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/)


(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.

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.


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.

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.

The United States spends $60 billion each year on incarceration and has the highest incarceration rate in the world (due more to the length of sentences than the number of individuals incarcerated each year), as this New York Times article details. The only other major industrialized nation that even comes close to the U.S.’s rate is Russia, with others having much lower rates (1/5 the U.S.’s rate or lower). The U.S. has less than 5% of the world’s population but almost 25% of its prisoners, with 2.3 million criminals behind bars, more than any other nation. China is a distant second with 1.6 million people in prison.

And as this NAACP report points out, there’s a lot more to worry about:

–  The majority of the 2.3 million people incarcerated in U.S. prisons and jails are people of color, people with mental health issues and drug addiction, people with low levels of educational attainment, and people with a history of unemployment or underemployment. (According to a 2008 study, 1 in 100 U.S. adults of any age and 1 in 9 black men ages 20-34 are in prison).

–  The nation’s reliance on incarceration to respond to social and behavioral health issues is evidenced by the large numbers of people who are incarcerated for drug offences – nearly a quarter of all those incarcerated.  (And as mentioned here, in 1980, we had 41,000 drug offenders in prison; today we have more than 500,000, an increase of 1200%.)

– During the last two decades, state spending on prisons grew at six times the rate of state spending on higher education.  (And according to a Pew report, total state spending on corrections, the bulk of which is spent on prisons, quadrupled during the past 20 years, making it the second fastest growing area of state budgets, trailing only Medicaid.)

Even worse – much of what we do in terms of incarceration does not seem to be preventing crime, much less helping people escape the various vicious cycles that can lead to things like poverty, crime, substance abuse, poor education, poor health, etc. This can be seen not only in the recidivism rates mentioned above (with about 1 out of 4 American offenders ending up right back in prison within three years of release), but also limited drug offender effects,  negative impacts on family and community, and other issues detailed in this Sentencing Project report. Moreover, as the report goes on to say, “a variety of research demonstrates that investments in drug treatment, interventions with at-risk families, and school completion programs are more cost-effective than expanded incarceration as crime control measures.”

The call is echoed in editorials such as this one, written to describe a consensus reached in a Pennsylvania conference among prosecutors and defenders, victim advocates, prison reformers, and parole officers and judges. The consensus: the need for a change in the justice paradigm, from a system focused primarily on punishment to one emphasizing restorative practices. The editorial goes on to highlight a number of public health strategies as promising alternatives including therapies that address addictive behaviors and mental and emotional disorders.

And there have also been repeated calls to take some of the billions of dollars we spend on incarceration and put it toward education, one of the more recent calls coming from Gaye Tuchman, a University of Connecticut sociology professor, in one of this week’s New York Times Room for Debate articles about Rick Perry’s “plan” for a $10,000 B.A. degree – “New money for education has to come from somewhere,” Tuchman writes. “Why not a new kind of retrenchment: Cut back on imprisonment for some victimless crimes — like marijuana possession — and use the money for higher education. As The New York Times reported in February, arrests for marijuana use have been skyrocketing in New York City alone. Better to educate people than lock them up.”

And indeed better to educate and support high risk youth than lock them up. Let’s target youth in high risk communities (a la “hot spotters”) for intensive tutoring and mentoring support, provision of safe spaces, and more, providing them with role models and people and places to turn to when in distress or in need of help accessing various resources.

John F. Kennedy once said “children are the world’s most valuable resource and its best hope for the future” – let’s invest in this resource and nurture this hope, preventing our children from entering the criminal justice system in the first place.

At a conference on gang awareness and prevention that I attended last week, I heard folks from a local community service board speak about their work supporting youth in the community through in-school and after school programs. They showed video testimonials from some of the youth they worked with, and it was just amazing to hear these teens’ heartfelt words about the CSB personnel and the impact they had on these young people’s lives as tutors, mentors, role models, and trusted sources of support and advice. These were for the most part high-risk youth, growing up with a number of factors against them – poverty, unsafe neighborhoods, unstable family lives, constant exposure to drugs and alcohol, and more – making the impact of the CSB’s work even more valuable. One girl, breaking into tears, said that this group saved her life.

And it got me thinking…

In Atul Gawande’s New Yorker article “The Hot Spotters”, he talks about how medicine’s primary mechanisms of service, the doctor visit and the E.R. visit, are vastly inadequate for people with complex problems, comparing them to “arriving at a major construction project with nothing but a screwdriver and a crane.”

In some ways, I feel like the way we handle young people in this country is like that too. On one end, you have the regular public education system, which is fine for those of us lucky enough to have grown up in a stable family and neighborhood environment, with all our basic needs and much besides that met. On the other end, you have the highly punitive criminal justice system, which some would argue is necessary to keep dangerous youth off the streets.

I have many qualms about the latter point, but that notwithstanding, there’s still a major problem here: both systems are vastly inadequate for the vast majority of high risk youth in this country, who need one-on-one mentoring and support, consistent role models and safe spaces, etc. that organizations like the CSB I mentioned above provide. This could result in a much healthier, happier, better-educated population of youth that are far more likely to break through the cycles of poverty, substance abuse, etc. that often contribute to their behavior. Neither the traditional education system nor a punitive approach is going to the trick for these youth.

In addition to being punitive, the criminal justice system makes it incredibly hard for young people to get back to living happy, healthy lives – their criminal records make it hard to become gainfully employed and the system does very little to help address the root causes of criminal behavior, and provides little in the way of education or job skills. And as this recent Pew Report details, more than four out of 10 adult American offenders return to prison within three years of their release, suggesting that “the system designed to deter them from continued criminal behavior clearly is falling short”.

Gawande points out in “The Hot Spotters” that if we recruited staffs of primary-care doctors and nurses and social workers, based right in the neighborhoods where the costliest patients lived, staff expenses would be more than covered with the tens of millions of dollars in hospital bills that could be saved.

Similarly, if we recruited staffs of mentors, tutors, social workers, educators, and prevention specialists, based right in the neighborhoods where the highest risk youth lived, expenses would likely be more than covered by the money saved in criminal justice expenses.

Seems like an investment worth making, doesn’t it? If I haven’t convinced you yet, more on U.S. criminal justice statistics and ways to support youth coming in Part II!

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