Each month, NACCHO will bring you a new public health book, read and reviewed by NACCHO staff. We hope to provide a well-rounded reading list that you will find enjoyable as well as informative.

This month, however, I had the opportunity to do something a bit different. After reviewing two of his books for previous recommendations (Pandora’s Lab and Vaccinated) I was able to (virtually) sit down with Dr. Paul Offit and discuss his new book, Overkill: When Modern Medicine Goes Too Far, his thoughts on public health, and how COVID-19 will change the public health landscape. This interview is also featured on NACCHO’s Podcast from Washington.

Emily Yox: Today I am speaking with Dr. Paul Offit, who is the Director of the Vaccine Education Center at the Children’s Hospital of Philadelphia, as well as the Maurice R. Hilleman Professor of Vaccinology and Professor of Pediatrics at the University of Pennsylvania School of Medicine. He has authored over 10 books, two of which have already been recommended for NACCHO’s book club; Pandora’s Lab and Vaccinated. Today, we will discuss his new book, Overkill: When Modern Medicine Goes Too Far, and discuss how we as public health professionals can be the best advocates for ourselves and our communities -- Welcome Dr. Offit!

Dr. Paul Offit: Thanks, happy to be here.

EY: I want to say that I really enjoy your books and love the way you take complex topics and make them digestible for your readers. To start off, your recent work, Overkill essentially debunks medical practices that we consider gospel; saying instead that they might be unnecessary and in some cases, even harmful. Some, like the over-promised benefits of vitamin supplements, I can easily get behind, but talk me through some of the more potentially controversial ones like completing the antibiotic course. I think people will be very surprised and interested to hear your thoughts on that…

PO: Yes, that is probably the thing in this book that will surprise people the most! Take this example: if you have asthma and you’re wheezing, you take asthma medicines until you stop wheezing—and then you stop. When you have pain, you take pain medicines until you don’t have pain anymore—and then you stop. You don’t assign a pre-determined length of treatment before you start.

But we do for these bacterial infections (ear infections, kidney infections, bladder infection, skin infections, pneumonia, etc.) We say, “Okay, we’re going to treat you for seven days or 10 days or 14 days.”

Well, what happens if in three or four days, you’re better? Let’s say you have a bladder infection and now the white cells are gone from your urine, the bacteria are gone from your urine, and you don’t have any pain anymore. Why are we continuing to treat?

The answer used to be that we continue to treat to make sure the infection doesn’t come back and to make sure that we don’t create resistant bacteria. First of all, you’re really creating resistant bacteria by treating for longer than you need to. Second, the question of “Does it come back” has been answered again and again in many scientific studies. There are studies that show now that you can treat for shorter periods of time.[1]

Advisory groups to the Infectious Disease Society of America and other groups that are interested in educating people who practice infectious disease or pediatrics or internal medicine, now have made those recommendations, so they’re in line with those studies. Yet still many doctors still stick to that longer period of time. There was an article actually in The Lancet called Is this the End of the Antibiotic Course, and I think the answer is yes. Treat the patient and treat individually, but you don’t need to set a predetermined length of time at the beginning of illness.

EY: The other section of your book that I was eager to discuss with you was your section on cancer screenings. The idea that some screenings cause unnecessary anxiety or in some cases, potentially unnecessary intervention, I can say from experience is now being discussed in MPH programs. Can you discuss that further?

PO: Sure-so there is this researcher named Gilbert Welch and he has this barnyard analogy. Imagine that there’s a barn and you open up the door and there’s three different animals in there: one is a turtle; one is a bird; and one is a rabbit.

The bird flies out the minute you open the door—there’s nothing you can do about that; you can’t close the door quick enough. That’s a cancer you’re going to die from no matter what you do.

The turtle is so slow-moving that it doesn’t matter how long you leave the door open, that turtle is never going to get out - that’s the kind of cancer that is not going to kill you. You’re going to die with that cancer, you’re not going to die from that cancer.

Then there’s the rabbit. With the rabbit, you can actually close the door quickly enough to stop it before it gets out. That’s a cancer where early diagnosis does make a difference. So, for cancers like prostate cancer, thyroid cancer, and breast cancer, the question really comes down to what is the ratio of birds to turtles to rabbits?

For prostate cancer and thyroid cancer, it is a lot of turtles and birds; there aren’t enough rabbits. People die of prostate cancer and people die of thyroid cancer, but usually they die independent of whether you diagnose it early or not. Similarly, a lot of people die with thyroid cancer or with prostate cancer, and not from it.

Now breast cancer is a little different; mammography does save lives. However, it doesn’t save nearly the number of lives that did when it was first introduced decades ago and that’s because we have much better cancer treatments for breast cancer, even fairly late-stage breast cancers. So, the earlier diagnosis is not as profound as it used to be.

Plus, the downside of all these cancer screening programs is that they scare people to death! There’s a lot of false positives and now you think you have a cancer that’s going to kill you when in fact, you don’t. That’s what I try and explain so people can be better informed about their decisions and they can be better advocates for their health when they go see their doctor.

EY: I have also recommended your book Pandora’s Lab for the NACCHO Book Club and that as well, espouses the general idea you mention at the conclusion of this book; that people should trust data over spoken claims and ask questions before believing everything you hear. The challenge for public health professionals is that data is often uninteresting for people who don’t understand it, and currently held beliefs are hard to change. As someone who, in my opinion, presents data in a very engaging way, what advice do you have for public health professionals who are up against vaccine hesitancy or similar challenges?

PO: I think the challenge for the people who are communicating science to the public is to try and make it fun, make it enjoyable, and tell a story. Surround those data with a frame that is passionate, compassionate, compelling, and colorful. That is a challenge and it’s certainly not the way you’re trained to behave as a scientist. I mean, you really just trained to be boring, frankly -- so it’s hard.

An example that I use in both books, Pandora’s Lab and this book Overkill, is the vitamin C story. There couldn’t be more clear data with vitamin C. There actually was one study that I would consider the perfect study to show that vitamin C does not prevent or treat colds. It couldn’t be clearer, yet it is an enormously popular product. People just take their Emergen-C and feel “Okay, now I’m not going to suffer a cold this winter” or “Now I’m going to treat this cold.” The cold gets better and they think it was because of the vitamin C, when in fact, it wasn’t. So, I don’t know -- what do you do to counteract that? You have this tremendous marketing push teaching people that this does work, and on the other hand, you have the sort of dry scientific studies that just don’t sell themselves.

I do think there’s one study, though, that we have to figure out a better way to get it out there because it was what I consider to be the rare perfect study. What they did was they took volunteers, and they tested their bloodstream to see whether they were susceptible to a particular kind of common cold virus called rhinovirus 44 - all these people were susceptible. That’s always one of the confounding variables out there when you do these studies, some people are susceptible to viruses, some people aren’t, so this took that away. Then, these volunteers were challenged with a known amount of rhinovirus 44. That also took out another confounding variable which is that we’re all challenged with more or less of these viruses. Then, this physician examined them every day, so that took out the third confounding variable which is how people actually report their symptoms. They were examined every day by the doctor and taking 3000mg of vitamin C at any stage made no difference. It was the perfect study.

The person who actually promoted vitamin C was Linus Pauling, who won a Nobel Prize in Chemistry and a Nobel Peace Prize. I mean, you know, they’re not giving away these things in crackerjack boxes, it’s hard to win two Nobel prizes! The man had a tremendous platform, but unfortunately hit a blind spot when it came to vitamin C. He disregarded that study and said it was too small. I mean, he just kept disregarding study after study—there’s actually been more than 50 studies that have looked at vitamin C solutions, are still this idea that vitamin C prevents colds is out there! So I don’t know what it’s going to take to change people’s minds, I really don’t know.

EY: I guess trying to make it interesting and engaging is one approach though.

Generally thinking about your books, what is the biggest takeaway that you want public health professionals in particular, to take away from what you’ve written?

PO: It’s all about the data it is all about the science and the studies. I think that we as communicators and advocates for health, we really need to get that information out there, but it’s hard because you’re up against two powerful forces. One is the pharmaceutical industry who does everything they can to promote their products. Two is the dietary supplement industry, which has the advantage of not being FDA regulated so they can say the kinds of things that they normally wouldn’t be able to say, because they’ve never had to show that their product was safe and effective.

Finally, there are celebrities who are, you know, much more attractive as a general rule than scientists, and people think that they know those celebrities because they’ve seen them on the big or little screen, which is why celebrities are used to endorse products. You’re up against a lot. It’s very hard for studies to trump emotion and the advertising business, but if you really want to be as healthy as you can, then you should pay attention to the science and the data.

I’ll give you one more example because I think this is relevant to COVID-19, which is the issue of the day -- don’t treat fever. It just seems so counterintuitive to people that you shouldn’t treat fever, but you shouldn’t, and here’s why. First of all, we all make fever. Everything that walks, crawls, swims, or flies on the surface of this earth can make fever -- why? We pay a metabolic energy cost for that, for every degree centigrade of temperature that is increased, your basal metabolic rate increases by 12%, so you really work to get fever, you shiver, you shunt blood from your arms and legs into your core, you put on warm clothes. You want to be warmer. Your body wants you to be warmer, you feel cold and your body wants you to be warm. Why does our body do that?

The reason is simple - your immune system works better at a higher temperature. Regarding COVID-19, if you want to rid your body of COVID-19, the best way to do that is to make antibodies to that virus. When you give anti-fever medicines, although you feel better from the symptoms that are associated with a fever, like chills, muscle aches, and headaches; you’re actually allowing that virus to be shed from your body longer and that’s putting yourself as well as others a greater risk. People don’t seem to get that, but study after study has shown that when you treat fever, you prolong the illness. This couldn’t be clearer, yet still we feel compelled to do it.

EY: You mentioned COVID-19 which really is the hot topic for the foreseeable future, so I do want to conclude by asking that as we enter a potentially unprecedented time for public health in the era of COVID-19, do you see the landscape for public health changing and do you have any thoughts to share as we enter this new reality?

PO: Yes, I think this will be permanently scarring, in many ways as scarring as 9/11 was. I think we are going to see our world differently after this settles down, assuming it settles down at some point in the next few years. This, in many ways, reminds me so the early days of AIDS when it was unclear what was causing AIDS and it was unclear how you caught it. I mean, people were scared to pick up a piece of fruit in the grocery store at that time and that’s what this feels like now. People see anybody else who is walking on the street as someone who’s potentially dangerous to them.

Now that’s always true, at some level. I mean, we sort of grandfather influenza and this year influenza is going to cause anywhere from 40 to 50 or as many as 65,000 deaths. It’ll cause 700,000 hospitalizations and it’ll cause 30 million cases, and that happens pretty much every year. Interestingly, the instance of influenza since we’ve locked down or sheltered place has actually gone down more quickly than one would have imagined. So maybe the answer is we should stay inside every winter—but obviously we can’t do that!

I do think we will be smarter about this. I think as time goes on, we’ll become more thoughtful. I think people will stop shaking hands. I think they’ll just do the elbow bump or the fist bump. I think they’ll be more hesitant to get on a big bus or the subway for a while and I do think this is going to change how we see our neighbor.

EY: Well, Dr. Offit, thank you very much for sharing some insights on your new book Overkill and discussing some of the other works we featured on the NACCHO Book Club! I really appreciate your time today.

PO: Thank you—my pleasure.

[1] https://www.bmj.com/content/358/bmj.j3418; https://theconversation.com/why-you-may-not-need-all-those-days-of-antibiotics-81820; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5661683/