DARE to question things implemented with no evidence

A retrospective of the madness of crowds…

DARE Marks a Decade of Growth and Controversy

Today [Sep. 9, 1993], 5,200 communities in all 50 states have DARE programs, and more than 5.5 million children this year will learn about drugs through police officers using the DARE curriculum. At home, DARE has been called the first test of community-based policing, a law enforcement notion favored by Police Chief Willie L. Williams that involves bringing police officers into contact with the communities they patrol.

A brief history of DARE

DARE was founded in 1983 as a partnership between the Los Angeles Police Department and the L.A. public schools. The idea was simple: Officers would go into schools to talk to kids, “boosting the self-esteem of students so that they can resist the temptation to use drugs,” as the Los Angeles Times put it in a 10-year retrospective on the program in 1993.

The program drew bipartisan praise and spread like wildfire. Politicians realized that by supporting DARE, they could paint themselves as pro-cops and pro-kids: a win-win. President Ronald Reagan proclaimed the first “National DARE Day” in 1988, a tradition that continued well into the Obama administration.

Eventually, the program was in place in up to 75 percent of the nation’s school districts, by DARE’s own count. At its height, the group boasted an eight-figure budget, with much of that money coming from government sources. Individual state affiliates raised millions more.

But with success came scrutiny. Public health researchers started looking for evidence that the program was meeting its goals of reducing teen drug use. The first wave of studies, published in the early 1990s, didn’t find any.

Studies on effectiveness

1992 – Indiana University

Researchers at Indiana University, commissioned by Indiana school officials in 1992, found that those who completed the D.A.R.E. program subsequently had significantly higher rates of hallucinogenic drug use than those not exposed to the program.

1994 – RTI International

In 1994, three RTI International scientists evaluated eight previously-done quantitative analyses on DARE's efficacy that were found to meet their requirements for rigor. The researchers found that DARE's long-term effect couldn't be determined, because the corresponding studies were "compromised by severe control group attrition or contamination." However, the study concluded that in the short-term "DARE imparts a large amount of information, but has little or no impact on students' drug use," and that many smaller, interactive programs were more effective.

After the 1994 Research Triangle Institute study, an article in the Los Angeles Times stated that the "organization spent $41,000 to try to prevent widespread distribution of the RTI report and started legal action aimed at squelching the study." The director of publication of the American Journal of Public Health told USA Today that "D.A.R.E. has tried to interfere with the publication of this. They tried to intimidate us."

1995 – California Department of Education

In 1995, a report to the California Department of Education by Joel Brown Ph. D. stated that none of California's drug education programs worked, including D.A.R.E. "California's drug education programs, D.A.R.E. being the largest of them, simply doesn't work. More than 40 percent of the students told researchers they were 'not at all' influenced by drug educators or programs. Nearly 70 percent reported neutral to negative feelings about those delivering the antidrug message. While only 10 percent of elementary students responded to drug education negatively or indifferently, this figure grew to 33 percent of middle school students and topped 90 percent at the high school level." In some circles educators and administrators have admitted that DARE in fact potentially increased students exposure and knowledge of unknown drugs and controlled substances, resulting in experimentation and consumption of narcotics at a much younger age. Criticism focused on failure and misuse of tax-payer dollars, with either ineffective or negative result state-wide. 

1998 – National Institute of Justice

In 1998, a grant from the National Institute of Justice to the University of Maryland resulted in a report to the NIJ, which among other statements, concluded that "D.A.R.E. does not work to reduce substance use." D.A.R.E. expanded and modified the social competency development area of its curriculum in response to the report. Research by Dr. Dennis Rosenbaum in 1998 found that D.A.R.E. graduates were more likely than others to drink alcohol, smoke tobacco and use illegal drugs. Psychologist Dr. William Colson asserted in 1998 that D.A.R.E. increased drug awareness so that "as they get a little older, they (students) become very curious about these drugs they've learned about from police officers." The scientific research evidence in 1998 indicated that the officers were unsuccessful in preventing the increased awareness and curiosity from being translated into illegal use. The evidence suggested that, by exposing young impressionable children to drugs, the program was, in fact, encouraging and nurturing drug use. Studies funded by the National Institute of Justice in 1998, and the California Legislative Analyst's Office in 2000 also concluded that the program was ineffective.

1999 – Lynam et al.

A ten-year study was completed by the Donald R. Lynam and colleagues in 2006 involving one thousand D.A.R.E. graduates in an attempt to measure the effects of the program. After the ten-year period, no measurable effects were noted. The researchers compared levels of alcohol, cigarette, marijuana and the use of illegal substances before the D.A.R.E. program (when the students were in sixth grade) with the post D.A.R.E. levels (when they were 20 years old). Although there were some measured effects shortly after the program on the attitudes of the students towards drug use, these effects did not seem to carry on long term.

2001 – Office of the Surgeon General

In 2001, the Surgeon General of the United States, David Satcher M.D. Ph.D., placed the D.A.R.E. program in the category of "Ineffective Primary Prevention Programs". The U.S. General Accounting Office concluded in 2003 that the program was sometimes counterproductive in some populations, with those who graduated from D.A.R.E. later having higher than average rates of drug use (a boomerang effect).

2007 – Perspectives on Psychological Science

In March 2007, the D.A.R.E. program was placed on a list of treatments that have the potential to cause harm in clients in the APS journal, Perspectives on Psychological Science.

2008 – Harvard

Carol Weiss, Erin Murphy-Graham, Anthony Petrosino, and Allison G. Gandhi, "The Fairy Godmother—and Her Warts: Making the Dream of Evidence-Based Policy Come True," American Journal of Evaluation, Vol. 29 No.1, 29–47(2008) Evaluators sometimes wish for a Fairy Godmother who would make decision makers pay attention to evaluation findings when choosing programs to implement. The U.S. Department of Education came close to creating such a Fairy Godmother when it required school districts to choose drug abuse prevention programs only if their effectiveness was supported by "scientific" evidence. The experience showed advantages of such a procedure (e.g., reduction in support for D.A.R.E., which evaluation had found wanting) but also shortcomings (limited and in some cases questionable evaluation evidence in support of other programs). Federal procedures for identifying successful programs appeared biased. In addition, the Fairy Godmother discounted the professional judgment of local educators and did little to improve the fit of programs to local conditions. Nevertheless, giving evaluation more clout is a worthwhile way to increase the rationality of decision making. The authors recommend research on procedures used by other agencies to achieve similar aims.

2009 – Texas A&M

"The Social Construction of 'Evidence-Based' Drug Prevention Programs: A Reanalysis of Data from the Drug Abuse Resistance Education (DARE) Program," Evaluation Review, Vol. 33, No.4, 394–414 (2009). Studies by Dave Gorman and Carol Weiss argue that the D.A.R.E. program has been held to a higher standard than other youth drug prevention programs. Gorman writes, "what differentiates D.A.R.E. from many of the programs on evidence-based lists might not be the actual intervention but rather the manner in which data analysis is conducted, reported, and interpreted." Dennis M. Gorman and J. Charles Huber, Jr.

The U.S. Department of Education prohibits any of its funding to be used to support drug prevention programs that have not been able to demonstrate their effectiveness. Accordingly, D.A.R.E. America, in 2004, instituted a major revision of its curriculum which is currently being evaluated for possible effectiveness in reducing drug use.

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) identified alternative start-up regional programs, none of which have longevity nor have they been subjected to intense scrutiny.

Project D.A.R.E. Outcome Effectiveness Revisited

Objectives. We provide an updated meta-analysis on the effectiveness of Project D.A.R.E. in preventing alcohol, tobacco, and illicit drug use among school-aged youths.

Methods. We used meta-analytic techniques to create an overall effect size for D.A.R.E. outcome evaluations reported in scientific journals.

Results. The overall weighted effect size for the included D.A.R.E. studies was extremely small (correlation coefficient = 0.011; Cohen d = 0.023; 95% confidence interval = −0.04, 0.08) and nonsignificant (z = 0.73, NS).

Conclusions. Our study supports previous findings indicating that D.A.R.E. is ineffective.

Analysis of HOV lanes

The United States has invested heavily in High Occupancy Vehicle (HOV) lanes despite very little evidence showing HOV lanes deliver on their promise to reduce vehicle miles traveled (VMT) and improve air quality.

Why indoor ventilation is important

…to reduce Covid-19 cases Building ventilation is always an important part of a healthy building environment as it ensures that a steady stream of outside air is brought into the building whilst stale air is exhausted. Stale air includes bioeffluents (body odours and exhaled breath), airborne pollutants (such as smells from cleaning products and furniture), amongst others. Ventilation is also a very important way of diluting any airborne pathogens and there is good evidence that demonstrates room occupants are more at risk of catching an illness in a poorly ventilated room than in a well-ventilated room. This is because in a poorly ventilated room occupants are exposed to a higher concentration of airborne pathogens, and the risk will increase with a greater amount of time spent in such an environment.

Risk = exposure x time

The risk of airborne infection to the individual can therefore be reduced by:

- Reducing time spent in the location

- Reducing airborne exposure concentration of infectious material

- Reducing risk of contact spread through regular handwashing, surface cleaning and reducing deposition of infectious particles.

Ventilation rate and effectiveness play a role in both airborne exposure and deposition rates. The risk for SARS-CoV2 transmission will be from asymptomatic or pre-symptomatic individuals who occupy a building without knowledge that they are shedding viral particles. Current government advice should be consulted with regards to reducing risks posed by symptomatic individuals. 1.1 Covid risks Evidence is beginning to emerge that SARS-CoV2, the virus which causes Covid-19, can spread by very small particles – called aerosols – which are released by an infected person when they cough, sneeze, talk and breathe, as well as the larger droplets that are released. Larger droplets will fall by gravity and influences the 2m social distancing measures to reduce spread. However, these fine aerosols can remain airborne for several hours. Although it can be difficult to definitively prove airborne transmission, our knowledge of other similar viruses and the emerging evidence showing high rates of infection in poorly ventilated rooms suggests that we should consider this as a potential transmission route and undertake measures to reduce that risk. These small droplets may be breathed in and cause infection. As our understanding of the significance of the various transmission routes of SARS-CoV2 develops, we recommend increasing the rate of supply of outside air to occupants wherever it is practical as a pre-cautionary measure. This is particularly important in poorly ventilated areas. Increasing the ventilation rate helps dilute any airborne contamination and reduces the risk of exposure for building users. This guidance is subject to change as SARS-CoV2 transmission routes become more clearly defined. Until then this takes a risk averse approach to reduce indoor pollution without significant capital expenditure

Which Mask And When? (Australian Dental)

Which mask?

Masks supplied for use in dental practice are required to conform to AS/NZS 4381 developed by Standards Australia. This standard specifies types of masks and their use. Below is an explanation of the types of masks that dental practitioners might use.

LEVEL 1 
Level 1 masks are not generally or widely used in dental practice, and they would only be appropriate where there is no risk of blood or body fluid splash. This may be the case in some areas of practice (e.g. when conducting post-insertion reviews for removable prosthodontics, mouthguards or removable orthodontic appliances, or performing orthodontic adjustments which exclude the use of the triplex syringe).  
 
LEVEL 2 
Level 2 masks are most commonly used in dental practices due to their ability to block particle sizes commonly encountered in routine dental practice. Restorative, endodontic and periodontal procedures using powered devices such as air turbine high-speed drills, ultrasonic scalers and triplex syringes generate large quantities of aerosols of three microns or less in size.

When undertaking such procedures, National Health and Medical Research Council (NHMRC) and ADA Infection Control Guidelines stipulate that clinical staff are to wear surgical masks which meet Standard AS 4381 that block particles of three microns or less in size, with level 2 splash resistance, so that splashes of fluid do not compromise the filtration performance of the mask.

A correctly fitted well-adapted Level 2 surgical mask will block 95% of total viral influenza particles, but effectiveness drops to 56% or less if loosely fitted or if the mask is gaping at its sides. Instructions available HERE.

LEVEL 3
Level 3 masks have a higher level of splash protection and are used for procedures where there is a greater risk for potential exposure to blood and body fluids, such as surgical procedures and major trauma. The correct use of Level 3 masks is specified in Australian Standard AS4381:2002.
 
During the COVID-19 pandemic Level 2 and 3 surgical masks may be used while treating low risk and medium risk cases (where aerosols are avoided).

P2/N95 Respirators

Airborne precautions are required when treating medium risk COVID-19 patients if aerosol generation is likely (there is no reasonable alternative), and for all treatment of high-risk patients. Airborne precautions, such as wearing P2 (N95) surgical respirators, are designed to reduce the likelihood of transmission of microorganisms that remain infectious over time and distance when suspended in the air. In addition to COVD-19, other infectious agents for which airborne precautions are indicated include measles, chickenpox (varicella), and Mycobacterium tuberculosis, as well as novel respiratory pathogens such as H5N1 influenza and avian influenza.

Maintaining safe practice

With respect to the challenges many practices are facing as a consequence of the mask supply issue it is vital that as a profession and individuals maintain safe practices, to protect ourselves, our staff, our patients, family and friends.

Examples of unacceptable practices include:

• Using one mask for more than one patient.

• Using one mask for more than 2 hours.

• Resterilising masks. Steam sterilising would alter the charge on the microfibers that are responsible for particle filtration, cause degradation of the mask straps, render the splash protection useless, and cause parts of the mask to disintegrate or melt, and release some toxic vapours.

• Using a cloth (e.g. cotton or gauze) mask.  These have poor filtration (no bacterial filtration or particle filtration), no splash protection and no resistance to fluids from the user coming through.

• Using a face-shield with no mask.

Similarly, it is important that we all be prudent in our use of masks as a consumable item as overuse will contribute to a greater supply issue. For example, it is not necessary for a dental assistant to change their mask at the end of a patient appointment just to undertake the normal change-over environmental cleaning stage.

ADA Guidelines for Infection Control

Page 8 of the ADA's Infection Control Guidelines offers further information as outlined below:

Dental procedures can generate large quantities of aerosols of three microns or less in size and a number of diseases may be transmitted via the airborne (inhalational) route. In the dental surgery environment, the most common causes of airborne aerosols are the high-speed air rotor handpiece, the ultrasonic scaler and the triplex syringe. The aerosols produced may be contaminated with bacteria and fungi from the oral cavity (from saliva and dental biofilms), as well as viruses from the patient’s blood. Therefore, dental practitioners and clinical support staff must wear suitable fluid-resistant surgical masks that block particles of three microns or less in size.

Masks protect the mucous membranes of the nose and mouth and must be worn wherever there is a potential for splashing, splattering or spraying of blood, saliva or body substances, or where there is a probability of the inhalation of aerosols with a potential for transmission of airborne pathogens. However, it is suggested that masks be worn at all times when treating patients to prevent contamination of the working area with the operator’s respiratory or nasal secretions/organisms.

Surgical masks for dental use are fluid-repellent paper filter masks and are suitable for both surgical and non-surgical dental procedures that generate aerosols. The filtration abilities of a mask begin to decline with moisture on the inner and outer surfaces of the mask after approximately 20 minutes. It is difficult to change masks during long procedures (such as surgical procedures) and is not necessary unless the mask becomes completely wet from within or without. 

Unmasking the surgeons: the evidence base behind the use of facemasks in surgery

…The facemask has been used in surgical settings for over a hundred years; first described in 1897, at its inception, it consisted merely of a single layer of gauze to cover the mouth, and its primary function was to protect the patient from contamination and surgical site infection. This practice was substantiated, at the time, by a recent discovery which demonstrated that bacteria could be disseminated from the nose and mouth during normal conversation as observed by bacterial colony growth on strategically placed agar plates in theatres. In the 1940s and 1950s, antibiotics and aseptic technique came to the forefront of infection control strategies within the surgical setting. Until recently, it has remained unclear as to whether bacterial colony growth on an agar plate was a direct correlate of surgical site infections and also whether the purpose of the surgical mask has been superseded by more modern strategies of infection control.

In order to advocate the validity of an intervention in medicine, it must satisfy three levels of evidence: efficacy, effectiveness and cost-effectiveness. In the context of facemask, efficacy is whether masks prevent the propagation of droplets derived from the mouth and nose of the operating staff. Effectiveness is whether efficacy translates into a significant reduction in surgical site infection morbidity and mortality. And finally, cost-effectiveness determines whether the cost-to-benefit ratio of this effect would be desirable compared to an alternative course of action.

Intuition would suggest that facemasks offer a physical barrier preventing the emanation of droplets from the oral or nasal passages and therefore satisfy the efficacy requirement of the evidence ladder. However, there are a number of different hypotheses as to why this may not be the case. ‘Venting’ is a phenomenon whereby air leaks at the interface between mask and face which can act to disperse potential contaminants originating from the pharynx. The accumulation of moisture, during prolonged usage, may exacerbate this problem by increasing resistance to air flow through the filter itself. Moisture accumulation is also thought to facilitate the movement of contaminants through the material of the mask itself by capillary action. These bacteria can subsequently be dislodged by movement. Friction at the face/mask interface has also been demonstrated to disperse skin scales which can further contribute towards wound contamination.

In the modern era, there has also been a scarcity of experimental evidence to support the effectiveness of facemasks in the prevention of surgical site infections. The earliest retrospective studies failed to demonstrate any statistically significant improvement in surgical site infection rates following the use of masks. Indeed, the latest National Institute for Health and Care Excellence guidelines on the matter do not require operating staff to wear a mask in theatre. This decision was based primarily upon the findings of a Cochrane systematic review. This review was guided by the findings of two particular randomised/quasi-randomised control trials. The latest update of this review, which was amended after the publication of current National Institute for Health and Care Excellence guidelines, included one further study.

…Overall, we found very few studies and identified no new trials for this latest update. We analysed a total of 2106 participants from the three studies we found. All three studies showed that wearing a face mask during surgery neither increases nor decreases the number of wound infections occurring after surgery. We conclude that there is no clear evidence that wearing disposable face masks affects the likelihood of wound infections developing after surgery.

…More research in this field is needed before making further conclusions about the use of face masks in surgery.

see also:
https://www.isitzen.com/blog/2021/3/cochrane-mask-studies

the trolley problem

The trolley problem: should you pull the lever to divert the runaway trolley onto the side track?

Foot's original structure of the problem ran as follows:

Suppose that a judge or magistrate is faced with rioters demanding that a culprit be found for a certain crime and threatening otherwise to take their own bloody revenge on a particular section of the community. The real culprit being unknown, the judge sees himself as able to prevent the bloodshed only by framing some innocent person and having him executed.

The trolley problem is a thought experiment in ethics modeling an ethical dilemma. It is generally considered to represent a classic clash between two schools of moral thought, utilitarianism and deontological ethics. The general form of the problem is this:

There is a runaway trolley barreling down the railway tracks. Ahead, on the tracks, there are five people tied up and unable to move. The trolley is headed straight for them. You are standing some distance off in the train yard, next to a lever. If you pull this lever, the trolley will switch to a different set of tracks. However, you notice that there is one person on the side track. You have two options: 

Do nothing and allow the trolley to kill the five people on the main track.Pull the lever, diverting the trolley onto the side track where it will kill one person.

Which is the more ethical option? Or, more simply: What is the right thing to do?