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Violence is a critical public health issue and one that contributes to an astounding number of years of life lost, with homicide and suicide among the top 5 causes of death for those aged 1-44.

Yet our response to violence as a society is not to treat and prevent but rather to criminalize and punish, which doesn’t seem to have helped prevent crime, much less have addressed the root causes of crime, as I have noted before.

The issue of criminal justice in the U.S. and the desperate need for a shift in the justice paradigm, from a system focused primarily on punishment to one emphasizing restorative practices, is one that has once again been on the forefront of my mind in the face of extensive coverage of the trial of Dharun Ravi last month.

Ravi and Clementi

Quick background: Dharun Ravi was charged on all 15 charges he faced for using a webcam to spy on his roommate, Tyler Clementi – Clementi killed himself soon after the spying incidents, though as this board member of the American Foundation for Suicide Prevention eloquently captures, blaming Ravi for Clementi’s suicide is utterly inaccurate and unfair. Suicide is an incredibly complex phenomenon, which always has multiple risk factors at play, including diagnosable mental health conditions which are present in over 90% of cases of completed suicide. You cannot draw a causal link between any one specific incident and suicide and you certainly cannot blame another individual for one’s suicide. Although Ravi was not charged for Clementi’s death, I find it highly unlikely he would be facing 10 years in prison as he currently is if it were not for the fact that Clementi killed himself.

Though Ravi’s actions – and any homophobic motivations behind them – were wrong, I am sure they have been, are, and will be repeated across dorm rooms everywhere – college kids can be foolish and immature, and I fail to see how putting Ravi behind bars for 10 years does anything to address the root issues here. We as a society need to be more tolerant of differences, more respectful of each other, and more communicative with those around us. We need to stop discriminating against others based on race, sexual orientation, religion, and any other such category. But instead of revisiting what we as a society are doing wrong that leads to incidents such as this one, we are instead throwing the blame at the feet of one college student, punishing him in a way that will neither help him, nor prevent cases like this in the future. It seems we perpetually take the easy way out – revisiting what we do as a society and as university, school, and other communities, would be much too difficult; blaming one individual and punishing them – far easier.

Moving beyond this one incident to the array of crimes that land people in prison, the true solution lies in prevention. At the individual level, depending on the nature of the issue, this means things like drug treatment, interventions with at-risk families, and school completion programs (among other things), all of which research has demonstrated to be “more cost-effective than expanded incarceration as crime control measures” according to this Sentencing Project report. At the population level, this means instilling values of respect and equality, tolerance and diversity, beginning at very young ages, at home, in our schools, and in our communities – through education, prevention programs, policies, laws, and more.

Yet, this does not seem to be the direction in which we are moving. I recently attended a symposium during which a prominent political figure, speaking on internet crimes (particularly child sex trafficking and sexual abuse), said “I really think the most meaningful solution is to put these people behind bars for as long as possible – as far as I’m concerned, that’s what prisons are for.”

I felt sick to my stomach – not a word about prevention or restorative practices in his talk, do people really not see how we are not only failing to treat and prevent and improve society, but also resigning ourselves to perpetually be throwing people in jail?

But there is hope, and there are ways out of this mess. A more recent publication of The Sentencing Project compiles the essays of 25 leading scholars and practitioners on their strategic vision for the next 25 years of criminal justice reform.

A truly incredible compilation of perspectives that is worth a read, but for now I will highlight some points from the essay capturing the public health perspective, written by leading violence prevention public health scholar and practitioner, Deborah Prothrow-Stith.

She writes, “We can’t address the many challenges in the criminal justice system without reducing the number of people entering the criminal justice system in the first place. This means prevention must be on par with law enforcement and punishment. As a nation, we already promise to respond to violence with expensive and sometimes harsh solutions. We need a companion promise, the promise of prevention.”

And, as she points out, this is an area in which we do have firm science as to what works and what doesn’t. Public health-based programs such as CeaseFire Chicago and the Urban Networks to Increase Thriving Youth (UNITY), school-based violence prevention efforts that have proven effective, programs like Boys and Girls Clubs and the Big Brothers Big Sisters of America initiatives, and the Nurse Family Partnership home visiting program have all proven to reduce crime and violence in meaningful ways.

Instead of focusing on punishment within a flawed and discriminatory system, instead of cutting prevention funds (as of last week, the Prevention and Public Health fund is yet again on the chopping block, much to my – and many other’s – dismay), let’s focus our attention on programs like the ones mentioned above – programs that prevent violence, promote health, and foster a more vibrant and productive society.

This post is cross-posted at http://occupyhealthcare.net

National Public Health Week kicks off today!

Let’s start with the basics: what is public health?

Ultimately, public health is about prevention at the population level.

As the Johns Hopkins Bloomberg School of Public Health’s motto so fittingly states, public health is “protecting health, saving lives – millions at a time.” We design neighborhoods more conducive to exercise; we strive for improvements in hospital systems so as to reduce mistakes; we pursue policy changes to ban false marketing by cigarette companies – all these things affect not one or two people, but hundreds, thousands, and millions.

Public health is also largely about prevention – keeping bad things from happening in the first place, as opposed to solving or managing already-present problems (although public health does a fair bit of that too). We clean environments to prevent asthma, we don’t provide inhalers; we teach you to cough into your elbow to prevent the spread of flu, we don’t prescribe antiviral medicine; and we redesign cars and roads to prevent injury, we don’t perform surgery.

Focusing on just this kind of population-level prevention, National Public Health Week offers us the following daily themes:

In addition to the above topics, National Public Health Week provides us a time and space to delve into the idea of integrating primary care and public health, an idea that was the focus of a recent IOM reportas explained on the occupy healthcare site just a couple days ago.

In addition to the case studies mentioned in that post, the operation of community health centers back when they originated provides a phenomenal example of true integration of primary care and public health.

The community health center movement started about 45 years ago, with roots in the civil rights and social justice movements of the 1960s, and with some incredible leaders at the helm. At the dawn of this movement, community health center leaders saw health as but an entry point to solving a broader range of problems, without raising the same level of opposition as more blatantly political “social change” programs. The goal was to not just to provide primary care and related outreach and patient education, but to address social determinants of health through job development, nutrition, sanitation, and social services. All while maintaining a core principle of respect for and involvement of community residents (aided by the legal requirement that governing boards of community health centers must be composed of at least 51% consumers).

While community health centers in the U.S. continue to do phenomenal work providing much-needed high-quality primary care services to largely underserved populations, most have become primarily – some entirely – deliverers of medical care. I would love to see these centers take a turn back to the roots of the community health center movement, propelled by grassroots advocacy by community members, national organizations such as the National Association of Community Health Centers, and advocates for integration of primary care and public health such as those of us here.

For more tips and action steps, visit www.nphw.org!

This post is cross-posted at http://occupyhealthcare.net 

In our attempts to encourage people to lead healthier lives, we often make the mistake of bombarding them with facts and stats, do’s and don’ts, assuming the problem is a lack of knowledge. But let’s be honest – most people know that French fries are not the healthiest food in the world, fruits and vegetables are good for you, and that you really ought to exercise regularly.

So, what’s the problem? One aspect of the problem is of course the systems level issues of food access, cost, time and space to be active, etc. that we have mentioned before.

Another aspect though is one of attitude and culture.

Feel Rich, which launched in December, is attempting to address just this (sidenote: the organization’s CEO and others involved were on a SXSW Panel just this past weekend).

Feel Rich’s goal is the creation of a health and fitness culture born from the urban and hip-hop community’s love and respect for music, movement, and entertainment. Their message: health is the new wealth.

As opposed to your typical public health campaign centered on facts, stats, and do’s and don’ts, Feel Rich is attempting to first foster a desire for health (in other words, crafting an attitude and creating a culture that sees health as critical and desirable as wealth), engaging urban youth in a meaningful way that speaks to their interests. In Feel Rich’s own words – “It’s health on your terms, fitness in your style, and food choices that make sense on the streets where you live.” It’s also about making health and wellness cool.

I think it’s an exciting and inspiring approach, and the way the Feel Rich movement taps into attitudes (not just information), reminds me of the baby carrots campaign I’ve written about before. After all, whether we’re talking about the junk food industry, big tobacco, or pretty much any other product we see commercials for, appealing to emotion and attitudes is the way advertising is done. It’s long past due that prevention and health promotion advocates started utilizing this powerful strategy.

Feel Rich ties this powerful appeal to attitude and culture with empowering information on food, fitness, and health, and an array of videos and stories to engage and inspire their audience.  And with over 3 million YouTube views, it looks like they are doing just that.

I’ll close with some food for thought on this topic from David Katz’s most recent Huffington Post article:

“What if health were more like wealth?

  • If health were like wealth, we would value it while gaining it — not just after we’d lost it.
  • If health were like wealth, we would make getting to it a priority.
  • If health were like wealth, we would invest in it to secure a better future.
  • If health were like wealth, we would work hard to make sure we could pass it on to our children.
  • If health were like wealth, we would accept that it may take extra time and effort today, but that’s worth it because of the return on that investment tomorrow.
  • If health were like wealth, society would respect those who are experts at it.
  • If health were like wealth, young people would aspire to it.

This post is cross-posted at http://occupyhealthcare.net 

Carmen shared with us a couple great Martin Luther King, Jr. quotes in her Occupy Healthcare post on Monday, and it inspired me to take a look at some of Dr. King’s other quotations. So many of them captured concepts relevant to public health that I wanted to share some of my favorites here. Here’s hoping we can take some of Dr. King’s wisdom and apply it to our work!

“True compassion is more than flinging a coin to a beggar; it is not haphazard and superficial. It comes to see that an edifice that produces beggars needs restructuring.”

I think this quote truly captures the essence of public health – public health isn’t about treating individuals with band-aids or quick fixes; it is about protecting health and saving lives– hundreds, thousands, sometimes millions at a time – by restructuring the systems that produce sickness, violence, and other problems that ail our society.

“Rarely do we find men who willingly engage in hard, solid thinking. There is an almost universal quest for easy answers and half-baked solutions. Nothing pains some people more than having to think.”

Indeed, we often see programs and initiatives implemented without nearly enough strategic planning and thought to sustainability, input from communities, constructive criticism, and/or evaluation (formative or post-program evaluation). Public health work (any work, really) is difficult and nuanced. We have to think hard and critically about what works and what doesn’t, and whether we are helping, hurting, or making no difference at all. At the risk of repeating myself one too many times – good intentions are not enough.

All labor that uplifts humanity has dignity and importance and should be undertaken with painstaking excellence.”  

Speaking of good intentions not being enough – I think we all owe it to ourselves and society to not rest upon the fact that we are at least trying to help, but to undertake our work with “painstaking excellence”.  If we’re going to try to do this, let’s try to do it right.

“It may be true that the law cannot make a man love me, but it can stop him from lynching me, and I think that’s pretty important.”

I have to admit, this quote made me laugh. And it’s a good point – laws and policies have their limitations, but they are also an incredibly powerful tool for change, particularly at the level of populations and systems.  I recently came across the Network for Public Health Law, and particularly love their overview of different public health topics.

And lastly, a quote from Dr. King that speaks for itself:

“Our lives begin to end the day we become silent about things that matter.”

The CDC calls tobacco use “the single most preventable  cause of disease, disability, and death in the United States” with an estimated 443,000 smoking related premature deaths and 8.6 million living with serious illnesses caused by smoking. In addition, according to the CDC, tobacco use is responsible for more than $96 billion a year in medical costs and another $97 billion a year from lost productivity. So there’s no question that tobacco plays a major role when it comes to our country’s (and the world’s) health, health care, and medical costs.

One of the most infuriating aspects of the tobacco saga is the role of the tobacco industry and its unlawful and deceptive practices, for which companies have been repeatedly called out and in the U.S. government’s landmark lawsuit,successfully sued. As U.S. District Judge Gladys Kessler stated in the final opinion of this lawsuit: “Despite [the] knowledge [of the harmful effects of tobacco], [the Defendants] have consistently, repeatedly, and with enormous skill and sophistication, denied these facts to the public, to the Government, and to the public health community… In short, Defendants have marketed and sold their lethal products with zeal, with deception, with a single-minded focus on their financial success, and without regard for the human tragedy or social costs that success exacted.”

The stories of deception continue to this day, with a new analysis from UCSF, published just a couple weeks ago in PLoS Medicine, showing that tobacco scientists altered their study protocols to obscure the increased toxicity of additives in cigarettes.

Despite the seemingly never ceasing stories of deception and defrauding the public, U.S. tobacco companies had the audacity to sue the federal government this past summer over proposed graphic cigarette warning labels, saying the warnings violate their free speech rights and will cost millions of dollars to print (the latter point elicits a very bitter laugh, given we’re talking about an industry that rakes in billions and billions in profit).

The case was decided in favor of the tobacco companies in district court, but is currently being appealed (and I was happy to see that 24 attorney generals filed a friend of the court brief a couple weeks ago, saying the First Amendment doesn’t prevent the government from requiring “lethal and addictive products carry warning labels that effectively inform consumers of the risks those products entail”).

But what I’d like to turn to is public reaction to the graphic labels fight. Certainly, there are those that support the use of graphic labels on cigarette packages as a way to discourage tobacco use (there is in fact quite a bit of scientific evidence supporting this). But there are also those clamoring about the “nanny state”.

Public health professionals are pretty used to such “nanny” claims, and I think Yale University’s Dr. David Katz captured it perfectly in his Huffington Post article, “Public Health and the Illusion of Your Autonomy”, a few days ago:

“You may think you are defending your autonomy by opposing a ban on toys in Happy Meals. But while you are resisting the tyranny of public health, you are playing right into the hands of a large and rich corporatio­n that is far more concerned with its profits than the health of your child.”

EXACTLY. Why are some people so much more willing to be dictated by for profit corporatio­ns (whether in the fast food industry, tobacco industry, or otherwise)  than the recommenda­tions of public health and medical professionals?

They are infuriated by the idea of government placing graphic warning labels on cigarette packets, but seemingly unfazed by the continued deceptive practices of tobacco companies  (including supposed public service announcements about the harmful effects of cigarettes, which have been shown to be ineffective and sometimes even cause youth to start smoking or have more favorable beliefs about tobacco companies – which is exactly what they have worked to achieve).

They are infuriated by the idea of curtailing the freedom of McDonald’s to put toys to Happy Meals, never mind that it was most likely a decision made after “highly-paid marketing executives told them how to manipulate you by manipulating your children,” as David Katz puts it.

What can we do on this front? My advice today is not so much specific action steps, but more about thinking critically. First, let’s look into the “illusion of our autonomy” in a variety of different arenas – who really controls our behaviors and choices, and what are their motives? Then let’s ask, what can we do – on the ground in our communities and in the policy sphere – to limit the sometimes manipulating and deceptive influence of those with their bottom line in mind instead of what’s best for our health and well being? If you have any thoughts about these questions or related topics, please sound off in the comments!

(This post is cross-posted at http://occupyhealthcare.net)

Speaking of New Year’s Resolutions, here’s another one to add to our lists: give wisely. With the holiday season just behind us, many have volunteered time and/or donated money, and perhaps even made resolutions to do a better job of it in 2012.

Our #occupyhealthcare principles, and an array of other important causes, are being actively pursued by nonprofits around the world, and many of us have and will in the future donate our money and volunteer our time with these organizations.

In doing so, it is important to remember that good intentions are not enough – a trap we often fall into in social service fields. We think we are helping others, so we go home feeling good about ourselves, but we don’t spend nearly enough time challenging our assumptions about whether or not what we’re doing (or what organizations we support are doing) is actually making any kind of sustainable difference.

The Boston University Economics Club highlights one common trap we fall into in an article entitled “When is it a bad idea to give the poor free stuff?”This criticism of TOMS Shoes also describes the problem of free stuff outcompeting local goods, but goes further, pointing out issues such as doing things for instead of with people, marketing ploys disguised as awareness raising,  harboring a “whites in shining armor” mentality, and failing to match the needs of those on the ground.

This last one is a particular pet peeve of mine – we often fall into the trap of taking up the cause du jour, never mind what people on the ground actually need. Daniel Halperin addresses the issue of well-intentioned but far-from-optimal (as far as improving health outcomes) donations towards HIV/AIDs prevention and treatment in a wonderful 2008 op-ed in the New York Times. He speaks of the 100-to-1 “disastrously inequitable” imbalance between U.S. spending on AIDS programs ($3 billion) vs. safe-water projects ($30 million) in Africa. This despite the fact that most African nations have a stable adult H.I.V. rate of 3% or less and despite the fact that in certain African countries, AIDS money remains unspent as even state-of-the-art H.I.V. clinics cannot accept such large influxes of cash, and in others, children suffering from basic diseases are left untreated (as clinics cannot afford to stock basic medicines) while H.I.V.-infected children are offered exemplary treatment.

Another example is breast cancer related “awareness-raising” and fundraising in the United States. Injury, violence, and a host of other diseases all claim more lives than breast cancer.  This is not to say breast cancer doesn’t deserve any attention, but all the hype seems to have contributed to misperceptions about the risk of breast cancer vs. other cancers and diseases, not to mention the ridiculous slogans that objectify women, potentially furthering social norms that contribute to gender-based violence and other problems. On top of this, many of the efforts are entirely nonsensical (e.g., Yoplait’s pink yogurt lids) – unless your goal is to increase revenue for the companies that sponsor them. Even more distressing is when the products being promoted in the name of breast cancer awareness actually contain ingredients that have been linked to increased risk of breast cancer.

As one blogger put it, “The ostensible focus of all this pseudo-philanthropic pink jockeying is a kind of nebulous breast cancer “awareness,” rather than any serious effort at prevention or investigation into what actually causes breast cancer in the first place.” One of the comments on this blog post captures the issue well: “If there was some real research into the root causes of cancer or providing widespread access to quality healthcare (prevention, early detection, dealing with the disease, cure) for women, maybe I would understand. Instead a friend gives me a T-Shirt that says “Save the ta-tas” and I am supposed to believe that all is right in the world.”

How can we avoid some of the traps mentioned above, and give in ways that are more likely to contribute to actual, sustainable change?

*Choose wisely – be critical, and do your research. It’s hard to truly measure a nonprofit’s impact, but we can at least try to get a better sense of their work. What exactly does the organization do? How well does what they do match the needs of those they aim to help? What does research and evaluation say about the kinds of tactics they use? Is their work sustainable? Are they engaging and empowering those they try to help?  In addition to these, goodintents.org provides a fabulous list of  Dos and Don’ts for Disaster Donations and issues and tips related to voluntourism, and Think Before You Pink provides questions to ask before you buy pink (but much of what they say is relevant to looking into any cause).

*When volunteering, maximize your impact by volunteering in a way that puts your skills to use. Check out sparked.com: even more than their online, micro-volunteering approach, I appreciate the idea of trying to match a person’s skills (web design, marketing, legal, etc.) with the needs of an organization.

*Start local. Contributing your time and money to local organizations doing good, smart work (choosing wisely is still important) can help build a sense of community (for you and those you work with) and help you build long-term relationships with the organizations you choose to support and those that turn to the organization for its services. It can also be easier to get a sense of an organization’s work when you can be there in person – it’ll make for wiser giving anda more personal sense of the impact the organization and your support is having.

Here’s wishing everyone Happy and Wise Giving in 2012!

(This post is cross-posted at http://occupyhealthcare.net). 

I have written about the behavior shaping role of the entertainment and news media before, but of course, marketing plays a huge role too. And the behavior shaping role of marketing has been in the spotlight this past month, specifically in the context of marketing of junk food to children. Between the continual delays and watering down of what are alreadycompletely voluntary recommended nutrition standards for marketing foods to kids (composed by the Federal Trade Commission’s Interagency Working Group on Food Marketed to Children) and the release of a study revealing that popular cereal brands “pack more sugar than snack cakes and cookies”, it seems like a good time to take a closer look at the world of fast food and junk food marketing to kids.

As the Prevention Institute points out:

*The food and beverage industry spends approximately $2 billion per year marketing to children.

*The fast food industry spends more than $5 million every day marketing unhealthy foods to children. 

*Kids watch an average of over ten food-related ads every day (nearly 4,000/year).

*Nearly all (98 percent) of food advertisements viewed by children are for products that are high in fat, sugar or sodiumMost (79 percent) are low in fiber.

In a study comparing the nutritional content of food items observed during advertisements (during 84 hours of primetime and 12 hours of Saturday-morning TV broadcast during the fall of 2004) to the recommended daily values, researchers found that a diet consisting of observed food items would provide 2,560% of the recommended daily servings for sugars, 2,080% of the recommended daily servings for fat, 40% of the recommended daily servings for vegetables, 32% of the recommended daily servings for dairy, and 27% of the recommended daily servings for fruits.

This disproportional marketing of foods high in fat and sugar might be concerning in and of itself – but the real problem is that it’s working. Beyond the evident fact that childhood obesity is an enormous problem in the United States, numerousresearchers and government agencies have found specifically that marketing and advertising of foods does in fact impact children’s food preferences, as well as purchase requests directed to parents and short- and long-term dietary consumption.

Moreover, in recent years, researchers at the Yale University Rudd Center for Food Policy and Obesity have concluded that “the traditional models used to explain advertising effects have overemphasized the importance of children’s understanding of persuasive intent”, echoing an Institute of Medicine Report which points out that although the most common models used to explain the effects of food marketing assume a conscious and rational path from exposure to behavior via persuasion, more recent psychological models suggest repeated exposure to food advertising can lead directly to beliefs and behaviors without active, deliberate processing of the information presented.

In this context, branding and cues such as cartoon spokescharacters, colorful packaging, and pictures have been identified as important in this link between food advertising and beliefs and behaviors. Studies have shown that children 3-5 years prefer the taste of baby carrots, milk, and other products out of a McDonald’s bag and that kids 4-6 years prefer the taste of graham crackers and gummy fruit snacks with Dora, Shrek or Scooby Doo on packaging.

If that’s not worrisome enough, the Prevention Institute has more statistics for us:

*Nearly 40% of children’s diets come from added sugars and unhealthy fats.

*Each day, African-American children see twice as many caloriesadvertised in fast-food commercials as White children.

*Even five years after children have been exposed to promotions of unhealthy foods, researchers found that they purchased fewer fruits, vegetables and whole grains, but increased their consumption of fast foods, fried foods and sugar-sweetened beverages.

*By 2030, healthcare costs attributable to poor diet and inactivity could range from $860 billion to $956 billion, which would account for 15.8 to 17.6 percent of total healthcare costs, or one in every six dollars spent on healthcare.

So what can we do? I think the solution lies in not only in trying to limit the marketing of unhealthy foods to children but also in tapping into their strategies (which clearly work) to promote healthy options to kids. As the Institute of Medicine points out, the field has “underutilized the potential to devote creativity and resources in promoting food, beverages, and meals that support healthful diets for children”. One of the few examples I’ve come across: the recent baby carrots campaign, which “takes a page out of junk foods’ playbook and applies it to baby carrots” with Doritos-like packaging, seasonal tie-ins like “scarrots” during Halloween, and TV spots that portray baby carrots as extreme and futuristic.

We have a responsibility to be creative and tap into strategies that work when it comes to marketing healthy foods – not just preach and list facts (since we all know how appealing kids find that technique).

We also have a responsibility to step up and speak up against the massive junk food and fast food industries in their aggressive marketing to children – the Prevention Institute has a great video and easy action items on this front.

Check it out and add your voice to the discussion!

(This post is cross-posted at http://occupyhealthcare.net)

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