Thursday, April 01, 2004
The uses and abuses of deception in public health
If I had become a physician, I like to think that I would be in public health, perhaps epidemiology. I am fascinated by the conflicts that arise between the consequences of publicity and the objective of preventing the spread of disease.
Obviously, in most cases there is no such conflict. Messages like "stop smoking" and "cook the shit out of your hamburger" result in less smoking (except maybe among rebellious teens) and less transmission of disease from the consumption of quasi-raw ground cattle.
Occasionally, however, the truth hurts. Suppose, for example, some lunatic sends powdered anthrax through the United States Postal Service office in Hamilton, New Jersey, and you start getting your mail in little baggies with warning labels on them (did that really happen to us?). Further suppose that you learn that there is only one antibiotic actually labelled for the treatment of anthrax. What if you and all your well-read and affluent friends run out and buy some, just to be on the safe side, and the antibiotic goes on a three-month backorder? Didn't we just leave the general population unprotected against an anthrax attack?
The Cipro scenario is fairly simple to think through, in that the solutions are really no different than in other cases when we need to prevent hoarding or panic. Gas shortages, runs on banks, and the crazed and panicked buying of milk in the supermarket before a blizzard in New Jersey all come to mind. Especially in the case of drugs that can only be purchased by prescription, regulators can intervene and prevent the run if necessary.
What about cases when we use deception to achieve a public health objective? Cervical cancer prevention and screening come to mind.
For many years many, or even most, cytopathologists have believed that some of the strains of human papillomavirus ("HPV") were a factor contributing to, and perhaps the cause of, cervical cancer. There was a lot of evidence for this, including the presence of HPV infection in virtually all women with "high grade" precancerous changes, carcinoma in situ, or invasive cervical cancer. Also, nuns almost never got cervical cancer, which bolstered the theory because HPV is a sexually transmitted disease.
How did gynecologists respond? Most of them didn't tell their female patients about HPV, and they didn't disclose that the Pap smear, the ancient standard of care for cervical cancer screening, was indirectly a test for a sexually transmitted disease. Why? They were concerned that women would avoid Pap tests out of modesty or shame, which would result in lower screening rates, more cancer, and less effective public health.
In recent years gynecologists have become more candid about this (according to my anecdotal sample of female friends), but probably not because they have abandoned deception as a useful public health device. I speculate that the new candor about HPV comes from several different sources. First, everybody (or rather, almost everybody) wants to promote condom use to prevent the spread of AIDS. If a doctor can throw up cervical cancer as yet another reason for women to insist on condoms, all the better. Second, more gynecologists are women. They may be less willing to be paternalistic (assuming, arguendo, that a female gynecologist can ever be paternalistic) toward their patients. Third, there are well-funded companies (Digene and Cytyc among them) that have been busily educating both doctors and women about the importance of HPV testing in addition to traditional cytology screening.
Against this background, we have this annoying story:
That tiny bit of print on a condom packet is at the center of a raging debate now that President George W. Bush has asked the Food and Drug Administration to modify the current warning to include information about human papillomavirus, commonly called HPV or genital warts.
On one side are scientists who believe that condoms should be promoted as a crucial line of defense against several STDs and cervical cancer. On the other are groups that advocate waiting for sex until marriage, and who see the dangers of HPV as an argument for their cause.
So groups that support abstinance-only sex education want to block the disclosure of a true fact -- that condoms can reduce the spread of HPV -- because they want to preserve the dangers of HPV as a reason to avoid sex before marriage.
This is an astonishingly poor argument, in that it begs an obvious question: if uncorrected fear of HPV is a good means for promoting abstinance before marriage, why educate people that condoms can prevent the spread of HIV?
However, looked at differently, the argument against the HPV label does get to the center of a public health question. America has a tremendous problem with uneducated sex, especially compared to other rich countries. Our children have sex for the first time at a younger age than in the similarly affluent countries in that den of inequity, Western Europe, and our teen pregnancy and abortion rates are three or four times European levels. How do we deal with this?
Since we can't clap them in irons, virtually all ideas for delaying and reducing teen sex come down to persuading teenagers to behave differently. That persuasion can take the form of practical arguments (teaching them about the burdens of teenage pregnancy, the risks of disease, and so forth), or moral and psychological arguments (sex is a sin, sex too young will make you sad, sex out of wedlock will destroy the joy of sex in marriage, etc.). If technology (i.e., condoms, anti-mocrobial gels and information about pregnancy and disease) can mitigate the threats behind the practical arguments, does it mean that teenagers will be more likely to give in to their urges at an early age? Or will these technological fixes themselves cause the educators to invest more effort in the moral and psychological arguments against early sex, which are much harder to refute?
And one question for the road: Should we tell people that unprotected oral sex is actually a lot less likely to result in the transmission of HIV than unprotected anal or vaginal sex? Would the dissemination of this knowledge cause people to substitute unprotected oral sex for protected vaginal sex, with deleterious long-term consequences? Or would it cause people who did not have a condom to limit themselves to oral sex, which would lower the risk of transmission and average aggregate cases? Is too much knowledge really a dangerous thing?
Obviously, in most cases there is no such conflict. Messages like "stop smoking" and "cook the shit out of your hamburger" result in less smoking (except maybe among rebellious teens) and less transmission of disease from the consumption of quasi-raw ground cattle.
Occasionally, however, the truth hurts. Suppose, for example, some lunatic sends powdered anthrax through the United States Postal Service office in Hamilton, New Jersey, and you start getting your mail in little baggies with warning labels on them (did that really happen to us?). Further suppose that you learn that there is only one antibiotic actually labelled for the treatment of anthrax. What if you and all your well-read and affluent friends run out and buy some, just to be on the safe side, and the antibiotic goes on a three-month backorder? Didn't we just leave the general population unprotected against an anthrax attack?
The Cipro scenario is fairly simple to think through, in that the solutions are really no different than in other cases when we need to prevent hoarding or panic. Gas shortages, runs on banks, and the crazed and panicked buying of milk in the supermarket before a blizzard in New Jersey all come to mind. Especially in the case of drugs that can only be purchased by prescription, regulators can intervene and prevent the run if necessary.
What about cases when we use deception to achieve a public health objective? Cervical cancer prevention and screening come to mind.
For many years many, or even most, cytopathologists have believed that some of the strains of human papillomavirus ("HPV") were a factor contributing to, and perhaps the cause of, cervical cancer. There was a lot of evidence for this, including the presence of HPV infection in virtually all women with "high grade" precancerous changes, carcinoma in situ, or invasive cervical cancer. Also, nuns almost never got cervical cancer, which bolstered the theory because HPV is a sexually transmitted disease.
How did gynecologists respond? Most of them didn't tell their female patients about HPV, and they didn't disclose that the Pap smear, the ancient standard of care for cervical cancer screening, was indirectly a test for a sexually transmitted disease. Why? They were concerned that women would avoid Pap tests out of modesty or shame, which would result in lower screening rates, more cancer, and less effective public health.
In recent years gynecologists have become more candid about this (according to my anecdotal sample of female friends), but probably not because they have abandoned deception as a useful public health device. I speculate that the new candor about HPV comes from several different sources. First, everybody (or rather, almost everybody) wants to promote condom use to prevent the spread of AIDS. If a doctor can throw up cervical cancer as yet another reason for women to insist on condoms, all the better. Second, more gynecologists are women. They may be less willing to be paternalistic (assuming, arguendo, that a female gynecologist can ever be paternalistic) toward their patients. Third, there are well-funded companies (Digene and Cytyc among them) that have been busily educating both doctors and women about the importance of HPV testing in addition to traditional cytology screening.
Against this background, we have this annoying story:
That tiny bit of print on a condom packet is at the center of a raging debate now that President George W. Bush has asked the Food and Drug Administration to modify the current warning to include information about human papillomavirus, commonly called HPV or genital warts.
On one side are scientists who believe that condoms should be promoted as a crucial line of defense against several STDs and cervical cancer. On the other are groups that advocate waiting for sex until marriage, and who see the dangers of HPV as an argument for their cause.
So groups that support abstinance-only sex education want to block the disclosure of a true fact -- that condoms can reduce the spread of HPV -- because they want to preserve the dangers of HPV as a reason to avoid sex before marriage.
This is an astonishingly poor argument, in that it begs an obvious question: if uncorrected fear of HPV is a good means for promoting abstinance before marriage, why educate people that condoms can prevent the spread of HIV?
However, looked at differently, the argument against the HPV label does get to the center of a public health question. America has a tremendous problem with uneducated sex, especially compared to other rich countries. Our children have sex for the first time at a younger age than in the similarly affluent countries in that den of inequity, Western Europe, and our teen pregnancy and abortion rates are three or four times European levels. How do we deal with this?
Since we can't clap them in irons, virtually all ideas for delaying and reducing teen sex come down to persuading teenagers to behave differently. That persuasion can take the form of practical arguments (teaching them about the burdens of teenage pregnancy, the risks of disease, and so forth), or moral and psychological arguments (sex is a sin, sex too young will make you sad, sex out of wedlock will destroy the joy of sex in marriage, etc.). If technology (i.e., condoms, anti-mocrobial gels and information about pregnancy and disease) can mitigate the threats behind the practical arguments, does it mean that teenagers will be more likely to give in to their urges at an early age? Or will these technological fixes themselves cause the educators to invest more effort in the moral and psychological arguments against early sex, which are much harder to refute?
And one question for the road: Should we tell people that unprotected oral sex is actually a lot less likely to result in the transmission of HIV than unprotected anal or vaginal sex? Would the dissemination of this knowledge cause people to substitute unprotected oral sex for protected vaginal sex, with deleterious long-term consequences? Or would it cause people who did not have a condom to limit themselves to oral sex, which would lower the risk of transmission and average aggregate cases? Is too much knowledge really a dangerous thing?
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