Sep 212011

What’s Going to Happen when the Clinics Close?

I’ve had a lot of conversations this past week regarding my data visualization tracking STDs, HIV, and AIDS in Texas from 2006 to 2010 (see

One of the bigger questions that may have been overlooked in my accompanying blog post is what is going to happen over the next two years as state budget cuts take effect? Consider the chart below that shows the increase in reported STD cases over the past five years.

Granted, combining Chlamydia, Gonorrhea, Syphilis, and HIV into one lump and not taking overall population growth into account may be misleading, so consider the chart below that shows the number of STDs and HIV cases, incident rates, and percentage changes from 2006 to 2010.

Even without drilling very deep it looks like Texas is having a lot of trouble just containing the spread of STDs and HIV.  To be fair, one of the reasons the number of Chlamydia cases has increased so much is that the Texas department of State Health Services has adopted new technology and screening techniques which in turn has led to much better detection and reporting.

That said, we pretty much see all the trend lines moving upward.

So why should we be very worried?

The numbers shown above reflect a state healthcare system that had previously budgeted over $50 million per year for family planning initiatives, including education, screening, and treatment for STDs and HIV / AIDS.  These funds have been severely cut (see

So, what’s going to happen when clinics close and those clinics that do remain open have to cut staff and shorten office hours?

(To explore the interactive visualizations, click here.)

 Posted by on September 21, 2011 4) Health and Social Issues, Blog 1 Response »
Sep 202011

You all know I love Tableau, yes? We’re cool with that…

… but…

There are times when I see Tableau guiding people to make less than ideal visualizations; situations where your have to grapple with the tool to get better results.  A good example may be found at the Tableau Public blog.  Here’s a screen capture.

There’s some great information here, but a lot of the impact is lost for two reasons:

1) Alaska and Hawaii

I’ve been griping about this since the release of Tableau 4.0, but this viz underscores the problem of always being “longitudinally correct”:  There’s no room for the information! (Damn that Pacific Ocean).  Alex Kerwin offers a solution to this here but it’s not built into the product and it requires some futzing (but it is very cool).

2) Default divergent colors

I’ve already railed about this in an earlier blog post but if you need a reminder, here’s a simulation of what this type of color combination looks like to a person who is color blind:

The solution?  Make Blue / Orange the default divergent palette.

And while I’m at it…

I really need dashboard-specific filters, but I’ve already begged/complained about that.

Maybe in Tableau 7?

 Posted by on September 20, 2011 1) General Discussions, Blog 6 Responses »
Sep 162011


The Texas State Legislature’s recent and sweeping funding cuts to all family planning organizations – including the complete defunding of Planned Parenthood – has lead Data Revelations to examine historical data on sexually-transmitted diseases (STDs) and HIV / AIDS and suggest what the case count and incidence rates will look like in the near future.

Note: The Center for Disease Control (CDC) divides the disease we studied into two groupings: STDs (which include chlamydia, gonorrhea, and syphilis) and HIV / AIDS.  While much of the following analysis that follows looks at overall case count and incidence rates, the interactive dashboards allow exploration by both disease category and individual diseases.

Data source: Texas Department of Health Services

The interactive dashboards may be found at the end of this blog post.

Special thanks to Joe Mako for building the county polygons and providing invaluable advice.

Key Findings

  • Roughly ten percent of Texas’ 254 counties account for 80% of all cases.
  • Within these counties, the incidence rate for STDs is up 28% from 2006.
  • Incidence rate for HIV is up 5%, but for AIDS it is down 31%.
  • The two counties that can boast the largest rate decrease for all diseases tracked in the study are Hays (-13.9%) and Travis (-7.4%).
  • The two counties with the greatest incidence rate increase for all diseases tracked in the study are Jefferson (+122%) and El Paso (+65.5%).
  • There appears to be a strong correlation between the existence of Planned Parenthood locations and decreased incidence rates (though not in all locations).
  • We believe that the recent cuts in family planning funding will lead to a large increase in cases in 2012.

Understanding the Landscape

The image below shows the incidence rate (number of cases per 100,000 persons) for all diseases broken down by county.

Note that if you hover over a county you can see information about that county.

If you click a county in the top view the table at the bottom of the screen will show results for just that county:

Where to start?

Let’s change the view and focus first on the counties that have the largest number of cases.  We can do this easily by coloring the map by Cases instead of Rate, as shown below.

Now we can see that a small number of counties are responsible for a large number of cases.  Which counties should we focus on first?

Vilfredo Pareto and the 80-20 Rule

The Pareto Principle, or 80-20 rule, is named after Italian Economist Vilfredo Pareto who early in the 20th century observed that 80% of the land in Italy was owned by 20% of the population.

In Texas it’s the 80-10 Rule

The visualization below shows that when it comes to the number of cases, just over 10% of the counties are responsible for 80% of the cases.

Note that if we highlight just the first ten percent of the bars in the top visualization we will limit the number of counties displayed in the bar graph to the 28 that account for 80% of the cases.

Specifically, selecting ten percent of the bars (1), reduces the number of counties from 254 to 28 (2) and reduces the overall case count from 697,456 to 588,416 (3).

So, now that we know what counties to focus on, what can we learn about them?

Cases, Rate, and Percent Rate Change

The next dashboard offers several ways to see how counties have performed from 2006 through 2010 as we can look at Cases, Rates, Percent Change, individual diseases, and so on.

We found “% Rate of Change” the most enlightening view so we’ll focus on that.

Let’s see what happens if we just focus on STDs and exclude HIV / AIDS from the mix.

So, what’s up with Chlamydia and Syphilis?

If you look at the individual counties using the visualization in the top portion of the dashboard you will see that without exception the percent change in Chlamydia rates from 2006 is up in all 28 counties while Syphilis is down in many counties (and way up in others.)

When asked about these numbers, an epidemiologist at the Texas Department of Health Services stated that the increase in Chlamydia rates should be attributed to an increase in better testing technologies, expansion of electronic lab reporting, and increased screening.  Chlamydia is often asymptomatic and that five years ago many cases were undetected or unreported.  As both detection and attention to reporting have improved one should see a larger number of cases.  That said, some counties are much worse in this respect than others.

As for Syphilis and Jefferson County’s “off the chart” numbers for 2009 … we’ll look at this in a moment.

Looking at the Trend for All STDs

Another way to view the data is to combine a disease group into one line by selecting Show overall from the drop down list box.

In the screen below we track overall % rate change for STDs from 2006 through 2010. It’s very easy to see where the outliers are.

Now that we have some tools to determine where counties are succeeding and failing, let’s see if we can determine why this is happening.

Location, Location, and…

The dashboard below compares the percent rate change among the 28 counties.  The size of the circles indicate the number of cases and the color indicates whether the incidence rate has increased (orange) or decreased (blue) from 2006.

We’re particularly interested in the dark orange and dark blue dots (the outliers), so let’s see what happens when we click the dark orange dot that borders Louisiana.

So, what happened in Jefferson between 2006 and 2007 to cause the initial spike, and eventual peak in 2009?  We believe it has to do with clinic locations as well as a once-in-a-generation environmental event which we will explore in a moment.  (We still don’t know why, but at least we know when the problem started.)

If we clear the selection and look at the larger, albeit not as dark, dot all the way to the west we see the following:

What happened in El Paso between 2009 and 2010 that caused such a large increase?  Again, we’ll explore this in a moment but we believe clinic location and administration has a lot to do with this.

Enough of the orange dots; let’s look at the other end of the spectrum and explore Travis County where we see an impressive decrease for all STDs.

So, we have a better sense of when problems (or improvements) occur, but we still don’t know why they occur

One additional set of data that might help us figure out why some counties are succeeding while others are failing is to look at the location of family planning clinics; i.e., clinics that provide screening, counseling, education, and treatment for STDs and HIV/AIDS.

All clinic locations

The diamond shape indicates locations of family planning centers as of August 2011.  The size of the dot indicates the number of centers within a county.  You can hover over a dot to see more information about a county and the number of clinics.

At this point there doesn’t appear to be an obvious correlation between location and number of current clinics and the percentage rate change.  Let’s see what happens if we only look at clinics run by Planned Parenthood.

Planned Parenthood locations

Three questions come to mind upon seeing this visualization:

  • Why are there no Planned Parenthood locations in El Paso (1)?  Is this related to the spike in cases from 2009 to 2010 that we saw earlier?
  • Why are there no Planned Parenthood locations in Jefferson (2)? And as we saw earlier, why the large spike in cases, particularly Syphilis, between 2006 and 2007?
  • Why is Potter County (3) succeeding where almost all the other counties are struggling?
  • Why is it that some clinics appear to be succeeding while others are failing?  Are there other issues besides location?

El Paso

Dr. Fran Hagerty, CEO of the Woman’s Health & Family Planning Association of Texas, states that there was in fact a Planned Parenthood office in El Paso but it was forced to close at the end of 2008 and the new entity that took over for it went through a fair amount of turmoil.  The epidemiology office at Texas Department of Health Services agrees that things were indeed in flux at that time.  We see that as of 2010 there are still problems.


While I have not yet found out why there is no Planned Parenthood office in Jefferson (or if there ever was one) there’s one thing that might explain the spike in cases (particularly syphilis):


At the end of 2005 and through much of 2006 there was a wave of what can best be described as refugees from Hurricane Katrina that settled in Jefferson County. Many were poor and without jobs and adequate housing.  Incidence rates peaked in 2009 but the significant decrease in case count in 2010 suggests that the Texas Department of Health Services has now controlled the epidemic.


There’s no Planned Parenthood location here, but Potter County can boast only a very small increase in STDs from 2006:

What is this county doing differently from the others?

A call to Dr. Ron Barwick, CEO of the Haven Health Clinics in Amarillo indicates that the clinic he runs had been affiliated with Planned Parenthood but broke off from them in 2006 as the then-named Texas Panhandle Family Planning & Health Center was no longer going to offer abortion services.

We asked Barwick why he believed his clinic was doing so much better than most others and he stated that the main reason was that, in addition to emphasis on education, Haven had opened a male health center and this was having a significant impact on reducing STDs.  Specifically, men that would be uncomfortable sitting in a waiting room where there were women were not uncomfortable going to the male-only clinic.

Clearly, Dr. Barwick and his colleagues are doing something right.  Unfortunately, the recent budget cuts will make it difficult for them to continue, let alone share their best practices with others.

Is it All About Location?

We started to perform an analysis where we looked at the number of cases vs. the number of clinic locations and realized that we would be missing a critical data point: How well-funded and well-staffed is the clinic?

We would want to explore the relationship between clinic headcount and funding before being able to state whether a particular location is succeeding or failing.  For example, Harris counry has the greatest number of cases and certainly has many clinic locations.  Are these clinics staffed by one person or dozens?

The same question would apply to Hidalgo where there appears to be a lot of clinics given the number of cases.  How many people staff these clinics?  What is the funding for each one?

Clearly, just mapping clinic location to the number of cases is not enough.

What Now?

In addition to exploring the relationship between cases, funding, and staffing, one obvious next step would be to look at just what it is that high-performing clinics do differently from the lower  performers and have the lower performers adopt the practices of the high performers.

Unfortunately, the unprecedented state budget cuts will prevent this from happening as many clinics – including those that are getting good results – will either have to close or severely curtail their operations.

To get an idea of the impact of the budget cuts we can look back to 2006 when the Texas legislature enacted far less sweeping cuts.  Indeed, had we used 2005 as our baseline year rather than 2006 when the cuts were enacted we would see that the rate of STDs is up 39% from the baseline year vs. 28%.  But those budget cuts pale in comparison to Texas’ complete defunding of Planned Parenthood and severe defunding of other family planning entities.

We believe that a view of these dashboards in 2012 will show more, larger orange dots, indicating a much larger number of cases which will lead to an over-taxed health system, lost productivity, and increased human suffering.

 Posted by on September 16, 2011 4) Health and Social Issues, Blog 5 Responses »