Welcome

You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010

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Friday, December 31, 2010

Texting and Health Promotion Policy

Recently I’ve been reading research reports on the effects of cell phone use, particularly texting, on driving safety. Because of the rapid diffusion of cell phone technology and the practice of sending text messages, the research has been proliferating, but has not kept up with the diffusion wave.


The immediate reason for my interest in cell phone safety is that Kentucky has passed specific legislation prohibiting texting or e-mailing while driving for all ages, and prohibiting all driving cell phone use by those under age 19. The new rules went into effect summer, 2010; actual penalties begin January 1, 2011.

The rationale for Kentucky’s legislation and parallel bills around the country is that cell phones interfere with safe driving. In my searching I’ve discovered an obscure web site – http://www.distraction.gov/– maintained by the U.S. Department of Transportation. The larger issue is distracted driving, of which cell phone use is only one example. Distraction in driving can occur in three ways. Manual distraction is when a driver’s hands are doing something besides driving, such as using a phone, applying make-up, or interacting with a global positioning system. Visual distraction occurs when a driver is not looking at the road and surrounding traffic. This is a problem for most drivers when we look at things on the side of the road or inside the vehicle. Finally, cognitive distraction is the circumstance where drivers are thinking about something other than driving. Most drivers are unable to keep all of their brain power focused on driving, even if they are alone in the car. From the outline of types of distraction it is obvious that all drivers are distracted at times.

The forms of distraction come together in a perfect storm with texting. When a driver is conversing with a passenger, the distraction may only be cognitive, but not manual or visual. While all distraction increases risk for collisions, texting seems to present more danger than most other distractions, since it constitutes all three forms of distraction. The other factor that makes texting so concerning is that it is more frequently done by younger people, who have other characteristics that make them less safe as drivers.

Part of the reason many states are outlawing texting is that not only is it dangerous and worth trying to decrease if not eliminate, but the laws are effecting predominantly youth, who have very little political power and influence. If laws were to be directed more broadly at distracted driving, there would be more intense and more organized political opposition.

A final point is about the actual risk of driving while cell phoning. A lot of the research is done with driving simulators. Research subjects go through a series of typical driving challenges, with and without cell phone use. In general, these studies consistently show that drivers using phones perform more poorly, indicating higher risk for collisions. This science supports what most people would think intuitively. However, I wonder if it is more complex?

All cars come with radios, and operating and listening to a radio while driving is distracting from the task at hand. However, drivers also have collisions from fatigue and “highway hypnosis.” Those problems may be moderated by having a radio. If we compare perfect driving performance with radio-assisted driving, the perfect driving will have a lower collision rate. But if we compare real world driving with radio-assisted driving, the radio-accompanied driving may actually be better. It will be interesting to see in the future whether hands-free cell phone use actually has a safety benefit in real world driving.

At the present time we rely on public education to persuade people not to use cell phone functions while driving.  In addition, there is a growing body of policies trying to restrict and regulate drivers with cell phones.  It is too early to know what works and what doesn't.  Educational messages are fairly simple (Don't
!) so that makes communication easier.  However, cell phones and texting in cars have become ingrained in our culture, so this makes the behavior change process more challenging.  I think it will take a lot more people to have personal narratives about cell phone induced collisions before there is a critical mass of public credibility given to the issue.  As far as policy restrictions, support seems to be growing, but it is not clear yet what policies actually matter.

People are skeptical about enforcing cell phone with driving policies, and obviously that is a challenge.  However, that was and still is a concern regarding seat belt laws.  Forty years into the seat belt campaign, we still don't have universal compliance with the laws.  However, it is clear that the combination of educational messages and legal mandates have been effective in bringing seat belt habits to the level of a social norm, making our highways much safer than before.  We must work for that same outcome with drivers and cell phone use.

Monday, December 20, 2010

Mental Health and Public Policy

As I've discussed in earlier postings, health promotion applies tools to help individuals change their behavior, as well as applying tools to change communities and social circumstances to support and promote better health.  In recent years I've been persuaded that health policy is much more powerful than I've thought in the past, and probably more powerful, in general, than individual behavior change strategies.  There are lots of examples of the two prongs of health promotion with infectious diseases, chronic diseases, and injuries.  When we turn to mental illnesses, the picture is not so clear.

Mental illness can cause death, and in the case of suicide, about 30,000 in the U.S. per year.  Intentional violence can also be related to mental illness, but the mortality toll is less clear than with suicide.  Aside from those most severe manifestations of mental illness, the greatest concern is disability.  By some estimates, mental illness is the greatest cause of disability in the U.S., and probably also in most developed nations.  Surveys of mental illness estimate that in an average year, 30% of the adult population will have a mental disorder, including phobias, post traumatic stress, general anxiety, depression, and drug dependence.  More than half of cases are serious or moderate severity, though those classifications may be more art than science.  Nevertheless, something like one of every 17 adults will have a"seriously debilitating mental illness in a year's time.

Because of the population impact of mental disorders, they must be considered through the public health lens.  There has been interest in perfecting our ability to measure the nature and extent of mental disorders in communities, and to tease out the personal and social risk factors to guide interventions.  Unfortunately this research has not advanced to the point where there are simple recommendations for progress.  What I mean is, if you want to avoid lung cancer, try not to breath in smoke, particularly from cigarettes.  For most people that's all they need to know. 

For mental health, there are no simple guidelines. Physical and emotional conditions of early life certainly are important - if you have a choice, try to be born into a family with two parents present and emotionally engaged, middle class income, with an extended social network, including relatives, neighbors,  coaches, music instructors, and other supportive adults.  This statement is obvious, but also supported by research.  Our dilemma is how to assure that every child is chosen and every family is successful in its social mission of nurturing children.  We dable with this through public and private programs, but there is such a strong tradition of family independence in our culture that we frown on outside intervention, except in the most egregious cases, so that the safety net has lots of holes through which disadvantaged children fall.

A significant portion of health is socially determined, with correlations between a person's vitality and life expectancy and where they are located in society - physically, socially, and geographically.  Those on the bottom rungs of income, education and status typically will have the worst health, including mental health.  This is a self-feeding cycle, so that disadvantaged persons have the smallest chance of achieving the best health, and because of sickness and disability, are more challenged to move into higher levels of education and income.  Theoretically, this circumstance should be responsive to public policy tools and strategies, but as a society we have not made much progress in this regard.  We don't even agree on whether government has a stake, or whether individuals should be empowered only by market incentives.

Perhaps none of the above thoughts are new to most people.  I think it important to point out that mental health is to some extent a function of broad social policies.  If we believe that society and governments should seek to promote the best mental health possible for citizens, this will not take place unless we put in place policies which assure social conditions in which people can thrive in every way.  This will be a long, uphill climb.

Monday, December 13, 2010

Conservative Misunderstanding of Public Health

In some circles, the blame for our current troubles as a nation is all government, all the time.  The notion of government is synonymous with waste, fraud and abuse.  Every government employee, no matter how highly trained or hard working is reduced to "government bureaucrat."  There is also the widely held belief that government workers are more highly paid than private sector employees.  However, when factors such as education and experience are taken into account, it is not so clear that there is a disparity.  In fact, the pay disparity may be in the other direction - highly trained government employees are paid less than equivalent workers in private companies.  Since most of public health effort takes place in government, these attitudes and stereotypes matter.

Last week I had the privilege of interacting with a group of employees at the U.S. Centers for Disease Control.  I was there providing a training workshop, serving a group of about 50 civil servants in various specialties of public health.  I found them to be eager learners who are sincere about making an impact with their endeavors.  They were not unlike hundreds of public health workers I've either taught or otherwise associated with over the last three decades.  These are people who go to work every day, trying to contribute to the public welfare by decreasing tobacco exposure, diminishing community violence, protecting people against environmental toxins, and reducing the toll of infectious diseases.  At CDC as well as countless local and state public health settings, I have not found pikers sitting around trying to avoid real work until they can retire.

The facilities in which the training took place were not opulent, but in fact quite ordinary and basic.  That is also what I've found in hundreds of state and local public health offices and settings.  In fact, comparing my observations of these public sector facilities with my experiences in the private sector, such as in hospitals, insurance companies, and various corporations, the private sector sites have uniformly been better appointed, more spacious and well endowed.  While not all private facilities are luxurious either, it is just not true that public agencies are spendthrift for personnel or places of work.

Are there waste and abuse in government, including public health?  Most certainly.  Can you find public health workers who are unproductive, not serving the public good?  Without doubt.  But these things don't only occur in government.  There are workers in the private sector, including employees not in unions, who don't serve their employers well.  There is waste in every workplace, not just in government.  That is not to accept this as a good thing, but it is to reject the conservative narrative that fraud and abuse are unique to government. 

Public health agencies have a responsibility to be good stewards of the public's dollars.  Managers should expect evaluation of functions and accountability from employees.  This is good practice in every organization.  It is not hard to find examples of government services that are not very effective, and we need to always be trying to be better.  But, does anyone feel well served by insurance companies and banks?  Painting public health workers, as all government employees, as illegitimate is unfair, based on a lack of information.  There is the old expression, "What you're not up on, you're down on."  Because people don't understand public health, it makes an easy target.


And so I want to express my thanks to those mostly invisible public health workers who go about doing their jobs, trying to make healthier communities today and going forward into the future.  Those CDC professionals I met last week are a proxy for the public health workforce.  Many people don't know what they do, but those of us who do, must stand in their defense, with appreciation and support.

Thursday, December 9, 2010

Holiday Traditions and Social Change

As a preface to comments to follow, I want to make a full disclosure:  I really like eggnog, fruit cake (Yes, I do), many types of Christmas cookies, and look forward to sumptuous holiday meals.  Sometimes health promoters sound shrill and joyless.  THEY TAKE THE FUN OUT OF LIFE.  I don't believe that, but because we are often challenging people to stop doing things they enjoy, or start doing things they don't enjoy, it is easy to be the Grinch meets Scrooge.

Having set this stage, I also wonder why so many of our holiday traditions are not healthy?  By the way, I'm mostly thinking about the holiday cycle that starts in the U.S. at Thanksgiving and goes through New Year's Day, encompassing Hanukkah, Christmas, and Kwanzaa.  Other cultures and religions also have holidays, but I am less familiar with the health ramifications of, for example, Diwali or Ramadan.

In the U.S. and Western cultures, the "holidays" are marked with many social traditions, including special events, both religious and secular.  Our social definition of celebration usually includes eating too much, too rich, too often.  I challenge readers to visualize celebrating and merry making in ways that are truly health promoting.  Can you imagine sharing carrots to commemorate New Year's Eve?  How about the kids setting out a fresh pear for Santa?  Does a celebration have to be unhealthy?

The answer is that our culture, and maybe most cultures, have developed over hundreds and thousands of years, during which a variety of forces have come together to shape our traditions and our sense of what is fitting in a given situation.  So for example, culinary arts have developed to feature salt, fat, sugar, and alcohol - none of which are completely bad, but with typical culinary arts, the only thing important about food is to taste and look good.  Of course in the present day we have technology that enables more refined foods.  Up until the 20th century, it wasn't really possible to have a lot of high sugar foods, at holidays or any other time.

My point here is to illustrate that holiday food and drink customs and traditions are socially enmeshed.  They are driven by many factors, some not even conscious.  We can chip away at unhealthy practices by typical health promotion interventions, but to change the entire frame will require basic social change.  We can promote better understanding about how our holiday activities are related to over-all health, and illustrate some better options.  This is a common effort in many communities, but it doesn't have a huge impact because of the social background.

I won't say it is hopeless to think that the holidays could celebrate with health rather than unhealth, but it will be difficult.  On the other hand, there are examples of positive social change that led to health benefit.  I remember the time when it was customary for fathers to give cigars to their male family and friends at the birth of their children.  That custom has gone away, even though I have never heard of any direct efforts to discourage the practice.  Society has undergone basic underlying change with respect to our attitudes of what is appropriate regarding tobacco.  This profound change is possible with food, but it won't be simple or quick.

In the meantime, let's lift a glass to good health.

Friday, December 3, 2010

Health Information Overload

This week I attended a workshop to learn about EndNote, a software program designed to help with library research and citation management.  With EndNote you can search the world wide web for journal articles, books, and web-site based materials.  In the case of journal articles, those articles that are available electronically in full text can be downloaded onto your computer for future reference.  Once references are located, the software will capture the citation and incorporate it automatically into a new document, and will configure the citation into the reference style you are using, such as the American Psychological Association format; there is also a provision to automatically convert the reference style into the preference of hundreds of specific periodicals.  Truly an amazing tool.  My context is the memory of undergraduate days when we would spend a lot of time in the stacks of a library, writing notes and citations on index cards.  That sounds like the stone age by comparison.

As I was learning all the various functions of EndNote I was impressed again with the mind-boggling volume of intellectual material published every year.  Like all disciplines guided by science and research, health promotion tries to keep up with the latest consensus on effective practice.  That means being sure that we are promoting the most accurate health science information, but also that we are applying skills and techniques with the strongest evidence for effectiveness.  This is not new.  It is just that the volume of new information is expanding so quickly that few people can really keep up.  This is true for consumers, as well as front-line practitioners, and finally academics and researchers.  I spend at least half my workday in front of a computer, so that I have almost constant access to information sources.  I can't keep up, except in a few very narrow areas.  The pratitioners and consumers have almost no chance.

So what we have is a mixed blessing.  On the one hand, the accumulated knowledge is certainly far more than ever before, but the gap between what is actually known (somewhere, by someone) and what is put into practice by others is perhaps also greater than ever.  Since our capacity to learn is not growing, and the speed with which our brains can process information has not changed, solutions to this dilemma must come from the production and dissemination side.  EndNote is an example of something that can deliver more information faster and more efficiently, but I still have to find time to read those articles!

Somewhere in the future, we can hope there will be technological advances to couple our brain functions with new tools that can actually speed up the process of absorbing and synthesizing the flow of information.  Perhaps there is a way to break the mass of new information into new "cognition units," something other than traditional language-based words and sentences.  Maybe there will be ways to more efficiently filter the information that comes to us.  Professional journals are supposed to do that, but they are swamped by the tidal wave of scholarship being produced.  Magazines also serve a filter function, but the filtering used by the editors may be biased for commercial reasons.

For now, I have to live with the uneasiness that the graduates I proudly escort into careers will most likely fall farther and farther behind once they leave the university resources behind and have to function based on the tools they have and what seems right in the moment.  I'm hoping that the research enterprise will increasingly concentrate on dissemination, not just pumping out new science content information.  Perhaps social media will have a role in this, beyond the current focus on chatting about relationships and life's trivia.    There are giant leaps waiting to be taken.

Tuesday, November 30, 2010

Vitamin D and Public Health Communications

For a number of years health researchers and communicators have been suggesting that the population may be deficient in Vitamin D and calcium, and this not only is a concern for bone health, but also may have negative consequences on a number of important chronic diseases, such as heart disease, cancer, and diabetes. It has been suggested that the shortage is due to a decrease in milk consumption and growing caution about limiting sun exposure.

No reputable health information source has trumpeted loudly the benefits of taking supplements of calcium and Vitamin D, but there has been much media discussion by "experts" and consumer health advocates, and curious consumers could go to prominent health information websites (e.g. Mayo Clinic, National Institutes of Health) and get the idea that there probably is some benefit to increasing consumption of those two nutrients.  Those consumers would also have found inconsistencies regarding how much intake is recommended and how much is safe.  The U.S. Preventive Services Task Force, well respected as a guide to disease prevention efforts in clinical care has been silent regarding this issue, except in reference to osteoporosis.
 
This week, the Institute of Medicine has issued a report regarding the health claims and hazards of Vitamin D and calcium supplementation.  The Institute determined to thoroughly review the published literature on the topic and issue a report establishing, for now, the state of the science.  The work of the review was the responsibility of a committee of experts from reputable institutions in the U.S. and Canada.  Their findings were: 1) the only certain health benefit of calcium and Vitamin D supplements is to promote bone health; 2) most people are not deficient in these nutrients, and therefore don't need supplements.  Readers are encouraged to review the report to fill in the details.
 
My reason for writing about this is not to add anything to the Institute's work and report, but to consider the implications for public education and health promotion.  We live in a world of unbridled access to health information, some dependable, some not so much.  The profession of journalism seems to be on life-support and anyone (including bloggers!) can be an unfiltered source.  Consumers are covered with a nonstop stream of health-related ideas and are often unprepared to process and detect value.  Furthermore, their task becomes even more difficult when the experts disagree or change the recommendation.  They deal with communicators who have varying degrees of skill; the least effective communicators might be the most accurate and reliable sources, but how is the consumer to know?  I analyzed the Institute of Medicine report and note that the narrative tests at college junior year reading level, hardly suitable for the average consumer.  Finally, those of us living in the health promotion professional world accept the Institute of Medicine as eminently reliable;  the average consumer is much less likely to be impressed by that name.  They have learned that organizations frequently call themselves misleading names (see also, political campaign advocacy groups).
 
There is no question that the work of health promotion would be easier if the flow of information could be managed, but that is not possible, and also not fully desirable in a free and open society.  The problem that confronts us is how to help consumers sort the rubies from the rubbish, and to apply simple rules to assess a source and the specific health information content.  At the present time, no single source is the single go-to place for people to seek answers to health questions.  Significantly not included as the single source is the primary physician, because the practice of medicine in 2010 and going forward is not really hospitable to quality health counseling, and a single practitioner cannot be as fully informed as a large organization with abundant resources.
 
The combination of proliferating sources and the changing nature of health science means that a very important role for health promotion is helping people maneuver the communication environment.  We also have to help people understand that science-based guidance will change as the research machine does it's work.  Everyone's job is to try to find the most accurate advice and follow it until such time as there is a trustworthy indication to change.  There are no simple solutions, and this will not be done with perfect effectiveness.
 

Thursday, November 25, 2010

Thanksgiving Health


Part of me thinks talking about warm fuzzy gratitude as a constituent of health is trite and treacly.  Standard fare in human interest news stories this time of year is thanks to the troops serving overseas, in war and out.  The other theme is to present stories about homeless’ soup kitchens and Thanksgiving dinners for the poor, in counterpoint to those of us gorging on a Turkey Day meal, in preparation for a spending spree that starts the next day, Black Friday.

Are the soldiers’ sacrifices and relative wealth things that warrant our gratitude?  Absolutely!  Many Americans are really in the category of “haves”: good health, functional families and loving relationships, good housing and adequate incomes.  Taking time on Thanksgiving and every other day for meditation on these blessings is surely a balm for otherwise frazzled souls.  The Spanish translation for Thanksgiving is sometimes El dia de acciones de gracias – day of thankful actions.  With little basis in health science, I believe the combination of grateful thinking and motivated actions has benefits for mental and physical health.

My reservations about this stem from two points.  First, gratitude in most people comes in fits and starts.  There is a dose response of thankfulness: it seems that many of us are stuck in MORE, with occasional glances at ENOUGH.  With this reality, the occasional moments of grace, such as happen on Thanksgiving are welcome, but only go so far.

The other concern is the distribution of the sources of gratitude.  We are encouraged by religious leaders that thankfulness is a state of mind, not a reflection of our circumstances.  A lofty sentiment, but much easier for those with most favored social stations.  The easy platitudes about being thankful may be a defense mechanism with which we dismiss the raw injustice in our communities.

I’ve not heard anyone describe the epidemiology of blessings, but because there are winners and losers in the lottery of life, some people hare sicker and die younger.  While we luxuriate in the health promotion of quiet gratitude, our challenge is to change the social factors determining that so many have so few blessings.

Wednesday, November 24, 2010

Do Health Observances Promote Health?

For many years a unit of the federal government has provided a web site clearinghouse for special days, weeks, and months designated to commemorate particular health issues. The site is called the National Health Information Center and the list of events is called National Health Observances. For example, the first Monday in May is called Melanoma Monday, the 3rd week in March is National Poison Prevention Week, and February is American Heart Month.  The purpose of the health observances clearinghouse is to be a resource for health promotion professionals as well as journalists, pulling the observances all together in one place.  The purpose of the observances themselves is to highlight a particular health problem, enhancing public understanding and promoting public support for research.  Knowing that November is Lung Cancer Awareness Month might inspire a journalist to write a feature story on that topic, or for a health promoter to organize a local event coinciding with the national observance.

I understand that real journalists turn away from the list of health observances because the list is contrived, not real news.  The commemorations are entirely arbitrary with respect to scheduling; nothing unique happens in November regarding the nature and extent of lung cancer, though it is an important problem throughout the year.  The journalists also object because organizers sometimes use the observances as fund raising opportunities.  Because of financial entanglements, following the lead of a designated "month" runs the risk of compromising the objectivity that is an ethical benchmark for professional journalists.

So what is the value of the health observances?  Some of the events are sponsored by health organizations with a large national profile: the American Heart Association is the organizer behind National Heart Month.  For AHA and similar organizations, the health observance is just part of a year-long calendar of public education and fund raising.  They might use the February emphasis to reach out to media with press materials, but also might coordinate local community events.  While the national media campaign is conceptually done from 30,000 feet, the local events will enlist individual activists lending local credence to this cause.

Other events may be initiatives mounted by an individual or small group: December 5-11 is National Handwashing Awareness Week, an event promoted by the Henry the Hand Foundation, not exactly a household name.  For such an organization, the clearinghouse will actually bring people to their website, and might generate interest and engagement that would not occur without the health observance.

These events can play a minor role in health promotion.  The keys are that they must do more than disseminate information, and the information they do provide must be at a language level accessible to the public; that means at a reading grade level of 6-8.  In addition, the observances will have a greater impact if there are functions of the websites and of the campaigns that will engage people in more than just health information.  Community connections are essential to build momentum for these social marketing campaigns.  Energy is created through local advocate participation in raising money and staging awareness activities.

This is a very American quality to our health promotion efforts.  One of the up sides to the value our culture places on individualism is that people take initiative to  make their voices and pocketbooks be heard.  We don’t celebrate a “let the government go it” month.

Thursday, November 18, 2010

Secondhand Drinking?

Once it was recognized that tobacco smoke was harmful, it wasn't long before people connected the dots and began to worry that if a smoker was doing something harmful, then maybe it was harmful to breathe in smoke from someone else's cigarette.  The suspicion eventually was declared fact, and now it is thought that so-called "secondhand smoke" kills about 38,000 per year in the U.S.  Usually those hurt by secondhand or environmental tobacco smoke either live with one or more smokers or work where there is a lot of smoking going on.  Substantial harm doesn't come from fleeting occasional exposure, but risk goes up when exposure is prolonged and intense.

Ironically, the establishment of the reality of secondhand smoke damage may have been more powerful than public knowledge about the health effects of primary smoking.  Many smokers enjoyed smoking, even though they became aware of the damage done, but were willing to continue and take their chances.  There was an attitude that you have to die from something, so why not take a chance with something that fills a need in the smoker's life.

The social dynamics of secondhand smoke were entirely different.  Once it became common understanding that secondhand smoke was damaging to the health of others, that made smoking socially unacceptable  Whereas in the past, smoking was thought to be sophisticated and chic, the secondhand smoke awareness made smoking seem akin to belching in public; socially unacceptable.  Whereas no one used to ask "Do you mind if I smoke?" that was the question smokers always had to ask.  This developing social stigma was a powerful incentive for millions of smokers to make quit attempts.

This brings us to alcohol.   We have known for quite some time that for most people, the hazards of alcohol drinking can be portrayed with a U-shaped curve (see below).  For overall mortality, total abstainers have elevated risk compared to moderate drinkers, whereas drinking beyond a moderate level quickly drives mortality risk to rise dramatically.  While alcohol in small amounts has some protective value for heart disease, stroke and diabetes, rising consumption brings increased risk for liver disease, highway injury, neurological damage and seizures, alcohol-related violence and suicide and damage to unborn children.  There is a huge array of other social and personal problems that come to the individual drinking alcohol excessively.
In general, we have not seen the concept of "secondhand" applied to alcohol.  Remember in this context, secondhand would mean consequences harming third parties, incidental to their being in the presence of drinkers.  It is clear that the analogy is useful and legitimate.  People are harmed by abusive drinking by others.  Binge and heavy drinkers are responsible for injury and death to other drivers and pedestrians.  Many acts of violence and suicide, if not caused by alcohol, are committed under the influence of alcohol, which is clearly a contributing factor.  There is a lot of vandalism and property damage done by intoxicated drinkers; this includes damage related to motor vehicle accidents as well as intentional vandalism of private and public property.  Alcohol abuse on university campuses makes the living circumstances such that most people in middle class neighborhoods would not tolerate.  This includes vomiting in people's cars and in public places, rowdy behavior disturbing sleep and study time,  Finally, there is a substantial amount of sexual assaults committed by alcohol impaired persons.

Up until now, these secondhand alcohol effects have not generated a social stigma.  Especially on college campuses, this behavior is accepted as normal and acceptable.  It is possible to recognize this acceptance as a contributing factor making campuses a toxic social environment for alcohol abuse.  People drink this way because the consequences don't lead to social condemnation.

Secondhand alcohol effects are real, and effect millions of bystanders.  It remains a challenge for health promotion to design ways to martial the power of social support and social shame to mold people away from destructive alcohol drinking.  Failing that, we continue to rely on education campaigns and policies to limit the harm.  While educational programs have not shown much success, there are many policy solutions that could make a dent in primary and secondary alcohol exposure.  Examples include making alcohol more expensive with tax increases, putting limits on where alcohol may be purchased, registering the names of keg purchasers, to hold them accountable for abusive drinking which may occur after the purchase.  It will take time to build a social consensus to accept and establish policy solutions. Attitudes which accept secondhand alcohol effects as normal are the same ones which are barriers to policy solutions.

Alcohol is America's number one drug problem, perhaps because a lot of people really don't think it is a problem.

Wednesday, November 17, 2010

Warning about Cigarette Warning Labels

Recently there has been a lot of media attention regarding new tobacco warning labels proposed by the U.S. Food and Drug Administration.  The ads are graphic, large, and much more prominently placed on the cigarette packages.  Here is an example of one of the new labels:



This is an interesting story which has evolved over several decades.  For many years tobacco was categorized as an agricultural commodity, not a drug, and so federal jurisdiction came through the U.S. Department of Agriculture rather than the FDA.  Because of this arrangement, tobacco was supported as a crop, instead of being treated like the dangerous drug that it is.  Of course this was politically rigged by powerful tobacco supporters in the federal government. 

The tobacco companies resisted public pressure to post health warnings on their labels and advertising material on 1st Amendment Constitutional grounds:  U.S. citizens are not only guaranteed freedom to speak, they are guaranteed the right not to speak when particular speech harms their interest.  Tobacco companies in effect mocked the Constitution, by claiming the same rights as citizens and applying free speech protections for marketing a product killing millions of people.

Eventually, an ironic twist occurred when the cigarette companies decided that warning labels would provide them with liability protections.  The avalanche of liability suits was just beginning, in which people were claiming damages by the companies selling products causing people to be sick and die.  The companies could then point to the warning labels as a defense, saying that people were informed that cigarettes were harmful, and therefore the companies could not be blamed.  This argument got traction in the court system, so that very few of the liability suits resulted in awards being given to sick smokers.  While the labels provided legal shelter for the companies, in actuality, the labels had little impact on consumers.  The labels were relatively small and unobtrusive, and tended to fall into the background of all the other label material.  From a health promotion theory perspective, the warning labels were disconnected from other strategies designed to encourage smoking cessation.  The labels helped tobacco makers more than consumers.  This continued for many years.

Finally, in 2009, legislation passed giving the FDA authority to regulate tobacco products.  Here is a link for the so-called "Tobacco Control Act."  The provisions of the bill went into effect in June of this year, and the agency is just now working on the revised warning labels.  For more information about the proposed labels, click here.  While it is gratifying to see an aggressive effort to stop the dishonest marketing of cigarettes to the public, including kids, we need to be cautious about high expectations.  While the labels are eye catching and impressive in design, it is too early to know how prospective or current smokers will respond.  It is a rule of thumb that information alone is almost never enough to change health behavior.  Time will tell whether these new ads will be more impactful than the old ones.  I'm guardedly optimistic.

Tuesday, November 16, 2010

Diabetes Futures

When I was a health science student I remember learning about the old time practice of tasting urine to detect a fruity taste indicating diabetes. During that lecture green students would become green with nausea contemplating a bygone era incomprehensible in our modern sanitation sensitive world. We have come a long way in measuring and treating diabetes in more sophisticated ways.

While testing and treatment have advanced, the actual frequency of diabetes has continued to rise in dramatic fashion. Projections on the rise in diabetes are based on sophisticated statistical methods. While many people die from diabetes, many people with diabetes die from other things, meaning that our most complete measure of the population’s health, the death certificate, is not a valid measure of the overall prevalence of diabetes. Though diabetes can be a ravaging disease if not managed well, often people with diabetes die from other things. This can be either because the disease contributes to other chronic illnesses, like coronary heart disease, which become an immediate cause of death, or because improved treatment prolongs life enough for diabetes patients to succumb to unrelated diseases like cancer.

After death statistics, the next consideration is the number of people sick. We don’t do as well with nonfatal illness counting. We try to extract data from a very disconnected health care system. These efforts include the National Health Interview Survey, the Health and Nutrition Examination Survey, the Behavioral Risk Factor Surveillance System, the National Ambulatory Health Care Survey, and the National Diabetes Surveillance System. Diabetes is included in all of these data collection systems because it is such an important health problem, effecting one in ten adults (diagnosed). However, even with all these data sources, there is still an element of uncertainty: we don’t have a data system which captures the actual health care records for all people diagnosed with diabetes, and certainly not for the thousands of people undiagnosed.

With these caveats on the current extent of diabetes, there is now a projection that diabetes will increase from about 1 in 7 adults(diagnosed and undiagnosed) in 2010 to between 1 in 5 to as high as 1 in 3 by 2050. Several factors are attributed for the increase. First, the population is living longer, and more elderly life spans means more diabetes. Next, treatment is more effective, so that people with diabetes are living longer, inflating the sub-population with the disease. In addition, the groups in the population with higher rates, such as Hispanics and Pima Indians are growing at a rate faster than the general population. Finally, the increase in obesity in the population is directly related to the increasing diabetes prevalence, including the growing count of children and teenagers having what used to be called “adult-onset” diabetes.

The only reason to measure these trends is to guide plans to intervene. Are we doomed to a third of adults having to manage diabetes? Of course screening and treatment could improve, so that a higher proportion of diabetes patients can live otherwise normal lives. It might be that in the future, diabetes consequences will be less frequent, less severe: even though more people will have diabetes, there could be fewer people suffering diabetes blindness and amputations.

The current state of the art with diabetes health promotion leaves much room for improvement. For decades we’ve tried ways to help people follow diabetes-specific diets, practice healthy foot care, take medication correctly, and prevent diabetes-related damage through physical activity and weight management. This work will continue, but increasingly there will be a search for policy solutions which bypass the messy business of trying to change people’s behavior.

I've become convinced that the most promising frontier for diabetes prevention as with all health promotion, is the creation and establishment of policies which change the food and exercise environment.  There is much work to do to determine whether a given policy works, to navigate the political system to make it possible to apply the policy, and to do long term evaluation to be sure the policy is having the intended effect without undesirable unintended consequences.  Sometimes policies will be seen as antagonistic to free markets, but sometimes policies will give rise to entrepreneurial opportunities.  Long term sustaining of policies will be more assured if we can create a win for all involved.

Monday, November 15, 2010

Health Consequences of Elections

We have become accustomed to warning labels on many commodities: health advisories on tobacco and alcohol, safety labels on many consumer products, and signage in rental cars reminding us about the danger of driving without a seat belt. Perhaps we should have warning labels on election ballots: Caution – Your candidate selection may be hazardous to your health. Now that the elections of two weeks ago are over, I’d like to reflect on what the campaigns and the results mean for health promotion, and talk about the dangers that may be ahead.

Certainly in all the elections there were some purely local issues. However, aside from the many local issues, perhaps the biggest campaign issues which seemed to turn the election were job creation and Obamacare. Both of these have implications for health promotion. Employment is impacted by health in both directions. Health is an important prerequisite for a job, and full employment is one of the most basic ways to promote good health in society. It is clear that the nation’s health status did not cause the current recession and unemployment crisis, nor will health programs contribute much to digging us out of the economic hole in which we find ourselves.

On the other hand, if we can really think about the future and not just the next business cycle, health and continuing prosperity are inextricably linked. There is great concern about the disconnect between educational performance and readiness for technical jobs of the 21st century. Certainly in disadvantaged segments of communities, malnourished kids or kids struggling with asthma are not able to be as successful in school as they might otherwise be. In addition, as our workforce gets older and the retirement system squeezes workers to stay on the job a few years longer than was common in the recent past, it will be important to help those older workers maintain wellness levels as high as possible.

The Patient Protection and Affordable Care Act of 2010 (Obamacare) is obviously a health issue, front and center. Some of the most angry rhetoric and ugly campaign ads were directed at this so-called “massive government takeover” of the “best health care system in the world. Perhaps some of the partisans actually believe that charge, but forgive me for being cynical. We have government control of most of the education system, police and fire services, the Postal Service, and libraries; government assuming these functions has not ended life as we know it. Furthermore, Medicare is an entirely government health care system, and most people think it works quite well in providing good care in a cost-effective way. Health care reform is mostly designed to help the 15% of the population with little or no access to the system now, while people with health insurance may see little if any change. When it comes to the relative quality of our health care system, compared to other nations, we don’t stack up very well. The claim that we have the best health care system in the world may be true for some consumers, but is not an accurate picture of what most people experience. A harsh reality that the opposing politicians don’t want to recognize is that even people with good insurance now may be only one serious illness away from medical bankruptcy, or at least losing their coverage. For people with good employer-provided health insurance, what would happen if they were sick enough that they could no longer perform their job. Once they lose the job, health insurance goes with it. This is a risk to a majority of citizens, not just those with no health insurance now.

The health care reform legislation passed earlier in the year includes three basic components. First, no one can be excluded from insurance coverage because of pre-existing conditions. Next, people have to be in the system; people will be required to buy health insurance if they are not already in one of the government programs (Medicare, Medicaid, Veterans’ Health Care). The only way health reform will work without dramatically increasing cost is to include everyone, including those young and healthy in the risk pool. The third component is a system to pay for all the new people brought in the system, including incentives for small businesses to provide coverage for workers. The system, which will be phased in over a number of years, represents a dramatic change in public policy, broadening the safety net so that everyone is assured a floor level of health care. While change is hard for people to accept, the current system of health care doesn’t seem worthy of fighting for, unless you are one of the few people well served as a fortunate consumer or a well-compensated provider. Those two categories are shrinking unless we accept the challenge to mold the system to one that will serve all the people.

The completed elections brought in a large number of people who are opposed to progressive change, with the belief that the free market is always better than anything organized by government. The next few months and years will be a battle to see which ideas about change prevail.

Thursday, November 11, 2010

Preempting Health

Many years ago I was associated with a tobacco control coalition in a local Kentucky community. Among all the things we wanted to do was pass a local ordinance banning smoking in public places. We were told that state law didn’t permit such an ordinance because tobacco legislation at the state level precluded tobacco related legislation by cities and counties in the State. This illustrates the concept of preemption (pronounced pre-emption).

Preemption is often the bane of health-related policy. It is inserted into legislation or regulations, at the federal or state level, to prevent independent rules being put in place at a lower level of government. Most often, preemptive language is inserted into government policies during “back room” negotiations. Often these dealings represent corruption in which special interests manipulate the democratic process for their own benefit.

Why do corporations or organized industries seek to preempt policy making at the state or local level? Usually it is because such policies have a real or imagined harmful effect on business activities. Lobbyists for industries often believe that it is easier to bring about preemption with a relatively weak rule at a higher level, rather than having to deal with all the entities at the lower level.

In the case of my tobacco experience, the tobacco companies were convinced that public smoking restrictions would hurt their profits. Of course they couldn’t say this publicly and expect a very sympathetic response from communities, so they would disguise their real motives by talking about job losses and the problems caused if every community had different rules regarding public smoking. As an aside, both of those arguments have been shown to be bogus.

Our first step was to build support for challenging preemption at the state level. There was a campaign to get individuals to sign petitions, demanding that state government change the preemption restriction. At the same time, local governments were asked to pass resolutions, establishing the principle that cities and counties should be able to determine their own rules for public smoking.

Ultimately is was determined that the specific tobacco preemption language was not consistent with the Kentucky state constitution. This created a legal pathway for local smoking ordinances. Since that time there has been a steady stream of communities deciding that banning public smoking is right for them. Currently about half the State’s population is covered by a smoke-free ordinance, though a minority of local jurisdictions has enacted such ordinances. Public smoking bans are opposed for a number of reasons, but eliminating preemption language in the state statute has made it possible for advocates on both sides to work through the democratic process.

Whether the issue is local regulation of smoking, school food service rules, community jurisdiction over large hog farms (called concentrated animal feeding operations), or many other issues, preemption is a barrier to good public health and is rarely in the public’s interest.

On an interesting final note, Kentucky right now is seriously considering a state-wide ban on public smoking. That this is being considered is a stunning turn of events in a State where, not that long ago, tobacco was a sacred cow, health concerns be damned. I don’t know who the powerful players are behind the scenes, and why they think it is time for a state-wide ordinance, but for sure, tobacco control advocates will be looking for any preemption language, to be sure that local communities don’t lose their democratic rights of self determination.

Sunday, November 7, 2010

Seasonal Health

Yesterday I was on a stretch of highway on which I frequently drive, and noticed a lot of road kill, much more than normal, it seemed.  I began to wonder if there might be an explanation.  Is there something about mid-fall that might bring more animals out crossing roads?  Are animals more restless due to a change in mating behavior, or has the food supply changed, requiring them to range farther to find enough to eat?  Maybe animals are slower moving in cold weather, making it harder for them to avoid a vehicle crossing their paths.  Of course it could be that the night weather was foggy, cutting down on driver visibility enough to put more animals at risk.  At least one more possibility occurring to me was that there may have been more traffic on the road, either because of some event occurring in the area, or perhaps there was something happening in trade and commerce, such as trucks delivering goods as stores gear up for holiday sales.  What we need to answer these questions is a veterninary epidemiologist.

I don't know if there is such a field, but human epidemiologists have taught us the factors related to human injury and deaths on our roads, and there are seasonal patterns.  You will expect to see more highway accidents in winter months, because road conditions tend to be worse.  On the other hand, the rate of bicycle and motorcycle accidents goes up in the summer months because there are more riders in warm weather, fewer in the winter.  One study found more child pedestrian accidents in summer, perhaps because children are more likely to be out in warm weather, but more adult pedestrian injuries, in winter.  This last observation is harder to explain.

There are seasonal variations with many other health concerns.  For example, colds and flu spike in the late fall and winter months, but generally are lowest in incidence in the summer months. The explanation is that as weather turns colder, indoor air quality declines.  People spend more time indoors in close quarters with others.  Heating systems dry out skin and mucous membrane barriers, making people more vulnerable to those types of infections.

Violent death and injury increase in the summer, presumably because heat is a stressor, and people are involved in more social interactions for potential conflict.  In the winter people tend to cocoon more, with less social contact.  With youth, summer represents more unsupervised time, providing opportunities for trouble.

Allergies usually spike in the spring and summer, because of the plant constituents in the air, and people spending more time out-of-doors.

In far northern or southern regions that experience extremes of frigid conditions, we expect to see seasonal variations in cold-related illness and injury.  Likewise, there are seasonal variations in heat stroke and exhaustion.

Cardiovascular disease also increases in the winter, with several reasons suggested.  Smoking and secondhand smoke exposure increase in winter months.  People are more sedentary, and body weight tends to increase in the winter.  In addition, it is proposed that because of reduced sun exposure, Vitamin D levels drop, having an impact on cardiovascular system dynamics, including an increased cholesterol level.  Finally,  cold temperatures impact the components of blood, particularly the tendency of blood to clot.

As is apparent from the various types of seasonal patterns in health, causes are a combination of biology, ecology, social organization and behaviors related to annual events and cycles.  As far as we know, wild animals are oblivious to these changing risks, and are incapable of taking timely precautions.  Humans on the other hand can learn from these patterns, applying appropriate steps to avoid things putting them at higher risk.  While there are seasonal variations that effect us in this way, there should not be seasonal variation in intelligence and thoughtfulness about it.

Thursday, November 4, 2010

The Pursuit of Happiness

One of the most famous phrases from the stirring U.S. Declaration of Independence(1776) is "the pursuit of happiness," cited as an unalienable or natural right which cannot be taken away by any legitimate government.  The obvious implication is that happiness is something people not only should have, but should be able to acquire more.  This raises questions about human beliefs, and is related to health behavior.  Some persons think of happiness in a passive sense - either you have it or you don't, not something over which we have control.  Other people are much more confident in their ability to create happiness, to control the things that bring about happiness. 

This contrast is also found in health promotion.  Some individuals and social groups think about health and disease with indifference and submission.  Not that they don't want good health, but they feel powerless to play any role in assuring it.  To the extent people feel health is determined by luck, the devine, or the demonic, they will be less inclined to a self-activated approach to health promotion.

Today we would reflexively say people have a right to the pursuit of health, but in the sensibility of 1776, people had almost no basis for being proactive about health.  It would be about 175 years before the epidemiologists would give us guidance for health promoting life habits.

To come full circle, happiness is becoming more recognized as a component of health, and to many people something which can be cultivated with practice.  The catch is how.  While there is an emerging field of research called happiness studies, there is not really what might be called "best practice" or established principles.  If you Google "improving happiness" you  will get a huge number of sites which usually describe their advice as "tips."  That is code for "These might be helpful and just seem like good common sense."  You will find things like organize your life better, get more sleep, slow down, spend time with good friends..... You get the idea.  No one will argue with these suggestions, but they are hardly definitive.  Imagine if you went to your physician, and all she could offer were tips of a general nature, but nothing specific with a proven record of effectiveness?  We expect that about medical care, and we should expect it about health promotion practice.

The problem is that our understanding of what makes for happiness is incomplete.  For example, we reject the notion that money can buy happiness, but surely to some extent it can support conditions in which happiness is easier to come by.  Is it realistic to think that a person who sleeps under bridges just needs to think optimistic thoughts in order to be happy?  And how is it possible that someone with severe disabilities can still be happy in their life?  And yet there are.

Here are a few things that come closer to being science-based.  Happiness requires a healthy brain, which is promoted by good sleep habits, good nutrition, exercise, and caution with things brain-toxic like too much alcohol.  Eye health requires changing field of vision - too much unvaried focus, such as extended reading or screen viewing is not good for the eys, which need the opportunity to have a distant focus from time to time.  In the same way, brain health is probably not as well promoted by constant imersion in the same job or task, but will do better with changing attention.  This is like taking a brain vacation every day, and sometimes for longer periods.  Social support from family and friend relationships is also an important building block of happiness.

One way to promote happiness, though I admit not established in science, is reminding ourselves about the good people and good things around us.  I hear an awful lot of whining from people, in many circumstances, and not enough gratitude.  "I can't get no satisfaction" has become the national song of Americans.

In the future we should look for more and more definitive principles of happiness science.  In the meantime, think happy thoughts.

Tuesday, November 2, 2010

The Worst Drug

This week I came across a news review of a report published in the British medical journal, The Lancet.  The report was about an effort to rank the harmfulness of 20 commonly abused drugs.  Rankings were done by 15 experts on drug addiction, policy and toxicity, all from Great Britain.  They used a complex scoring system which considered physical and psychological harms to the individual user as well as harm to society at large.  The number of users in British society was part of the calculation.  The findings of the project caught the attention of news organizations because we are programmed by the drug warriors to think of cocaine, heroin and methamphetamine as the worst drugs.  Instead these experts determined that alcohol was the most harmful drug.  Here are the rankings:


The upshot of the report is that government policies which categorize drugs for the severity of restrictions have limited connection to the actual harm caused by specific drugs.  For example, Ecstasy and LSD are highly restricted and regulated, though not very harmful, while alcohol, the most harmful drug, is restricted hardly at all.

In the U.S. we have a parallel circumstance.  In 1970, the U.S. Congress passed the Controlled Substances Act, which created categories, called schedules, of drugs according to their potential for harm, their addictive risk, and whether or not there are legitimate medical uses.  For a good cure for insomnia, try this link for details on the Act.  You may need a stimulant to get through the text of the Act.  Since the original passage, there has been debate regarding the validity of the placement of various drugs.  For example, Schedule I, defined as the group of most dangerous drugs, includes heroin, but also marijuana and LSD.  While there is no argument that heroin addiction is a destructive lifestyle and a blight on the communities in which addicts live, the case can be made that use of heroin is made much more harmful because of well-intentioned government policies.  Today, it is hard to find an expert voice who will say that marijuana is a particularly harmful drug.  Notably absent from the schedules of the Controlled Substances Act are alcohol and tobacco, which at the time, were not considered drugs by most people, including members of Congress.

In my view, the findings of the British experts are paralleled in the U.S.  Our greatest drug problem is alcohol.  Tobacco kills about five times as many people as alcohol, but smokers live entirely normal lives until about 25 years in they get life-threatening chronic illnesses like cancer, heart disease and chronic obstructive lung disease.  There are almost no social harms caused by tobacco, and in fact, there are social benefits in employment and trade.  Alcohol doesn't kill as many people, but destroys the user's life once consumption passes the moderate level of drinking.  This leads to serious and worsening health problems, loss of employment, family turmoil and breakup, domestic and public violence, highway accidents, homelessness, poverty, huge productivity losses and treatment costs.  To be fair, alcohol has some medical and social benefits.  The evidence is strong that moderate alcohol use, particularly with wine, has medical benefits, though this fact does not mean that everyone should drink.  In addition, alcohol has social benefits in employment, trade, and tax revenues.

The fact that alcohol is used by two thirds of adults, and that there are some health and social benefits, makes health promotion messages and policies complicated.  Health communication directed at the public doesn't incorporate nuance well.  Effective communication needs to be direct and unequivocal, and for this and other reasons, we struggle as a nation to educate and influence to find benefits from no more than moderate consumption while trying to block all the destruction alcohol can do.

We are soon going to face this with marijuana as well.  The momentum behind legalization of that drug seems to be gaining speed and strength in states and local communities.  The challenge will be to build up public precaution about the potential hazards without blocking the real or imagined benefits.

Sunday, October 31, 2010

Voting for Health Promotion

At this time of year, maybe this year more than ever, the fever of electioneering is way hot.  There is a lot about our political campaigns that one could lament, but there is a core value that gives many people pride.  In the U.S. we do have a voice in determining what kind of community and nation we have.  Is there too much power held by special interests?  For sure.  Is there too much money spent on political and media campaigns by people with hidden agendas?  Absolutely.  Is it frustrating that political leaders seem to spend more time getting re-elected and less time working together to solve problems? Without a doubt.  However, there is no evidence that any other system is better, and most other places are clearly worse.  And by the way, the private sector is not so hot either: consider banks, coal and petroleum companies, health insurance corporations.

People have opinions and positions on many issues.  For people interested in health promotion, there are many health issues that either are or should be represented on election days.  In other words, for the issues we think are important, it may be that some candidates are more likely to take action to advance a particular policy.  This year there are a number of health-related issues that are being discussed by candidates, though there are many more issues important to health promotion that have not gained enough traction with the public to attract any attention by candidates.

One of the more common health issues debated is climate change.  In spite of people who believe climate change is either a total myth or at least "unsettled science," it is a slowly worsening problem that needs to be addressed sooner rather than later.  Once you find a candidate who believes the threat from climate change is real, then you've got to find one willing to risk jobs in the coal and petroleum industries, also willing to invest government funds in advancing the supply of alternative energy sources of fuel.  On some days it seems like the deniers are winning that debate and the American public seems to care about nothing but jobs.  It is hard to find a candidate willing to stand up to this barrage of opposition.  Profiles in courage are few.

The other huge issue in health policy getting discussed and debated by candidates is the health care reform bill passed by Congress last spring.  Many untruths have been told about the legislation, and since the opposition has spent the last six months shouting how it is going to ruin the nation's health care system, it is no surprise that people don't support the bill.  Of course if you ask people about specific provisions of the health care reform bill, large majorities support what the bill actually will do.  Nevertheless, even candidates who voted for the bill either don't cite it as an accomplishment in their campaign, or simply say it is a start which will need much more work in the future.  Of course about half of all federal candidates running say they will do all they can to repeal the bill.  It is not at all clear what these opponents are defending, considering all the problems in our current system.

There are many other more localized bills and policy proposals being debated in state and local elections.  In California, there is an effort to legalized marijuana.  Immigration reform has implications for health, both in terms of the way immigrants are treated but also how immigration policy will impact the distribution of wealth in the country.  Abortion is less of an issue in general, though many candidates will state their position to increase their support from various constituencies.

While still a small slice of the electorate, the libertarian banner seems more vocal and influential than in past years.  This is a mixed bag for health promotion.  Libertarians want to get rid of as much government as possible, and allow the capitalist market to create solutions to community problems.  They might say that the government should not be providing influenza vaccination, but should get out of the way so that the private system can efficiently fill this need.  Libertarians would generally oppose government regulation unless it is required to protect against immediate threat. For example, they would support a government imposed highway speed limit, but would oppose a public smoking ban in restaurants and other workplaces.  They would certainly oppose a ban on trans fat in the food industry, but would rely on educated consumers to mold the practices of the food industry.  On the other hand, libertarians would also oppose drug laws, and many people, not just libertarians, are being persuaded toward that view.  In general, it is hard to reconcile a hard libertarian view with public health, that believes government policy should be used as a force to improve life and health for all in our communities.

The challenge with voting with an eye toward health promotion is that candidates who are consistently true to health promotion values are rare.  Of course as a voter, it is generally better to be holistic in scrutinizing a candidate, not basing support on a single issue.   However, often you will find a candidate promising to support one health promotion idea or policy while disavowing support for another.  This is compounded by the difficulty of learning about a large field of candidates in multiple races.  In Kentucky this Tuesday, the average voter will be choosing candidates in 30-40 races at the local, state and federal level.  There are not many people going into a voting booth who really are well informed about all those office holder wannabees.

Our political system does give us wonderful opportunities to participate in deciding our future, including the formation of a sounder basis for a healthy population.  However, while these rights can be romanticized, exercising them can be bewildering.  At the same time, developing and advocating health promotion policy solutions is also very challenging.  Together they are even more confounding.

Nevertheless, good candidates who support health promotion initiatives are frequently elected.  There is good justification for health promotion advocates being optimistic, but it is an essential character trait for those who make this their business.

Friday, October 29, 2010

Election Day and Healthy Halloween

This time of year we frequently see health and safety advice related to Halloween: 1) too much sugar promotes obesity; 2) sticky candy risks cavities while hard candy can break teeth or braces; 3) caution about unusual looking candy that may be poisoned; 4) pedestrian hazards when costumed children are out in the street; 5) knife injury risk from pumpkin carving; 6) adult alcohol abuse encouraged by beverage makers using Halloween-themed marketing.  All these are legitimate concerns which are addressed by health promotion advocates in different venues.

This year local, state and federal general elections come just two days after Halloween.  While the annual holiday is always October 31, Election Day is on the first Tuesday of November, some years as late as November 7.  For this reason, it is unusual for there to be so little separation between the two days, and such intense competition for the attention of the public.  It is hard to miss the comparison.

The election is like Halloween in a number of ways.  The holiday is about deception, with people presenting themselves as someone or something they are not.  So are the election campaigns.  Halloween generates spending and stimulates the economy.  So do the elections, with billions of dollars of campaign spending.  Halloween tries to scare people, such as with ghosts, vampires and pirates.  Elections scare people with the ugly, hateful things candidates say about each other.

In addition to the general comparisons, the health concerns of Halloween also apply to the elections.  Some campaign candy is dangerous because the promises may prove to be toxic.  Just like the holiday candy is very appealing but has no nutritional value, many of the campaign ads and promises are empty of ideas and careful thinking.  Just like trick-or-treaters are sometimes hit by big vehicles in the street, many times worthy ideas and genuine leadership are run over by big campaign budgets from special interests.  Finally, just as people may be injured while cutting out a jack-o-lantern, candidates and campaigns must suffer soul scars from the destructive words and actions they hear about themselves and say about others.

What I'm talking about is not really health promotion, though a significant part of health promotion takes place in the political system of which elections are an important part.  We rely on these leaders to craft and support important health policies, after surviving the very sordid affairs elections have become.

Both Halloween and elections as currently conducted are detrimental to health.  This generation of kids will survive another round of trick-or-treating and America will survive another election cycle.  However, it is hard to not believe that health promotion is in order for both.

Wednesday, October 27, 2010

Healthy in a Hurry Revisited

During the summer I blogged about food deserts and talked about one solution being tested: using corner or convenience stores to provide access to fruits and vegetables.  This entails a public private partnership in which the store owner makes space for selling fresh produce and posting signage in and outside the store, to promote purchases of these healthy foods by consumers. On the public side, city government 1) provides management consultation to help the store owner get up to speed regarding the handling and sale of perishable produce; 2) assists with establishing a delivery chain to be sure shelf or bin space is continually replenished; 3) supplies low interest financing to offset the costs of store modification; 4) provides local communications and marketing support to build a customer base for the new foods.  The test in Louisville is called Healthy in a Hurry; so far two locations have been established with more being planned.  Photos linked here will give readers better understanding of this concept.

I serve on a team to evaluate the effectiveness of the corner store concept.  We have quickly learned that the enterprise is very complex.  We have considered a number of questions directly related to the operation of Healthy in a Hurry, but also more basic questions about food deserts.  For example, while it is true that low income residents in disadvantaged urban neighborhoods don't have stores selling fresh, high quality produce, and that these residents typically eat unhealthy diets, are those two facts related?  Are the poor diets determined by poor access, or does low consumer demand, as a first cause, provide a market in which full-service grocery stores cannot be successful?  Because we are sold on the value of healthy eating, we assume that if healthy foods are made available in the food desert, so that people are able to make healthy choices, they will.  In the real world, this may not be the case.  Access is a critical resource, but also important are peoples' motivations, decision making, values, and so forth, as well as social norms and interpersonal support for buying and preparing meals with fresh fruits and vegetables.  The evaluation team is discussing ways to obtain answers to some of these questions, but the task at hand is to look for the operation and success of the Healthy in a Hurry stores.

Immediate issues for the stores are the junction between the range of produce sold and the consumer demands of the surrounding neighborhoods.  Those people more favored by life's lottery are accustomed to buying and preparing a wide range of fresh fruits and vegetables.  They have had opportunities to be exposed to many fresh products that might be rarely part of inner city diets.  Some examples are asparagus, egg plant, apricots, and cherry tomatoes.  While a full service grocery store has a large enough customer base that someone will buy anything stocked, in one of these convenience stores, it is more critical to know what people in the neighborhood will actually buy.  A related question is How much can that consumer demand be changed?  Can we, as outsiders, influence the local residents to value and purchase new products not part of their traditional diets?  The answer is a very guarded yes.  Consumer behavior can be changed, but rarely is it a quick process.  In the case of the Healthy in a Hurry project, time is of the essence.  Unless people begin to buy these healthy food choices, the effort is not sustainable and the produce sections will go away, without long term government subsidy.

Other things are being done to enhance the diets of inner city residents.  The public schools are reducing the sugar, fat and salt content of their menus, and expanding the availability of fresh fruits and vegetables.  At the same time, they have begun to limit the selling of junk food from vending machines and school fund-raisers.  In Louisville, there is an effort to support and encourage community gardens: public property on which people can plant small garden plots.  The idea is that anything grown in a garden not only helps family budgets go farther, but usually will be healthier foods than things purchased in packages and cans.

Another strategy which is becoming more and more common is to organize and provide space for urban farmers' markets.  This is a way to bring fresh produce into urban neighborhoods.  Logistical problems include mechanisms to enable the use of credit cards and food stamps for market purchases.  In general, farmers' market fare is more expensive than produce sold in a bog box retail store, though quality is often better.  Nevertheless, price differentials between the farmers' market and a grocery store will be an issue for low income families.

Both of these strategies (community gardens, farmers' markets) are being promoted in Louisville, and many other communities around the U.S.  We don't yet have good data on who participates and how these might actually improve the nutritional status of disadvantaged Americans.

As an innovation, Healthy in a Hurry is an exciting concept.  We need to learn much more about how it contributes to health in the inner city, and how to make these stores the most effective. 

Monday, October 25, 2010

Celebrity Chef or Lunchbox Health

In the days when I was attending grade school, I carried a lunch to school every day.  The preferred container at that time was a metal lunch box, fashioned in basic shapes and colors, sometimes with graphics portraying animals, cars, or other objects attractive to kids.  Lunch boxes were gender specific in color and design, but marketers had not yet made the connection between TV or movies and a whole range of unrelated products.  I don't remember lunch boxes with designs from the Disney children's movies of that time.

On the inside of the lunch box was a lunch made by my mother.  Evey day the menu was different.  Many days I didn't know what the lunch contained until lunch period.  Just like students universally compare test scores, we always compared lunches.  The conversation went something like this: "What did you get for lunch?" "I got PB&J."  "I got cottage cheese and tomato."  (gestures indicating gagging.) "Do you want to swap?  I'll give you my sandwich and some chips for your PB&J."  And so it went.  Sometimes a classmate would forget her lunch.  The class and the teacher would usually find enough remnants so that all would be fed.

There was undoubtedly some inequity.  Some students had smaller, less nutritious lunches.  Some students had extras that others didn't.  In those days, nutritious mostly meant vitamins, minerals, and protein.  No one worried much about sugar, fat, or salt, and people believed a healthy lunch should include whole milk.

Two things stand out about this school lunch memory from decades ago. Aside from the merits or deficits of lunch on any given day, this represented a connection between home and school, student and parent. The medium was the message, and it certainly carried some health promotion value. The second point is that even though my mother or father were fixing one lunch for me, sometimes I didn't like what I found at lunchtime, and foods were thrown away. Fast forward to the time when most kids eat lunches prepared by a cafeteria team, and it becomes clear how challenging it is to serve up healthy meals that children will eat. 

Even as early as the end of my grade school days, school lunch boxes were going away, replaced by backpack pouches.  However, the shift from home-made lunches to school lunches is parallel to society's shift from home cooked meals to restaurant meals.  School lunches represent kids "eating out," just like adults do more and more often.  There are lots of reasons for this social change, but health promotion is not one of them.

The other day I read about an effort in the New York City schools to bring successful chefs from local restaurants into the management team responsible for school lunches. The idea is to make small steps in transforming the cafeteria menus from tater tots and chicken nuggets to something more like culinary arts.  It is an intriguing idea to see if those most expert in making food look beautiful and taste even better can work within the economic limits of school budgets and meet the logistical challenges of trying to please about 1.2 million children in the system.  The key question is whether the chefs can add value to menus, so that kids will eat more healthy foods.  Up until recently, schools have relied on sugar, salt, and fat to entice students to patronize the school cafeteria offerings.  Time will tell if the chefs can blaze a trail to prepare fruits, vegetables, and low fat protein foods that don't come in cans, and in a way that fits within the school lunch budgets.

School meals have become a tool for several community goals.  They have become an important component of farm commodity stabilization, linking farm production with the stable market of school meals, facilitated by government supervision and tax subsidies.  Of course, school meals are now an important way to be sure that all children have sufficient nutrients to enable them to succeed in school.  School lunches are also viewed as a component of the school health program:  the cafeteria as a nutrition and health classroom.  There is a fond hope, without much evidence, that it is more efficient to instill healthy eating values in school lunch rooms, rather than trying to change the eating and food preparation practices of parents and families.

It is probably not possible to return to the days of the lunch box, with the values it represented.  That train has left the station.  However, trying to mold children at school to seek out healthy meals probably won't really take hold without support from parents who have gotten the health promotion memo.  Just like schools can be helped by the chef consultants, parents and families may need assistance in assembling healthy lunches, with whatever container is in vogue.  Realistically, eating out has become a basic component of our society.  Doing it less in school or in the community will not occur easily.

Friday, October 22, 2010

Staying the Health Promotion Course

Once upon a time in the 1980s, public concern about drug abuse prevention was at a fever pitch.  The issue got heavy attention in media.  Political leaders, including Presidents spoke about it.  Corporations wanted press coverage for charitable gifts made to drug abuse prevention efforts.  Grass roots efforts in local communities proliferated to confront the "menace of drug abuse."  With all this attention and support, serious government resources flowed to programs and policy strategies.  While success was not proportionate to the size of the effort, progress was made.

Today, drug abuse has largely disappeared from the popular radar screen.  There is little if any discussion of drug abuse in political campaigns.  If there are news stories about it, they get a yawn or a change-the-channel reflex.  What we don't know is whether this lack of focus and determination will lead to a resumption of the drug epidemic.  There is reason to be concerned.

We have seen this with vaccination.  In the 1950s and 60s, the public had firsthand knowledge of infectious epidemics.  The ambient fear and respect for childhood infections translated into widespread support for vaccinating children.  The new vaccines were welcomed as wonder drugs.

As the decades have passed since then, a lot of apathy has set in.  Parents today have no memory of children severely sick and disabled from infections of early life.  This has given rise to apathy when it comes to getting children immunized.  At the same time, some parents believe, without any evidence, that vaccination is a cause of autism.  In addition, birthing has seen a relative shift away from mainstream to low income minorities and particularly Hispanic families.  This presents access and health literacy barriers to vaccination, making the job more complicated.  Nevertheless, there is reason to be concerned that as a society we take our eyes off this particular ball, allowing rates of measles, mumps, pertussis and polio to rise again.

To an extent we are seeing this happen with a shift of attention away from tobacco toward obesity prevention.  It feels like our commitment to tobacco control is running out of steam.  While overweight and obesity is a very serious problem, tobacco is still with us, taking over 1,000 U.S. lives a day.  We should be concerned that society may be losing interest, and will pay a price of increased smoking rather than pushing a continuing decline.

So then, the key question is how do we in public health prolong the attention span?  How do we keep individuals, institutions and government agencies focused on a health promotion task when it is no longer exciting in the public's eye?  How do we break the cycle of fits and starts, always moving on to
 the next big thing?

I don't have the final answer, but offer two things to consider.  The first has to do with insisting on strategic planning driven by community needs, rather than funding opportunities.  Public health agencies are often seduced into designing programs because funding is available.  This gives rise to a cycle of always moving on, whether or not a job has really been completed, which of course, it usually has not.

Recently, a lot of federal stimulus money has been invested in community health programs around the country.  Communities were invited to compete for these funds.  It was not a coincidence that the ending date for the health projects is spring, 2012.  The initiation and success of these projects are part of the strategy for the 2012 Presidential campaign.  Campaign strategists want to be able to point to successful stimulus spending.  This point is not to fault the projects, but to say that beginning with funding opportunities is not always the same as beginning with local health priority needs.

The second way to help break the cycle is to rely more on theory-driven, evidence-based strategies and solutions, and to constantly fine tune our interventions with careful evaluation.  Some of the reason for losing interest is because the things we do are not effective, so people become demoralized and give up.  Demanding more connection between research and program planning, and relentless attempts to find more effective methods might keep people engaged and inspired for the long haul.

In the end, we are talking about human nature and social evolution that we have few tools to manage.  Nevertheless, it is health promotion's burden to keep people striving until the work is done, not before.

Tuesday, October 19, 2010

Health on a Plane

Some years ago there was a film that became a byword for tasteless, mindless movies: Snakes on a Plane.  I managed to miss the experience of fears being exploited.  It there were snakes or something else menacing people within the confines of an airplane, people would feel particularly vulnerable and defenseless, being unable to escape.

Recently I was on a flight across the country, and began to think about the health threats to airline travelers.  It is a modest list.  Obviously, people are not dropping like flies, but concerns are real, and a huge segment of the population, the traveling public, is effected.

So what should travelers worry about?  Coincidentally, the first thing to worry about is worry.  For all but the most seasoned travelers, the airport and airplane experience is stressful, starting with getting to the airport on time, finding a place to park, getting through security, finding the correct gate, discovering that someone else is sitting in your seat and there is no room in the overhead bins for your bag, getting your blood pressure down when the plane is delayed for 73 minutes, waiting on the tarmac for takeoff while the backlog of planes is cleared, sitting in a cramped seat in front of a crying baby, next to someone who gets up a lot to go to the bathroom, finding that when you arrived, your bags did not......Are you stressed out yet?  In the current economic environment, airlines are trying to squeeze out as much inefficiency as possible; human comfort and tranquility do not have places in the systems modeling equations.

Perhaps the next thing is hand hygiene.  Certainly in flu season, one of the most important precautions is to keep your hands clean and away from your face, nose, and mouth.  Airplane hand hygiene is difficult because, in spite of the ad slogan - "You now are free to move about the cabin," people find it not so easy to wash hands.  Most people prefer to stay in their seats unless a trip to the bathroom is unavoidable.  Once security measures were scaled back to permit up to 4 oz. of liquid to be brought through check points, it became possible to carry and use hand sanitizer.  I have not noticed many people using hand sanitizers on planes, but this should become a social norm in the future.  It may be a mixed blessing that airplane food is going away: people will have fewer chances to eat with unwashed hands.

Closely related to hand hygiene is air quality.  On an airliner carrying 150 or more people, it is certain that someone has a cold or flu, and their coughing and sneezing puts at risk, passengers and crew alike.  If protecting health was the only concern, we would have seating in three zones: business class, coach, and sick bay.  While the public's health might benefit, it is hard to see how the airlines gain.  If you are sitting near someone who is sneezing and coughing, you can ask to be moved to another seat if the plane is not full.  You could also have the foresight to carry a surgical mask, putting it on when infection risk goes up.  In other words, there are no reliably good options.  Upper respiratory infection is a risk of commercial flying, not unlike going to work, school, church, or parties.  This risk is unavoidable, with the the backup of flu vaccine for the most severe URI threat.

Another risk is orthopedic problems, from carrying, dragging, and lifting heavy bags.  People could learn to travel lighter, and this would help.  On the other hand, the airlines' recent policy of charging for bag checking probably means that more people have carry on luggage, requiring them to move bags longer and to lift more weight.

There are a few more hazards.  People prone to blood clotting in the legs may have trouble from sitting on long flights.  Mobility is harder on planes than at home or work.  Another risk is the food choices.  We'll know society has shifted when flight attendants come down the aisle with baskets of fresh fruit.  Finally, some people suffer from headaches precipitated by altitude-related pressure changes.

What can be done about all these threats?  Maybe whoever said, "If man was intended to fly, God would have given him wings!" was right?  More realistically, we realize that risk-free living is impossible and perhaps undesirable.  Be prudent when you can.

Most of the problems outlined above are diminished or avoided entirely by train transportation, more on long distance trains, less on commuter trains.  When you can, ride the rails - for your health and the Earth's as well.