This is Not the Flu

Critica Clarifies Its Message on COVID-19

         In our recent commentary about the novel coronavirus pandemic, we tried to make several points. First, we noted that despite the fact that flu has caused far more cases and deaths than COVID-19, the media rarely mentions the former but addresses the latter daily. Second, there is a known way to reduce the number of cases and the severity of flu that many people have not taken advantage of: the flu shot. Third, the US Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and other agencies have not done a good job of communicating risk or strategy to the public.

         All of these points remain valid for us, but they probably create the false impression that COVID-19 and flu are comparable illnesses. This is clearly not the case. Without in any way minimizing the severity of flu, it is important to understand that the virus that causes COVID-19, designated as SARS-CoV-2, is about 10 times deadlier than the flu. The mortality rate for flu is around 0.1%; for COVID-19 the most recent estimate is 1.4% and it approaches 15% for people 80 and older. Everyone should still get a flu shot. But saying that COVID-19 is no more serious than the flu and therefore all the measures governments are imposing are unnecessary is a totally misleading view.

Are Measures to Control COVID-19 Effective

         Many people do wonder whether the increasing number of restrictions being placed on our lives by government guidelines and rules will actually help mitigate the spread of COVID-19. Evidence and experience with previous epidemics indicate that they are. Three general types of interventions are now being employed to control the spread of the coronavirus that,  if rigorously carried out, will work to “flatten the curve” of expanding case rates.

         The first are travel restrictions. Governments have imposed bans on travel to and from areas where rates of novel coronavirus infection are high. A study published in the journal Science on March 6 showed, however, that travel restrictions are only “modestly” effective in preventing the spread of the virus. Now that the virus is already spreading within the U.S., for example, it is not clear that banning travel from European countries will be effective. It is still wise to avoid travel as much as possible because, as CDC notes, being in crowded areas like airports and train stations increases the chances of coming in contact with someone who is infected.

         The second approach is an attempt to prevent transmission from silent cases (that is, people who are infected with the virus but not yet experiencing signs or symptoms of the illness) to uninfected people. This is what “social distancing” and hygienic steps like increased and more effective handwashing are designed to do. One study showed that in China, about 10% of new infections were caught from people not yet showing symptoms. The median interval (the value in the middle between the highest and lowest) for getting infected and showing symptoms, known as the incubation period, for SARS-CoV-2 appears to be about five days, with almost all infected people showing symptoms by 12 days. As has been widely noted, this means that it is possible to have a “silent” infection for almost two weeks, during which time an infected person can infect others. Limiting contacts with other people, keeping a distance of six feet when there are other people around, washing hands frequently for at least 20 seconds, and avoiding touching one’s face are all ways of limiting the spread of COVID-19. Evidence suggests that things like proactive school closures—closing schools when a case of coronavirus has been confirmed in a community but not yet at the school—and other forms of social distancing can be effective in limiting the spread of viral epidemics.

Frequent and efficient handwashing is one of the most important tools we have to limit the spread of SARS-CoV-2, the virus that causes COVID-19 (image: Shutterstock).

         The third approach is testing as many people who may have been exposed to the virus as possible and isolating those who test positive for infection.  But, as has been widely reported, we are woefully short on test kits in the U.S.  That is why public health officials do not have an accurate estimate of just how many people are already infected with SARS-CoV-2; we only have good data on the number of people who are symptomatic and have come to clinical attention and of the number of people who have died. For every person known to be infected, it is now estimated that there are between five and ten people who are silent carriers, capable of spreading the virus to others without knowing they have it themselves. Although children are generally spared severe illness, they are just as easily infected by SARS-CoV-2 and capable of spreading infection. We need to test almost everyone if we’re going to get ahead of the virus, as was done in South Korea, and hopefully the loosening of restrictions on private labs performing tests will enable us to expand the number of people who get tested. The failure to rapidly adopt near-universal testing for the coronavirus in the U.S. is probably due to multiple factors and represents a failure of our public health system.

All three of these approaches are effective means of limiting the spread of infection, or what epidemiologists call “flattening the curve.” They should all be pursued simultaneously because at present they are the only tools we have that are likely to have some benefit. Pharmaceutical companies and medical school researchers are now working to identify existing medications that might suppress coronavirus activity and be useful for people who are already infected, but it is unclear whether any such medications exist and unlikely that we can develop new antiviral drugs in time to have an impact on the current pandemic. The ultimate solution would of course be a vaccine. Chinese scientists published the complete genome of SARS-CoV-2 just two weeks after the first cases were reported to the WHO and there are now more than 35 candidate vaccines in various stages of development. But the most optimistic time frame for getting medications that prove to be safe and effective and approved by FDA is 12-18 months. By then, we hope this pandemic will have resolved.

The Infodemic

At the same time that we take measures to limit the spread of COVID-19, we need to improve our ability to get accurate information about the virus to the public. The WHO has called the COVID-19 pandemic an “infodemic” because of the vast amount of misinformation that is being promulgated on the internet. Although they are trying to control misinformation on their social media platforms, Facebook, Twitter, Google, YouTube, and others are said to be stumped by a surge of misinformed posts and videos.

Some of the recommendations for preventing or “curing” COVID-19 that appear on the internet are wrong, but probably not harmful, such as gargling salt water. Others, like drinking bleach and taking steroids, are both useless and potentially harmful. Myths that have been prominent on the internet include that products shipped from China can carry live coronavirus capable of infecting someone; that there is a vaccine already available; that facemasks will prevent infection; and that the virus was engineered and released by a variety of conspiratorial organizations, like the Chinese government, drug companies, and the U.S. Army. In fact, SARS-CoV-2 most likely originated in bats.

We know that the longer misinformation goes unchallenged, the more influential it will be. This is particularly important in view of a recent poll that showed that nearly half of Americans, including a majority of Republicans, believe the seriousness of COVID-19 is being exaggerated. Some scientists are now using social media to provide accurate information about the pandemic,  but scientists have traditionally been reluctant to challenge misinformation and when they do venture into this field it can take days or weeks before experts respond to a myth posted on one of the platforms. For their part, public health agencies often have to be careful with the statements they make for political reasons and therefore spend time carefully crafting their messages. That makes them ill-suited at present to be able to respond rapidly to a proliferation of misinformation, like the COVID-19 infodemic. Rapid refutation of myths and falsehoods must be initiated immediately after they appear online, but that repudiation must be done in accordance with evidence-based methods. Merely stating the facts, especially if done in a condescending manner, will not dissuade people from believing misinformation about any topic in health and science.

A solution that we have advocated is the creation of a core of online misinformation “first responders.” Scientists, including those working at Critica, have developed methods for the detection of misinformation about a specific topic almost as soon as it appears. In our plan, first responders trained by medical and scientific societies and by universities would be alerted immediately when a falsehood is posted and begin responding. We’ve developed an evidence-based protocol to guide those counteracting responses and maximize the chances that they will be persuasive. We plan to test the protocol in the coming months. We further recommend that organizations like the CDC and WHO, medical and scientific societies, and research institutions like the National Institutes of Health (NIH) and Wellcome Foundation all develop cohorts of first responders with expertise in their disciplines and trained in the Critica Protocol.

To these traditional first responders, we propose adding a cohort that responds immediately to online misinformation about science and health (image: Shutterstock).

COVID-19 is not similar to flu. Both are dangerous viral infections with the capacity to cause severe illness and death, but because of its high level of contagion and mortality risk, COVID-19 requires more drastic prevention and mitigation solutions. Proven public health interventions to prevent the spread of pandemic-level infectious disease are available; they are being implemented at different speeds by different states and countries and will hopefully be successful in controlling and ultimately ending the pandemic. In order to make these interventions work, it is crucial that the public receive scientifically correct, understandable information that guides them to the correct steps and behaviors. Given the dazzling speed with which misinformation proliferates on the internet, we call for the creation of a corps of science and health misinformation first responders.

What’s Behind the Increase in Adolescent Suicide?

What we do and don’t know about teen suicide.

Although the first season of the Netflix show 13 Reasons Why was released several years ago, its questionable portrayal of adolescent suicide continues to make waves in the suicide prevention community. At first glance, it would certainly seem that the show’s portrayal of a high school student who eventually dies by suicide would raise the risk of suicide contagion. After all, the show’s representation of young Hannah Baker, her struggles with a desire to escape her life, and her eventual suicide seems to flout almost every single rule about safe messaging that exists. And of course, these rules exist for a reason—irresponsible portrayal of suicide and suicidality can absolutely increase the risk for contagion.

Source: Shutterstock

Yet the extent to which this show actually led to a noticeable increase in rates of adolescent suicide is very much up for debate. Lately, it often feels like we are going in circles with this question. A recent time series analysis found a significant increase in monthly suicide rates in teenagers aged 10 to 17 following the release of the show. Another time series analysis published in May of 2019 in JAMA had the same finding.

Yet more recently, a reanalysis of these data showed no clear link between the show and adolescent suicide rates. How is this possible? Is 13 Reasons Why partially responsible for a rise in adolescent suicide rates? If not, what is and do we really understand what’s going on? What could be leading to such disparate results and a lack of consensus on the true effects of the show on rates of adolescent suicide? 

It seems that some of the research suggesting an increase in suicides as a result of 13 Reasons Why failed to take secular trends into account. That is, there was a background story of an already increasing rate of suicides among teenagers in the U.S., so the rise in the time period following the show may have been expected regardless of the show itself.

This is obviously part of what makes determining the effect of anything in public health so difficult. We usually track large populations over long periods of time without much ability to understand whether the trends we are seeing are due to the “cause” we are studying or whether these trends would have emerged this way regardless.

This problem is similar to not asking “what’s the denominator” when looking at a particular state of affairs in public health. That is, we must strive to understand what’s already going on in the background before we can understand the effect of whatever we are studying. This, of course, is easier said than done, as the easiest way to separate secular trends from effects stemming from a particular, studied cause is through a randomized controlled trial, which is not always possible in public health research. 

The question still remains: What could be behind the rise in rates of adolescent suicide? Some blame it on technology, particularly social media and smartphones. Yet just because there is a change in the technology teenagers are using and a concomitant rise in suicide doesn’t mean the two are connected. It is true that social media is associated with anxiety and depression, but even this does not explain the increase, as most people with anxiety and depression do not die by suicide.

Some blame it on the economy, and there does seem to be some legitimacy to this claim. But at the same time, some experts such as Jean Twenge have noted that the trends don’t completely line up with economic patterns or traumatic events like school shootings. There’s also a shortage of mental health professionals in most parts of the country and structural issues like lack of access to care, which has only gotten worse.

The reality is there’s still a lot we don’t know. The issue is complex and we don’t really understand suicide well in any population because it’s still a rare event. For now, the best we can do is continue to study the trends alongside other phenomena to see what might be causing this unsettling change. And of course, we should always correct our mistakes if a conclusion we have drawn may turn out to be not the best representation of reality.

LinkedIn Image Credit: PT Images/Shutterstock

Oceans Away

Are new medical systems shrinking our planet?

By Peter Mackenzie Brown

Editor’s Note: Peter McKenzie-Brown is a much-valued occasional commentator for Critica. This piece details how using a combination of empathy, philanthropy, and new technologies we can make healthcare accessible to more people in more places.

Tyranny and egotism grip many countries, and these are deplorable. But civility and kindness remain widespread, and the basic decency that evolved with liberal democracy and economic prosperity remains a source of kindness and empathy around the world. Take the case of a few people in Calgary, and their impact on the other side of the Pacific and Indian oceans. Their vehicle of change is a tiny charity named CHILD Foundation, which founded, funded and now operates a hospital in rural India.

To put its work in perspective, India has a population of 1.35 billion. Most physicians work in cities, which provide more conveniences, yet 70 percent of the country’s population live in the countryside. According to Calgary physician Bhavini Gohel, rural Indians lack access to basic medical care. Citing a study conducted by the Indian Institute of Public Opinion, she says 89 per cent of rural patients have to travel “long distances over miserable, crowded roads to access even basic medical treatment. Given the lack of basic infrastructure in rural India, it’s awfully difficult to retain doctors in village hospitals,” which themselves are uncommon. The inequalities in health care access between rural and urban people are huge.

Dr. Gohel sits on the hospital’s 13-member board, as does my spouse. This has sometimes led to odd conversations at the dining table. For example, one evening, my wife started using what to me sounded like gobbledygook. “We’re having discussions with ICE Health Systems to develop a telemedicine-type system we call Medicine at Home. It will facilitate health care by satellite through our hospital to remote villages and the broader community,” she began.

“Hmm?” I asked.

“This will enable us to broaden the patient base and the geographic area we serve. Our Maya Devi Hospital will become the hub for the expanded provision of service. It’s an exciting project.” My eyes widened. It was beginning to make sense.

A decade ago, my Rotary club had instigated a project to support the work of Calgary businessman Anil Jain and his family. Years earlier, his family had registered a charity named Canadian Health, Immunization, Learning and Development (CHILD) Foundation, and my wife was one of the first to join the new organization’s board. From small beginnings, the project grew quickly – spurred to a large degree by fund-raising events in Calgary, substantial grants from Rotary, and matching grants from the province of Alberta. In those days, you may remember, oil prices were high and Alberta’s outlook rosy. Everything seemed possible.

The project’s original aim was to provide a clinic for women in a “small village” (population 60,000) in the state of Uttar Pradesh, India. The board organized a number of fund-raising events, however, and soon the charity had funding enough to build and operate a 20-bed hospital instead of just a clinic. The new facility “saw a lineup of patients on its first day,” Jain says proudly. “Designed to serve only 3,000 patients in its first year, it treated 14,000.”

Working with MOTHER Foundation, which Anil’s Delhi-based brother founded in India, hospital construction began on a small piece of land donated by the late mother of the two men – a woman named Maya Devi, after whom the hospital was named. Because the grid was unreliable, an early order of business was to install solar panels to provide reliable power. The facility soon began hiring staff and grew – recently adding a badly-needed X-ray system.

CHILD has done a remarkable job in raising funds, addressing education in nutrition and hygiene among local families and obtaining sanitary napkins at cost thanks to an arrangement with Johnson & Johnson Corporation. Initially working with the Calgary-based Centre for Affordable Water and Sanitation Technology, it has also sponsored programs teaching villagers how to inexpensively purify their drinking water, and improve sanitation and hygiene in their own homes.

Telehealth and telemedicine. But the big story was in the future, and that future is now. Although there are numerous languages and dialects in India, the country has only two official languages: Hindi and English. The country’s increasing fluency in English is an important asset for the application of telehealth systems in the country. Calgary physician Bhavini Gohel, who is also a member of CHILD’s 13-person board, claims the idea as “my baby.” She it was who put the notion on the agenda, about a year ago.

The notion is still embryonic, but the beating heart of the matter is simple. Although telehealth tools have been available in Canada for decades, the idea is now going global. In recent years there has been a considerable amount of interest in harnessing technology to reduce differentials in the distribution of health care services. From mobile health monitoring systems to telemedicine, she says, technology is increasingly narrowing the gap in health delivery.

CHILD’s Maya Devi Hospital will soon be a significant beneficiary of these new technologies. “This year we will be launching a fully integrated electronic medical record system that has telemedicine capabilities,” she says. The system will integrate into a wider program designed to deliver primary and tertiary care in the village. A recent development on the international scene, telehealth tools “enable long-distance patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and even remote admissions, telehealth can bridge gaps brought on in rural settings by poor transport and mobility and lack of trained staff.”

These systems provide distance learning. They enable online meetings, supervision, and videoconferencing among practitioners. They provide online integration of health data management and healthcare systems. “They even enable robotic surgery through remote access,” according to Gohel. Physical therapy can now take place through “digital monitoring instruments, live feed and application combinations,” she says. Tests can be forwarded between facilities for interpretation by a other specialists. Home monitoring can take place by continually sending in patient health data. “You can even get videophone interpretation during a consult.”

These systems can also be used as a mobile record system enabling healthcare professionals to provide assessment and care in homes throughout the town, she adds. “Such mobile functionality will allow professionals in Delhi, for example, to provide immediate decision making and care for patients. There’s big potential in this for saving both time and money.”

As the sole health record system in the CHILD-funded hospital in Sarurpur, ICE Health Systems already provides such services as keeping the hospital’s clinical records, lab data, integrated imaging and pharmacy support. Most importantly, she says, “our integrated telehealth system will soon enable doctors in rural Sarurpur to consult with specialists.”

Human touch is pivotal for patient care, of course. “We need to be sensitive to cultural concerns about having technology provide medical care, something which is still foreign to Indian society.” As the CHILD Foundation’s board and the staff at Maya Devi Hospital implement these systems, “we must not be oblivious to these systems’ challenges.” 

Cover-up vs. Scientific Progress

Has There Been a Conspiracy to Hide BPA Dangers?

Bisphenol A (BPA) is a widely used chemical product found in plastic bottles and containers, food cans, and a host of other sources. There has been a long-standing debate about the extent to which humans are exposed to BPA and whether it is harmful. About 93% of people six years and older have detectable levels of BPA in their urine, but the FDA has taken the position that the amount of BPA detected is too small to be harmful. FDA did ban the use of BPA in infant formula, baby bottles, and sippy cups in 2017.

         Against this reassurance about the benign nature of BPA exposure, there have been persistent reports about health harms. BPA is known to bind to several hormone receptors and has therefore been called a “hormone disrupter.” Scientists academic institutions linked it in animal and epidemiological studies to a variety of disorders, including infertility, diabetes, obesity, and some tumors. Advocacy groups have persistently pointed to evidence that BPA is toxic.

BPA is present in many products we use everyday, including plastics that hold food and beverages. It leaches into those products and we consume them (image: Shutterstock).

         In order to bridge the gulf between regulatory agency reassurance and academic and advocacy group warnings, several federal science agencies initiated the CLARITY-BPA Program. The program involves research done at a federal laboratory and the laboratories of 14 grantees conducting research at independent academic institutions. The final CLARITY-BPA report should be released soon. A draft report from the government’s arm of the study failed to find any toxic effects from BPA in laboratory animals.

New Study Finds Higher Exposure Levels

         Now, however, a new wrinkle has been introduced into the entire BPA controversy. A study published last December in the respected British journal Lancet Diabetes & Endocrinology reported that levels of BPA in adults may be much higher than previously reported. The study’s publication was unsurprisingly followed by headlines such as “Human exposure to BPA systematically underestimated”. One website declared that “Human exposure to bisphenol A (BPA) may have been underestimated as a result of a ‘flawed’ analytical technique commonly used to measure levels in urine”.

         It would be understandable for people to leap to the conclusion that the “government” has been deliberately covering up the possible harms to human health of BPA. Words like “systematically” and “flawed” sound as if FDA and other regulatory agencies are at fault and even imply that they somehow conspired to knowingly minimize the effects of BPA. The motive, some assert, is to protect the business interests of the many industries that use BPA in their manufacturing processes.

The Reasons Behind the Differing Views of BPA Safety

         While we too have been very concerned lately about the roll-back of many federal environmental and health regulations, seemingly at the behest of commercial interests, the situation with the new BPA study is more nuanced and deserves some explanation. In the end, it turns out to be more a matter of a scientific advance than a deliberate cover-up.

BPA is present in plastic beverage containers. How harmful that is to our health is a matter of debate in the scientific community (image: Shutterstock).

         First, why has there been a controversy all along about the effects of BPA? The traditional way that regulatory agencies like FDA and EPA determine if something is toxic to humans is to feed it to rats and other laboratory animals in higher and higher doses, examining the effects on each organ of the animals’ bodies at each dose level. Inevitably, they eventually reach a level that causes some kind of harm to the rats, like a tumor that does not occur in animals fed placebo. The scientists at FDA then calculate how much of the substance a human would have to be exposed to in order to match the dose in rats that caused the problem. If that amount is far greater than a human could possibly ever encounter, the substance is declared to be safe. That is the case so far with FDA’s assessment of BPA. This kind of study is called a “guideline study ” and must be conducted in accordance with a strict set of rules, called “Good Laboratory Practice” (GLP).

         But academic institution scientists may work the problem from a different angle, called “hypothesis testing”. Instead of looking at every organ of the body, the academics might start with a hypothesis like “this substance can cause the kind of damage to DNA that is associated with cancer in humans.” They then use advanced molecular techniques to see if there is a dose of the substance that does indeed damage DNA in the predicted way. Often, that does turns out to be lower than the dose a regulatory agency has found to be harmful to laboratory animals. Academic scientists often insist that the GLP rules are too restrictive and present barriers to probing for potential harms. They assert that their methods are more sensitive to picking up potential toxicities, but regulatory agencies disagree, insisting instead that non-GLP studies lack the rigor necessary to reach meaningful conclusions.

         It remains to be seen whether CLARITY-BPA will resolve this divide in methodologies and opinions. But once again, finding that we may all harbor higher levels of BPA than we knew about means that doses previously considered too high to be indicative of likely toxicity may not hold.

New Technologies Mean New Findings

         Pouring through the very technical study in Lancet: Diabetes & Endocrinology, what we see is that the scientists have developed a completely new laboratory method for detecting BPA in human urine. The method traditionally used to measure BPA levels is called an “indirect method,” whereas the scientists in the new report developed a “direct method” and concluded that “ Importantly, because estimates of human exposure have been based almost exclusively on data from indirect methods, these findings provide compelling evidence that human exposure to BPA is far higher than has been assumed previously.”

         Two things are very disconcerting to many of us about the BPA story. First, it is hard for us to know what to make of disagreements among highly qualified and well-meaning scientists. The GLP rules that academic scientists seem to dislike are an attempt to ensure that toxicology studies are performed according to rigorous standards. They are not an attempt to hide evidence. On the other hand, academic scientists have the flexibility to use novel methods to search for evidence of human health harms and these may or may not accord with GLP standards. This is not an easy thing for most of us to adjudicate.

         Second, no one likes to read headlines that the basis for a long held scientific finding may be wrong. Science often advances only when new technologies are developed that permit greater insights into biological processes. Positron emission tomography (PET), CRISP-R, and genome wide assessment studies (GWAS) are just a few of the many technological advances developed since the late 20th-century that have revolutionized what we know about the ways that cells and organs work. In this case, a not quite so dramatic advance in technology potentially enables us to have better information about BPA levels and may be a game-changer, but it has nothing to do with conspiracies to hide data. Rather, it follows the usual trajectory of science—a new discovery can invalidate what we previously knew (or thought we knew).

         What would be amiss, however, is if scientists, both academic and regulatory, fail to follow-up the new study with work that takes into account its findings and determine if indeed we are being exposed to toxic levels of BPA.[1] There is ample precedent for industry to try to derail such investigations. Until we had powerful epidemiological tools, it was not possible to understand that cigarette smoking causes lung cancer. Until computer modeling became more powerful, the extent of global warming was not apparent. But once those things became clear, there was an outrageous delay in accepting the findings and working to mitigate their implications for human health and survival.

         If BPA turns out to be worse than FDA thought, it is indeed upsetting that so many of us have been exposed to so much of it for so many years. Rather than rushing to cast blame, the way to deal with a  situation like this, however, is two-fold: first, fund research that develops the technologies that give us important new insights and second, act on findings as soon as they are confirmed. It will be extremely interesting to see how the regulatory community reacts to the finding in the Lancet paper. We will follow that along with you and report on what happens in future commentaries.

[1] Incidentally, as we pointed out last month, Critica strongly recommends against the use of disposable plastic beverage containers because they pose a significant environmental hazard.

Why Intermittent Fasting Is Gaining Support

Some evidence supports intermittent fasting—but is it practical long-term?

Ketogenic diets—diets that switch the body from using glucose for energy to burning ketones—have been promulgated for many years and in many forms. The idea was actually first tested as a treatment for epilepsy in the early 20th century, for which it remains today as a medically-prescribed intervention for children with medication-resistant focal seizures.

The classic ketogenic diet for weight loss involves eating foods high in fat and low in carbohydrates. The Atkins diet is an example. Although studies show that ketogenic diets do result in weight loss, they have been controversial because of fears that high levels of ketones might be harmful, and the difficulty people have staying on them for long periods of time in order to sustain weight loss.

Another approach to switching the body’s metabolism from carbohydrates to ketones is intermittent fasting. Recently, a review in the New England Journal of Medicine (NEJM) by scientists from the National Institute on Aging and Johns Hopkins medical school suggests that intermittent fasting may in fact be a safe and effective method not only to lose weight, but to increase lifespan as well.

How does intermittent fasting work? When we eat three meals a day plus snacks—the usual American diet—our bodies preferentially burn carbohydrates in the form of glucose. But with either the ketogenic diet or fasting, carbohydrates become unavailable and the body switches to turning stored fatty acids into substances called ketone bodies (see illustration), which are used for fuel by many organs, including the brain. This results in lower glucose levels and in depleting fat stores, hence weight loss.

According to the NEJM review, there is abundant evidence from animal models that intermittent fasting improves signs of “obesity, diabetes, cardiovascular disease, cancers, and neurodegenerative brain disease.” In addition, authors Rafael de Cabo and Mark Mattson write “studies in mice and nonhuman primates [i.e. monkeys and apes] show consistent effects of caloric restriction on the healthspan [i.e. the length of time an individual lives in relatively good health].”

Ketones Have Many Positive Actions

It turns out that weight loss may not be the only way that switching to metabolizing ketones from sugars may suppress disease. Ketones apparently have important physiological roles of their own; they “regulate the expression and activity of many proteins and molecules that are known to influence health and aging.” These include proteins and molecules involved in inflammation, cardiovascular and brain function, and glucose utilization. The NEJM review does not discuss any possible harms from high ketone levels and for the most part, these do not seem to be clinically significant for most individuals.

In humans, de Cabo and Mattson review studies reporting that “intermittent-fasting interventions ameliorate obesity, insulin resistance [the problem in type 2 diabetes], dyslipidemia [such as high cholesterol levels], hypertension [high blood pressure], and inflammation.” It is claimed that intermittent fasting can have a positive or preventative effect on a very wide range of disorders, including asthma, brain tumors, rheumatoid arthritis, and cognitive decline. De Cabo and Mattson make recommendations about how to initiate intermittent fasting in order to reach a goal of 5:2—five days a week eating and two days fasting. Other fasting regimens are also possible.article continues after advertisement

Source: Shutterstock

The NEJM encomium to intermittent fasting appears to give support to a growing fasting-for-health fad. It has, however, has been met by some pushback from experts. Perhaps the major concern is whether people will, in fact, be able to continue the intermittent fasting regimen over long periods of time. So far, most of the studies in humans are relatively short term, usually not more than months, and even those can have high dropout rates. According to Guy Mintz, a New York City cardiologist, some studies show patients eating more than recommended amounts of food on fasting days and less on feast days. Mintz also cautions that for some people, like those with diabetes and the elderly, intermittent fasting could be dangerous.

Indeed, not all studies of intermittent fasting in humans have yielded positive results. As noted in the NEJM review, a 12-month study showed no differences in weight loss or other measures of health between an alternate day fasting regimen and daily calorie restriction. There was a 38 percent dropout rate in the fasting group versus 29 percent and 26 percent respectively in the calorie reduction and control groups.

Other Health Diets May Be More Manageable For Longer Periods

There certainly are no data that can indicate whether intermittent fasting would make people live any longer, healthily or otherwise. That would take following people for decades who do or do not practice intermittent fasting to see who lives longer, and even that kind of observational study would be hard to interpret given the many other variables that would affect the groups’ outcomes. The only definitive way, of course, to know if it extends lifespan would be to randomize people to either an intermittent fasting group or some other diet group. Such a study would be very expensive, so we are skeptical it will be pursued any time soon.

There is, then, irrefutable animal evidence that intermittent fasting has health benefits and evidence from some, but not all, short term human studies that it may be beneficial. The real question, however, remains whether significant numbers of people will be able to do it on their own (that is, not as part of a monitored study) for many years. We don’t know the answer to that yet, but there is reason to think it may be very difficult to spend two twenty-four-hour periods a week without eating for many years.article continues after advertisement

It is curious in the current fervor to consider intermittent fasting that other, possibly more easily adhered to, diets are not simultaneously being kept in the public’s mind. For example, a recent study randomized 6,874 men and women aged 55 to 70 years with metabolic syndrome but no cardiovascular disease to either a reduced-calorie Mediterranean diet or an unrestricted calorie Mediterranean diet. The former group also received encouragement for physical activity and behavioral support.

At the one-year analysis, 96 percent of the study subjects were still adherent to the diets to which they were assigned, with greater adherence in the intervention than the control group. The Mediterranean diet has also been shown by numerous studies to have a wide range of health benefits, including many of the same ones claimed for intermittent fasting. What we really need to know at this point is which are the healthy diets that people will actually be able to sustain for years.  

It is abundantly clear that the American diet is generally not a healthy one. We eat too many highly processed and heavily advertised foods, consume too much sugar, and exceed recommended calorie levels. The result has been an epidemic of obesity and diabetes. All nutrition experts agree that we need to improve our diets and increase our quota of daily exercise.article continues after advertisement

We also know, however, that instituting changes in diet and exercise is very difficult for most people and the best of intentions often last for only a few days or weeks. If it could be shown that intermittent fasting is something that a lot of people can really maintain for life, it is becoming increasingly clear that it might be a very good strategy to improve health and, maybe, increase lifespan.

We remain skeptical, however, that this will be adopted by a meaningful proportion of the American population. Therefore, we believe that too much hype about things that are impossible to achieve distracts our attention from what might actually work. We need both more research and enhanced public health messaging about practical, sustainable strategies for improving what we eat.

The Novel Coronavirus Challenges Our Perception of Risk

         Since early January not a day has gone by without headlines in print, broadcast, and social media that highlight the spread of the novel coronavirus that originated in Wuhan, China. With that level of daily attention, most of it carrying dire warnings that the virus will spread rapidly throughout the world, leaving many deaths in its wake, it is no surprise that Americans are worried.

         We do not dispute that concern and preparedness are fully warranted in this case. As facts emerge about the Wuhan coronavirus, officially called 2019-nCoV, it is clear that it is spreading from China to many countries, that the virus can be transmitted by human-to-human contact, and that there have been fatalities. As of February 3, there were 11 confirmed cases in the U.S. with 82 tests pending. There are also 167 cases of people who were concerned they had contracted the virus but tested negative. Worldwide, again as of February 3, the virus has infected more than 17,000 people in 23 countries (most in China) and caused about 360 deaths.

Despite its rapid spread and severity, there are two things we want to explore about the new coronavirus. First, it is unclear if people in the U.S. truly understand what their own personal risk is. Recently, for example, we have heard people ask, “is it safe to eat in a Chinese restaurant?” Where should such a person go to get a reliable answer to this kind of basic question that is important in everyday life?

         Second, the daily mass media output about the coronavirus may be obscuring health threats that are already much greater and about which people can take immediate preventive action. Yet such health threats receive almost no regular media attention, giving the public the misimpression that they are not important. Indeed, Critica Chief Medical Officer David Scales and his colleagues at Harvard and Yale Universities showed in a 2013 paper that in the setting of a pandemic, there is truly a crowding out of other important health news

         We will address both of these points in more detail in a moment. First, let’s review briefly what we currently know about this new virus and the risk it poses.

What Do We Know about 2019-nCoV?

Scientists use a statistic called Ro (pronounced “R naught”) to characterize how infectious an illness is. An Ro of one means that an infected person generally will transmit the illness to just one other person. The novel coronavirus appears to have an Ro of between 3 and 5—every infected person can infect three to five other people. 

To put that into perspective, Critica CEO and public health specialist Sara Gorman notes that measles has an Ro of 18. In order to prevent spreading the virus, the most important steps are frequent and thorough handwashing and covering one’s mouth and nose when coughing and sneezing. Surgical masks probably do not filter enough air to effectively prevent either transmission or acquisition. Americans are advised not to travel to China right now if possible. 


A Coronavirus like the ones that causes SARS and MERS, looks like a crown under high magnification (source: Shutterstock).

                 Most of the above information is readily available by reading the newspaper or going to the websites of the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). But how do we get answers to questions like the Chinese restaurant one?

CDC Does Not Prioritize Informing the Public

         On January 21, the CDC issued a press release titled “First Travel-related Case of 2019 Novel Coronavirus Detected in United States”. It lists five things the CDC “has been proactively [doing to prepare] for the introduction of 2019-nCoV in the United States for weeks.” Each of the five bullet points gives important information for healthcare professionals and public health officials. Each demonstrates the CDC’s usual high level of scientific expertise and remarkable ability to rapidly identify and mitigate potential infectious disease health risks to people in the U.S. Included were things like developing a test to diagnose cases of infection by 2019-nCoV, alerting physicians what to look for in suspected cases, and initiating screening at airports of people entering the U.S. from countries where there are high rates of infection.

         We were struck, however, by a bullet point that was absent from the press release: how is the CDC communicating the risk of getting infected to the American public? Surely the CDC understands that once a case inevitably arose in the U.S. that people would become worried, especially given the nearly unprecedented level of media attention given to the novel virus. Yet there was no mention of what public communication efforts the CDC was undertaking to ensure that we all have accurate information.

         Inaccurate information predictably flooded social media. Everything from fake cures like saltwater, alcohol, and vinegar to conspiracy theories that the drug companies were provoking panic about the virus so they can make money selling a vaccine could be found on the internet. To their credit, Facebook, Twitter, and YouTube all announced steps to mitigate the flow of misinformation. Scientists have also, perhaps for the first time, initiated concerted efforts to counteract online misinformation with correct information in real time. Nevertheless, the CDC must have anticipated that incorrect information would find its way onto hundreds of internet platforms, further confusing the public. And we desperately need an esteemed agency like CDC to help us grasp what is known about the virus and how much of a threat it is believed by scientists to pose.

         Just how risky 2019-nCoV is to the American public seems to be unclear. A January 27 article quoted a spokesperson from CDC saying that the virus posed a “low risk” in the U.S. A few days later, a report on CNBC was headlined “Ex-Obama health advisor: US needs to ‘stop panicking and being hysterical’ about coronavirus”.

         Yet also during late January a headline in the Washington Post read “First U.S. case of potentially deadly Chinese coronavirus confirmed in Washington State”. One could also find an online post titled “New coronavirus may be much more contagious than initially thought”. Words like “deadly” and “much more contagious” do not seem to convey the same message as “stop panicking” and “low risk.”

         We believe it is imperative that the CDC not only take the lead in uncovering the epidemiology and biology of 2019-nCoV but that it also takes the lead in communicating risk to its constituents. We also think this can be done without interfering with the work of state and local health departments. In this scenario, CDC would issue press releases and online communications on a regular basis that clearly lay out what is and isn’t known. These press releases should answer questions like whether wearing a mask is protective and whether you can catch the virus if someone coughs near you in a subway train or public bus. And what about the question about whether it is safe to eat in Chinese restaurants? The answer seems to be “yes”, although we could not find a CDC source for that information. We agree thoroughly with Saad B. Omer, director of the Yale Institute for Global Health, who wrote in the New York Times that “public health authorities should be candid with the public about the uncertainty that inevitably surrounds a new virus”. Our view is that the CDC should initiate an Office of Public Communication that imparts information aimed at people who aren’t epidemiologists or infectious disease experts, information that addresses the concerns and fears these non-experts are actually expressing.

Headlines That Distort Risk

         Which brings us to our second point. While we once again assert that 2019-nCoV must be taken very seriously, as of this writing there are 11 confirmed cases in the U.S. and no deaths. Compare that to the fact that CDC estimates that this season (through January 25), at least 19 million people have contracted the flu and at least 10,000 have died. A vaccine is readily available that will at the very least substantially reduce both the risk of getting flu and the severity of illness if someone does get it, yet only about half of U.S. adults got the flu shot last year. As Joseph Guzman wrote in The Hill recently “…the flu rarely gets the sort of headlines an outbreak like the coronavirus does, despite killing more Americans each year than any other virus, and Americans do not seem to be particularly worried”.

Although it gets far less attention than the coronavirus, flu kills more people every year than any other viral illness in the U.S. (source: Shutterstock). 

         This of course is part of a long-standing story about how risk is reported and perceived. Automobile crashes kill far more people than airline disasters, but only a plane crash makes the front page. Still, responsible media need to realize that what it highlights shapes the public’s perception of what is and isn’t an important health risk. Stories about the coronavirus are important news, but they can obscure other, even larger risks. Could we ask the media to pay at least a bit more attention to encouraging people to recognize how serious infection with the flu virus is, for instance, and the importance of getting the flu vaccine? More broadly, does the media have a responsibility to put epidemic risk in context? We think it does. 

         So, here are a few more things we know. You should wash your hands frequently and thoroughly. Wearing a surgical mask probably won’t prevent you from getting or spreading coronavirus. It is safe to eat in Chinese restaurants. Get the flu shot.

         Let’s hope the CDC, World Health Organization (WHO), and media can get together and craft a useful flow of practical information that includes points like these. Critica will be happy to help.

Is Tap Water Safe to Drink?

A Metaphor for Income Inequality

The question “is my tap water safe to drink?” seems simple enough. We all have at least some basic idea that the water that comes through our faucets is purified somewhere, somehow. People have been drinking tap water in the United States for almost 200 years and many of us don’t think twice about it. Certainly, we are fortunate in this country not to have to worry about water-borne epidemics like typhoid and cholera that still plague many parts of the world.

        If we start reading online articles about drinking water safety, we see that a lot of them start with the refrain “the drinking water in the US is generally safe, but…” We also encounter terrifying articles that claim our drinking water is laced with toxic, cancer-causing, and immune and hormone system disrupting chemicals. Perhaps this is one of the reasons that bottled water is a multi-billion dollar a year industry.

Sometimes, problems do emerge with drinking water, as we have of course seen in Flint, MI and Newark, NJ. But even when real concerns emerge, they often breed fake claims in their aftermath. How do we put the fortunately fairly limited real problems with drinking water in context?

Is our publicly provided tap water safe to drink? (source: Shutterstock)

Where Our Drinking Water Comes From

         Most municipal water comes from lakes, rivers, reservoirs, and groundwater. That water is sent to water treatment plants where it undergoes a variety of filtration and chemical treatments and then is pumped through water mains to service pipes that connect the mains to buildings. The federal Environmental Protection Agency (EPA) sets standards for community water supply systems under the jurisdiction of the Federal Safe Drinking Water Act of 1974; states and localities often have their own, stricter standards for levels of various potentially harmful substances that can be found in drinking water.

         There are over 150,000 drinking water supply systems in the US. The consensus is that public drinking water in the US is among the safest in the world. Yet no less prestigious a source than Science magazine published a story in 2018 with the headline “Millions of Americans drink potentially unsafe tap water. How does your county stack up?Typical of such articles, the story begins by quoting a University of California water economist, Maura Allaire, as stating thatthe U.S. has really safe water” and then goes on to detail a seemingly frightening number of violations of EPA regulations, leading to higher levels of contaminants in some community water supplies than allowed. And some watchdog organizations, like the Environmental Working Group (EWG), contend that those EPA standards are too lax in the first place. This statement by Goop, Gwyneth Paltrow’s organization, is characteristic of what we can find throughout the internet on the subject of water:

The US has some of the cleanest drinking water in the world. Yet our tap water supply still contains hundreds of contaminants linked to cancer, brain and nervous system damage, endocrine disruption, and many other health effects. Most Americans’ water meets the federal government’s legal requirements. But there is often a big gap between what’s legal and what’s safe.

         So do we have very safe drinking water or dangerously contaminated water? Our review of this topic leads us to the following provisional conclusion: people who live in affluent communities have very safe drinking water, but people who live in poor communities often do not. Thus, in some senses water quality in the US is a metaphor for the country’s well-described and worsening state of income, racial, and class-based inequality.

Claims of Toxic Contaminants Abound

The list of toxic contaminants said to be routinely found in drinking water includes fluoride, chromium, radium, nitrates, PFAS, chlorine, and lead. We will return to the lead problem later in this commentary. Some of these “contaminants” are actually deliberately added to drinking water for specific health-related purposes. Fluoride has been added for decades because of the well-documented finding that it reduces dental decay. Nevertheless, the non-profit organization Fluoride Action Network insists that consuming it can cause cancer and a bevy of other dreaded diseases and also reduces I.Q. in children. Most recently, in a draft report by the National Toxicology Program concludes that fluoride is “presumed to be a cognitive neurodevelopmental hazard to humans”. Similarly, EPA mandates that chlorine be added to drinking water in order to reduce pathogenic bacteria, algae, and fungi levels. Nevertheless, one can easily find claims on the internet that chlorine in water causes cancer.

Some naturally occurring substances make their way into the water supply and must be filtered down to lower levels for safety. Radioactive radium is naturally present in rock, soil, and surface water and can be effectively removed from drinking water by a variety of methods, yet reports of elevated radium in drinking water alleged to be carcinogenic crop up periodically. Nitrates and nitrites, which in high levels cause the “blue baby syndrome” (methemoglobinemia), are another example of this phenomenon.

Finally, some substances may get into drinking water supplies from factory and mining discharges. Per- and polyfluoroalkyl substances (PFAS) are an example of a group of potentially toxic contaminants that are used in manufacturing and can wind up in drinking water. Perhaps the most famous such example is hexavalent chromium, the substance featured in the famous movie Erin Brockovich. In that movie, based on a real-life story, Brockovich links what she believed to be an unusual cluster of cancer cases in Hinkley, California to run-off of hexavalent chromium from a Pacific Gas and Electric plant.

         An examination of these claims reveals that high levels of contaminants in drinking occur infrequently, most often involving elevated levels of coliform bacteria that result in gastroenteritis. Often, the claims that something is carcinogenic in water turn out to stem from studies in rats and mice in which doses far higher than anything a human would ever consume are shown to cause cancer. In fact, such studies should reassure us that the level of contaminant in our water is safe: cancer in such instances can only be induced in rodents when doses are pushed to extreme levels that are far out of range for humans. For example, an often-cited study from the National Institutes of Health did show that hexavalent chromium causes cancer in mice and rats, given doses of chromium between 14.3 mg/L and 516 ml/L for two years. But the lower of these doses is still ten times higher than what humans could consume from the most highly contaminated water sources identified in California and only the highest doses actually caused cancer in the rodents.

The claim that chlorine when consumed in drinking water increases cancer risk seems to come mostly from the fact that chlorine does so when inhaled as poison gas used in warfare (now outlawed by international law). Evidence is actually weak that chlorine is carcinogenic in the concentrations EPA mandates for drinking water, and the risks of not chlorinating drinking water are deemed far greater than any increased risk of cancer. Nitrates and nitrites in drinking water were found to pose no human health risk in a careful analysis by the National Research Council.

Although the recent National Toxicity Program draft report on fluoride in drinking water raises concern about the compound’s potential to lower IQ in children, that finding will likely be challenged as scientists examine the specifics. Moreover, the finding demands that we believe that the IQs of children born in most US cities and towns since the 1950s would be higher were it not for fluoride their mothers consumed while pregnant with them and that they later consumed themselves. Even the claims about chromium popularized by the Erin Brockovich movie now seem suspect. Some studies have found no increased rate of cancer in Hinkley in the time period covered by the movie. Independent scientists have also questioned the connection claimed in the movie between chromium and the various illnesses people in Hinkley reported having.

Finally, much of the insistence that our water is contaminated comes from the Environmental Working Group (EWG), a controversial organization that once helped spread the myth that vaccines cause autism. The EWG has set its own maximal levels for various potential water contaminants, usually lower than those set by EPA. EWG says that its “scientists reviewed the best and latest scientific evidence, legal standards and health advisories, and defined water quality goals that will truly protect public health.” Unlike EPA, EWG asserts that their standards take into account “heightened vulnerability of children, infants and developing fetuses to toxic chemicals” and also consider emerging potential toxicities for which there are as yet no EPA standards. Most of their standards are based on those of the California Office of Environmental Health Hazard Assessment. Some EWG skeptics complain that it has conflicts of interest because of involvement with organic product companies and that it promotes ideas and warnings of dubious scientific validity.

Overall, then, we are unpersuaded that substances present in the American drinking water supply that most of us consume pose significant health threats. That conclusion is challenged, however, by recent loosening of EPAs standards by the current administration. While we once could trust the EPA to be an impartial, scientifically-based regulatory agency, the basis for that trust has clearly been eroded in the last three years. But for now, it seems that the people most concerned about chlorine, PFAS, fluoride, and nitrates in water are affluent people who can afford to buy bottled water.

Lead Contamination is a Real Threat

         On the subject of lead contamination, however, we came to a different conclusion. The service lines that connect water mains to buildings, including homes, are often made of lead and very old (they were banned in 1986). Municipalities add compounds to the water that coat lead service pipes and prevent lead from leaching into tap water. This method is usually effective, but old pipes can still corrode and break and various factors like higher acid levels can erode the protecting chemical lining. Because of this, the EPA mandates regular testing of municipal water for lead and actions that must be taken if the level exceeds 15 parts per billion (ppb) in more than 10% of customer taps sampled. The most famous recent cases of lead contamination in drinking water occurred in Flint, Michigan and Newark, New Jersey.

The situation in Flint evolved when the city manager in a cost-cutting measure discontinued purchasing water from Detroit, which gets its drinking water from Lake Huron, and instead began pumping water from the Flint River. The water in the Flint River is more acidic than Lake Huron and eroded the coating on the water pipes that normally keeps lead from leaching into the water. Lead levels in the Flint drinking water were soon detected above the maximum EPA allowable limit. In addition, buildup of coliform bacteria around the aging pipes lead city officials to increase the amount of chlorine in the water.

This led to high levels of chlorine breakdown products called trihalomethanes, some of which are believed to be carcinogens. Flint has now resumed getting its water from Detroit.

A change in the source of water for Flint, Michigan led to an increase in lead levels that officials at first seem to have dismissed (source: Shutterstock).

What seems to have happened in Newark is that the city was adding sodium silicate to the water to prevent lead leaching from service pipes into the water, which was working. Then, in 2015, the city started changing the water’s acidity to deal with other potential contaminants and that prevented sodium silicate from working.  In 2016 the water in Newark started failing the EPA mandated lead tests on multiple occasions. The city began handing out water filters that had worked in Flint, but for unclear reasons did not in Newark and the city was forced to hand out bottled water. Newark recently announced a $120 million program to replace its lead pipes, but this is an expense a city like Newark will find hard to bear.

What happened in Flint and Newark are certainly not routine occurrences and each involved some degree of denial by public officials in the face of clear warnings that water quality had been compromised. But there is one thing that both cities have in common with each other and many other American municipalities: both cities are poor and largely populated by people of color. Lead pipes are mainly found in older cities and fears about water quality are justifiably high among African Americans and other minorities who live in them. These are precisely the communities that are most likely to lack money to replace old lead service pipes. Some low income communities do not even have the luxury of drinking water from a municipal supply: Millions of low income Americans still do not have access to potable water or drink water from contaminated wells. Thus, unlike affluent communities where the water is usually perfectly safe but people nevertheless can afford to buy bottled water, people in poor communities drink water pumped through aging infrastructure but may lack the financial and political resources to do anything about the problem.

Ironically, most of the bottled water people drink is just filtered tap water.

And not all of it is regulated; the Food and Drug Administration (FDA), not the EPA, regulates the quality of bottled water but only if it is shipped across state lines. Water bottled and consumed within a state may or may not be regulated by state authorities.

When Consumer Reports tested bottled water, they found higher levels of contaminants in some products than the EPA permits for the public tap water supply.

And of course, most bottled water comes in plastic bottles, a well-described environmental hazard.

  Thanks to a generous grant from the Robert Wood Johnson Foundation, Critica is now engaged in a project that is examining what people think and say about our drinking water. As we continue to research this area, it is likely that new facts will emerge and some of our conclusions may change. For now, however, we are convinced about several things: most people can safely drink tap water, without filters, right out of the faucet; bottled water is unnecessary and bad for the environment; and poor communities that cannot afford to replace aging lead pipes or purchase filters and bottled water are at risk for consuming higher than recommended amounts of lead in the public water supply. Here we have one more reason to call on our public officials to address the country’s infrastructure needs and income inequality issues. For some people, these are affecting the very water we drink. Perhaps if bottled water companies are making billions of dollars selling municipal tap water that taxpayers pay for, those companies should contribute funds to replace lead service pipes around the country so that even people who can’t afford their products can have safe water to drink.