direction of the epidemic.

A perspective article by Nigel Rollins on the research was also published as part of the poverty collection. These articles appear in the Global Theme Issue on Poverty and Human Development organized in October by the Council of Science Editors.

Trackback URL for this post:

http://www.plos.org/cms/trackback/281

In the August issue of PLoS Medicine

Andrew Hyde — Thu, 30 Aug 2007 12:33:22 -0700

The PLoS Medicine Editors, in the editorial for August 2007, focus on the role of qualitative methods in medical research. (We were promoted to write it having recently published another qualitative paper.) Our understanding is that it is now generally recognised that such methods do have an important role to play. Or have we got it all wrong; is there still a reluctance to accept that anything useful can be learned from research without numbers?

The International Journal of Social Research Methodology, a journal that is unlikely to be seen often by PLoS Medicine readers, recently published an optimistic article [1] claiming the ‘paradigm wars’ that have raged amongst social scientists over quantitative and qualitative methods are finally over, and that peace has been brokered not by the years of unproductive philosophical debate but by the emergence of pragmatism. Do we also have ‘paradigm peace’ in medical science or have our paradigm wars only just begun? It’s a point on which we’d like some feedback from our readers.

I have observed hostility towards both the two paradigms. I once took a nutrition course alongside a social scientist who was visibly distressed by her first statistical exercise – food aid was being distributed to villages in a fictitious country on the basis of whether the prevalence of malnutrition (based on an anthropometric index) was determined by a statistical test to be significantly greater than the national average. This approach was not only offensive to everything the social scientist had personally believed in but went against everything she had been taught. How could the complex situation faced by each child and each community be reduced to mere numbers?

But no doubt an equal degree of horror would be expressed by many a quantitative researcher at such aspects of qualitative methods as purposive sampling, an example of which is provided by a study by Green et al [2]. In a survey of how patients were coping with glaucoma they came to hear of a young woman was dealing with her situation in an unusual and successful way; they felt she had to be added to their sample, even though she was entirely unrepresentative. In research of this kind it is important to examine the full range of experience; at the far ends of the range one is more likely to discover something new, thus generating hypotheses and opening new directions for research

But, if qualitative research is to be published, it must be of good quality. There is no general agreement as to the criteria that we as editors should apply. Bryman1 argues for ‘bespoke criteria’; in other words each paper should be regarded on its own merits and in terms of the research question it is addressing. Most medical researchers would in contrast argue that there is a need to develop criteria that can be universally applied. (Appropriate criteria have been suggested, for example, by Greenhalgh.) Further debate is clearly needed and what better place for it than PLoS Medicine?

Elsewhere in the August issue can be found research that features a diversity of methods and specialties, not to mention what we are publishing in our ‘magazine section’. Having lived in Kenya and having slept under many a mosquito net there and elsewhere, I’m drawn to the Kenyan research reported in a paper by Noor et al. We already know that insecticide-impregnated nets (ITNs) are effective, but the best approach to adopt in order to ensure that all children at risk of malaria sleep under an ITN is a separate research question, and an issue that has been the subject of considerable controversy. This findings of this study provide convincing evidence that ITNs must be made available free, and that the expenditure involved can therefore be justified. The data in this study forms part of the evidence used by the World Health Organization to support its revised recommendations (issued 16th August 2007) on the promotion and use of bednets.

References

1. Bryman A. Paradigm Peace and the Implications for Quality, International Journal of Social Research Methodology, Volume 9, Issue 2 April 2006 , pages 111 - 126
2. Green J, Siddall H, Murdoch I. Soc Sci Med. 2002 Jul;55(2):257-67. Learning to live with glaucoma: a qualitative study of diagnosis and the impact of sight loss.

On behalf of Paul Chinnock

Trackback URL for this post:

http://www.plos.org/cms/trackback/256

In the July issue of PLoS Medicine

Andrew Hyde — Mon, 30 Jul 2007 12:00:17 -0700

As illustrated by this month's image – the deceptively pretty Nicotiana tabacum, from which tobacco is made – the tricky question of whether the public health interest is served by publishing papers about harm-reducing but still harmful alternatives to tobacco is raised in the July issue of PLoS Medicine. Snus is a smokeless tobacco product that is widely used as an alternative to cigarettes in Sweden and is associated with less risk to health than smoking. In The PLoS Medicine Debate Carol Gartner and Wayne Hall argue the case for providing public information about snus, suggesting that it could be recommended to inveterate smokers. However, Simon Chapman and Becky Freedman argue that such an approach would simply play into the hands of the tobacco industry, which is already marketing the use of snus with slogans that promote smoking too. Bans on smoking in public places - such as the legislation that came into effect in England earlier this month - have not only benefited the non-smokers in the PLoS Cambridge office frequenting the Maypole public house every Friday lunch time, but have also stimulated smokers to quit. Should a medical journal advocate the abolition of all tobacco products? Or is the discussion of the use of a product such as snus as a harm reduction measure a legitimate topic? These issues are discussed in the the July Editorial and (not for the first time) the PLoS Medicine editors could not come to an agreement. What do you think?

The difficulty of changing behaviour is examined in a different context by Sally Munro and colleagues. They conducted a systematic review of the qualitative research into adherence to tuberculosis treatment; in other words, a review of the medical literature in which patients and their families had been asked to say how they felt about their treatment. From their careful appraisal they were able to classify the major structural, social and personal factors associated with the difficulty of completing treatment. Would the greater involvement of patients in the decisions made about their treatment improve adherence? The authors indicate that future interventions involving patients in decision-making could help reduce the global disease burden of tuberculosis.

Another research article in the issue investigates the difficulty of changing doctors’ prescribing habits. Antihypertensive drugs are a major part of national drug expenditure in developed countries, where nearly one person in ten is treated for uncomplicated hypertension (high blood pressure). The different classes of these drugs are all effective but their costs vary widely. Norway introduced a regulation requiring doctors to prescribe thiazides, which are a tenth of the price of many non-thiazide drugs. Atle Fretheim and colleagues evaluate the effects of the new reimbursement rule on drug expenditures and on the proportion of patients reaching their recommended blood-pressure goal.

Two magazine section papers on HIV that could have health policy implications are published in the July issue. Recent clinical trials in Africa – including a paper published in PLoS Medicine in 2005 - found that male circumcision reduces the risk of acquiring HIV from heterosexual sex. Patrick Sullivan and colleagues ask what the implications of these studies are for the United States. And in a policy forum relating to a recent court case against the US Agency for International Development, Nicole Frank Masenior and Chris Beyrer argue that the pledge organizations have to take condemning prostitution in order to receive US funding for HIV prevention has restricted the attempt to control the global HIV epidemic.

The latter piece has already provoked a number of replies that you can see in our reader response archive. As ever, we encourage our readers to contribute to the discussion through the blog or the reader response system.

Trackback URL for this post:

http://www.plos.org/cms/trackback/245