Monday, January 28, 2013

Medical Causes of the Sexual Revolution

Prof. Andrew Francis, an economist at Emory, is claiming that penicillin, rather than The (Birth Control) Pill, was the drug that gave us the sexual revolution of the 1960s. The idea is that the post-war availability of penicillin reduced the cost (to both partners) of intimate contact, by substantially reducing the risk (to both partners) of contracting an STD--especially syphilis. This effectively lowered the cost of sexual activity, inducing more people to engage in it (the benefits remaining more or less constant). An easily-accessible version of the story appears on the CBS news site, here.

Let us not lose sight, however, of the vital importance of The Pill. I have spoken personally with women of the 60s generation who were admitted to medical school (imagine this!) only after they'd told an interviewing dean--an actual Dean--that they were on The Pill, and that they didn't intend to let a pregnancy interfere with their progress through medical school, or with their entry into medical practice. "A medical school education, after all," the argument went, "is expensive not only to the student, but also to the faculty and to the government which (at least in the US) has substantially subsidized it for decades; why should we offer it to someone who will quit (and waste the investment) the moment she has a child? We're rather more inclined to enroll you if you can guarantee that you won't have a child--that is, if you tell us you're on The Pill, or will have an abortion if The Pill fails." The assumption, of course, was that if a woman were to have a child, it would be she, rather than her partner, who would give up on her profession and waste the investment made by others in her career. The idea of the working mother--though it was a reality for many working-class Americans--wasn't yet acceptable to Americans of the professional class.

Like access to birth-control, the abortion right announced in Roe v. Wade made it easier for professional schools to admit women. It meant that women could legally prevent themselves from having children whose rearing would interfere with their professional careers. They could control their reproduction even if their efforts at birth control had failed. (Remember, please, that men were *never* asked whether their having children--whether in or out of wedlock--would interfere with their taking full advantage of their educations.)

Punchline: Yes, Professor Francis, it may well be that penicillin did more than The Pill to facilitate the Sexual Revolution--by which we might mean, the widespread acceptance of pre-marital sexual relations. But it was for The Pill  (and the abortion right) to translate that newfound sexual freedom into sexual equality.

Tuesday, January 22, 2013

Harvard Prof Isn't Recruiting Neanderthal Moms

Oh, good. This story isn't true. There isn't actually a Harvard professor who wants to recruit a woman to bear a Neanderthal child from an embryo constructed, using stem-cell and cloning technology, from Neanderthal bone DNA. Turns out there was some translation error in the account of his interview with a German magazine. And the professor is upset. He's not actually proposing to clone a Neanderthal baby; he only thinks the issue should be up for discussion. For several years.
Oh, good.

Quick, Effective Public Health Measures

I'm freshly back from the annual meeting of the Public Health Law Research program, sponsored by Robert Wood Johnson.

At most academic meetings, I prefer schmoozing in the halls to listening to the talks. That's part personal vice, and part stage-of-career: at this point, it matters more who I talk to than whose paper I hear. This conference was different, though--perhaps because I'm new to it. A very large percentage of the papers (and posters!) repaid close attention.

But the best session of the conference, to my mind, was the "Critical Opportunities" session. The session, which is apparently an annual affair, is presented as a competition: a handful of public health law scholars are invited to present their best ideas for high-impact, evidence-based public health interventions that have a chance at actual enactment. The audience votes on which one they think is (to put it roughly) most worth peddling to health-policy folk under the banner, "Do it now!"

This year's choices: a proposal for corn masa flour fortification for the prevention of neural tube defects, made by the CDC's Erica Reott, MPH, LCDR S. Kinzie Lee, MPH, and Amy Cordero, MPA; a proposal for legal reforms to prevent opioid overdose from Corey Davis of UNC Chapel Hill; a proposal from Adam Finkel, Sc.D., of UPenn Law, to make "smart disclosure" rules, like nutritional content labels, more complete and accurate; a proposal to put decals on the cars of teens subject to "novice drive" license restrictions, from Allison Curry, PhD, MPH, of Children’s Hospital of Philadelphia; a proposal for better (and better supported) local governance of public health institutions from Scott Hays & Janine Toth of the University of Illinois at Urbana-Champaign; and a set of proposals for gun-control laws from Marvin Swartz, MD, of the Duke University School of Medicine.

All of the proposals were terrific and important, but I want to take a bit of time to mention a few that might surprise my blogging audience, as they surprised me. I leave aside the Hays/Toth proposals about public health governance, though they were completely sensible and apt to have immense impact over time; and I leave aside the gun control measures, as you're all apt to be reading a great deal about them these days; and, finally, I leave aside the superb presentation on labeling and "smart disclosure" rules, as I have the sense--perhaps wrongly--that we are all aware that many disclosures, mandated as a substitute for regulation on the grounds that people can decide for themselves when adequately informed, do not in fact inform adequately.

I shall instead mention the three options that, for different reasons, gobsmacked me. In each case, I'm relying entirely on data from the presenter's own slides, which I've obtained from the PHLR folks (Thanks, Bethany!)

I present, first, corn masa flour fortification. (This ended up being the crowd's favorite.) Neural tube defects like anencephaly and spina bifida affect about 3000 pregnancies per year. NTD's affect the Hispanic population more profoundly than the rest of the population. This is likely because flour is enriched with folic acid, which helps prevent NTD's, but corn masa flour (widely used in the Hispanic community) is not fortified. Flour fortification has reduced NTD rates by more than a third. A similar rate among Hispanics would prevent 40 NTD's a year. Given the high cost of NTD medical treatment, the public health intervention saves $100 for each $1 spent. And here's the kicker: there is but one major manufacturer of corn masa flour in the US, and this firm has in fact joined public health groups in petitioning the FDA for permission to fortify.

Second, legal reforms to prevent opioid overdose. Did I know that prescription pain-killer overdoses had passed automobile crashes and gun accidents as the number one accidental cause of death in America? No, I did not. 100 a day die from prescription painkiller overdoses--more than die from heroin overdoses and cocaine overdoses combined. There's a drug called Naloxone, which, if administered nasally to someone who's OD'd, will actually interfere with a prescription opioid's effects on the body, and prevent the OD from being fatal. Ambulances and first-responders carry it, but physicians are reluctant to co-prescribe it to people to whom they prescribe pain-killers. This is mainly because the Naloxone is apt to be administered to their patient by someone with whom they don't have a doctor-patient relationship (a relative, or bystander). Docs worry about liability for prescribing a drug to X which is mainly to be administered by not-X. But of course, isn't that how epi-pens are used? Maybe law could be used to create a standard of care that involves co-prescribing the emergency cure with the problematic pain-killers. Next, bystanders often fail to call 911 because they fear arrest. The solution here is a relatively simple, narrow, legal grant of immunity to people who telephone first-responders from the scenes of drug overdoses. Turns out that police--who, after all, have a lot of depressing experience in finding the dead bodies of prescription drug overdosers--don't even mind granting that limited sort of immunity. They'd rather let a few druggies get away than pick up another body. Me, too.

And third, putting decals on cars whose teenaged drivers are subject to various license restrictions, such as not having any non-family members in the car. As the father of a 15 year old, I like this idea. Yes, it makes your car into a police target. That's, um, the idea. Your kid knows s/he's a police target, and caution (or at least obedience to the license-restriction regulations) ensues. Some folks worry that predators will use the decals to make their search for vulnerable teens easier, but really, how hard is it for a predator to look at the driver? And predators, unlike cops enforcing license-restriction rules, aren't picky about the driver's exact age. Here's the main punchline, though: New Jersey put the decals on, and 1600 crashes per year were prevented. Driving is apt to be the most dangerous thing one's teen will ever do, and the decal law helps cops clamp down on teens who evade the sensible rules. In New Jersey, graduated driver's license enforcement rose by 14% after the decals went on. That means, teens who were breaking the rules by driving with their friends in the car were cited, and teens who were driving after dark were cited. As a dad, I'm all in favor.

So: fortify that corn flour! Co-prescribe that antidote! Label those teens! And save lives.