When I finished grad school in Chicago a few years ago, I moved back home to Minneapolis and had pretty much everything anyone could ever wish for.  I had a new job as an epidemiologist in a hospital.  In addition, I spent some evenings working for a youth center as a counselor – I made some extra money, and was lucky to be involved in these kid’s lives.  I was in a relationship, and we were pretty much inseparable.  We found an agent and started looking at buying a house.  After years of struggling to stop drinking soda, I had successfully quit and was even going to the gym a few times a week (on my way to losing that extra grad school weight).  I fell asleep every night thinking I was the luckiest guy in the world.

So, I’m sure you can see where this is going.  Life is filled with the highest highs and the lowest lows.  So, naturally, everything began to unravel.  I got laid off from my part-time position (the center lost some grants and donors, and was on its way to shutting down).  There were management changes at work that were causing some serious headaches.  My relationship ended abruptly with a job offer from some fruity little company in Cupertino. The second housing bubble was getting ready to burst, and home buying was nearly impossible (first world problem, I know).

I’m not looking for sympathy.  You take the cards you’re dealt, and you handle it any way you can.  In my case, I turn to Reddit, a social news site.  I get my daily dose of tattoos-gone-wrong, huge spiders, and other mishaps to remind me that things can always be worse.  On bad days, I look for pictures of kittens and puppies (nature’s SSRIs).  And, of course, I look to the forums for information on how other people handle different situations – whether medical or mental health, or just everyday living.

I’m not alone.  The average 24 year old will spend more time on facebook in the next week than they will with a physician in the next 20 years.  Whether you like it or not, people (particularly teens and 20-somethings) are living their lives online.  When good or bad times come, they play out online both actively and passively.

In my case, my problems came spewing out online.  My employers on Facebook changed.  My relationship status changed.  I lost friends on Facebook as a result of the breakup, and I gained connections on LinkedIn as a result of leaving the job.  I mostly stopped updating my status on Facebook and Twitter… and when I did, it was one of those obnoxious, ambiguous, needy updates (no judgment; we’ve all been there).  My music listening, as measured by Last.fm, changed suddenly from hip-hop to emo-rock (and, really, just one or two songs on repeat for an entire summer).  So, the internets knew that I was in the midst of a quarter-life crisis.  My physician, however… well, let’s be honest, I hadn’t seen my physician in about 3 years.

And therein lies the problem with and solution for our healthcare system.

That average 24 year old – there’s a 1 in 3 chance that he’ll develop diabetes in his lifetime.  There’s a 60% chance that he’s already overweight, and a ~30% chance that he’s prehypertensive.

If we want real change for our health care system, we need to be concerned about primary prevention efforts.  We need to figure out ways to find signal from our everyday interactions, and build interventions that fit into the context that we actually live.  Lucky for us, we’re now living in a world where a substantial amount of this information exists about us online.

So, in my little crisis, I started drinking soda and stopped going to the gym.  It wasn’t that I didn’t want to be healthier, it’s just that I had other more pressing issues to focus on.  However, if there was a way to alert someone on my care team to call me to help identify a plan to ameliorate my situation; that could have helped keep me on a healthy path and potentially mitigate health problems decades before they emerge.

That’s exactly what we’re working on at Epi.md, a medical informatics company currently in the Rock Health incubator.  Ultimately, something needs to be done because, while it’s not ideal, patients are increasingly turning to services like Reddit, Google, and Facebook for information and support.  That means they’re leaving a trail of data about their needs, and are perfectly susceptible to intervention.  And public health, research, and clinical medicine will have limited success if they don’t acknowledge and utilize this fact.

So, why isn’t Foursquare actively being used to improve health?  It has enough data about me to provide personal recommendations to improve the way I live.  Many people have recognized the potential impact Foursquare could have, but there are very few (if any) health-related applications developed around this service.

Tony and I, in consultation with our resident behavior designer (Steph), worked to address this issue during the first-ever Foursquare Global Hackathon. In less than 40 person-hours (and, combined, 10 cans of Mountain Dew Throwback), we created Fourhealth.

The goal is simple: we want to help users make healthier decisions about where they eat out.  We do this in a couple of ways.  First, when a user signs up for Fourhealth, we ask them for height and weight information (and continue to collect weight via text message on a weekly basis).  Then, about 90 minutes after each checkin to a restaurant, we text the user to find out how they’re feeling after eating there.  This information is aggregated to the food venue, giving us a data source of objective (i.e., BMI) and subjective (i.e., feelings) health elements.

Immediately after each checkin (thanks to Foursquare’s new Push API), we look for previous feelings the user has had about the venue, and try to find a potentially healthier restaurant near where they are.  If we find either, we immediately text them to let them know, giving them the knowledge to make a potentially healthier decision:

Of course, you can’t always just leave a restaurant because you got a text message telling you to go somewhere else.  Maybe you’re meeting a group there, or the suggested venue is closed, or you just really want a triple whopper with cheese value meal.  But, there are times when you’re just hungry and go for the first place you see (only to find the organic cafe just around the corner).  Or are sorta thinking about your health, but just need a gentle nudge.  Or are in a completely new city and don’t know where to go.  We can help with all those situations.

Future Development

What I’ve described so far is our first iteration, and was completed in less than two days.  It’s live, and you’re welcome to sign up and try it out

However, there are many more things that need to be developed/thought out/changed, including:

• Improved analytics.  Imagine a Klout-esque score, only for how healthy a restaurant is.
• Ability to search.  We want to help people find healthier restaurants when they’re in unfamiliar cities.
• Personalized visualizations and data.  Some people really like exploring how their data affects their health.
• Withings integration (so you don’t even need to enter your weight).
• Weekly email summary.
• Venue-specific healthy food recommendations.

Porn analogies aside, I’ve spent the past two months in San Francisco working for a health tech start up.  I’ve been to events and happy hours, and met many people working on many projects (Steph has a great post characterizing the kinds of people out there).  The only thing I have really learned is that nobody quite knows what’s going to work (but everyone is trying very hard).

Through this, I’ve noticed four different kinds of health innovation:

Entrepreneur-centric

Health 2.0 is very entrepreneur-friendly.  People identify a problem (or are incentivized to find a problem) and create a solution to it.  Sometimes the solution works out well, sometimes it doesn’t.  But the emphasis is on trying to solve the problem.  Often there’s a business plan behind the idea.  Sometimes there’s a health behavior theory.  But the underlying goal is to keep trying until something sticks.

Research-centric

Sex::Tech is the ISIS-run conference about sex and technology.  Many of the presentations come from large, NIH-funded research studies.  At the pre-conference for researchers, discussion focused around the difficulties of keeping up to speed on changing technology.  When you have to submit an NIH grant proposal 6 months to a year before funding, it’s hard to anticipate what the technological landscape will be like when the money actually comes.  Case in point: ISIS did a study around teens, social networking, and sexual health.  Halfway through the development, there was a mass exodus from Myspace to Facebook.  ISIS had been developing on Myspace, so they had to essentially start from scratch on Facebook.

Developer-centric

Rock Health is a health tech incubator in San Francisco.  They brought in a bunch fo developers with ideas around fixing health care, and are giving them money, space, and support in hopes they’ll create something amazing (and they are!). Massive Health… well, I don’t really know what they do, but they have a really cool website.  They were founded by Aza, an awesome designer formerly of Mozilla, in hopes of providing the design Renaissance in health care.  Both companies are working to bring in outsiders to help re-shape our health care system.

Hospital-centric

My experience in large hospital organizations has been that innovation is confined to a department, and mostly consists of the strategic project management of large can’t-fail projects.  Lots of really smart people in business suits, sitting in windowless meeting rooms talking about payment models and risk adjustment.  Conversations often revolve around Health Care Homes (the Minnesotan version of Medical Homes) and Accountable Care Organizations.  The projects are incredibly important.  In some cases, the fate of the organization rests in the success of these projects.  It’s a completely different kind of innovation.

So what will work?

None of these kinds of innovation will work on their own.  Massive Health’s diabetes app is not going to single-handedly solve our fiscal problem and, similarly, an Accountable Care Organization is not going to solve diabetes.  However, an Accountable Care Organization that encourages people to use a suite of tools, including Massive Health’s app, might actually make a difference.

At some point there will be a shake-up of health care, to the same degree that Napster disrupted the music industry.  It won’t happen in the same way — medicine is too highly regulated to allow a complete outsider disrupt the entire system.  That is, not matter how cool your app is, you still need a doctor to diagnose diseases and prescribe medications.

For health care to actually change, these four kinds of innovation need to take a collective, very large step closer to each other:

• Entrepreneurs need to prove what they’re doing is effective.  Maybe not initially, but it should be part of their roadmap and budget.  Just because it’s a good idea and people use it doesn’t mean it’s going to save lives.
• Government funders need to speed up the funding process.  Give money to smart people, not to smart ideas — a smart idea today will probably be dated a year from now.  A smart person today will probably continue to have smart ideas in a year.
• Developers need to listen to the needs and wants of experienced health care providers.  Sometimes, that might mean translating what you are doing/want to do into terms and concepts providers understand.  But, ultimately, if you don’t have buy-in from current providers, you will not have the reach you could have otherwise.  Doctors prescribe medications, and there’s no reason they can’t prescribe an app too (if they understand what it does).
• Large hospitals need to realize that innovation doesn’t happen when you’re wearing a suit.  The biggest (and perhaps most effective) change may come from someone wearing a hoodie and sitting on a lovesac.

Obviously, fixing health care is much more complicated than just the above.  It requires having an IT infrastructure that supports using new technology (and not perpetuating IE6 because that’s what your EMR requires).  It requires having technologically-competent providers and consumers (or people who can train them).  It requires changing the health professional admission processes to make more Indu Sabaiyas, Jay Parkinsons, and Alan Greenes (physicians who understand “helping people” means more than just prescribing drugs when someone gets sick).  It requires changing the financial model of health care by either convincing insurance companies to fund the implementation of innovation, or to move beyond insurance companies completely.  But, ultimately, health innovation starts when we all start working together.

The Minnesota Department of Health (MDH)¹, from analysis of data collected by their partner services program, says:

Commonly reported risk factors were meeting partners on the internet, anonymous sex, and no condom use

Now, I don’t want to be the debbie downer, but if I’m not using condoms and am meeting partners on the internet for anonymous sex, then being told to use condoms and being handed a brochure is not going change my behavior.

I’ve been working in sexual health education/testing for nearly a decade, and I have yet to meet a young man that didn’t know he should probably be wearing a condom.  Education is not the problem².  The problem is that having sex without a condom feels really good.  Much better than with a condom.  So much better that, in that moment, the risk of getting syphilis or HIV feels like a pretty equal trade for the feeling of sex without a condom³.

A brochure can not compete against our biologic drive to exchange body fluids.  Ever.

Craigslist Explored

What can compete, however, is sex.  But before I explain, let’s look at a few personal ads from Craigslist (sorry, this is sexually explicit):

22 one fifty 6′ 7cut bottom/vers
gl.ddf, into jo, oral, making out, want to bottom safely
looking for ddf, good shape, top under 30 unless really hot
host/travel won’t respond to replies w/ no pic

Looking for a btm who’s willing to let me go wild….flip on your stomach, put your ass up, I slide in… I am 5’10″, 145lbs, blond, 7″ cut, nonsmoker, DDF, HIV-, popper friendly. Would prefer u be nonsmoker and definitely DDF/neg. Hit me up! Please send age pics.

looking to have some fun now, 29yo hiv+ looking for some fun, vers, oral, body contact, open to whatever, bb or safe cool, lets get together

A few definitions/codewords:

• “bb” or “wild” = bareback, anal sex w/o condoms
• safe = generally anal sex w/ condoms
• ddf = drug and disease free
• neg = HIV-negative
• popper = amyl nitrate
• gl = good looking
• jo = jacking off
• top = insertive partner; bottom or btm = receptive partner; vers = either

So, each of these personal ads share two characteristics: 1) they explicitly state what they want (e.g., “let me go wild”, “bottom safely”, “bb or safe cool”), and 2) they state their HIV or STD status (e.g., “DDF/neg”, “hiv+”).  Of course, not every Craigslist post does this, but many do — if you don’t believe this is an accurate representation, then start browsing (and comment on this post with your findings).

In public health terms, they’re practicing harm reduction by attempting to serosort.  But there are two major questions that are raised:

1. Are you actively ensuring your partner is “DDF”?  Or are you relying on your post to sort out all those who aren’t “DDF”?
2. How do you know your partner knows their HIV/STD status?  When were they last tested?(I’ve met more than one person who assumes they’re HIV-negative, yet has never been tested).

Data-Driven Sex

Qpid.me provides HIV/STD test verification for online dating⁴.  They work with your clinic to get your HIV, syphilis, gonorrhea, and chlamydia test results, and then allow you to share them with whomever you like.  Right now, it’s done via text message, although there are plans to expand soon. So, for example, you can get my test results by texting “Verify John Demo” to 774363.  ”John” is my username, and “Demo” is my access code — this allows me to ensure I’m only sharing my results with the people I want to.

This could be a huge game-changer for sexual health.  Now there’s a tool available to help those no-condom-wearing, internet-using, anonymous-sex-having heathens men serosort using actual, verified data.  And, of course, all of the normal just-want-to-be-close-to-someone guys and gals could benefit from Qpid.Me, too.

Even more important, there’s a sexual incentive to get tested more frequently.  If the status quo is to use self-reported HIV/STD status as a criteria for selecting sexual partners (e.g., “I will only have sex with you if you say you don’t have HIV”), what happens when you can verify the status along with approximately how long ago they were tested?  A potential partner would be more attractive if they’ve been tested more recently, meaning: getting tested = getting laid.  And who doesn’t want to get laid?  (it sure beats having your doctor hand you a brochure about syphilis).

For people living with HIV, you can verify your viral load and also share that with potential partners.  With an undetectable viral load, one becomes less infectious (it is still possible, but less likely).  So, this allows people living with HIV to have informed conversations with their partners about the risk of HIV transmission.  Done correctly, this could actually alleviate some of the stigma of HIV-infection, get more people laid, and decrease HIV incidence.  Win-win-win.

Use fire to fight fire.  [insert your own joke about red-heads or gonorrhea].  That is, use sex to fight sexually transmitted diseases by redefining how people have sex.  Instead of having a traditional information campaign or continuing to hand out condoms, actually arm people with a tool to be able to make informed decisions.  Even better, give them a tool to allow them to do something they’re already doing, a little bit better.  By encouraging people to make informed decisions with actual data, you’ll see them get laid more often while getting fewer STDs and getting tested more frequently⁵.  And, most importantly, it requires essentially no change in current behavior.

If you haven’t figured it out by now, Qpid.Me is the health tech start-up I took a job with.  We’re currently in private beta, while we work on building out a bunch of the back-end.  If you’re interested in signing up, head to the website, or comment here/email me — I might be able to hook you up

Seriously, who footnotes a blog post?
1: I pick on MDH because I’m from Minnesota.  They’re actually quite good at what they do, given the constraints of politics.  The issues I raise are pretty ubiquitous among all major public health departments.
2: While I argue education is not the problem, I do believe comprehensive sexuality education in schools would help lower HIV/STI rates.  That’s more of a shift in attitudes than providing students with facts.
3: Of course, I wouldn’t know from first hand experience…
4: Now, if only there were a Qpid.Me for verifying penis size.
5: There are a couple of research studies in the works regarding this, but right now this statement is based on qualitative information from users and theory.

The Minnesota HIV Services Planning Council

The Minnesota HIV Services Planning Council is an appointed body that allocates all of the funding for Part A Ryan White Services and recommends funding for Part B Ryan White Services in Minnesota.  In less jargony terms, they decide which services are most important for people living with HIV in Minnesota, and then fund those services using federal dollars.  The Council is made up of around 30 people, including those living with HIV/AIDS (“consumers”) and those who provide services to people living with HIV/AIDS (“providers”).  As an epidemiologist, I was appointed as a provider to their Needs Assessment and Evaluation committee.

So, it came time to do our needs assessment, prioritization, and allocation processes.  This is the primary function of the Planning Council; we had spent over a year doing research and studies, preparing summaries, and sitting in long committee meetings. In this process, the Part A Grantee provides their recommendation, and the Council discusses, amends, and ultimately approves a proposal. This cycle, the Council approved the recommendation with little discussion, no amendments, and more than 2 hours left in the scheduled meeting. Members were excited to leave and get back to work/home/whatever, and patted themselves on the back for a job well done.

Then, there was a survey of Council Members about how they thought the process went.  More than half disapproved.  The Council staff members were quick to dismiss the results because “three of the responses came from the same IP address,” suggesting that foul play had negatively skewed the results.  In reality, there are three Council Members (including myself) who work for the same hospital, and probably took the surveys from within the same network.  When I asked what the IP address was, I was told it was not appropriate to ask that, and they would not be released out of concern for members’ privacy.

In response, I made a Minnesota Government Data Practices Act (MGDPA) request to the Hennepin County Attorney’s Office.  The head of the Ryan White Program for Hennepin County called my supervisor to complain that I was consuming resources in filing my request, and suggested that I be disciplined [note: this is illegal].  The County Administrator called me to personally apologize.  Months later, the data I requested was released, and I was proven to be right:  the three surveys were all legitimate and, in fact, the majority of Council Members did not approve of how they allocated funds for HIV services.

As a result of my MGDPA request and data practices concerns, a County Attorney came to a subsequent Council meeting to discuss MGDPA and Open Meeting Laws.  I followed up via email with the attorney, specifically outlining my concerns regarding the Council.  He sent a follow-up memo.  This was discussed at a Planning Council meeting (emphasis added):

Memo from County Attorney’s Office – Tim distributed a document from Dan Rogan titled HIV Planning Council.  This document provides written answers to questions asked when Dan attended a Council meeting to talk about Open Meeting Laws.  Questions/Comments:

• Antonio Mo. asked about #4.  Tim said we have always treated Council information privately.  Because of the law we are required to provide the home address of Council members if requested.  Current staff have never received this kind of request.  The question was brought up around the Council roster which includes addresses, email addresses, and phone numbers.
• Keith asked that Council member information being shared with other members be discussed with new applicants.  Tim said this is discussed during the interview and in the application.
• Loyal said a Google search of his name will bring him up on the Council website.  He is disheartened that his affiliation with the Council is so public. 
• Mike B. asked that this document be posted somewhere so it can be referenced.
• Adam asked if this can be addressed at Operations.  Tim said yes.

Loyal is a good guy: very thoughtful, well-spoken, and respectable.  He is not the only one on the Council with this concern (although, he may have been the only one with the guts to express it).  It certainly is valid.

However, this concern epitomizes my issue and belief.  Every time I vote on a matter, regardless of how seemingly insignificant, I want to be absolutely sure that I have a reason behind my decision.  If what I say and do is publicly available, then I should assume that at some point somebody may ask why I said or did something.  I’ve failed if my response is simply, “I voted for it because everyone else did.”  In the same vein, my name and contact information being publicly available provides a means for this to occur — if nobody knows who I am or how to reach me, then they have little recourse in expressing their disagreement.  So, for me, MGDPA and Open Meeting Laws provide an impetus to ask questions and, when appropriate, dissent in public meetings.

The Public Health Advisory Committee (PHAC)

The Public Health Advisory Committee for the City of Minneapolis hears concerns from citizens about public health issues, advises the Minneapolis Department of Health and Family Support (MDHFS), and distributes (with City Council approval) $400k in Public Service Community Development Block Grant (CDBG) funds.  I serve as a Co-Chair of this Committee.

When it came time to distribute the CDBG dollars, we established a process, funding principles, and priority areas (PDF).  We had a large community review process, and long discussions about the various needs of the community and what services would meet those needs.  Ultimately, we came up with a proposal that the Committee (and City Council) felt satisfied with.

Of course, it’s never that simple.  There were funding cuts, and our $400k dropped to $140k.  The decision was thrown back to the Committee to decide how to absorb this cut.  We returned to our principles, ranking, and discussions.  Being reminded of what we originally thought was important, and remembering the desire to address socioeconomic determinants of health and health disparities, we (relatively easily) came to a conclusion as a committee about where to put our remaining dollars.  It sucks that we didn’t have enough money to go around, but it feels good that we debated and considered almost every possible solution and ended up making a decision that seems fair and socially just given our constraints.  I feel confident defending the decision to fund those specific organizations, and believe they will be able to make the most impact on the health of Minneapolis residents.

Open Government = Public Health

Most public health organizations strive to address socioeconomic determinants of health, eliminate health disparities, and (in general) help people be healthier.  The Planning Council and PHAC both, to their own extent and in their own way, do that.  However, in their last funding cycles, PHAC had a much more significant discussion regarding the needs of the community.  The Planning Council essentially rubber-stamped a flat-funding proposal with barely any discussion.

The only way public health is going to identify and address the needs of a community are by talking to members of that community.  That’s exactly why the Planning Council and PHAC exist.  However, the Planning Council, in their creation of a privacy-centric public body, has created an atmosphere where few community members are willing and able to start or engage in meaningful dialogue.  The result is a process that few are happy with, and a product that could only be improved.  Neither of these results creates an environment where innovative policy solutions to health disparities and improvements to socioeconomic determinants of health can be created.

When a positive attitude towards open government and transparency is adopted, members let go of their personal privacy.  If there is no personal privacy, then concern shifts from protecting information (e.g., “I don’t want anyone to find anything about me online”) to protecting reputation (e.g., “I want to make sure my statements and votes are accurate and consistent with my ideology”).  If concern is primarily regarding reputation, then members feel compelled to seek out information and knowledge to make informed decisions about presented topics (i.e., an informed decision will, hopefully, prevent public criticism).

In order for public health to be successful, we need our elected and appointed leaders to engage in meaningful discussions about problems in our communities.  For that to occur, we need a constituency informed and ready to hold public officials accountable.  Information only comes when the public has access to data, and that can only occur when the government is compelled (willfully or legally) to provide it.

That is, public health can only succeed within an open and transparent government.

So, I’ve spent the last few years working as an analyst for hospital organizations.  This is great, except hospitals are slow to try new things.  My experience has been that innovation is confined to a department within the organization, and not encouraged of all its employees.  New ideas are met with a deafening “meh” from middle management, followed by stern encouragement to focus on getting back to writing reports or whatever exactly it is that you do.  There are departments for innovation and process improvement.  Let them do their job so you can continue doing yours.

This puts me in an awkward position.  My goal, as is the case for most med school hopefuls, is to help improve the lives and health of people.  I think this can be accomplished by using policy, technology, public health, and medicine.  It’s clear from pretty much every health-related news story I’ve read in the last 5 years that the status quo isn’t working.  US health care is expensive.  People are getting sicker.  That’s not exactly a formula for success.

And I’m part of the problem.  My salary isn’t used to provide direct patient care, and I’m not given the resources to really be able to create solutions to the problems I’m presented with.  So, I’m forced to do just enough to keep the machine moving without actually fixing any part of it.  It’s job security at the expense of patients.

So, out of all of this, I am thrust into yet another quarter-life crisis.  Perhaps the most epic of my quarter-life crises: how do I help improve the lives of the greatest number of people, see my contributions recognized and adopted, and still continue to pay my mortgage?

I wish I had an answer.

Being a physician could be a move in the right direction.  I was accepted in a subsequent application cycle to TouroCOM, an osteopathic medical school in Harlem focusing on underserved populations, but I have deferred for a year.  Medical school is expensive, both in dollars and time.  And I do not want to be forced to practice medicine instead of innovation just to pay back student loans.

In the meantime, I locked myself in my bedroom for a weekend, turned off my cell phone and gchat, and started coding.  The result was Epicenter, a tool (currently being re-written) to help analyze patient data, combine patient data with other data streams, share findings, and take action.  This app ended up winning Practice Fusion‘s Analyze This! Health 2.0 Developer’s contest.  Who knew I could code?

Since then, conversations started on Twitter led to new jobs, friendships, and opportunities.  It quickly became clear that the path I was headed was not going to accomplish my goals, so it was time to try something new.  I quit my job and found a place in San Francisco.

I have mixed feelings.  In a way, my story (and others) epitomize the problems with health care and medical education.  The systems talk about the need for change, fresh ideas, and leadership among incoming medical school classes, but then continue to admit people based heavily on very traditional measures of aptitude and pre-medical experiences.  How can you expect change to occur when you’re continuing to admit all the same people?

However, in rejection comes opportunity.  I would not be doing what I’m doing today had I been admitted to medical school when I first applied.  In fact, I wouldn’t be doing much of anything for the next 7 years other than study and work.  So, if my goal is to improve the lives of people, then what I’m doing today is closer to immediately achieving my goal than my original plan.

Regardless, I’ve learned to acknowledge that I have no idea what I’m doing or where I want to go.  I just know what isn’t working for me and the greater health care system, and that I want to be part of the solution.  Medical school, graduate school, or health tech start-ups are all potential answers to my question.  I’ve tried two of those before, so I think it’s time to try the third.

Today was a much more relaxed day, as I have finally bought into the “marathon not a sprint” mentality for this conference.  I also ventured out of the HIV/sexual health into a data and practice session.  But, in summary, here is some of what I learned (~1500 words for 10 hours of conventioning… I think that’s pretty good):

MRSA infections in MSM associated with PNP.  Popular media was very quick to label Methicillin-resistant Staphylococcus aureus (MRSA) as the new “gay STD” but that’s not entirely accurate.  MRSA is spread by close contact with someone who is a carrier or infected, so in a sense, it could be sexually transmitted.  There was an outbreak in men-who-have-sex-with-men (MSM) in New York City in 2006.

Qualitative research by the New York City Department of Health and Mental Hygiene found that this outbreak was caused by three issues:  Party-n-play (PNP – drug use and sex) activities, MRSA misinformation, and stigma.  Participating in PNP caused people to have sex for longer periods of time increasing their exposure.  Also, HIV-positive individuals and PNPers were less likely to use condoms and water-based lube, opting for grease or oil-based.  This has a tendency to clog pores, further facilitating transmission.  Once someone was infected, they’d attempt a variety of home-remedies, including alcohol-baths, peroxide, and lancing the pustule.  This would further insult the skin integrity while not resolving the infection.  Finally, individuals felt MRSA carried an additional stigma, thinking that, as one individual said, it’s just “another gay disease, one more thing conservatives can use” against them.

HIV-positive men mostly feel responsible for preventing HIV transmission. Is an HIV-positive individual responsible for keeping an HIV-negative individual safe?  Or is it always the HIV-negative individual’s responsibility to protect themselves?  A study by Dr. Hugh Klein discussed the locus of control among HIV-positive men who have sex with men with HIV-negative partners.  He found that 70% of HIV-positive men felt they had an obligation to keep their partners safe, while 49% thought it was also the negative partners responsibility (these are separate questions, so they don’t add up to 100%).

Further analysis showed five factors, explaining 21.6% of variance, helped explain HIV-positive individuals external locus of control:  having HIV “burnout”, being younger, partner communication problems, knowing fewer people with AIDS, and being a meth user.  Partner communication was  related to the need to improve communication, making it a two-way street.  Ultimately, most HIV-positive men believe they have a duty to keep HIV-negative men safe, although more than 1 in 6 disagree, and more than 1 in 3 think the HIV-negative individual is also responsible.

Internal ejaculations don’t always happen in unprotected anal intercourse. There’s a general assumption in HIV research and practice that if you’re having sex without a condom, you’re also ejaculating inside your partner (or being ejaculated inside).  This, according to Dr. Klein and Mr. David Tilley, is not always true.  Only 50.2% of sex involved internal ejaculation.

When examining factors related to internal ejaculations, they found four issues that explained 18% of the variance: knowing people who died of AIDS, use of the internet to seek partners, perceived accuracy of their partner’s HIV status, and a negative attitude towards condoms.  They also found significant associations with other risk activities, including felching and snowballing.  If you don’t know what those are, you should probably google them from your non-work computer.  This information makes a very compelling case for encouraging harm reduction — people may not be practicing “safer sex” by using a condom, but they are taking steps to reduce their risk of HIV infection by at least not allowing their partner to ejaculate inside them.

“Boys must be men, and men must have sex with women.” Dr. Scott Rhodes did a qualitative study of risk taking among African American, Latino, and White MSM.  His findings, similar to what I learned from yesterday’s sessions on HIV, seemed to show a lot of similar issues among different groups of people.  Latino men reported loneliness and social isolation, largely related to being secluded in rural North Carolina where their jobs and families were.  African American men reported feeling isolated from their church.

Condom use was also an issue.  One African American man said that “condom use is antithetical to love.”  And, dealing with their own coming-out process left feeling a bit overwhelmed and not ready to also use condoms:  ”having sex with another man is a step in the right direction.”  Participants also expressed that alcohol/drug use was sometimes used an excuse — if someone “didn’t want him to cum inside him, he wouldn’t” let it happen.

This study suggested a number of recommendations for HIV prevention, including implementing a coupon system for non-department of health testing venues, using more social media, implementing chat room interventions, and operating hotlines and websites specific to MSM of Color.

Submissive men use condoms (or don’t) when their partner tells them to. Continuing research that Dr. David Moskowitz has previously done relating to leathermen and condom use, he explored the relationship between being more dominent or submissive (i.e., sexual control) and condom use.  I’ll be honest — this is one of the few presentations where I got a bit lost (mostly because I was just so concerned about how power bottoms fit into this picture).  However, my take away was that dominent men are in control of whether condoms are used.  Further, when someone is in their non-preferred role (e.g., dom men being submissive), they’re more likely to eschew condoms.  This suggests that perhaps condom negotiation should be done prior to sexual activity — perhaps condoms should be discussed when chatting online or in a bar, so there’s less pressure to have that conversation in the heat of the moment, after you’ve already been tied up.

Data-Driven Public Health Practice.  My one non-HIV session that I went to  Ms. Ami Shah with Mount Sinai in Chicago talked about their use of data to implement public health changes in the community.  They received a Robert Wood Johnson grant to do local, neighborhood-level surveys relating to health.  They did this in a about 10 neighborhoods in Chicago, based on certain ethnic/racial groups or mixes of interest.  This data allowed people to identify local issues, create private-public partnerships, generate news coverage, and help inform elected officials about public health issues.  Some Jewish Synagogues, now having data about obesity rates in their children, implemented programs to reduce childhood obesity.  Another community in northern Chicago found poorly controlled diabetics in their neighborhood, so some diabetes centers opened up in those neighborhoods.

In New York City, they produced local data based around 10 metrics, and then provided data back to the individual neighborhoods.  Their rationale is that neighborhoods become empowered by having access to their data, and then the Department of Health and Mental Hygiene becomes empowered to help the neighborhoods with issues.  This work has informed elected officials about needs in their communities, and has led to policy changes.  For example, New York City, already saturated with food carts, is allowing 1000 “green carts” in designated neighborhoods in order to provide healthier food options to citizens.  Certain farmers markets have “health bucks” which provide a $2 voucher for every $5 EBT transaction.

King County, the county containing Seattle, has developed CommunitiesCount.org.  This was the product of a community process to develop indicators for local municipalities.  This information is made available back to the municipalities to allow them to inform elected officials and budget decisions.  As they continue developing their web presence, they intend to make this data available in a more user-friendly and dynamic manner.

This presentation sparked a lively conversation with some of the presenters, myself, and a few former classmates of mine from the University of Illinois-Chicago.  We discussed the need for public access to raw data, and the desire to put this data into the hands of the neighborhoods.  As one of my former classmates pointed out, she doesn’t have the staff in her health department to analyze all of the data.  But if local colleges or Schools of Public Health (or even high schools!) were to take on data projects using *real* data, they could get a much stronger bang for their buck and even further empower their local communities. NYC has started doing this, and King County has plans to do similar work.

There’s a lot of exciting things happening and there’s an overwhelming amount of information out there.  So, even though I can’t possibly go to every session and poster presentation, I think that’s ok.  The networking, conversations, and socializing have been inspiring; and the presentations have been enlightening.  I’m excited for the conference to wrap up, the opportunity to really process everything that’s happened, and then to get back to work.  It’s our world to change, as Dr. Cornel West said, because we are the American Public Health Association.

Most interestingly, there were a few themes that I realized in the presentations:

1. Everyone is the same, but different.
   There was an entire session on current research for men who have sex with men (MSM). This included a presentation from someone focusing on African Americans, one on Asian/Pacific Islanders, and one on (by convenience) Whites. When talking about their qualitative concerns and issues, they all seemed to be same. Nobody likes getting tested for HIV. It’s really hard to use a condom, particularly when you’re in love. Drugs (especially crystal meth) make sex feel better.

   However, when developing HIV prevention interventions, each population was also clear that they need to be culturally specific. We, as public health professionals and medical providers, need/want to encourage people to be healthier — and that means making people feel comfortable and ready to make changes. So, while the core message may be the same (e.g., “use condoms”, “get tested”), it still needs to be customized for and delivered in a culturally competent manner.

2. Access isn’t enough
   Dr. David Malebranche summed this up very well: “testing facilitators [are] not just an access issue, [they're] a quality issue.”

   Simply having access to HIV testing isn’t enough.  Being tested for HIV is a traumatic experience, so patients need to feel comfortable when going in for testing.  That means making sure that providers are properly trained, staff are open and non-judgmental, the waiting room feels comfortable.

3. Providers suck at taking sexual/social histories
   This came up in multiple presentations.  Providers don’t feel comfortable taking sexual or social histories, and (in some cases) don’t think it fits with the work they’re doing.  That is, it’s not a strictly a medical history, and they don’t have time to ask any other questions.

   This isn’t, as Dr. Malebranche suggested, as simple as asking, “Mr. Jones, have you ever had a penis in your butt before?”  It requires taking time to ask and assess what kinds of risk the patient has.  Knowing this information would then inform the patient and provider about the needs for HIV/STI testing.

4. There’s no one good method.
   Multiple approaches allow patients to choose an option that makes them feel most comfortable. Not everyone wants to get tested at their primary care clinic.  Similarly, not everyone feels comfortable in an STD clinic.  However, some people are willing to work through their discomfort if needed — they may not want to be in the STD clinic, but they know if they test positive, the provider may handle it better than their PCP.

I also learned a lot about gay sex parties in Boston today, through the work of Matthew J. Mimiaga.  As you might expect, there are two kinds of sex parties: safe and unsafe.  The safe (i.e., condoms required) parties are surprisingly well regulated.  Party hosts maintain a listserv of ~1500 men whom they’ve recruited from Manhunt ads, word of mouth, and other websites (although a typical sex party has ~50-60 people).  There’s a screening process — you have to meet certain physical requirements, and sign an agreement that you will practice safe sex.  They enforce condom use by physically checking with flashlights.  Sex parties are typically themed around certain groups:  young men, daddy/son, diapers, etc.  However, parties are not serosorted (i.e., people of any HIV status may participate).  Taking this formative research, Dr. Mimiaga is working on a randomized controlled trial measuring the effectiveness of hosting safer sex parties… and are actually starting to find it to be effective.

Nate Stupiansky used Manhunt to conduct a survey relating to STI diagnoses in over 26,000 men who have sex with men.  Curiously, 37% of respondents reported being in a relationship with one person.  That is, 37% of people who opened an email on a primarily sex-seeking website stated they’re in a relationship with one person.  Why are you on the website then?  But that’s not the point.  His analysis looked at the association between type of sex (insertive or receptive) and odds of self-reported STI diagnosis.  Persons reporting insertive anal intercourse and inconsistent condom use were at 41% higher odds of STI diagnosis.  Persons reporting receptive anal intercourse and inconsistent condom use were at 72% or 65% increased odds.  Most interestingly, people reporting an STI diagnosis in the past two years were at 76% decreased odds of being tested for an STI in the past year.  This is problematic.

I’m still trying to digest all this (and the information from the awesome social media panel at the end of the day).  There’s clearly room for improvement in the work that we do, and I’m excited to share this with my colleagues back home!  Time to sleep, so much more happening tomorrow…

Dr. Bill Jenkins, one of the people instrumental in ending the Tuskegee syphilis experiment, gave an opening keynote address. Racism, he argued, is the only example of a condition where we study the symptom and not the cause. There’s not a race problem in the US, there’s a racism problem. We need to broach the uncomfortable to start addressing actual determinants of health. And, like Martin Luther King, Jr did, we need to move from being a corporate leader to being a servant leader — and this means putting people before papers.

Dr. Cornel West closed the opening ceremony, in one of the most inspirational, energetic, and entertaining public health speeches I’ve ever heard (I can only hope APHA posts the video for free online). “Justice is what love is called in public [...] Love is a steadfast commitment to the wellbeing of others.”

So, this is my first national conference. My first day really reflected this, as I left the opening ceremony, and immediately tried to do everything. It was an apt twitter user that pointed out that APHA is a marathon and not a spring. However, I’m still glad I managed to meet and chat with other public health people, and learn about interesting topics…

I met the founders of The Positive Project, a Colorado-based organization working to share the stories of people living with HIV/AIDS. They are two therapists working with HIV+ clients who began noticing that many of their clients were experiencing similar situations. But, bound by confidentiality, there was no way for them to share stories. So, they created a website and posted interviews with consented people living with HIV/AIDS. It’s a simple, yet brilliant, idea — this way, people can privately hear the stories of all kinds of individuals living with HIV.

I talked with the a member of the Houston Public Health Department about their use of almost real-time data in responding to a syphilis outbreak.  In 2007, they were 2nd in the nation for Syphilis.  They mapped syphilis cases, clinics/services, and various determinants of health.  This, in turn, influenced where their mobile clinic went.  The clinic ended up serving 1,489 clients that year, and Houston managed to relinquish their position of second highest syphilis incidence in the country.  A true success story for data-driven practice.

I also learned that alcohol outlet density is associated with crime, but not gonorrhea cases.  Medical students like the idea of a Personal Health Record, but not necessarily for them personally.  And the gold standard of lab-confirmed STD cases may underreport compared to self-reported cases in public health research.

I really didn’t know what to expect coming to APHA.  But, I’ve learned that it’s important to focus and plan what you want to do (including planning your wandering time through the Expo).  There are so many passionate people here.  I’m amazed that I can stop at a poster that looks really boring, ask the person what they did, and just through their brief speech I can become energized and excited about their research.  It’s revitalizing, and I can’t believe I haven’t come here before.

The editorial (intentionally) does not spell out any details about what kinds of programs should be done. That’s simply too much detail to fit into the space allotted. Since it couldn’t be done there, I’d like to share a few ideas and examples of ways to truly utilize social media and the internet:

• Advertise online. That seems stupid and simple, but when was the last time you saw a HIV prevention message online? Red door has done this… but I haven’t heard of or seen any other Minnesotan organization doing HIV prevention through online advertising.
• Video contest. The Ryan White program unsuccessfully tried this. One of their major failures was that they viewed the intervention as the end product and not the process. By having a video contest that’s graded by peers, the peers are also receiving the prevention messages. That’s the social aspect of social media :p
• Midwest Teen Sex Show. It’s not a naughty website. It is, however, an example of a way to step away from the overly-sterile messages that sometimes come out of health organizations.
• DC FUK!T. This is a dirty website. But that’s also what makes it so great. It’s essentially a sex ed video you can jack off to. And, there’s some evidence to suggest this kind of approach is effective in certain populations.

Ultimately, my issue is that it doesn’t feel like prevention is evolving to keep up with the epidemic. Prevention workers are already over worked, and there isn’t new money coming in. The internet is still relatively new, and many people that have been working in HIV prevention don’t comfortable on facebook, twitter, youtube, etc. So, in some ways it makes sense that new programs are slow to emerge.

However, we won’t know what works until we try. There’s a group of young people interested in stopping this recent epidemic that has started to meet. The idea is that among this group, we have the skills and resources to develop and execute pilot projects. And, hopefully, we can do things that will raise awareness about this problem. So, if you’re under 30 and interested in finding out more, send me a message.