An article that is forthcoming in The Lancet concludes that there will have been a prevalence of nearly 800,000 cases of cholera in Haiti by the end of November, 2011–nearly double the number projected by WHO. WHO’s estimates have themselves been increasing dynamically and are not based on any knowledge of transmission dynamics–in short, they are educated guesses. The reference paper, posted online on March 16, 2011 (www.thelancet.com) is based upon a detailed knowledge of transmission dynamics and interventions, and is a recursive mathematical model by two well known disease modelers (Andrews JR and Basu S. Transmission dynamics and control of cholera in Haiti: an epidemic model. Lancet DOI:10.1016/S0140-6736(11)60273-0) Geographers and spatial epidemiologists will recognize that the model is a multiregional form of disease model that is based on the number of susceptible people, infected individuals, and recovered individuals (“SIR” models) that have been the basis for growth models for decades. Moreover, and perhaps *most importantly*, anticipated early declines in cholera incidence in the coming months are predicted to be part of the natural course of the epidemic, and not the result of any specific public health interventions.
Cholera is a waterborne bacterial disease, transmitted via the fecal-oral route, that can progress from asymptomatic stages to death within a period of less than 18-24 hours. The only effective treatment is oral or intravenous rehydration using physiologically balanced water/electrolyte solutions–with the electrolytes in clean water only. When available, this can be combined with oral or IV doxycycline, ciprofloxacin, or other appropriate antibiotics. Oral rehydration in this form–a fundamentally simple and low-tech treatment–was devised by Dr. Richard Cash of the Harvard School of Public Health, credited with saving millions of lives.
There is tremendous unexplained variation in rates of surgical procedures from hospital catchment area to hospital catchment area, and region to region that cannot be explained by epidemiologic factors. For example, colleagues and I discovered in 1992 (see Spine, 1992) that the 15 fold difference in surgical procedures on the spine in Washington State was inexplicable by almost all population and diagnostic factors.
These sorts of studies were first called “small area analyses” by John Wennberg, MD, of Dartmouth Medical School–a specialist in internal medicine who then combined this with epidemiology and geography and who has a profound impact on understanding our heath care system–and those of other countries. His work has figured prominently in recently passed health reform, and figured prominently in policy alternatives in the Clinton administration. Quite simply, geographic variation is explained largely by different practice styles–and the greater the spatial variation, the less the consensus on the evidence base for proceeding in any given direction from a medical point of view. Put another way, the weaker the evidence base clinically, the greater the spatial variation in practice patterns. As Wennberg writes:
In Health Care, Geography is Destiny
Early in my career, I was hired as director of a federally sponsored program whose goal was to ensure that all Vermonters had access to recent advances in the treatment of heart disease, cancers, and stroke. As part of the program, my colleagues and I developed a data system that we thought would help us identify which Vermont communities were underserved, and thus in need of the program’s help. As the results came in, however, rather than evidence for underuse (i.e., patients not getting care they needed), we found extensive and seemingly inexplicable variation in the way health care was delivered from one Vermont community to another. In Stowe, for example, the rate of tonsillectomy was such that by age 15, about 60% of children were without tonsils, while in the bordering town of Waterbury, only 20% had undergone the surgery by that age. Among communities, the chances that a woman would have her uterus surgically removed varied by more than fourfold, and the rate of gallbladder surgery varied by more than threefold. Rates of hospitalizations for a host of different medical conditions also varied in ways that made little sense; on a per capita basis, patients were hospitalized in Randolph two times more often for digestive disease than in Middlebury and three times more often for respiratory disease.
Wennberg was the moving force behind Dartmouth’s “Atlas of Health Care” center, and subsequent centers for comparative clinical effectiveness. His work has spearheaded the whole movement of evidence-based medicine, the necessity of which became obvious from the mysterious spatial variations in care–mysteries originally uncovered by Wennberg nearly 40 years ago that in some counties, only 20% of teenagers were missing their tonsils, whereas in other counties, 70% had had tonsillectomies–with no seeming underlying rationality.
Wennberg has now published a thought provoking analysis of the implications of his work. Most significantly, it may be possible to eliminate billions of dollars from our health care bill without negative consequences for health status. These are funds that could then be allocated to increasing the access for disadvantaged groups.
So I highly recommend Tracking Medicine: A Researcher’s Quest to Understand Health Care, Oxford University Press, 2010, not only because it is a prime example of how geographic reasoning has had a profound impact on health care legislation, but as a glimpse into the intellectual history of an individual who has one of the deepest understandings of what lack of evidence-based medicine has done to our society.
For a local perspective on place-based and race-based health care provision and health outcomes, see the current American Prospect story, “Home Disadvantage,” about health disparities and people of color in Seattle’s South Park neighborhood.
Professor Michael Brown (UW-Seattle Department of Geography) and Professor Larry Knopp (UW-Tacoma Director of Interdisciplinary Arts & Sciences) have been awarded a 3-year, $250,000 National Science Foundation grant to conduct a study titled “Urban Governmentalities in Local-State Relations with a Marginalized Population”. The project explores the roles of the Seattle-King County Department of Public Health and the Washington State Liquor Control Board in the regulation and control of male homosexuality between 1945-1982 and will employ two graduate students for seven quarters over three academic years.
As always, there are plenty of talks around campus this week that may be of interest to Geographers. Interested in gender, race and care work; the construction of truth claims about the social and cultural past through archaeology; mental health in the US; ocean acidification; or recent revolutionary movements in the Middle East? If so, then check out some of these great talks!
“Forced to Care: Race, Gender and the Obligation to Care”
WHEN: Tuesday, February 15 at 6:30 pm
WHERE: 120 Kane Hall
SPEAKER: Evelyn Nakano Glenn, professor of Gender & Women’s Studies and of Ethnic Studies at UC Berkeley
MORE INFORMATION & RSVP: Find out more and RSVP here
“Who Owns the Past?: Stewardship and Collaborative practice in Archaeology”
WHEN: Wednesday, February 16, from 12:30 – 1:20 pm
WHERE: 220 Odegaard Undergraduate Library
SPEAKER: Alison Wylie, Department of Philosophy
OTHER INFORMATION: This is a part of Research Exposed!, a series of presentations on current UW research that can also be taken for credit.
“Transforming the American Conversation about Mental Health”
WHEN: Wednesday, February 16 at 5:30 pm
WHERE: 220 OUGL
SPEAKER: Jennifer Stuber, University of Washington, Social Work
OTHER INFORMATION: This is part of the “Unspeakable: Disability History, Identity, and Rights” film & lecture series.
REGISTRATION: This is event is co-hosted by the School of Social Work and Department of Communication. Registration required
“Gender Stereotypes – How They Discourage Unconventional Career Choices and Limit Opportunities”
WHEN: Wednesday, February 16, from 7:00 – 9:00 pm
WHERE: 120 Kane
SPEAKERS: Sapna Cheryan, Assistant Professor, UW Department of Psychology; Alice Eagly, Professor of Social Psychology, Northwestern University Department of Psychology
OTHER INFORMATION: Women continue to be underrepresented in the sciences and engineering and in leadership positions within politics and business despite considerable gains made in other areas over the last few decades. Drs. Cheryan and Eagly examine the social and structural obstacles that contribute to this underrepresentation. They also will share promising individual strategies and institutional interventions that promote gender equality in traditionally male-dominated domains.
REGISTRATION: Please RSVP for this event
“Can an Acerbic Congress Deal with Acidic Oceans?”
WHEN: Thursday, February 17 at 4:30 pm
WHERE: 102 Fishery Sciences
SPEAKER: Brain Baird, U.S. Congressman
DETAILS: Ocean acidification has been called “the other CO2” problem because it gets far less attention than climate change but may be even more destructive to the planet. Congressman Brian Baird, former chair of the House Science and Technology’s subcommittee on Energy and Environment, and author of the Federal Ocean Acidification Research and Monitoring Act of 2009, will discuss the environmental implications of ocean acidification and the policy and political demands of meeting this challenge. This issue is particularly acute for our region, where the latest research has shown acidification levels much higher than had been predicted and where adverse environmental impacts are already being observed.
OTHER INFORMATION: This is a part of the Bevan Series on Sustainable Fisheries
“Revolt in the Arab World: Activists from Egypt, Tunisia & Palestine Speak Out “
WHEN: Thursday, February 17 at 7:00 pm
WHERE: 211 Smith
SPEAKERS: Tarek Dawoud, Egyptian activist and President of the Council on American Islamic Relations (CAIR)- Washington; Amin Odeh, member of Voices of Palestine & Arab American Community Coalition; Zied Mhirsi, eyewitness and participant in the Tunisian revolution (skyping live from Tunisia)
OTHER INFORMATION: Celebrate the first victory of the Egyptian revolution and join this panel of activists from the Middle East in a discussion about the wave of revolution sweeping the Middle East and what lies ahead.