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Archive for the ‘Determinants of Health’ 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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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 

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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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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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Note: This post is cross-posted at Occupy Healthcare – be sure to check out the other posts there, and check out #occupyhealthcare on twitter too, the movement is growing! 

In my last post, I wrote about the importance of occupying an array of fields that impact our country’s health. Lest this task seem too daunting to be accomplished, I thought I’d take a moment to highlight some success stories on this front.

Access to healthy foods is an important determinant of health and an important factor in health inequities. The Food Trust, a non-profit based out of Pennsylvania, is tackling this problem, aiming to make healthy food available to all. Among their many innovative projects is the Pennsylvania Fresh Food Financing Initiative, a grant and loan program to encourage supermarket development in underserved neighborhoods throughout the state, an idea that is now being replicated nationally. Some other creative developments in the field of nutrition and healthy food access: taking a page out of the junk and fast food industry’s book, with their billions spent on marketing, and branding baby carrots in a way that’s fun and exciting; and tapping into behavioral economics to redesign cafeteria lunch lines in a way that increases purchase of healthy foods and decreases purchase of unhealthy foods (an inexpensive and effective approach!).

Given that homicide and suicide are among the leading causes of death among those age 1 to 34, violence prevention is another key aspect of attaining the health our society deserves. Chicago-based CeaseFire combines research and street outreach to track violence, interrupt and intervene (with well-trained professionals from the communities they represent with a background on the streets), and engage in longer term risk reduction and behavior and norm change. Even more exciting – it’s working.

Neither access to healthy foods nor neighborhood safety – not to mention walkability, pollution-free environments, and a host of other things – is possible without intelligent and innovative urban planning. Thankfully, we have the likes of The Congress for the New Urbanism working to promote walkable, mixed-used neighborhood development, sustainable communities and healthier living conditions.

And while our national political discussion is so bogged down by discussions of whether to help low-income individuals and families that we haven’t had a conversation about how best to help them, organizations like the Family Independence Initiative, which was featured in the New York Times this past summer, are taking an approach radically different from our typical social service model, tapping into the strengths and support systems of low-income families, allowing them to determine their own paths and advance together. This too, has been shown to work.

Across all of these health-related issues, the media plays a role in shaping behaviors and norms, and Hollywood, Health, and Society is bridging two drastically separate sectors with its work to provide entertainment industry professionals with accurate, timely, and engaging information and case examples for health storylines, as well as study the content and impact of these storylines.

Of course, just because it’s not all about healthcare doesn’t mean healthcare isn’t at the table – healthcare providers can play just as important role in prevention and promotion as they do in treatment, and places like the Codman Square Health Center make that crystal clear. A community health center in one of the most impoverished areas of Boston, the Center provides a range of public health and community services (ranging from computer classes and financial help to fitness opportunities and hands-on cooking classes, not to mention youth services, civic engagement initiatives, and a close linkage with the Codman Square Academy charter school).

So, as daunting as the task of occupying for health seems, there are many people in many places doing amazing things. To quote the founder of the Codman Square Health Center: “We need to create integrated systems that promote community and health values. Like all change such cultural shift will take a generation or more to accomplish. But I am reminded of the story President John F. Kennedy told of the French leader who asked his gardener to plant a rare tree on his estate. ‘But the tree won’t bloom for 100 years’ the gardener said. The response: ‘In that case, plant it this afternoon.’”

So here’s to starting planting – and occupying. Cheers.

 

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Note: This post is cross-posted at Occupy Healthcare – check it out to read the comments posted there, as well as the rest of the occupy healthcare posts. 

Certainly, there is a need to occupy healthcare. Healthcare is essential, and the prevention and treatment that happens in clinics and hospitals, emergency rooms and community health centers, is integral to improving and saving lives.

Yet, while medical care is essential, it accounts for only an estimated 10-15% of preventable mortality in the U.S. The true causes of our country’s poor health outcomes and health inequities – and thereby the real solutions to improving health – are not rooted in the provision of healthcare.

They are rooted in communities: in sidewalks and parks, in access to healthy food and adequate housing, in clean air and safe neighborhoods.

What does this mean? It means that to alter health outcomes and inequities, we must go beyond occupying healthcare.

We must occupy the junk food and fast food industries, whose marketing power and lobbying power (leading to the maintenance of skewed agricultural subsidies) impact what we eat and what is available for us to eat.

We must occupy the criminal justice system. The U.S., with less than 5% of the world’s population, has almost 25% of its prisoners, the majority of whom arepeople of color, people with mental health issues and drug addiction, and people with low levels of educational attainment. This exacerbates poor health outcomes related to substance abuse and mental health; worsens health inequities by race, ethnicity, and socioeconomic status; and to boot, has done little if anything to make neighborhoods safer.

We must occupy zoning policies and construction and planning industries to improve inequities in access to healthy food, enhance safety and walkability, reduce unintentional injuries (which are the leading cause of morbidity and mortality among children in the U.S.), and reduce the excessive energy use and pollution that stems from our homes and buildings, as well as long commutes in personal motor vehicles (of which we have more in this country than licensed drivers).

We must occupy the welfare system, which focuses on services that – despite what are often good intentions – do not empower citizens, tap into their problem solving capacity, or enhance their ability to take collective action to better their communities, as John McKnight argues in an article entitled “Services are Bad for People”.

We must occupy the news and entertainment media. Whether it is news stories that inaccurately and dangerously link bullying directly to suicide in a way that can elevate suicide contagion risk by suggesting suicide is a natural response to bullying; fictional TV characters eating hordes of junk food day in and day out, without any consequences; or music videos that normalize gender-based violence, the media play an enormous role in our perceptions of what is “normal”, shaping our behaviors in a way that has significant impact on health outcomes.

The list goes on. Our health is determined more by where we live, work, and play – our physical and social surroundings – than anything else. And the list of institutions, industries, policies, and laws that unjustly impact these places and environments extends many miles, and spans many fields.

So, yes, we should occupy healthcare. But let’s not make the mistake of stopping there. There’s a lot more to be changed…revolutionized…occupied.

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