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Archive for the ‘Policy’ Category

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

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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)

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As this video from the Center on the Developing Child illustrates, in looking at determinants of health and well being, it is important to consider the enormous influence early childhood and later youth development have on children’s futures. Physical, social, and emotional health and well being, as well as factors related to health and well being such as education and income levels, can often be predicted from childhood exposures. Moreover, brain development research suggests young people are particularly receptive to prevention and youth development interventions and supports, as well as strategies geared towards developing resilience and social competence.

In a 2010 report entitled The Foundations of Lifelong Health Are Built in Early Childhood, the following framework is put forward.

The framework highlights much of what we are striving for here at #occupyhealthcare – public health, community development, primary healthcare – all with the goal of better health across the lifespan.

And while interventions and supports in very early childhood are critical, continuing this support through adolescence is also imperative. Young people who are surrounded by a variety of opportunities for engagement encounter less risk and ultimately show evidence of higher rates of successful transitions into adulthood.

The positive youth development movement centers around cultivating five essential characteristcs, commonly known as the five Cs:

While both early childhood development and positive youth development are extensive fields, with a vast array of research and related programs and policies, this simple introduction establishes the essence of these fields and the link between them and health and well being.

So, what can we do? This week’s action items:

*Support evidence-based positive childhood and youth development programs by volunteering, fundraising and donating, and advocating for policies that help sustain and expand them.

*Be a mentor – January is National Mentoring Month, and what better New Year’s Resolution can we make than to invest in the future by mentoring a child?

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

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(Note: this post is cross-posted at Occupy Healthcare.)

An op-ed in the New York Times last week described the United States’ disproportionate spending on healthcare in comparison to other social services that have an impact on health – a characteristic that puts us in the minority, as one of only three industrialized countries. The chart below shows the ratios of healthcare:social service spending in the U.S. vs. peer countries (for details on these numbers and information on which countries are included, check out the published study).

In addition, when considering the combined spending on health and social services, the U.S. no longer leads the pack (as it does when examining only healthcare spending) – in fact, we come in 10th of 30 OECD countries examined. Furthermore, the authors of the study found that infant mortality, life expectancy, and potential years of life lost outcomes were significantly worse in countries where health-care spending was high and social-service spending low.

As the authors note, “The implication of our findings is that, if improved population health is our goal, then the United States should be looking beyond the health-care system to achieve that goal. Current reforms—targeting medical care and health services only—are unlikely to deliver that result.”

Amen. So, let’s look beyond the healthcare system. Each Monday starting today, I’m going to kick off our week here at #occupyhealthcare examining something outside the healthcare system that has enormous implications for our health (i.e. social determinants of health). I’ll try to end each post with a practical step or two you can take to address the topic at hand.

This week, let’s talk urban planning.

The idea that where you live, learn, work, and play is a major – perhaps the major – factor influencing your health is a core principle of public health.  Place matters.

While this idea encompasses far more than just physical living space, physical living space is certainly a key component. Development decisions can affect our physical health (through walkability, green spaces, proximity to healthy foods, pollution caused by vehicular traffic), our emotional and mental health (length of commutes, spaces for social interaction) and societal well being (spaces for civic engagement, degree of segregation by race and income).

Many in the fields of urban planning and public health have come to this realization, epitomized by the smart growth movement, which holds among its principles:

*Mixed land uses

*Mixed income housing – providing a range of housing opportunities and  choices

*Taking advantage of compact building design

*Creating walkable neighborhoods

*Preserving open space, farmland, natural beauty, and critical environmental areas

*Fostering distinctive, attractive communities with a strong sense of place

*Providing a variety of transportation choices

*Encouraging community and stakeholder collaboration in development decisions

Imagine the potential benefits:

*Less segregation could lead to more equitable policies across communities, and ultimately more equitable health and wellness outcomes

*More walkability and green spaces could increase physical activity

*Providing a variety of transportation choices could minimize our reliance on motor vehicles, and the resulting pollution and sedentary lifestyle

*Attractive communities with a strong sense of place could make us happier and more connected, reducing rates of depression

The list goes on. Moreover, many of these benefits have already been demonstrated through research. It is clearly time for us – and the U.S. – to invest in smart growth for healthier, happier communities.

So, what can we do? Today’s practical step: encourage use of health impact assessments in your local community when any kind of development project is being discussed, and advocate for state and federal laws that mandate or incentivize HIAs. HIAs provide a way to assess the health impact of any policy (development or otherwise) and would likely reveal the positive impact of smart growth, and the detrimental impact of development projects that don’t take into account smart growth principles. Certainly, there are complexities and challenges involved in conducting HIAs, and it is important to make sure they are being conducted in useful, cost-effective ways – but that is a topic for another post! Despite the complexities, I think HIAs when done well provide a concrete way to start thinking about the specific ways in which any policy that impacts the places we live also impacts our health and well being – and hopefully provide the impetus to start not just thinking about, but acting upon the results.

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A couple weeks ago, President Obama proposed $3.5 billion in cuts to the federal Prevention and Public Health Fund as part of the President’s Plan for Economic Growth and Deficit Reduction.

And as the Prevention Institute alerted me to via e-mail, the Senate Appropriations Committee approved a bill on September 21st that “zeroed out funding for the CDC’s Youth Violence Prevention activities – suddenly and without input”.

The e-mail I received pointed out that elimination of this $19.7 million in funding would have a devastating impact on violence prevention efforts across the country and compromises decades of work.

I agree wholeheartedly. Even more frustrating though, is the fact that not only do these cuts to prevention and public health funding affect critical work, they go against the very purpose of these funding cuts, i.e. “economic growth and deficit reduction.”

Cutting prevention funding does NOT help the economy or the deficit. Whether it’s the Prevention and Public Health Fund, CDC’s Youth Violence Prevention efforts, or other funding streams, public health takes a systems level, upstream approach to preventing population-level health problems – this means a lot of public health efforts are targeted at things like helping people find jobs or gain a better education, and making neighborhoods safer and revitalizing communities. These things make our economic situation better, not worse.

As the Prevention Institute points out:

“Cutting prevention may seem to save a few dollars in the short run, but it will cost an enormous number of lives and money in the long run…Prevention shows a 5-to-1 return on investment. Cutting 3.5 billion in prevention would shut the door to as much as $20 billion in potential savings in health care costs in the future.”

And there are a lot of other cost savings too – keeping youth out of the criminal justice system, keeping community members gainfully employed, and more.

I understand that cuts need to be made, but let’s stay away from cutting things that are actually saving us money, shall we?

Pick up the phone, call your senators and representatives (I just did!), and try to make it to clear to politicians and the general public that prevention funding is not merely an expendable cost, but an investment – and one that is far more likely to pay off than pretty much any other.

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