Kevin Lewis

October 09, 2018

Public Health in a Cross-National Lens: The Surprising Strength of the American System
Michael Sparer & Anne-Laure Beaussier
Journal of Health Politics, Policy and Law, October 2018, Pages 825-846


Critics of the US health system argue that a higher proportion of the health dollar should be spent on public health, both to improve outcomes and to contain costs. Attempts to explain the subordinate status of public health in America highlight such factors as distrust in government, federalism, and a bias toward acute care. This article considers these assumptions by comparing public health in the United States, England, and France. It finds that one common variable is the bias toward acute care. That the United States has such a bias is not surprising, but the similar pattern cross-nationally is less expected. Three additional findings are more unexpected. First, the United States outperforms its European peers on several public health metrics. Second, the United States spends a comparable proportion of its health dollar on prevention. Third, these results are due partly to a federalism twist (while all three nations delegate significant responsibility for public health to local governments, federal officials are more engaged in the United States) and partly to the American version of public health moralism. We also consider the renewed interest in population health, noting why, against expectations, this trend might grow more quickly in the United States than in its European counterparts.

Weaponized Health Communication: Twitter Bots and Russian Trolls Amplify the Vaccine Debate
David Broniatowski et al.
American Journal of Public Health, October 2018, Pages 1378-1384

Methods: We compared bots’ to average users’ rates of vaccine-relevant messages, which we collected online from July 2014 through September 2017. We estimated the likelihood that users were bots, comparing proportions of polarized and antivaccine tweets across user types. We conducted a content analysis of a Twitter hashtag associated with Russian troll activity.

Results: Compared with average users, Russian trolls (χ2(1) = 102.0; P < .001), sophisticated bots (χ2(1) = 28.6; P < .001), and “content polluters” (χ2(1) = 7.0; P < .001) tweeted about vaccination at higher rates. Whereas content polluters posted more antivaccine content (χ2(1) = 11.18; P < .001), Russian trolls amplified both sides. Unidentifiable accounts were more polarized (χ2(1) = 12.1; P < .001) and antivaccine (χ2(1) = 35.9; P < .001). Analysis of the Russian troll hashtag showed that its messages were more political and divisive.

Happy birthday? An observational study
Gabrielle Kelly & Cecily Kelleher
Journal of Epidemiology & Community Health, forthcoming

Methods: Birthday and deathday for the following groups were recorded: British prime ministers, US presidents, Academy Award best actor, best female actor, best director, Nobel Prize winners, Wimbledon men’s and ladies' singles winners, all from when records began. For each group, the difference in days between the deathday and birthday was calculated. Under the hypothesis of no association, one can expect the difference to have a uniform distribution. This is assessed using goodness-of-fit tests on a circle.

Results: All groups showed some departure from the uniform and it occurred around the birthday in all groups. British prime ministers, US presidents, Academy Award actors and directors, Nobel Prize winners and Wimbledon men show a ’dip' in deaths around the birthday. The length of the ’dip' varied between the groups and so they gave different p-values on different test statistics. For Academy Award female actors and Wimbledon ladies, there was rise in deaths before and after birthday. When Nobel Prize winners were subdivided into their categories, Science and Literature had a ’dip' around the birthday, but not other categories.

Humidity as a non-pharmaceutical intervention for influenza A
Jennifer Reiman et al.
PLoS ONE, September 2018 


Influenza is a global problem infecting 5–10% of adults and 20–30% of children annually. Non-pharmaceutical interventions (NPIs) are attractive approaches to complement vaccination in the prevention and reduction of influenza. Strong cyclical reduction of absolute humidity has been associated with influenza outbreaks in temperate climates. This study tested the hypothesis that raising absolute humidity above seasonal lows would impact influenza virus survival and transmission in a key source of influenza virus distribution, a community school. Air samples and objects handled by students (e.g. blocks and markers) were collected from preschool classrooms. All samples were processed and PCR used to determine the presence of influenza virus and its amount. Additionally samples were tested for their ability to infect cells in cultures. We observed a significant reduction (p < 0.05) in the total number of influenza A virus positive samples (air and fomite) and viral genome copies upon humidification as compared to control rooms. This suggests the future potential of artificial humidification as a possible strategy to control influenza outbreaks in temperate climates. There were 2.3 times as many ILI cases in the control rooms compared to the humidified rooms, and whether there is a causal relationship, and its direction between the number of cases and levels of influenza virus in the rooms is not known. Additional research is required, but this is the first prospective study suggesting that exogenous humidification could serve as a scalable NPI for influenza or other viral outbreaks.

Education can reduce health differences related to genetic risk of obesity
Silvia Barcellos, Leandro Carvalho & Patrick Turley
Proceedings of the National Academy of Sciences, forthcoming


This work investigates whether genetic makeup moderates the effects of education on health. Low statistical power and endogenous measures of environment have been obstacles to the credible estimation of such gene-by-environment interactions. We overcome these obstacles by combining a natural experiment that generated variation in secondary education with polygenic scores for a quarter-million individuals. The additional schooling affected body size, lung function, and blood pressure in middle age. The improvements in body size and lung function were larger for individuals with high genetic predisposition to obesity. As a result, education reduced the gap in unhealthy body size between those in the top and bottom terciles of genetic risk of obesity from 20 to 6 percentage points.

Public Health Efforts and the Decline in Urban Mortality
Mark Anderson, Kerwin Kofi Charles & Daniel Rees
NBER Working Paper, September 2018


Using data on 25 major American cities for the period 1900-1940, we explore the effects of municipal-level public health efforts that were viewed as critical in the fight against food- and water-borne diseases. In addition to studying interventions such as treating sewage and setting strict bacteriological standards for milk, which have received little attention in the literature, we provide new evidence on the effects of water filtration and chlorination, extending the work of previous scholars. Contrary to the consensus view, we find that none of the interventions under study contributed substantially to the observed declines in total and infant mortality.

Sudden infant death and social justice: A syndemics approach
Melissa Bartick & Cecília Tomori
Maternal & Child Nutrition, forthcoming


Sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS) prevention has focused on modifying individual behavioural risk factors, especially bedsharing. Yet these deaths are most common among poor and marginalized people in wealthy countries, including U.S. Blacks, American Indians/Alaskan Natives, New Zealand Māori, Australian Aborigines, indigenous Canadians, and low‐income British people. The United States now has the world's highest prevalence of SUID/SIDS, where even Whites' SIDS prevalence now approaches that of the Māori. Using public databases and the literature, we examine SUID/SIDS prevalence and the following risk factors in selected world populations: maternal smoking, preterm birth, alcohol use, poor prenatal care, sleep position, bedsharing, and formula feeding. Our findings suggest that risk factors cluster in high‐prevalence populations, many are linked to poverty and discrimination and have independent effects on perinatal outcomes. Moreover, populations with the world's lowest rates of SUID/SIDS have low‐income inequality or high relative wealth, yet have high to moderate rates of bedsharing. Employing syndemics theory, we suggest that disproportionately high prevalence of SUID/SIDS is primarily the result of socially driven, co‐occurring epidemics that may act synergistically to amplify risk. SUID must be examined through the lens of structural inequity and the legacy of historical trauma. Emphasis on bedsharing may divert attention from risk reduction from structural interventions, breastfeeding, prenatal care, and tobacco cessation. Medical organizations play an important role in advocating for policies that address the root causes of infant mortality via poverty and discrimination interventions, tobacco control, and culturally appropriate support to families.

Why Is Infant Mortality in the United States So Comparatively High? Some Possible Answers
Peter Muennig et al.
Journal of Health Politics, Policy and Law, October 2018, Pages 877-895


The infant mortality rate (IMR) is the rate of death of children younger than one year of age. In the United States, the IMR has been declining over time. However, it has been declining much more slowly than in other nations. As a result, the US global ranking in IMRs is also declining. This analytic essay explores some of the reasons why it might be undergoing this relative decline by critically dissecting secondary sources of data. We found that slow progress in reducing IMR over the past decade is partly due to lower birth rates among immigrants, who tend to have healthier babies than native-born mothers. However, this does not explain longer-term trends, which reveal a relative decline in the well-being of women of reproductive age. We speculate that longer-term declines are partially due to a deemphasis on government health and antipoverty programs. This deemphasis results not only in weaker socioeconomic support but also in rising medical costs, which are consuming an increasingly larger share of Americans' declining disposable income.

Economic stress and well-being: Does population health context matter?
Tahira Probst et al.
Journal of Applied Psychology, September 2018, Pages 959-979


The purpose of this study was to investigate the role of county-level population health determinants in predicting individual employee reactions to economic stress. Using multilevel modeling and a population health perspective, we tested a model linking nationally representative individual-level data (N = 100,968) on exposure to economic stressors and county-level population health determinants (N = 3,026) to responses on a composite measure of individual well-being that included the facets of purpose, community, physical, and social well-being, as well as life satisfaction. Results indicate that higher income- and employment-related economic stress were significantly related to poorer well-being. Additionally, living in a county with more positive population health determinants was significantly predictive of individual well-being. Finally, the Level-1 relationship between income-related stress and well-being was significantly attenuated for individuals living in counties with more positive population health determinants. In contrast, employment-related stress had a stronger negative relationship with well-being for individuals who lived in counties with more positive population health determinants. We discuss these findings in light of conservation of resources and relative deprivation theories, as well as how they may extend the scientific foundation for evidence-based social policy and evidence-based intervention programs aimed at lessening the effects of economic stress on individual well-being.

The Limits of Simple Implementation Intentions: Evidence from a Field Experiment on Making Plans to Exercise
Mariana Carrera et al.
Journal of Health Economics, forthcoming


Recent large-scale randomized experiments find that helping people form implementation intentions by asking when and where they plan to act increases one-time actions, such as vaccinations, preventative screenings and voting. We investigate the effect of a simple scalable planning intervention on a repeated behavior using a randomized design involving 877 subjects at a private gym. Subjects were randomized into i) a treatment group who selected the days and times they intended to attend the gym over the next two weeks or ii) a control group who instead recorded their days of exercise in the prior two weeks. In contrast to recent studies, we find that the planning intervention did not have a positive effect on behavior. We observe a tightly estimated null effect even though the majority of subjects believed that planning is helpful and despite clear evidence that they engaged with the planning process.

Does genetic risk for common adult diseases influence reproductive plans? Evidence from a national survey experiment in the United States
Candas Pinar, Rene Almeling & Shana Kushner Gadarian
Social Science & Medicine, forthcoming


Prospective parents have long been able to learn details about their offspring's DNA, and social scientists have demonstrated that this form of genetic information influences reproductive decision-making. Now, new tests offer adults information about their own genetic risk for common diseases that begin later in life, raising new questions about whether this kind of personal risk will also affect fertility plans. Drawing on a survey experiment (N = 223) that assigned individuals a genetic risk (20%, 30% … 80%) for an adult-onset disease (heart disease, colon cancer, Alzheimer's Disease), this study examines whether such risks lead people to reconsider their plans to have children. Bringing together qualitative research on genetic risk and reproductive decision-making with demographic analyses of uncertainty and fertility, we find that when assigned a hypothetical genetic risk for a common adult-onset disease, childless individuals who plan to have children in the future are unlikely to reconsider those plans.

Association Between Population Density and Genetic Risk for Schizophrenia
Lucía Colodro-Conde et al.
JAMA Psychiatry, September 2018, Pages 901-910

Design, Setting, and Participants: Four large, cross-sectional samples of genotyped individuals of European ancestry older than 18 years with known addresses in Australia, the United Kingdom, and the Netherlands were included in the analysis. Data were based on the postcode of residence at the time of last contact with the participants. Community-based samples who took part in studies conducted by the Queensland Institute for Medical Research Berghofer Medical Research Institute (QIMR), UK Biobank (UKB), Netherlands Twin Register (NTR), or QSkin Sun and Health Study (QSKIN) were included. Genome-wide association analysis and mendelian randomization (MR) were included. The study was conducted between 2016 and 2018.

Results: The QIMR participants (15 544; 10 197 [65.6%] women; mean [SD] age, 54.4 [13.2] years) living in more densely populated areas (people per square kilometer) had a higher genetic loading for schizophrenia (r2 = 0.12%; P = 5.69 × 10−5), a result that was replicated across all 3 other cohorts (UKB: 345 246; 187 469 [54.3%] women; age, 65.7 [8.0] years; NTR: 11 212; 6727 [60.0%] women; age, 48.6 [17.5] years; and QSKIN: 15 726; 8602 [54.7%] women; age, 57.0 [7.9] years). This genetic association could account for 1.7% (95% CI, 0.8%-3.2%) of the schizophrenia risk. Estimates from MR analyses performed in the UKB sample were significant (b = 0.049; P = 3.7 × 10−7 using GSMR), suggesting that the genetic liability to schizophrenia may have a causal association with the tendency to live in urbanized locations.

In vitro gametogenesis and reproductive cloning: Can we allow one while banning the other?
Seppe Segers et al.
Bioethics, forthcoming


In vitro gametogenesis (IVG) is believed to be the next big breakthrough in reproductive medicine. The prima facie acceptance of this possible future technology is notable when compared to the general prohibition on human reproductive cloning. After all, if safety is the main reason for not allowing reproductive cloning, one might expect a similar conclusion for the reproductive application of IVG, since both technologies hold considerable and comparable risks. However, safety concerns may be overcome, and are presumably not the sole reason why cloning is being condemned. We therefore assess the non‐safety arguments against reproductive cloning, yet most of these can also be held against IVG. The few arguments that cannot be used against IVG are defective. We conclude from this that it will be hard to defend a ban on reproductive cloning while accepting the reproductive use of IVG.

An experimental investigation into the transmission of antivax attitudes using a fictional health controversy
Ángel Jiménez, Joseph Stubbersfield & Jamshid Tehrani
Social Science & Medicine, October 2018, Pages 23-27

Method: All participants (N = 64) read two conflicting views (pro- and anti-) about a fictional vaccine (‘dipherpox vaccine’). These conflicting views were held by a parent and a doctor, whose views varied across conditions. This information was transmitted along linear chains of four participants who recalled it and the product of their recall was passed to the next participant within their chain. They also responded whether they would vaccinate or not.

Results: The experience-based view held by the parent was better transmitted than the medical-based view held by the doctor, while the pro-vaccine and anti-vaccine views were similarly transmitted. Despite all the participants having neutral or positive attitudes towards vaccines in general, 39.1% of them decided not to vaccinate. Nevertheless, vaccination attitude was the strongest predictor of vaccination intention. The less positive participants' attitudes were towards vaccines in general, the less likely they were to vaccinate against dipherpox after exposure to the controversy.

The Impact of the Philadelphia Beverage Tax on Purchases and Consumption by Adults and Children
John Cawley et al.
NBER Working Paper, September 2018


In recent years, numerous U.S. cities have enacted taxes on sweetened beverages, but there is relatively little evidence about the effects of these taxes on purchases and consumption. In this paper, we examine the effects of the beverage tax of 1.5 cents per ounce that was implemented in Philadelphia starting January 1, 2017. We surveyed individuals in Philadelphia and nearby comparison communities before the tax and nearly one year after implementation of the tax about their purchases and consumption of beverages. We find that purchases of taxed beverages fell by 8.9 ounces per shopping trip in Philadelphia stores relative to comparison stores outside of the city and that Philadelphia residents increased purchases of taxed beverages outside of the city. The tax reduced adults’ frequency of regular soda consumption by 10.4 times per month, and there is some evidence of a slight reduction in adults’ overall sugar consumption from sweetened beverages, with larger reductions for African-American adults. The tax did not have a substantial effect on the frequency of adults’ consumption of other beverages. We generally do not find detectable effects of the tax on children’s consumption of beverages, although we find a substantial reduction in consumption of added sugars from sweetened beverages among children who had high pre-tax consumption levels.

Has the Growth in 'Fast Casual' Mexican Restaurants Impacted Weight Gain?
Osea Giuntella
University of Pittsburgh Working Paper, August 2018


The United States is witnessing a boom in fast casual restaurants owing to the recent growth of ethnic restaurants throughout the country. This study examines the effects of proximity to a Mexican restaurant – the dominant type of ethnic fast casual restaurant – on maternal and child health. I match data on the complete residential addresses of all mothers who gave birth in the Miami metropolitan area between 1990 and 2009 to a time series of all establishments (restaurants and stores) selling food and drink.This unique data set allows me to use mother fixed effects and to exploit the variation over time of the food environment to identify the effects on maternal weight gain and childbirth outcomes. The results show that living in proximity to a Mexican restaurant is associated with an 8% lower likelihood of excessive weight gain among US-born mothers. These effects are concentrated in low-income neighborhoods and among members of disadvantaged groups (e.g., low-skilled, young, and African- American individuals). However, the results show no protective effect for foreign-born mothers. Lastly, there is no evidence of significant effects on other maternal outcomes or on various child health metrics at birth.

The Pass-Through of the Largest Tax on Sugar-Sweetened Beverages: The Case of Boulder, Colorado
John Cawley et al.
NBER Working Paper, September 2018


We estimate the incidence of a relatively new type of excise tax, a tax on sugar-sweetened beverages (SSBs). We examine the largest such tax to date, which is two cents per ounce, in Boulder, CO. Using data that were hand-collected from stores and restaurants in both Boulder and two control communities, as well as internet data of restaurant menus, we find that the tax was largely, but not completely, passed through to consumers 5-7 weeks after implementation. Some retailers add the tax only at the register, indicating that estimates solely from posted prices would result in an underestimate of pass-through.

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