Medical GIS Guide
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# GIS Users Excel in Communication, Service, and Vision for Health and Human Services Applications

A link to the past . . . nearly ten years ago I presented the ecological method for evaluating West Nile disease.

I used this field surveillance process from 2000 to 2003, and by the end of the second year, managed to develop the prediction model for where West Nile tended to remain active within the ecosystem.  In Spring of 2003, my theory was proven by the re-emergence of positive testing vectors in April.  (for more on the method to my madness, see http://brianaltonenmph.com/west-nile/ , and continued from there for about 15-20 pages.

Brian Altonens insight:

Currently, I am promoting the hexagonal grid method for mapping, the site for which gets an incredible number of downloads and hits annually (I covered that stat in detail somewhere else.)

Hex grids eliminate most of the error that square grids result in.  They are a tradition of mid-19th century German geographers / spatial thinkers, revived once or twice by one or two western European and United States geographers, beside myself.

The field that loves to think hexagonally is "urban science" (the field that initiated it in Germany).   I believe it has high value to healthcare surveillance.

So why isn't hex grid mapping used, if it is 27% more correct that square grid mapping?  Old math habits are hard to break.  And sometimes, old math is really, really bad (although this new math being taught in elementary and middle schools may take the lead).

The visualization of space is habitually done using rectangular to square grids.  That is why we won't replace square grids with hexagons (imaging trying to read one of those maps on an overseas voyage).

But hexagon grids are more accurate for numbers and statistics analyses.  I therefore recommend that the hex grid process be used by students (no need in trying to change the habits of traditional professors with this new concept).  My pages on hex grid theory begin with:  http://brianaltonenmph.com/6-gis-ecology-and-natural-history/hexagonal-grid-analysis/ ;

Once I am through the dissertation, I will have several other tools to use for producing the hex grids in GIS.  I haven't applied the 2D hexgrid algorithm to my 3D modeling NPHG mapping technique, meant to by pass base mapping time and effort for surveillance purposes.  But that plan too is set for the near future.  (I am still trying to get other to understand one regular grid layer, in 3D, with multiple layers overlain for multivariate modeling.)

recently, I found my old mapping project from the 1990s, using Idrisi to design a 3D modeling algorithm that eliminated the elevation above sea level problem.  I wanted to map elevation relative to closes water edge.  Elevation data uses only the sealevel or surface of closes ocean as the zero point.  I needed a moving zero point to be laid over water bodies and rivers, and essentially flatten them out, but keep relative topography and landform constant, and recalculate those mountain heights, relative to the closest water surface.   The result was essentially an integral equation using a grid version of the river to define the new x0, at each recurring grid point of the river's water surface edge.

Enough of that, to see this work (again, ArcInfo and Idrisi and a very new ArcView were the sole GIS/RS tools in the classes and labs then), go to:  http://brianaltonenmph.com/gis/applying-new-methods-with-gis/space-time-behavior-in-contemporary-disease-patterns-and-models/ ;

I used that model to demonstrate and predict floodplain flooding due to a rising water surface, to predict cholera prone outbreak areas across the country.   (Thesis work.)

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# Medical GIS Guide

Recommended tools , resources, and methods. Examples of what can be done, what should be done, and what has been done.
Curated by Brian Altonen
 Rescooped by Brian Altonen from National Population Health Grid

## State With The Highest Immunization Refusal Rate Works To Fight Vaccine Stigma

The Oregon state Senate has passed a bill that would make it harder for parents to forgo their children's vaccinations for a non-medical reason. Like m
Brian Altonens insight:

This is a re-scoop of something I posted more than a year ago.

the recent outbreak of measles in California is an undeniable warning of what could happen in up and coming years. [see  http://pediatrics.about.com/od/measles/a/measles-outbreaks.htm ]

The Pacific Northwest is one of two epicenters for vaccination refusals in this country.  The other is just down the road from me in Westchester County-Bronx-Yonkers area just outside of New York City.

The fascination with "Natural Health" is the reason for these refusals.  These two parts of the country are peak areas with natural health philosophy, where some of the larger programs and meeting places devoted to this philosophy exist.  (Richard Geer and many celebrities come to this region to learn and experience Yoga, learn about Chi and experiment with new healing "faiths".

Few people know, but the Hudson Valley is actually the birthplace of most alternative healing in this country, with a history that extends back to its first European settlers--when christian alchemy as taught by Harvard chemist Charles Starkey became a century long practice faith.  The earliest psychology, spiritism and metaphysical preaching from what was later Greenwich Village were practiced between New York and the Hudson Valley due to the Fowler Institute of Phrenology that preached throughout this region (ca. 1834-1890, ca. 1850s, the Fowler Institute promoted pastoralism, seancing and being one with nature at its octagon house at the Wappingers-Fishkill border).  Early native American herbalism, "Indian doctoring",  Water Cure, Graham's Diet, Feminism (women in charge of their own health movement), vegetarianism, Naturopathy/Natural Therapy, Sufiism, all began here, where their leaders developed schools, educational programs and camps in this region, long before the bacteria theory ever came to be.

With Medical GIS, we can map anything and everything if the goal is to better understand a region and its communities.  That is exactly what I did twenty years ago to determine why the Hudson Valley is the heart of alternative medicine in this country.  Medical GIS can be used to map out more than just physical disease patterns.  I used it as well for better understanding social, cultural, economic/poverty related human behavioral and psychiatric/psychological diagnoses, and to understand such social problems as abuse, bullying, religious fanatacism, terrorist activities, pyromancy, culturally bound syndromes.

Brian Altonen's curator insight,

With Medical GIS we can demonstrate those areas most in need of interventions for certain disease patterns and unhealthy behaviors.  This map details the magnitude of difference that exists between numbers of vaccination refusals in the Pacific NW and the rest of the country.

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## What Florida is doing to stop the Zika virus

Florida's hot, humid climate puts its 20 million residents at risk -- along with millions more tourists
Brian Altonens insight:

It is one week into February.  For New York that means we are5 or 6 weeks away from paying close attention to the first mosquitoes.  The first pests are those that successfully  overwintered.  This spring will be full of those pests, because this winter has managed to steer clear of too many El Nino-La Nina effects.  It has snowed only once up in my county, and been miserably cold for just a week or two.

But the first adults to re-emerge from their winter hibernation should be carrying much, we hope.  There haven't been too many positive testing cases with West Nile and Chikungunya like we feared late last summer.

So weather and climate determine when the first southern disease bearers will impact this part of the States.  Whereas Aedes aegypti is the vector epidemiologists have to watch to the south, Anopheles are the pests we may have to pay close attention to up here, perhaps Aedes.

So where do the Aedes mosquitoes penetrate the US with their tropical diseases?

West Nile is a related disease; but it rapidly migrated across this country ecologically.  Can Zika virus do the same?  This video is of the success that West Nile had crossing this country in just a few years: https://www.youtube.com/watch?v=VKtREeEtkaY&nbsp;

The way Mosquito Viral Encephalitis is distributed in this country is at : https://www.youtube.com/watch?v=YGu_hY_r0Ko&nbsp;

It shows where the Dengue is brought into the US by Aedes, via people.  NY is the center for possible in-migration of the disease by infected people.  Whereas Florida, Louisiana, and numerous southern states riddles with mosquitoes are how it will enter this country ecologically.

I produced a rich resource on how to evaluate mosquito-vectored diseases using GIS.  I developed a method for ecologically profiling places, to determine where these critters are most likely to run rampant, and where they will mathematically cause to most chaos to ensue and the likelihood for unexpected diseases to penetrate the local wetlands and swamp-ridden areas.

The following is how I used a light sensing device to develop a better ecological understanding of mosquitoes, in relation to land use patterns and ecological vegetation-domain status:  http://brianaltonenmph.com/west-nile/west-nile-surveillance-2/

Remote sensing tells us plenty about an ecosystem and whether or not it has the features to develop a stable ecosystem for vectored diseases to survive.  See http://brianaltonenmph.com/west-nile/6-remote-sensing/ ;

My study of species for these vectors:  http://brianaltonenmph.com/west-nile/vectors/ ;

My vegetation survey derived plant ecology study: http://brianaltonenmph.com/west-nile/3a-west-nile-surveillance-1/ ;

My surveillance of cases:  http://brianaltonenmph.com/west-nile/case-related-surveillance/ ;

My method of assigning risk to areas:  http://brianaltonenmph.com/west-nile/assigning-risk/ ;

My review of topography, landform and vector patterns (won an award for this): http://brianaltonenmph.com/west-nile/topography/ ;

My NLCD grid mapping method of evaluating vector and host distributions: http://brianaltonenmph.com/west-nile/nlcd-grid-mapping-and-west-nile/ ;

My introductory page on how to do this monitoring of diseases using a GIS, with plenty of pages to follow, is http://brianaltonenmph.com/west-nile/

My award winning west nile ecology poster, 2006: http://brianaltonenmph.com/about/west-nile-ecology-poster-session-at-2006-esri-conference-denver-co/ ;

I posted numerous videos of zoonotic disease behaviors in the US based on 1998-2012 EHRs (the past 15 years), at https://www.youtube.com/playlist?list=PLWrApErk5byYvO6ZHvDzgzmPqOGs1WI9B&nbsp;

and

FOR STARTERS . . .

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## Foreign Born Disease penetration into the U.S. - Bioterrorism

This is one of several dozen videos displayed or reviewable on my ScoopIt!, my Tumblr, my Pinterest, and my NPHG page. http://nationalpopulationhealthgrid.wordpress.com/applications/10-bioterrorism/

Brian Altonens insight:

The Crimean or Congo Fever spatial pattern for transmission into the US demonstrates behaviors that overlap with those for many tropical disease patterns, most diseases from Russia and Europe, and the migration pattern for diseases that diffuse globally along the southern Pacific Rim.   The nests of disease or niduses depicted here are those areas that most infected during the past 10 to 15 years.

The one spatial pattern missing on this map is the influx of certain diseases from Mexico, Central America and South America, at a town serving as a cross-over for the Tex-Mex border.

A Pacific NW pattern not evident here is the NW entry from Vancouver-British Columbia.   This path is taken by tuberculosis patients who migrate in from Canada and the Pacific Rim, who then spread it further in the form of a resistant strain and/or a congenital disease passed to newborns.

This model demonstrates a hierarchical diffusion model for international infectious diseases passed on by human travel and migration patterns.

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## 1763 - the "Extraordinary Disease" at Martha's Vineyard and Nantucket

. PREFACE I can start off by stating that "the Extraordinary disease" that struck Nantucket in 1763, and referred to by the writer of this article, was not yellow fever, or at least not just yellow...
Brian Altonens insight:

A few days ago, November 24th, I had 450 people visit one of my historic medical geography pages.  This page reviewed the epidemic that stuck Martha's Vineyard in 1763.

I use two well tested theories to evaluate this diseases most likely to strike this setting during some of the earliest years of colonial history.  Sequent Occupancy and its equivalent idea penned around the same time by Benjamin Rush as a variation on the newly population Erasmus Darwinian evolution theory.

Erasmus Darwin (grandfather of the famous Charles Darwin, founder of the more modernly accepted evolution theory), identified the concept of speciation ["Speciation transition theory"], in which beings develop as a consequence of their ecosystem.  Applying this to humans, Rush stated that as people mature and their work environment and community mature, so too does their way of living and occupation (see "1786 – Benjamin Rush – An early rendering of Sequent Occupancy"  at http://brianaltonenmph.com/gis/historical-medical-geography/1786-benjamin-rush-an-early-rendering-of-the-sequent-occupancy-philosophy/&nbsp;).  Rush referred to these periods of sequential development to explain the different "species" of mankind that had developed. Man's way of living, building houses, setting up business, raising or grown food, all changed as a result of these living and work related environmental changes within the colonial setting (i.e. from the indigenous and settler's rugged landscape, to the cabin family and then home builder, farmer, large farm operator, and natural resource/energy based factories, each with their own greatly improved or modified landscape).

In the late 1800s, the geographers reiterated Rush's theory, without knowing he had in fact already invented it, when they described the sequent occupancy theory for how people evolve and change as the place they live in changes as well ("Epidemiological transition", at http://brianaltonenmph.com/6-history-of-medicine-and-pharmacy/hudson-valley-medical-history/european-multiculturalism/moravian-indian-medicine/medical-changes-over-time/&nbsp;).  These changes in the immediate environment are a consequence of changes in prevailing occupation patterns, prevailing resource and product needs, and prevailing skills and knowledge based needs in order for that business and its factory or industry setting to develop.

For each of these E-Darwinian evolution-ecology states, or Rush species periods, or sequent occupancy stages, come a specific set of medical conditions and disease types.  This direct relation of these three paradigms all precede the contemporary epidemiological transition theory by just a few decades.

Now of course, sequent occupancy, speciation, and early E-Darwinian ecology are not perfect matches for epidemiological transition.  Like any theory that exists in today's scientific community, older theories undergo change and upgrading every now and then.  Sometimes they fade out, only to return years or decades later in some new form, supported by some new paradigm.

Sequent occupancy is a far better way to map diseases and health over space and time today, as much as a century or two ago.  It is as much a valid theory for geographers to use in their studies of spatiotemporal disease patterns, as the traditional ecological theories are for the biological fields, or the demographic-environment theories are for pathogenesis.

Sequent occupancy is here for spatial analysts to use to study their topics with.  It provides a much better, more specific format to carry out this research with, defining as well the observations that need to be recorded and discussed to help show a value to sequent occupancy theory to the modern spatial epidemiology studies.

This page more than likely had such a great following during the first days of this week due to its sequent occupancy and review of history and health for a time when colonial medical theories prevailed.  Colonial medicine beliefs were very different from those of today--few overlap, except at the sentence level--we still occasionally uses leeches to treat the human body for specific conditions.  We bloodlet patients, but only those who are hyperemic.  We reserve religious beliefs for disease, but fall upon other culturally-related belief systems to try and explain our sickest behavioral health patients.  Some doctors believed in metaphysical theory and applied acupuncture to patients, for the electric energy or vital force it transferred, spread or helped to develop.  Such a philosophy differs extremely little from today's reasons for why we want to rely upon acupuncture for treating certain medical conditions, such as back pain or even cancer.

Whatever the reason for its high popularity right now, this item out of the U.S. medical history represents one of many examples of the value of historical medical research, for use by today's healthcare and medical research projects.  Very few medical scholars know and understand medical history.  They often re-write its meaning, purpose, definition and intent for the philosophy, in order to make it fit better with their own modern paradigm.

But theory is theory.  Theory works when we can make it work, and when if works real well, deserves to be tested for more applicability.  The sequent occupance part of this highly popular page, and its example of how epidemics in the past can be so hard to recognize and decipher when penned by non-medical writers, of why we must engage in this kind of work to better understand some of today's medical and public health issues, are the main reasons so many people took to this one page on a single epidemic that struck Martha's Vineyard.  In it, I provide as well as contemporary historian's take on the cause for this disease centuries ago; but the underlying basis for this modern diagnosis is so wrong in terms of time and place.  To make the right diagnosis today, it helps if we know the full history, even of the disease we are trying to decipher and diagnose.

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## U.S. STD Cases on the Rise for the First Time Since 2006

Is this a sign of epidemiological transition, now heading into a reverse mode?

Brian Altonens insight:

My suspicion is that is the case.  As the healthcare system flounders and fails to keep up with what society is doing to about personal health and responsibility, we see enough groups and cultures avoiding the practices that were common when I was a child, when my parents were children.

My parents did not experience a childhood life that was free of malnutrition, measles, mumps, diphtheria, or a host of other infectious diseases now considered more common to developing countries.  I however was one of the first generations to receive nearly a full round of shots by the time I was in college.  The generation after me not only had these shots, there was a way to keep track of this piece of personal health history.  It was required for them to go to school.  No me.  So when I returned to college for a second round of schooling in the late 90s, I took advantage of that opportunity to skip the renewals I was due, because of my late 1950s birth (apparently those earlier shots weren't the best and did not provide lifelong protection.)

My colleagues and friends in the early 2000s were proud of their "healthier way of living".  Sure, yoga made you better minded, kept your mind at peace.  Exercise helped the heart and blood, although the most needy age group engaged in it the least at that time.  But these were also the people whose kids got the mumps, had parties whenever someone got the pox.  They engaged in questionable practices, substituting quality of life improving drugs for environmentally friendly over the country nutriceuticals and phytomedicines.  That acupuncture made them feel they had a better chance of eliminating their "chronic pains."  Their diet changes were necessary due to the sudden IBS or Crohn's they thought they had developed.

But as for infectious diseases like the STDs, a major public health problem prior to the 1980s, there is little they can do to avoid or prevent this problem, except the obvious.

Healthy living has attached to it healthy lifestyles and out of house behaviors.  Healthy living also has healthy emotional experiences, healthy mindbody relationships, healthy friendships and healthy neighborhood relationships.  But to the younger generations, all that is seen are the events as they happen, not the events that preceded the possible rise in STDs now happening, or the consequences that are now emerging due to the "minority" of people who decided public health ideology was false and misleading.

The truth is this "minority" is no longer a minority.  It has become the commoners to many a setting in the United States.  And the impacts of religion and cultural change have yet to cause their impacts.

The possibility of us heading backward in terms of public health advancements has two causes for happening.  The first is human public health related laziness.  The second is the maturation and advancement of the pathogens' genomes.   Some diseases will get worse naturally over time and return, like tuberculosis has been doing.  Others will modify their traditional paths, and find new niches to explore within people, like cholera, shiga, and E coli.

International migrations will also bring back to the U.S. diseases that once were only from the past.  If Bovine tuberculosis returns, or the Texas fever in cattle, or a host of other 19th century disease outbreaks this national suffered with, that will be the final proof needed for claims that epidemiological transition is now going retrograde in its activities.

A better way to interpret these retroactive changes in epidemiological transition is through a review of my rendering of sequence occupancy theory, as a better way of expressing epidemiological transition.  This work I posted years ago at http://brianaltonenmph.com/6-history-of-medicine-and-pharmacy/hudson-valley-medical-history/european-multiculturalism/moravian-indian-medicine/medical-changes-over-time/

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## Did you know . . . ? About the HIT-GIS survey . . . .

One thing we don't realize, is that in the electronic/internet world, once you have been somewhere, somebody knows.

According to Prochaska's Transtheoretical Model of Human Behavior, the lack of initiation of a follow through on an important piece of new information --such as a new program on how to stop smoking--tells the observer that your are not quite ready.  And As James O. Prochaska puts it--the developer of the Transtheoretical Model--you are in either the Precontemplation or Contemplation Stage.

Brian Altonens insight:

If you spent any time at all reading the information source, following up on the new skill set and activities, then you are at least contemplating how a particular topic might pertain to you.  Those who don't spent more than a couple of seconds reading about it, before moving on, are in the less engaged precontemplative state.

But then there are those who are in this Preparation Stage, trying to learn more, with hopes of getting ready for the next "big move".

This "Big Move" is the transition to "Big Data" learning and analyses, and ultimately the use of a more efficient HIT.  If you are engaged in GIS, you are in the Action Stage.

If you are in the Action Stage, how does your activities, your program's activities, fit in to the above chart?

If you are in the Preparation Stage, you understand this chart, and are learning about its different facets.  Each of the images on this flowchart are medical GIS related end products, that avid HIT-GIS people should immediately be able to recognize.

If you are into that Contemplative stage, at least take this survey.

This New Survey is called "Applications of GIS to Managed Care (and other Health Insurance programs)"

As a student of Northcentral University, I am studying the applications of spatial analysis and GIS to managed care (health insurance and pharmacy benefits manager) programs, and why an HIT-GIS has been so slow at becoming the standard for most programs.

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## A new wave of diseases threatens Southern Europe and the Middle East - The Washington Post

With new infection hot zones developing in Europe, world leaders need to get ahead of potential epidemics.  My map videos for each of three geographically different Leishmaniasis patterns in the US, are [American] https://www.youtube.com/watch?v=hpxw97tM75k&nbsp;;&nbsp;

[Ethopian Leishmaniasis] http://youtu.be/jhw8nfEfNOw ; [Asian]  http://youtu.be/mkHYn-r-5WQ .

Brian Altonens insight:

Taking a close look at the history of diseases, they appear to recur in different countries as if a "new wave" of outbreaks was developing.  This new event leaders are trying to link to global warming and climate change, which could be very well correct, at least partially.

Global warming isn't the same reasons outbreaks of various international diseases occurred in the past.  The past events may have even planted some of the pathogens into our local ecology, long before the first outbreaks even happened.

Other factors that come into play with new foreign disease outbreaks in this country pertain to the migration diseases underwent centuries ago.  The common factor for most outbreaks brought from afar is travel, and the amount of people travelling.  During the mid-14th century, Taenia (African tapeworm) made its way to Europe by way of merchant and explorer ships.

During the mid-19th century, there is plenty of evidence suggesting the classical Vibrio cholerae was planted ecologically within the Mississippi River deltaic setting.  On and off it produced a few outbreaks in Mexico and the U.S., which were never considered an indicator suggesting the pathogen was part of the local ecology.

In the past five decades, travel has been the means by which disease causing organisms provided the opportunity to commute to a new ecosystem.  But, whereas fifty years ago in the 1960s, a plane from New York to the Caribbean was a unique transportation event, today, it is nearly a commuter's route to some, a recurring 'frequent flier' event for others.

As of this decade, travelers can easily take just a few hours to spread a disease anywhere they want around the world, from western Australia to Chicago in less than one business day.  The migration of a number of foreign borne diseases into the U.S. in 2014 and 2015 proved this inevitability was finally upon us.

Recently, several foreign born pathologies or diagnoses were brought to my attention, due to their "discovery' in the lower New England-Mid-Atlantic setting.  I remind people to check one or more of my postings, if you want to see the past behaviors of diseases on United States turf, over the past ten years.  Most of these maps are now being reconfirmed, using different data from different sources.  However, if things do get worse, they represent just this moment in US epidemiologic history.

For a number of examples of map videos I produced on what I termed "Foreign Intruder diseases", go to:

https://www.washingtonpost.com/opinions/preventing-the-next-disease-outbreaks/2015/10/23/c4564ec0-7817-11e5-a958-d889faf561dc_story.html?ref=yfp

My blog page with a listing of these (no video links), is at

http://brianaltonenmph.com/gis/global-health-mapping/foreign-disease-intrusion/

For those who don't want to search . . . see . . .

Ethopian Leishmaniasis – http://youtu.be/jhw8nfEfNOw

Asian Leishmaniasis – http://youtu.be/mkHYn-r-5WQ

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## Why HIT is not progressing as rapidly as it should to HIT-GIS or Medical GIS

These are examples of a number of programs/HIT-GIS projects I developed and implemented as part of my National Population Health Grid (NPHG) program.  The purpose of NPHG was to demonstrate potential uses for GIS in population health analysis, as a part of the managed care system,  in a way that focused on the combined annual, quarterly and ad hoc reporting needs typical of the Meaningful Use, QIA and PIP programs that many health care systems engage in.  The Managed Care HIT-GIS (or Medical GIS as some are now calling this process) focuses on the EMR/EHR differently than population health, epidemiology and environmental health programs.

Brian Altonens insight:

There are five tasks to keep in mind when trying to implement a GIS for use by a managed care program.

The first task is it must be able to report meaningful use outcomes and any outcomes for special studies engaged in for quality improvement or performance improvement using local, regional maps.  Preferably, two maps must be reproducible.  The first is the standard zip code choropleth like map depicting distributions of people, patients and specific health related issues.  The second is a map developed for internal use that depicts the same, only at the small area, intervention level, for use in targeting your services, defined needs, gaps in services with more precision.

The second task, is the system has to establish a monitoring and surveillance process, meaning that the GIS can be used weekly, monthly or ad hoc when specific questions are asked.  This is mostly a descriptive use of GIS, meant to serve curious healthcare providers trying to compare their program or services and outcomes to those of their competitors, of for directors and officers to use to evaluate quality and cost related features for given people, programs and regions.  The ideal surveillance program in a managed care setting would of course be live, an outcome that is possible with the right software and data management packages, the right skillset, and the right services from the software providers (I have seen just one or two managed care settings where all three of these are happening.)

The third task is to be able to predict in what direction specific forms of services are heading, such as a growing need for cancer screenings of the 50+ age group, or changes in immunization demands by specific neighborhood clinics and cultural settings.  The use of multivariate analyses in combination with GIS spatial modeling algorithm, in both linear and non-linear,  polynomials are the preferred ways to go when developing these algorithms.   The most accurate long term models I have found, and shown, are initially polynomial in nature with a total of 6 or more independent (unlimited) and dependent (2 or 3 max) variables, merged with an exponential equation used to define a similar outcome, but initiated just before the decay portion of the polynomial modeling ensues, thereby allowing for longer periods of prediction (I made previous postings about this regarding my more accurate way of predicting the 2014-2015 Ebola outbreak).

The fourth task is to provider upper level managers on up to CEOs, VPs and Presidents the visualization needed to bring the points of your research home, as a medical GIS spatial statistician.  This means that the upper level "leaders" must be savvy in their population, its data, the ways this data can be presented, and able to interpret any representation they are handed pulled from SAS, Cognos, Qlik, or GIS.

The fifth task is to document your finances, management, human resource and service industries, in a way that can be analyzed and monitored over a 10+ year period.  As a part of this upkeep, HR (and the managers they report to, make suggestions to) should become more responsible with mining for and utilizing their most valuable human resources.

To date, software, management knowledge base, management skills, and indirectly HR skills or lack of action have been responsible for the failure of HIT to advance enough to allow for rapid advancements in HIT-GIS to ensue.

It is now fifteen years into the popularization of the "Managed Care" philosophy for health care.  The current QI programs, Beacons, MCs and such that oversee changes in the healthcare system have remained slowly-progressive.  This in part is due to employee turnover, repeated software changes, data warehouse challenges, outsourcing based losses in important employee skills.  But it is management that produced the greatest barriers against HIM/HIT development involving a very productive HIT-GIS system.

Due to poor management, the most skillful employees when it comes to GIS are rarely used fully or effectively.  This results in reduced employee retention, further reducing the institution's momentum in this field.  The lack of managers with adequate GIS training further complicates this problem.  Experience and success are a necessity, if a manager is to have a worthwhile goal in mind, that is also advanced.  This barrier in turn results in a further loss in momentum and ultimately the opportunities for discovery and creation at the corporate level are lost.

My preliminary review of the roles of GIS and GIS-trained people in a managed care system demonstrate that most large companies have one or a few individuals highly skilled and knowledgeable in GIS, Medical GIS, HIT-GIS, and spatial analysis, with few used to their fullest potential (if they are working with GIS at all.).  Management's  the lack of knowledge of the potential value of GIS and these employees is the primary reason HIT is not advancing as quickly as we hope, and will certainly not lead to any major innovations in the near future for any current HIT-GIS program's status. (They must be able to produce hundreds of maps per day program).

The talent, resources, skillsets and knowledge base are there; it is up to management to catch up with this technology.

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## Suicide | Brian Altonen, MPH, MS

A Work in Progress SUICIDE Recent news (Joel Morales and the pre-teen suicide issue in New York, 5-31-12):  http://www.nydailynews.com/new-york/12-year-old-east-harlem-boy-driven-suicide-sick-bullies-taunted-dead-father-article-1.1087190 The spatial distribution of suicides is not equal across all age groups.  Some parts of the country are more likely to have the very young (<12 yo) or very old (75+ yo) people documented as having been…
Brian Altonens insight:

Attempted suicide is one of those regional behavioral health patterns that is underevaluated on a regular basis.

Suicide behavior has a cultural link to it that can vary from region to region, county to county, town to town, neighborhood to neighborhood.

When a story about a suicide is released to the press, there are often other behavioral patterns that we expect to occur over the next few days, weeks and occasionally months.   "Copycats" are both a local and national phenomenon, with social and cultural behaviors often defining the types of duplicate cases can prevail.

For example, it is unusual to see extensive duplication of a teen age event, unless there is a shared cause.  The places where these events happen, is where teen age suicide is greatest in the country, which the rotating 3D maps on this page demonstrate.  We do see more deliberate copycat cases with individuals who are sending a message, and have a reason, meaning they are young to mid-age often, and with some complaint or attitude in need of expression.

Isolated and coupled suicides cases impact older people.  Culture differences are often the reason group or family-related suicides happen in this culture.  The greater the cultural detachment from the local communities, the more likely some groups will express this attitude about their value of self and living more aggressively and deliberately.

Not yet published are the results I obtained years ago about age, gender, family size status and type of suicide the prime candidate tried to perform.  There is a gender related reason to how suicide attempts are made.  i.e.

Women are most likely to use gas-powered ovens, men are most likely to use hand guns.

Ceremonial weapons are also used by a unique class of people.

Alcohol based versus drug (OTC or illegal) are also linked sometimes to very difference sets of people.

Suicide in the outdoors, such as performed on top of a mountain and along a hiking trail, is more a practice noted for younger women than men.

Lovers' Leaps (there are two main ones in this country) demonstrate a large peak next to, but not exactly at Niagara' Falls; its used mostly by just one particular age range and gender.

Suicide by car, by garage, when canoeing or boating, by bike.

Teenage and young adult kids demonstrate peaks in certain urban settings, where runaways are common and well managed (or mismanaged, via teenage prostitution).

All of these processes can be evaluated using the detailed coding put in place for suicides when ICD9 was established.

(When I get a chance and have the time, Ill go back to this data and summarize these 'method of attempt' findings.)

What is unique, is companies often have a large enough dataset to evaluate suicides at such a level of detail: age, gender, form of attempt, and in some cases successfulness.  The current EMR/EHR makes this type of evaluation possible for your local community.

The video maps at this site provide some insights into what forms of suicide your local population may be trying to engage in.  Begin by looking for age range related peaks.

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## When even "only a few patients" is too much !

In a recent re-review of infibulation in the U.S., in particular a section of it that is predominantly black, with hundreds of thousands or people of the right descent, I uncovered ICD evidence for 4000 patients from a population of just about 160,000.  I then evaluated the age profile of these patients, and duplicated my findings from 7 and 10 years ago.  The most important repeated finding was that about 0.5% of these 4,000 were under 18 years of age, with the lowest frequency of events noted for the 12 year olds.  How do we interpret these findings?

Brian Altonens insight:

My interpretation of these findings is that the four peak ages for infibulation (ca. 1 year old, 3-4, 7, and 13-14) suggests the following:

1.  that there are at least two kinds of infibulation being performed on children (four are differentiated with the version 9 ICDs); the younger ones do get the less traumatic form perhaps, because of its potential fatalities.

2.  Children who undergo this process are the fewest at 12 years of age (in fact pretty much nil), because they are sen to their family's homeland for the process to be performed--it is illegal to perform in the U.S.

3.  The 1, 3-4, 7 and maybe even some of the 13 year old children who are noted as having endured this process, and are now U.S. citizens, may have in fact received that procedure in the U.S.  The younger the victim identified in this study, the more likely this practice was performed in the United States, and again--illegally.

There are cultural explanations for the 1, 3-4 and 7 years old procedures.  The 3-4 year olds stand out however, because they are the years just before pre-schooling and public schooling.

The number of patients who may have had this process performed in the U.S. is about 160 out of the 200, who are under 18 years of age and have this diagnosis in their EMRs.  Even if half of those very young cases were performed outside the U.S., this means that 80 were still illegally performed in the U.S.

So, there's no getting around this point: there are individuals in the U.S. who may be performing/practicing infibulation on very young girls, because the parents (and perhaps mostly the father) believe this cultural belief is essential, because she (the daughter) cannot be trusted, and must be taught how to remain a virgin until her "culturally appropriate" marriage.

One of the most incredible rates of change for this practice in the 4000 women identified and researched for this study, the escalation in numbers (percents) of cases between 15 and 25 years of age is phenomenal.  If your people, family, believe it must be practiced, then there is no way around this sociocultural requirement for growing up.

This study duplicates my past reviews of this most controversial issue, which I predict will increase several fold over the next several years.  The events that will increase the most are the illegal performance of this practice is certain communities, rather than send the 11 or 12 years old girl back to the homelands.  The field of medicine, and even the government offices that oversee health matters, haven't knowledge base, know-how or ability to manage these back room illegal practices that go on in culturally defined medical practices.

Medicine is often treated like religion by certain government services.  Some forms of health care practice are based on belief and cultural acceptance.  We do not intervene in these practices; the leaders turn their heads away from watching them happen.  "Politically correct" is a must for some religions, some medical philosophies.  In the case of infibulation, the patient's rights are being ignored each and every time we let that happen, make it possible for physicians from other traditions to practice things that are typically taboo and considered cruel to patients when engaged in within U.S. settings.

WHO does not support infibulation.  Neither should we.  My stats tell me that from one to five of these events occur every month in the region I am studying.

For more on this process, my past videos and maps of its happening across the U.S., based on an evaluation of 50-60M people, go to:

3 videos of the map of the U.S., depicting these cases (my 3D rotating map images of the US):

▶ 0:21

My review of the first documentation of this practice by a U.S. doctor, in a U.S. medical journals:
"A Disease Peculiar to the Children of Negro Slaves."

My 'Socioculturalism and Health' page, which incldues coverage of this sensitive topic, at:

Another individual's page on the cultural geography of this practice:

Articles on this controversial topic:

Cosmopolitan

A page with links to the Youtube videos on this controversial topic:

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## GIS Users Excel in Communication, Service, and Vision for Health and Human Services Applications

A link to the past . . . nearly ten years ago I presented the ecological method for evaluating West Nile disease.

I used this field surveillance process from 2000 to 2003, and by the end of the second year, managed to develop the prediction model for where West Nile tended to remain active within the ecosystem.  In Spring of 2003, my theory was proven by the re-emergence of positive testing vectors in April.  (for more on the method to my madness, see http://brianaltonenmph.com/west-nile/ , and continued from there for about 15-20 pages.

Brian Altonens insight:

Currently, I am promoting the hexagonal grid method for mapping, the site for which gets an incredible number of downloads and hits annually (I covered that stat in detail somewhere else.)

Hex grids eliminate most of the error that square grids result in.  They are a tradition of mid-19th century German geographers / spatial thinkers, revived once or twice by one or two western European and United States geographers, beside myself.

The field that loves to think hexagonally is "urban science" (the field that initiated it in Germany).   I believe it has high value to healthcare surveillance.

So why isn't hex grid mapping used, if it is 27% more correct that square grid mapping?  Old math habits are hard to break.  And sometimes, old math is really, really bad (although this new math being taught in elementary and middle schools may take the lead).

The visualization of space is habitually done using rectangular to square grids.  That is why we won't replace square grids with hexagons (imaging trying to read one of those maps on an overseas voyage).

But hexagon grids are more accurate for numbers and statistics analyses.  I therefore recommend that the hex grid process be used by students (no need in trying to change the habits of traditional professors with this new concept).  My pages on hex grid theory begin with:  http://brianaltonenmph.com/6-gis-ecology-and-natural-history/hexagonal-grid-analysis/ ;

Once I am through the dissertation, I will have several other tools to use for producing the hex grids in GIS.  I haven't applied the 2D hexgrid algorithm to my 3D modeling NPHG mapping technique, meant to by pass base mapping time and effort for surveillance purposes.  But that plan too is set for the near future.  (I am still trying to get other to understand one regular grid layer, in 3D, with multiple layers overlain for multivariate modeling.)

recently, I found my old mapping project from the 1990s, using Idrisi to design a 3D modeling algorithm that eliminated the elevation above sea level problem.  I wanted to map elevation relative to closes water edge.  Elevation data uses only the sealevel or surface of closes ocean as the zero point.  I needed a moving zero point to be laid over water bodies and rivers, and essentially flatten them out, but keep relative topography and landform constant, and recalculate those mountain heights, relative to the closest water surface.   The result was essentially an integral equation using a grid version of the river to define the new x0, at each recurring grid point of the river's water surface edge.

Enough of that, to see this work (again, ArcInfo and Idrisi and a very new ArcView were the sole GIS/RS tools in the classes and labs then), go to:  http://brianaltonenmph.com/gis/applying-new-methods-with-gis/space-time-behavior-in-contemporary-disease-patterns-and-models/ ;

I used that model to demonstrate and predict floodplain flooding due to a rising water surface, to predict cholera prone outbreak areas across the country.   (Thesis work.)

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## Applying GIS to Managed Care Quality Improvement Programs

Childhood Preventive Care Topics for utilizing a 2005 Medical GIS research methods, with examples of results for several 2009 to 2013 test runs  The above is an example of how national population h...
Brian Altonens insight:

This three layer map I produced for my study of diseases amongst the elderly.  On the top are parts of the US where two types of elderly care related mental health ICDs are found--one American and the other traditionally Asian.  The middle layer depicts the Asian culturally linked illness on its own.  The first layer depicts background mapping data overlain by the US case history of this mental health condition.

These three layer maps are easy to produce, and have the additional value of being useful for mapping a very unique three-dimensional dataset gathered only in urban settings--this can be used to depict people within buildings, with each layer depicting one of the floors of the building.

There are a few places in the country where this kind of mapping is powerful.  The most obvious example for me is the outbreak of heat stroke and exhaustion cases several decades ago in Chicago.   Another use pertains to V-code and E-code claims for such events as domestic abuse, crime and drug use for high rise buildings set up in low income areas.  Occupancy of a building can be evaluated using this building.  Outbreaks due to contagious disease may also be mapped.

The recent outbreak of Legionnaire's reminded me of the value of this algorithm.  In large bulding settings, where a disease is suspected to be generated by the local environment setting, you can use this procedure to illustrate in three dimensions the cases that are reported.

This type of mapping uses non-GIS software to be produced, and common formulas to generate the algorithm.  The value of that algorithm is detailed more extensively at my site nationalpopulationhealthgrid.com.

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## The cost for Preventive Care: Ebola-hit countries seek billions for recovery

The presidents of Guinea, Liberia and Sierra Leone come to the United Nations on Friday hoping to raise \$3.2 billion to put their countries firmly on course for recovery from Ebola. More than 11,200 people have died in West Africa from the world's worst outbreak of the virus, with a few new cases uncovered in Liberia last month after the country had been declared Ebola-free. New infections in Sierra Leone and Guinea have fallen dramatically amid indications that the epidemic is largely under control.
Brian Altonens insight:

Medical GIS must be ranked as a form of population health surveillance designed to play it most important roles as part of the preventive healthcare system.

Although not immediately gratifying, as installing sinks and hand-cleansing agents at every patient room entrance in hospitals is claimed to be, if a GIS were in place for most managed care settings, we would be more fully documenting whatever responsibilities we accept and actions we take within a healthcare environment.

Right now, it is possible to make a claim that the lack of GIS in most institutions is one of the major causes for wasted money, the inability to detect misapplied funding, or better yet, the detection of fraud.   A floor by floor mapping of an institution documents how many rooms are in use on a nightly basis.  The mapping of patients going in and out of surgery and surgical prep facilities can be used to detection when uses of these facilities go beyond the "safe and reliable use" feature, such as when patients are theoretically transferred in and out of a room 4 times per hour, events that purportedly happened at the Vassar Brothers Hospital in Poughkeepsie, NY, a couple of years back.

Now let's contrast with cost-effective internal use of Medical GIS in United States facilities with facilities that are abroad.

With an effect EHR/EMR in place, completely linked to a spatially-based healthcare fraud and security analysis system, we can automatically detect these events during their earliest stages.

For countries where even a decent managed care program that is self-monitoring is in place, these losses are even greater.  Poor management, inadequate tracing of funds, misuse of position, abuse of administrative rights, make it possible for performance in settings in other countries to cost the system billions of dollars each year.  The Ebola countries that need this money to recover cannot even monitor their own most basic preventive care services that effectively without good HIT systems.  Outside agencies determined not to provide these additional tools to them for support, like a Medical GIS, further this poor performance history prevalent in many developing country healthcare settings.

The billions of dollars needed right now for effective recoveries to happen after the Ebola attacks of 2014 and 2015, are a result of failure to make such low cost investments.  Even worse, the lack of forethought and ability to envision the value of a managed care population health monitoring system that Medical GIS can provide, suggests a lack of sufficient care related background, knowledge and experience with the spatial analysis of health.

You cannot ask a person to initiate new tasks and programs, when he/she is trained only in the previous generation's practices and ideology.  To change this spending problem in WHO and the rest, change its "leaders", for they are no longer those institution's leading problem solvers, professors and teachers.  They behave like poorly informed decision makers.

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## Making Choices for Surveillance

I am in the process of trying to define the levels of importance of the various metrics I am performing regularly on one of the larger urban healthcare data systems in the U.S.  I have to make choices about what topics to focus upon, how to research them, how to automate them so they can be performed fairly quickly.

A recent SAS-SQL program I ran was designed to evaluate 84 metrics for 5 major racial groups, several subsets of care processes within the medical institutions engaged, for several kinds of visits.  With SAS Macros I could write the programming for this, test it at its individual levels, and then run it in its entirety.

Last weeks version of this review took two hours to run completely, generating about 175 graphics to be merged into a single report.

What was this for?  I developed the war to analyze three of the most common population health metrics for the entire system, graph them as individual images for the two genders, 5 race groups each, or 10 times the number of metric groups originally defined.

For my sum productivity, 840x10 equals 8400 images, merged onto 8.5 x 11 sheets, for sharing with the staff and managers, with male and female of course mapped separately.  In addition to the approximately 175 pages of graphs I produced, some of these metrics were also turned into SGPLOT paired images in SAS, to show which groups of diseases were most common relative to the other groups.

Elixhauser (about 30 parts), Charlson (about 20 parts) and Chronic Disease (about 8 parts, with some flexibility) profiles were set up, totalling these 84 metrics.  These three scores were also combined as two-plot and all three-plot models of the data, as each of their individual components.  Additive and multiplicative combinations were calculated from each of the plots, and then a log of the sums tested as well.
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## Brazil reports 1,761 microcephaly cases as mosquito virus spreads

Brazil has reported 1,761 cases of babies born with unusually small brains, or microcephaly
Brian Altonens insight:

Microcephaly - - - another thing we have to monitor, and can do so, with an efficient Medical GIS developed for your managed care program.

I just posted my descriptions of things that I found can be routinely monitored in a highly productive system, with the right-skilled workers.  I have defined about 34 types of surveillance and documentation that can be readily performed, by the end of a three year plan.  These include the typical managed care  meaningful use metrics, but also include techniques for eliminating that lack of cultural interests we project in how we monitor population health.  For the investors and CFOs, I designed a way to monitor and reduce costs attached to long term care, for specific disease classes (better than the events-episodes methods I was trained with.)

To actually impact the health of your community, you have to engage in prevention and intervention at these basic levels I describe.  Some of those levels--like monitoring your complete data for congenital abnormalities and the like--are quite extensive, but also quite serious, and need only one adequate surveillance algorithm to develop a regular reporting program for.  The same goes for infection disease and international disease migration, linked to parts of the world and countries.

But some of the most worthy technique to learn are those which focus on cost containment, fraud prevention, over-billing, cost prediction modeling.  These can be easily ignored or overlooked when you lack the insight into developing these routines.

Finally, with the significant amounts of cultural change taking place currently in this country, and other developing countries, we need to be more than just "culturally aware"; we also have to focus on the epidemiological changes that are happening and the effects that the lack of efficient care for these groups may result in.  We cannot eliminate the problems due to social inequity; a Medical GIS can help a program develop a better understanding of its managed care population and population health needs.

To learn more about this, go to my page by searching "HIT/GIS Policy", along with my name in the search engine.  There are several dozen tested and truth population health analysis queries I developed the tools for at the end of this page.   I have also posted other detailed reviews in my work on managed care and medical GIS, my NPHG site (on how to efficiently map health without purchasing a GIS) and the numerous other postings on this ScoopIt! site.

Finally, I am searching for programs to team up with and begin to develop a more formidable spatial epidemiology comprehensive research team with (suspect I am about to "retire" so to speak).

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## From Anthrax, Hoof and Mouth, Mycobacterium bovis

These three livestock diseases  had tragic effects upon our economy throughout the 19th century.   For this reason, several local universities have agriterrorism and livestock terrorism prevention programs in place, relying upon a GIS.  A recent bottle dig by an associate of mine unearthed a number of livestock parts.  The bottles he found dated to the late 19th century, just before the first major Food and Drug Act was passed.  I've found animal parts as well in my digs, but never this much, suggesting a mass burial (only the first finds displayed).  So what caused so many deaths? is this upcoming week's research question.  What are New York's risks regarding the potential for agriterror, livestock bioterror, or zoonotic disease migration into this country?

Brian Altonens insight:

Anthrax was the most vicious disease of the century for 19th century farmers.  It was first fully documented in the U.S. about 1802, in a Medical Repository article on life in the Hudson Valley.  The transport of large herds of cattle from the south and west to the Chicago area and from there eastward into Philadelphia and New York made it possible for Texas fever and other animal borne vectored disease to strike the Northeastern Atlantic states.  By allowing the transport of bovine and equine herds to the U.S. in the late 1800s, Bovine Tuberculosis struck this country in epidemic proportion.  This Tb could impact people as well, and was the main reason all dairy farms had to display proof of public health inspection and a tab indicating that product testing was done before they were allowed to be distributed to the masses through grocery stores.

Much the same problems today are happening, but engaging new organisms, like choleritoxic E. coli and antibiotic resistant Salmonella.

Could unearthing past animal parts enable a disease like mycobacterium bovis to resurface?  As for anthrax, there is probably minimal worry.  Although pulmonary anthrax managed to first surface in the mid-1800s, its global distribution was barely possible for the time.  The viral form of the hoof and mouth disease is also a possible cause for this local livestock epidemic, but of less concern to people and also highly unlikely in this case due to local history.

There is a parallel to this matter as well with the return of infectious diseases that we thought were nearly eliminated.  The public health profession has been too complacent in recent decades, making it possible for measles to return, and possibly increasing the number of whooping cough and mumps cases.  STDs are now demonstrating a rise in the number of cases, and the regulars like Salmonella, Listeria, Strep., Tb and HIV are once again demonstrating surged in antibiotic resistance strains.

Is there a regionalism to this surge in infectious disease?  This is one of the questions my new Medical GIS was developed to research over the next several months.  Most certainly, I will use it to map out the local Tb, bovine Tb, anthrax and hoof and mouth as well, not to mention the 100+ other zoonotic diseases noted on my surveillance list.

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## Angry moms rail against city's mandatory flu shot requirement

Arguments over whether the city can require pre-K students to get flu shots reached a fever pitch in Manhattan Wednesday, with a courtroom full of anti-vaccination activists railing against everyth...
Brian Altonens insight:

I spent the past three months reproducing my 3D maps of disease, that I developed the NPHG program for several years ago.  These maps and videos include those that demonstrate the distribution of this refusal to immunize behavior seen across the United States. (See my page http://brianaltonenmph.com/gis/population-health-surveillance/production-examples/the-childhood-immunization-problem/ ;)

For those unfamiliar with my NPHG work, years ago I developed an algorithm for analyzing population health data, and then mapping the results of my analysis at the small area level (adjusted for particular density features), in order to produce a video of my results that depicts the US turning.  This presentation can be zoomed in on, and looked at using any 3D angle.  The purpose was to determine the best way to demonstrate disease outbreak clusters, ICD clusters, human behavior clusters.  I produced more than 1000 of these 3D videos, each with 1000 or more maps in them.

Duplicating this statistical method for a smaller area, large medical data company, focused on NYC, I produced identical maps for this part of the US megalopolis.  Most important to me was the fact that with the smaller dataset (1.5M-8M patients, 1B records), my results mimicked the results I produced for my 80M-120M patient population reviewed, that I posted quite a bit from over the past few years.

What is evident from thus duplication of findings is confirmation of a number of unexplored disease topics, in dire need of closer attention to culture, race and religion-related influences on the diagnoses, and the places where these events tend to cluster.  This is certainly a way to uncover both the genetic and the cultural makings of the many neighborhoods that make up a healthcare populations "region" of distribution.  It can be used to map out the value of where your facilities are placed, and how to link that info to community income level and types of medical needs.

The most controversial outcomes for these projects pertain to intercultural findings--behaviors, genomics, and culturally-linked ICDs that cross over into unexpected families and cultural communities.

The refusal to immunize your children is in part ethnic-culturally based, for two very clear reasons, and it is neodarwinian, U.S. based cultural beliefs--the notion that avoiding the vaccine is the safer way for a child to live.

It is up to the healthcare, managed care systems to be able to utilize findings like those produced using highly detailed spatial approaches to analyzing healthcare related needs, services and costs.  The single most reason managed care groups have enabled these behaviors to happen in the NYC community is obvious--leaders of healthcare systems are inexperienced in producing an impact on the health of their local community.  Another leadership related reason for the failure to improve healthcare practices and outcomes in recent years is also based upon poor experience and lack of adequate background in directing a managed care program as a healthcare system and business, not just one of either of these two.

Due to an efficient EHR, EMR, I can go to work and in an hour or two map the entire region and tell you where the most frequent use of these v-codes related to immunization refusal are documented.  I can then map these results and produce a video well before the day is even half over.

So, for a while, I wasn't sure why managed care programs still cannot engage in this level of spatial epidemiological research, much less get their act together with EHR and EMR.  But this new "theory" in the dissertations that have been published in recent years, demonstrates this problem due to be to management and directors.  Many if not most medical institutions have the employees with the skills for doing exactly what I do, map the results in record time, and analyze thousands of health related metrics per year.

My NationalPopulationHealthGrid.com page, personal blog site (brianaltonenmph.com), and YouTube sites provide numerous examples of this mapping technology.  Once my dissertation is over (or just before), I'll put out there the simple formulas I use to produce valuable epidemiological surveillance tools, without the need for a GIS.

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## Cholera Crisis: A Neglected Disease Is Back In The Headlines

Cases are spiking in the Middle East and in East Africa. Blame it on the refugee situation — and the weather.
Brian Altonens insight:

Since vibrio is often a part of the natural ecology in some very specific deltaic settings, we should hear more about the return of this disease for years to come.  In the early 1900s, the notion that cholera could be eliminated from certain parts of the world as a recurring outbreak is a theory derived from our lack of understanding of its ecology.  Understanding the survival of vibrio separate from man and in deltas other than the Ganges, where it probably originated, is a traditional and ongoing use of the Medical GIS tool.  Yellow fever put us in touch with the value of disease mapping.  Vibrio cholerae made it clear to us that disease mapping is essential to public health and the growing field of epidemiology.

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## MC's Goal for 2016: "Solving the Financial Crisis of healthcare"

Solving what crisis?!  Well, not really.  2016 is the year when managed care programs will either suffer and succumb to the pressures of HIT, or successfully find new talents and leaders to advance their system ahead of the rest and implement an actual Medical GIS.

2016 is also the year when a significant percentage of healthcare programs will fall behind in the most basic IT and HIT requirements even further.  Some may even fall so far behind their competitors, that it becomes necessary to sell, or initiate a major overhaul.

The first thing to go with a successful overhaul are the "leaders" of the past.  They are the ones who are dragging your managed care system behind, not only in its technology, but also it economic potentials, in the form of rewards and benefits for . . . . need I say? . . . .  "good service.".

Brian Altonens insight:

This philosophy defines the neoinstitutional theory of health care administration, the primary theory by which my dissertation work on managed care and the current barriers that exist for GIS implementation.  The lack of success and rapid growth, when compared with the advancements epidemiologists, marketing companies, surveillance specialists, and climatic health experts have made using GIS, is due to the absence of upper level management having any direct, first hand knowledge or field and hands on experience with GIS and the use of GIS skills to create your own maps . . . from scratch. . . . by hand . . . not just by using the routine shapefiles that most GIS's are provided.

Some very old habits have resurfaced again, due to the last two year's worth of failed healthcare information technology improvements.  The primary proofs of these failures are demonstrated best by programs still unable to produce an entire and effective HIT information management system.  realize, the bulk of these programs have only a few dozen metrics that are required of them, about 60 meaningful use metrics.

I have identified thirty-four major SETS of metrics that need to be developed, and then managed regularly on a monthly, quarterly or annual basis, for any managed care system to demonstrate its expertise in understanding population health and the roles of medical GIS in producing more cost effective HIT-GIS guided Managed Care programs.

These 34 classes I came up with define about 1500 to 2000 metrics.  Most of them were developed as part of a major MC program I was involved with back when the first contemporary forms of these systems came to be (more than 10 years ago). So these 34 classes on population health/meaningful use reporting shouldn't be too difficult to develop in three years or less.

Now I admit, this is just my preliminary set, and is based upon projects in which I was able to develop these reports in very little time over the past 10-15 years.  I suspect a few more details will need to be added as I recheck my sql and sas algorithms and rewrite them to more rapidly produce the end products that are required.  This project is based upon real life, real time data.  There is a real need for managed care systems to develop a programs that are more robust, not scripted as just a bunch of various "silo" projects, by unmanaged, non-integrated research teams and offices.  Working together as part of an HIT-GIS program, these programs can have a very significant impact.

On the page this 'blurb' is linked to, I define the following sets of skills and applications of GIS as the directions these programs need to be heading.  All but two of these items should be able to be accomplished in under one calendar year, with or without a GIS.

Location/Access improvements; redesigning plans and servicesCost savings by redesigning facilities, determining needsServices — quality and adding new services, documenting thisFuture planning (projection of health and patients and costs; plans/goals)Standardized reporting of valuable QA information; meet MU requirementsPerformance Improvement QI scores, documenting and reporting on 60+ specific metricsPerform Ad hoc reporting, per local needAchieve more recognition and support:Improve professional reputationIncrease Public Support and recognitionPress related support and recognitionObtain other institutional support and recognition (tertiary care settings, university hospitals, npos, clinics, allied health)Improve financier support and recognition; improve investments; improve IT infrastructure.Obtain more allied corporations support (manufacturers, inventors, innovators)Receive more Federal and State support and recognition, and publish more in the literature.

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## Back to the Drawing Board

Nearly 10 years ago (time flies!), I performed extensive research on the in-migration of diseases from Africa and other continents and large countries, completing that project more than five years ago.

I identified more than 100 diseases that can be easily monitored, continuously, by a managed care program. I used this project to demonstrate that if the ICDs of these diseases are placed into a single search tool for EMS, and the resulting "hits" assigned locations based upon their latitude and longitude, that plenty of leads can be found about how diseases migrate into this country, not to mention how people behave.  Ebola is one of those diseases I mapped.

Brian Altonens insight:

Now, with the possibility of sexual transmission of Ebola, living and working in the vicinity of one of the non-compliant healthcare providers to bring Ebola into this country, these events made me recall my years in medical school, during the early to mid 1980s, when AIDs had yet to receive a formal name, and when the first research into HIV and AIDs migration and sexual transmission patterns came to be, as one of my mentors was forced to leave his position as administrator of the medical school, due to his refusal to publicly refer to the university officials' desire to link the new epidemic coming to be to a small community located in and about Queens.

Now granted, the organisms behind AIDs and Ebola are very different.  What happened in New York and later California may not be at all like what happened 30 years ago in the U.S.  In an evolutionary sense, as well as a physiological and adaptive one, the organisms responsible for each are very different, although the routes of transmission, sexual behavior, may not be as different as we'd like to think.

What HIV taught us is that carrying and disease and spreading it elsewhere around the world can become a long, drawn out event, enabling the organism to mutate, survive better, change from a rapidly fatal pathogen to a wandering one in search for new hosts.

It will be interesting to see if people behave like they did between 1985 and 1986, and 1986 and 1988, when leaders in my medical communities in NY and later OR tried to lay blame on specific ethnic groups for the introduction of a new disease to specific communities in Long Island where I did my rounds on the hospital floor, and still later in specific parts of California, the second time through.

To understand how African diseases impact this country, back then, in African, and in the U.S., begin by reviewing my work of the Geography of African Diseases that I produced years ago from a large national health dataset . . .

My method of developing the first videos to display the national distribution of these diseases, individually as well as as a collective, appears much like a GIS, but it was produced without GIS software.  I designed my own algorithm for this 3D mapping methodology eons ago.

Begin with:

VIDEOS of the NPHG Product include:

African Diseases

Geophagia as an African behavior:

African Eye Worm

Obscure African Cardiomyopathy:

Bejel:

Guinea Worm

Crimean or Congo Fever

Elephantiasis

Assorted Videos in a row:

Ebola

AIDS/Severe Chronic Immune Deficiency

Noma Page

POSTINGS in ScoopIt! about Ebola, each a lesson in itself:

Pages on the Geography of Ebola:

http://brianaltonenmph.com/2014/07/08/the-geography-of-ebola-important-spatial-features-influencing-its-diffusion-patterns/

and Mapping the Outbreak of Ebola:

http://www.scoop.it/t/episurveillance/p/4039425741/2015/03/18/ebola-mapping-the-outbreak

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## Young child diagnosed with measles in northern Virginia

Doctors investigate source of measles case in northern Virginia after a young child was diagnosed. The child visited a daycare center, COSTCO and several medical offices while contagious.
Brian Altonens insight:

The real questions to ask are: 1) how actively are they using medical GIS to carry out this work?  2) are they engaged in live monitoring of these outbreaks in this community?   Health information technology and GIS have not been keeping up with the other subspecialties in health care that make regular use of GIS, and which have been doing so for more than 10 years.

I am currently working on a method for analyzing one of the most populated parts of the U.S.  The company/ies I work with/for have several IT specialists who have attempted to map the population health and services, each using a different tool.

Based upon past communications, I can tell the health care industry is still struggling to keep its head above water when it comes to developing an effective HIT set up, much less meet the first major requirement of a managed care program--monitoring the distribution and needs for your healthcare services, in relation to the local population.

Several years ago I defined levels 1 through 10 for GIS capacity for a managed care system.  This is posted at http://www.scoop.it/t/episurveillance/p/4009995081/2013/10/27/exploring-the-role-of-gis-during-community-health-assessment-problem-solving-experiences-of-public-health-professionals-article ;

A system that can produce a map of its population is at level 3 or 4, depending upon the complexity of that project.

Programs with specialists devoted to mapping specific diseases or medical data are somewhere between a 5 and 6.

They are a '6' if they can demonstrate the use of GIS to produce changes in quality or amount services, improvements in population health, or reductions in cost.

Agencies that score 7 or more can perform these tasks daily, report them regularly, engage in automatic or ad hoc epidemiological/surveillance activities, utilize GIS on a regular Monthly or quarterly basis and report their results to management, or engage in regular prevention related population health mining activities followed by the development of new research programs.

The best GIS users in managed care are programs that have multiple uses for GIS, including

i) utilizing both vector and raster/imagery related tools,

ii) have more than one form of RS and/or GIS or spatial tool applied to surveillance, prediction modeling, and certain forms of multivariate spatial analyses,

iii) engage in 3 different work/activities including programs related to preventive health, service/location theory projects, live or near-live health care services monitoring activities, and cost analyses, and

iv) use these tools and methods to produce, test and base corporate decisions upon prediction models.

In theory, there are several ways that this outbreak in Virginia could be applied to the above statements; it could be used to define several methods for how to establish a GIS and non-GIS spatial analytics program/department as part of your managed care program.

******************************************

My GIS and epidemiological work on vaccinated diseases and immunization refusals:

My sites:  "Why is Measles making a Comeback?"  http://brianaltonenmph.com/2014/11/15/why-is-measles-making-a-comeback/ ;

A Slideshow on the history of what patients with these immunizable diseases present as:  http://brianaltonenmph.com/2015/01/28/a-history-of-unimmunized-diseases/ ;

My collection of 3D videos on vaccine refusal patterns in the U.S.:

http://brianaltonenmph.com/gis/population-health-surveillance/production-examples/childhood-immunization-refusals/

My video with a close up on the Pacific Northwest, and where these vaccine refusals are concentrated, down to the small grid cell area.  "Immunization Refusal, Pacific Northwest."    https://www.youtube.com/watch?v=vS2W42TcTRA&nbsp;

Finally, nearly a decade ago I created an algorithm that maps medical data at the national level, in a way that converts the information to grid presentation, thereby avoiding the need for a GIS software tool.

This technology I call NationalPopulationHealthGrid.  Back when I developed it, I used it to produce nearly 1000 videos, 1.5-2M images, during a half year period, in a Teradata system.   For more on the NPHG technology, go to http://nationalpopulationhealthgrid.com .

Which includes the NPHG technology page on Childhood Immunizations at:  http://nationalpopulationhealthgrid.com/applications/01-childhoodimmunization/ ;

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## Grid mapping health and disease in the United States | Brian Altonen, MPH, MS

This page provides the math behind my grid mapping of the United States, without using a GIS.  This technique is called grid mapping and was popular when ArcInfo and the first versions of ArcView were the most common spatial analysis lab tools.

Brian Altonens insight:

I use these maps to produce my 3D models of the US and its various public health patterns.  The advantage to this method is in a decent system, it takes less than 10 minutes to map a large dataset, like that for the entire US, by zip code, block group, and/or gridcell plan (2500 analyses of 10s of millions of patient data rows, each depicting a standard one-row summary EMR).

Because this tool works very fast, I learned immediately to go through the extra effort needed to produce  the 1,000 to 1,500 maps, with varying angles, pitch, and rates of revolution, needed to produce a video.  A twenty second video requires about 1,200-1,500 images.  A few of these videos are 5 or 6 minutes long. Most were derived from 2,000 to 3,000 images.  Standard production rates in teradata are 15,000 to 20,000 images per day, developed into numerous videos.  I mapped all of the ICDs, including those depicting specific age groups (suicide, homelessness and other V and Ecodes), in under two months.

My remaining research question:  Can this same high rate of productivity (15k maps/day, for video production) be re-created in SAS-GIS, Cognos BI, ArcGIS, Qlik, Tableau or the host of other spatial tools out there?  (see http://www.capterra.com/gis-software/ ;)

My dissertation work focuses on the barriers to implementing GIS in the managed care workplace as a highly productive reporting tool, i.e.  reporting all ICDs, including age-culture-gender subgroups, with summary maps depicting the five primary ethnic disease pattern groups, on a daily basis.

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## GIS, in Sociocultural Medical Research

A traditional approach to studying sickle cell disease uses population health age-gender profiling in a very coarse fashion.  For a full population study of sickle cell and sickle cell carriers age-gender distribution, we see very unique and even unexpected differences in the longevity of men versus women.  During the past decade, I have seen this population health profile for Sickle Cell in boths of its ICD 9 identifier forms duplicate this model, for a number of difference parts of the U.S.  Due to the unique shapes of these numbers-prevalence profiles for "Active Disease vs. Carriers", this profile presented here demonstrates remarkable external validity.   This relationship exists at the national level, and local levels.

Brian Altonens insight:

Apply 3D NationalPopulationHealthGrid modeling algorithms to my data, the resulting maps provide a very unique sociocultural interpretation of how Sickle Cell exists and continues to spread throughout the United States.  More importantly, the population pyramid approach to analyzing this data shows us how treatment and intervention programs should be modified to better fit the needs of age-gender groups in specific parts of the country, or locally.

Most important to note is the difference in lifespans when men and women carry the sickle cell in its non-expressive ["carrier" or ss] form.  This is due to partial expression of the S gene, the degree of expression, and the impact it has on the longevity of the patient.

Social Darwinians might have a field day with the social implications of these spatial findings.  For it demonstrates that women who carry sickle cell live longer than men who are carriers, to the point that they remain alive throughout the primary fertility/fecundity years.  Men on the other hand lack this survival feature and are more likely to die, even as carriers, during their most  active reproductive years.

This method may also be used to model others diseases linked to the human genome.   (A number of my videos in Youtube provide examples of the various genetically-linked diseases and development disorders that I reviewed years back.)

About ten years from now, this way of modeling and interpreting genetic diseases will become one of the most important applications of NPHG style analysis of human EMR/EHR and lab/genome data.

For more on how I applied NPHG and ICD9 analyses techniques to human genome projects, ICDs, EMR, EHR and Managed Care planning strategies, see:

Socioculturalism and Health:

Fatal and Non-fatal Genetic Disease:

and the numerous NPHG mapvideos on the following :

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## GIS IN THE WORKPLACE FOR HEALTH & MEDICINE - A SURVEY

It has been nearly a year since I last pushed this survey I produced, focused on GIS and the health care profession.  My focus is on managed care, and whether or not it can become a part of a big data population health enterprise program that I am a part of on the east coast.

As a PhD student, my dissertation planned focuses on the potential applications for GIS to Managed Care (MC), and what barriers have prevented GIS from becoming a strong part of the MC system, like it has for separate agencies devoted to population health, disease surveillance, even market analysis for healthcare facilities and agencies.

Brian Altonens insight:

Prior to my PhD enrollment several years ago, I developed these two surveys on Medical GIS. They are still active. If you are interested in GIS and Managed Care, please visit the following pages to take one or both of these surveys. The purpose is to see how leaders, management and staff are trying to implement spatial population health surveillance systems around the country.

The general survey is at https://www.surveymonkey.com/s/HZ7MH7Q

The MANAGED CARE [MC] version is at:
https://www.surveymonkey.com/s/V5THRFQ

Brian Altonen's curator insight,

As a PhD program student, I developed these two surveys on Medical GIS that are both are in the testing/validation stage, and of course in need of participants.

I developed a GENERAL SURVEY on the applications of GIS in the public health/health care workplace, accessible at:     ---     LINK:

My MANAGED CARE [MC] version of the same focuses on MC facility use and applications, and targets quality improvement staff, healthcare administrators, employees engaged in NIH sponsored Beacon program, HEDIS and QIA/PIP/Meaningful Use activities:     ---

The more leaders and managers that provide me with insight into this topic, the more we can learn from this.

Because GIS is still very new to healthcare (not so much epidemiology), a lot of my work as a PhD student so far has been devoted to understanding the barriers that exist, which prevent the implementation of GIS in healthcare, especially managed care.

I am searching for interview/narrative or case study candidates at the management and analyst/data entry-miner levels for their insights into the role or potentials of GIS in healthcare.  Grounded Theory is the approach taken to these narrative/case study evaluations.

A number of years ago I developed a non-GIS algorithm for mapping health, making use of some of the standard software resources available at most institutions.  Because it maps without the standard textbook GIS necessities, it effectively produces maps in one-hundredth the time (for my videos, 15k-25k images per day) and can be used to generate reports on special topics, such as local SES related health metrics or metrics focused on a certain race or ethnicity.  It can also be used to analyze dozens to hundreds of health related events, ICDs, specific group needs, cost metrics, utilization rates, on a daily basis, and produce comprehensive population health reviews on a monthly or quarterly basis.

This SurveyMonkey survey is meant to determine how much your company or agency utilizes GIS for healthcare and public health reasons.

Level of use, knowledge about use, and barriers to implementing GIS are the focus of this part of my dissertation work.

Your insights into the value of GIS in healthcare, or your reasons regarding why it may not cost-effective for your program are value to this stage of my academic work.

Finally, , ,

I must also thank a lot of you for the support you have afforded me this past year . . . that has been quite a surprise!

Sincerely,

Brian Altonen

 Scooped by Brian Altonen

## Human smuggling ring dismantled in South Texas

SAN ANTONIO (AP) — U.S. Homeland Security investigators dismantled a South Texas ring that illegally smuggled thousands of immigrants across the border from Mexico and on to other parts of the state -- often tucked in small, dangerous truck crawl spaces.
Brian Altonens insight:

This is in fact the surface of a much greater social problem that exists in Texas.  Some of the most useful findings come from studies of V-codes, E-codes and ICDs, which demonstrate preventable human behaviors and cultural/poverty-linked diseases and public health issues.  In this NPHG study, pathways leading from Mexico into Texas also brought into this country a number of other controversial health problems, such as communicable diseases, zoonotic diseases, illegal drugs, and a host of very unique health related matters. In the n-squared image displayed here, notice the small town in Texas at the Tex-Mex border.  It is very indicative of the main route taken by kids into this country.  It is also where the greatest amount of physical and sexual abuse of teenagers prevails. This may be due to a number of reasons, but two of the most commonly cited ones are teen age prostitution and "domestic servant" contracts.

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## Reexamining El Niño and cholera in Peru: A climate affairs approach - Part 2

"In the 1990s Peru experienced the first cholera epidemic after almost a century. The source of emergence was initially attributed to a cargo ship, but later there was evidence of an El Niño association."

The highly supported hypothesis for this outbreak is that marine ecosystem in combination with cyclical climate change was responsible for this outbreak. The longest lived argument, which I support in my own thesis, is that Vibrio var. classical has always existed in the deltaic settings of Louisiana since the 1850s, and perhaps even Peru for this long a period.   Our lack of desire to report its presence has kept it from the popular health press.

Our lack of attention is why we did not find it, even when paying so critical attention to the intertidal ecosystems off Galveston due to its changing quality of water.  Scientists are stubborn group, even more stubborn when their place in the political world depends upon what they confess is true and what is not (sounds kind of like the Ebola problem recently with WHO, now, doesn't it?)

Brian Altonens insight:

The evidence for cyclical disease patterns is overwhelming.

However, since this research topic was taken on by the American Meteorological Society in the early 1900s, there have been many arguments for this theory in both directions.

These arguments and their related controversies are so controversial, in fact, they are in par with arguments that exist for and against evolution theory in the popular culture world.  For lack of better words, the notion of "Sunspot theory" cyclical weather patterns and diseases, followed by broader universal cyclical patterns, and now El-Nino-La Nina-Oscillation Theory,  has become a fairly "heated" topic one might say for meteorologists, a select few epidemiologists, and the environmental-Gaia mission theorists.

The "proof" that El Nino links to cholera is stated in the above recommended dissertation as follows (p. 18 of this rather short "Thesis"):

[Begin quote]

"Figure 4 shows the SSTA and cholera time series and Table 1 lists El Niño and La Niña  events, respectively. According to the Niño 4 region, the first possible cases of cholera (identified by Seas et al. [2000]) and the onset of the epidemic occurred in the midst of a prolonged El Niño (26 months) that developed in July 1990 (event [a]). The timing in the Niño 4 region, which represents the western equatorial Pacific, sustains the El Niño-cholera hypothesis and suggests a time delay of several months between El Niño and cholera emergence. On the other hand, regions Niño 3.4 and Niño 1+2, which represent the central and eastern equatorial Pacific, indicate that El Niño conditions followed the initiation of the epidemic, beginning in May (event [c]) or November (event [d]) of 1991.

Using Pearson’s correlation analysis, we explored these associations further and found the strongest link between cholera and SSTA in the Niño 1+2 region (r = 0.42, p-value = 0.010). This finding is important because the Niño 1+2 region includes coastal and equatorial upwelling near Peru and Ecuador (Glantz 2001, 60), which exhibited non-El Niño conditions preceding and during the initial outbreak in January 1991 (see Figure 4 and Table 1 [d]). In other words, it may have been La Niña and ENSO neutral rather than El Niño that contributed to cholera emergence in Peru."

[end quote]

In other words, something that many of us have been inferring for quite some time and the Predictability of certain disease patterns, may have some truths to reckon with, implying as well that those critics of this theory may have only delayed the finding of the inevitable, a behavior common to medicine we all might say.

The past is more credible than the present when it comes to proof.  Why rely upon guesses and estimates when we have so much history to support our disease theories with?

History is fact is full of information, only some of which we respect and republish over and over again.  Those theories that are outsiders, different, or even potentially innovative and destructive to a popular cause, are typically not welcome in medicine.  And need I say there is both good and bad to that.

The 'anti-vacc' culture has its theory, for example; but is it truthful enough to prevail over the pro-vaccine philosophy?

Unfortunately, the less trustworthy set back to this thesis argument, something that allows us to continue to question this theory, is the lack of illustrations that are de novo and authentic, produced by the writer, and the use instead of a theoretical figure that is no longer provided as part of the actual document, with a link that also does nothing to answer any questions we may have about the validity of this argument.

Now, the statistical checking of this claim is also very questionable, being limited to a basic analytic process; nothing complex; no reconfirmations provided through the use of other numbers methods.  So even though some of us will do our research of disease cycles, bearing a preconception in favor of the El Nino-La Nina theory, few of us will mention and continuously think about our reliance on that qualitative part of our supposed statistical overhaul of the topic.  In other words, we deny our own prejudice for the opposing theory--we remain following our King's lead, without a mind of our own.

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