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


Monday, August 30, 2010

Health Promotion and Harm Reduction

It happens in almost every city and town in the country: a woman stands up in a small meeting on a Tuesday night and says, “Hi, I’m Lisa and I’m an alcoholic.” AA meetings are part of the community woof and warp, woven together with Little League and Fire Department fund raisers. As traditional as the existence and format of an AA meeting is the fact that a big chunk of Lisa’s audience is smokers. Because of the anonymous nature of AA membership, there are no readily available data on who goes to AA, how many attend, and of course, what is their success regarding controlling alcohol abuse.

Nevertheless, is it conventional wisdom that a very large segment of AA members smoke cigarettes; typical meetings are smoke-filled. The purist health promoter wants to get these individuals to stop both abusive drinking and smoking. However, a more measured attitude is that cigarettes do little harm except serious illness and death beginning in middle age, while alcohol ruins everything: family, employment, health, safety, moral decision making, financial security, and self respect. This perspective believes that if people can control drinking they have dodged a nuclear explosion to the bullet of cigarettes. They would leave a concern for smoking to another day. First things first.

This certainly does illustrate, however, that many people, not just alcoholics, struggle mightily with quitting smoking. Fifty years into the international anti-tobacco campaign we still have 45 million U.S. smokers. This in spite of heart-to-heart advice from physicians, public media campaigns, package and advertising warning messages, local ordinances banning smoking in places open to the public, the dissemination of many tools for quitting, such as nicotine replacement skin patches, and dramatically increased price. All of this to no avail for all these millions of addicts.

So here is the question. What should be our approach to all those millions who are truly addicted to nicotine, and in spite of their best efforts, are unable to break their habit? There are basically two answers. The first is to continue to encourage, to provide new opportunities and new resources, provide more social support, teach quitting skills, and keep reinforcing the importance of stopping smoking. There is always hope that the next quitting attempt will be successful. This approach is certainly in the mainstream of health promotion, and is the one endorsed by organizations like the American Cancer Society and the National Cancer Institute.

The second approach is to ask, if we can’t get the person to quit smoking, is there a way to reduce the health risks they face? The answer is yes, though the alternative is quite controversial. Cigarette smokers are addicted to nicotine. The drug from any source will feed the smoker’s addiction. Cigarettes are familiar and provide a drug dosage which will satisfy the habit of most smokers. On the other hand, people could also obtain nicotine from smokeless tobacco. There are some health advocates who believe that providing smokeless tobacco as a stop gap measure, until such time as the person is able to break the nicotine addiction fully, is a much safer alternative to smoking. While I subscribe to that approach, it is certainly health promotion heresy for many people.

We have told everyone for decades that all tobacco-cigarettes, chewing tobacco, snuff, and cigars are hazardous to health, and that there is no safe tobacco consumption. All of this is correct. However, the various forms of tobacco are not equally hazardous. It turns out that cigarettes are many times more deadly than smokeless tobacco. The risk of smokeless is not zero, but it is far, far less than smoking cigarettes. Therefore, if a smoker can supply their nicotine habit with smokeless, that is a positive step. To discourage that step, giving the person only the option of continued smoking when they can’t quit entirely, is not a health promoting message. Of course over the long run it is still a worthwhile goal to eventually get rid of all tobacco, but until that time comes, people are much safer with smokeless than with cigarette tobacco.

There is one huge chink in the armor of this logic, and that is, What will the tobacco companies do with a health promotion endorsement? We have seen big tobacco trade on the false health claims of filters and low tar cigarettes. They are not to be trusted. It is one thing to offer smokeless hope to a confirmed smoker. It is another to publicly broadcast health claims about these products. Related to this issue is how do we prevent the tobacco companies from slyly though ingeniously marketing these products to kids? If you don’t think this will happen, you are smoking something else.

We are faced with a dilemma. I believe offering smokeless tobacco is a health promotion tool for many severely addicted smokers. This substitution for cigarettes will benefit those smokers and society-at-large. However, I don’t want to see smokeless marketed to teens or even for adults to add smokeless on top of cigarettes. We don’t really know how to negotiate this treacherous territory, but if the regulatory challenges can be solved, this is a way to significantly decrease the human toll of tobacco in our communities.

Friday, August 27, 2010

The Health of the Earth

My daughter completed a degree in culinary arts, and a big part of that degree is learning to be a chef.  When I watch her cook I notice that foods tend to be heavily salted, more than we would normally do.  Of course, it has to be sea salt because the flavor is better to a trained tongue.  The focus of culinary arts cooking is taste and appearance.  Everything else is secondary, including health.

There is a Biblical metaphor "salt of the earth," in reference to something bringing joy, hope, and encouragement to life, in the same way that salt could add excitement and enhance the pleasure of food.  The expression was born at a time when 99.99% of people ate very plain food, with none of what we call additives, and most people lived day to day, right on the edge of hunger.  Their challenge would have been getting enough calories and protein, not cutting down on fat, salt and sugar.

Today we have this thing called health: it ruins everythinig!  It used to be said "Eat, drink, and be merry for tomorrow we die."  Now it is eat healthier today so you will live to the next day or the day after that.  All of this is hyperbole, of course, but there is a grain of truth.  Health promotion often tries to get people to do things that are not, at least at first, pleasant.  Exercise is an example.  Other times we try to get people to stop doing things that they enjoy, like eating too much salt.

Earlier this year, the U.S. Institute of Medicine issued a call for Americans to decrease their salt consumption.  It seems that almost one third of adults have clinical high blood pressure (HBP), while 20% of those with HBP don't know it.  Prevalence increases with age, so that by the time we are 65, about 2/3 of us have HBP.  What does this have to do with salt?

A number of years ago, one of my students analyzed data from what is called the National Health and Nutrition Examination Survey.  This is a national collection of data on the health and diets of a large sample of Americans.  My student found that those who ate a lot of salt were no more likely to have HBP than people who ate moderate or small amounts.  In other words, salt was not a primary cause of HBP.  So why is the IOM trying to decrease salt for everyone?

While salt in the diet may not be a primary cause of HBP, it certainly elevates blood pressure among people who have the disease of HBP.  For people with this illness, salt in the diet leads to increased salt in the blood stream.  A high concentration of blood sodium promotes osmosis of fluids from surrounding tissues into the blood.  More fluid increases pressure inside the arteries.  HBP is an important risk factor for heart attacks, strokes, kidney failure, and blindness - all serious threats to life and health.

The IOM wants to decrease salt for all Americans because 1) HBP is extremely common and extremely serious; 2) low salt diets would benefit those who go for months and years not knowing they have HBP; 3) when someone with a new diagnosis of HBP is asked to eat a low salt diet, it is a difficult and radical change for most people.  If we could all get used to less salt, dietary change would be much easier for the third of us who will develop HBP.  The challenge is to work with the food industry and human motivation to wean ourselves from high sodium diets.

A lot of times, health promotion advice is received as bad news.  Our challenge is for health to be salt of the earth: a desired way to life.

Thursday, August 26, 2010

Medicine to Public Health: A Bridge Not Too Far

Some aspects of the health enterprise are purely related to clinical care for existing medical conditions. Other activities are obviously traditional disease prevention and health promotion. In between is a grey area where activities have roots in both clinical care and public health. This trichotomy is related to the concept of prevention.
There is a hierarchy of prevention that presents the levels of primary, secondary, and tertiary. Primary includes measures we take as individuals or as a community to avoid sickness or injury. Careful hand washing in flu season and fluoridating drinking water are two examples. Tertiary prevention is clinical care – not really prevention at all, except to the extent it prevents serious consequences if clinical care is not provided. Surgically removing intestinal polyps or skin lesions is often effective in preventing life- threatening cancers.

Secondary prevention bridges the gap between medicine and public health. It consists mostly of early diagnosis through screening. This is prevention because it seeks to find health problems at the earliest stage possible in order to block progression and additional damage. It is public health because screening tends to be made available to all, not as indicated by diagnostic processes. It is public health because it uses public media and marketing to proactively recruit people, in contrast to clinical care initiated by people feeling sick. On the other hand, screening is often done by clinicians, and positive test results should be brought to the attention of an appropriate health care provider for further evaluation. This activity then is based on an important partnership between public health and medicine.

Another dimension of the partnership is trying to deal with health professional shortage areas. A federal agency with jurisdiction has recognized and inventoried shortage areas for physicians, dentists, and psychologists/mental health therapists. Shortage is based on the ratio between the number of professionals in each category per population, using criteria of the estimated maximum number of people who can be served by one professional. It is possible for a community to be defined as a shortage area for one of the health professions while having adequate numbers of one of the others. Shortage areas are usually rural, but can also be inner city neighborhoods with a lack of services.

There is an infrastructure to deal with this problem in most U.S. states. The federal government funds agencies called Area Health Education Centers. Their purpose is to 1) persuade and support youth from underserved areas to get training and return to serve their home communities; 2) recruit health professional students to consider practicing in an underserved area: 3) provide various types of technical and administrative support to make practice in shortage areas more viable and attractive. These efforts, which have been going on for over 20 years, have found no easy fixes.

There are many barriers to this work. Areas with shortages of professional health workers often have other deficiencies, such as low educational quality, so that the talent pool may be smaller than in more advantaged communities. In addition, recruiting someone to a rural community is challenging. In the words of the WWI song, “How you gonna keep them down on the farm, after they’ve seen Paree?” Practitioners trained with an abundance of resources don’t relish no-frills practice in rural communities. In addition, most people train in urban institutions and come to appreciate the social, recreational and cultural advantages that will largely be absent in a rural community.

Rural areas often have death rates higher than for comparable conditions in more resource-rich communities. Health problems that don’t come to anyone’s attention except by pain and severe symptoms often will have a much poorer outcome. The Area Health Education Centers are important parts of the public health system, trying to strengthen the infrastructure so that secondary prevention can take place.

Wednesday, August 25, 2010

Healthy Exercise in the States

Earlier this year, the U.S. Centers for Disease Control published a document called “State Indicator Report on Physical Activity, 2010. I know, it sounds like a real page turner, doesn’t it. Ok, I’ll admit that, but the report had some interesting statistics on variations in measures of exercise and physical activity infrastructure among the states. In the following chart, you will see the extremes: those states with the highest proportion of adults with no leisure time exercise, lead by Mississippi, and those states with the lowest proportion, lead by Minnesota. This is irrelevant to health professionals with a clinical perspective, because if you have a patient or client who is not getting exercise, it would be an individual challenge to find ways to get her to be more active.

In public health and health promotion, the big patterns matter. The “active” states do much better than the national average, while the group of “inactive” states does far worse. Notice that sedentary adults in Mississippi outnumber those in Minnesota by almost two to one. Why should this be true? The reasons are many, but might give us clues to how to bring activity levels in more sedentary states to the levels found in the more active states, and to do it through community rather than individual processes.

The first thing you should understand about the chart is that the percents are not adjusted for gender, age, or race and ethnicity. In one sense that doesn’t matter. If you have about 1/3 of adults in your state or community not exercising, it doesn’t matter whether they are red, yellow, black, white, young, old, female or transgendered, it is still a problem. On the other hand, if the percent of the population in one state consists of 20% over the age of 65 while in another state that percent is only 11%, the comparison would be considered misleading. These populations are very different. It might turn out that if you compared physical activity by age group in each of the states, those percents could be very comparable. This is a technical point of no interest to anyone unless you are designing health promotion solutions.

Another point to make is that the sedentary states tend to be rural, poor, or both, whereas the more active states tend to be more urban and affluent. The rural dimension is surprising, but it turns out that people living in the country often are quite sedentary. Remember that most people living in rural communities are not farmers or farm workers, but instead work in small businesses servicing the farms or general retail, such as Wal-Mart. Other rural residents are employed by local government and the school system. Often there isn’t much else. These communities usually don’t have a lot of convenient places for people to be active. Most people drive everywhere because typical destinations are not nearby. Roads are not designed for pedestrians: they have no shoulders or sidewalks, and often visibility threatens safety. Finally, these communities usually don’t have public or private fitness facilities.

The CDC state report also looked at resources to facilitate more active lifestyles. Two of the measures were the percent of census tracts within 1) ½ mile of a park and 2) ½ mile of a fitness center. Once again there was a wide range. Some states, such as California, Connecticut, Maryland and Massachusetts, are very well endowed with these resources, while others, such as Mississippi, Montana, and North Dakota, have very few. When you look at the entire list, it looks very much like blue states versus red states. This is very political, and I don’t want this blog to be about partisan politics. However, the point is that those states (usually politically blue) which believe in public investment in things like parks and fitness centers, tend to have a more active population, while those states (usually politically red) which resist public investments like those, tend to have more sedentary citizens.

Pay now or pay later.

Tuesday, August 24, 2010

What Is Public Health?

This week the semester starts, and the first class for the graduate students in public health takes place.  The primary agenda for the course is to help them understand the concept of public health.  It is difficult for students and others not immersed in public health because they have no academic exposure to the discipline prior to college and maybe not even until they enter a graduate program.  Furthermore, most people have only limited contact with the public health system, so their perspective will be very limited.  It is like the old fable about the three blind men who were asked to describe an elephant: each one described the elephant by the part of the elephant they were touching, but were not able to explain the full proportions.

Whereas clinical health care does tremendous good in the world, removing pain and helping people recover from illnesses minor to severe, public health is more concerned with measures to avoid those problems in the first place.  Like most human activities, both systems can point to astonishing accomplishments while also acknowledging stubborn barriers to achieving full potential.  All of us know people successfully treated in the 21st century who would not have survived their ailments a few decades ago.  On the other hand, we also know people who would have much better health if there was an open door to the system for them.

Public health can also point to lots of great success.  For example, what have been called Ten Great Public Health Achievements   Based on the ideas of public health and what is theoretically possible, we have high hopes of moving the nation and the world forward to better health and quality of life for all people. The following video gives just a small glimpse of that optimism. 
Healthiest Nation in One Generation

On the other hand, there are challenges to reaching the potential of the public health enterprise.  Perhaps the greatest one is a lack of appreciation for its potential among the public.  For example, in the U.S. we spend over $2 trillion on health and medical care, but only 4-5% of that is for public health and prevention.  We tend to make sure people have access to the most acute care for the most seriously ill, but don't assure that people have access to the primary care and preventive services which would go so much farther to keep the population well.

Another problem we face is a better trained workforce.  The march of progress has continued in public health just like every other field of interest.  We know more than ever what is best practice and what is best to be left behind.  In clinical care, there is a problem with this as well, but because of the economic incentives linked to good care versus bad care, health care institutions have business reasons to invest in training and upgrading of the workforce.  Because public health is mostly government sponsored, and because there are very limited economic incentives to reward more competent practice, we have lagged far behind.  In local public health departments small and large, there are people who do amazing work but many others who are really handicapped by deficient and out dated skills.

Another problem hampering the full potential of public health, particularly now, is the political climate.  Public health advances the proposition that there is a WE, not just ME and MINE.  It says that together we can take steps to benefit all, as opposed to the view that for society to improve, everyone should have the right to promote their own welfare, without being hampered by "the nanny state," imposing various kinds of restrictions.  Some of this battle will play out in the elections of this and the next couple of years.  A small example of this is taking place in Louisville.  For many years the local school system has bused children to schools other than the one closest to them for the sake of racial and ethnic diversity.  Recognizing that housing patterns are historically very segregated, it was believed that the community would be better served by trying to make schools more cross-cultural than they would be if the schools simply reflected the discrimination built into neighborhood patterns.  Many people believe that this has a profound impact on health conditions and status, as educational success and social development are some of the most powerful determinants of health.  In the last couple of years there has been loud and assertive opposition to the whole notion of busing:  It is about ME and MINE, not US.

I'm always excited about introducing a new crop of students to these issues, and look forward to seeing them accepting the challenge of making a small difference for a healthier generation.

Monday, August 23, 2010

When Performance Enhancing Health is not Enough

This week America’s pastime was sullied yet again as pitching superstar Roger Clemens was indicted for lying to Congress about his use of performance enhancing drugs (PEDs). “The Rocket” joins a growing clubhouse of superstars similarly accused: Lance Armstrong, Barry Bonds, Marion Jones, Floyd Landis, Mark McGwire, Alex Rodriguez, Sammy Sosa, and many others less well known. Some of these have admitted use while others are contesting the charges. In all cases, the infraction of actual use is compounded by lying to the government, sports officials, and the public.

There is a bigger context in which to place all these individual cases, and it is the way we think about drugs in our society. We are decidedly ambivalent. Our better angels are opposed to non-medical or recreational drug use, with the exception of tobacco and alcohol. Our evil twins use illicit drugs by the millions. We are mildly pleased that schools and the government are trying to keep drugs away from kids, but we want our own drugs when we want them, or we remember when we used to use drugs, and it just didn’t seem like such a big deal.

It is interesting that the ramparts against drug use, while still standing, look far less imposing than they once did. Many states are reconsidering marijuana laws and the idea of drug decriminalization is not dismissed as beyond the pale. In contrast, drug use in the sports world seems to be as forbidden as ever. The sports leagues and regulatory bodies like the International Olympic Committee have consistently drawn a line on the playing field. Though testing and detection are not perfect, there have been no signs of giving up this part of the war on drugs.

The addictive properties of illicit drugs are that they either provide a high of energetic stimulation, lifting the user above daily doldrums, or they cover up emotional pain, shame, and broken dreams. It is an axiom that drugs having a quicker onset of effects and also a more rapid wearing off of effects tend to be more addictive than drugs more slow to act and dissipate. All of this is an interaction between specific drug effects, individual vulnerability, and social circumstances around users. For some people, the compelling reinforcement of drug effects will swamp all the normal values of mainstream life: family, employment, caring for health, building wealth, morality, and so forth.

Sports drugs usually are about promoting strength, power, and speed, not any fleeting mood change. It is not correct to use the word addiction with the PEDs. Saying that the guilty players are addicted to winning and crowd adulation doesn’t seem plausible. Players who are not competitive would not reach professional or the highest levels of amateur sports. The drive to win at all costs is a social pathology almost universal, if not for all individuals, in every nation and culture.

The case can be made that drugs are just another type of technology. New technologies, such as shoe construction, athletic clothing fabrics, and the weight and balance of baseball bats all help players perform better and set records unthinkable in the past. However, people oppose PEDs because they give players an unfair advantage and make record-breaking performances suspect. Mark McGwire’s 70 home run season, and Barry Bonds 73 home run season will never be given Hall of Fame merit because there is the suspicion that they were only possible with help from drugs. But, the same can be said about golfers driving a ball 400 yards. Would that be possible without the latest technologies of ball design and club construction? Of course, the drug-enhanced athletes knowingly break the rules: they cheat, and therefore deserve sanctions. However, the basis for those rules is not clear.

We say drugs are bad, but the medical hazards of PEDs are not well established. There are lots of unsubstantiated anecdotes about cancer and other health problems, but research ethics will never approve a clinical trial in which athletes are randomly placed in either a treatment group receiving PEDs or a control group doing just normal diet and training. The only real medical reason for the anti-PED rules is that they might be harmful. With at least hundreds if not thousands of athletes using PEDs, there is no apparent epidemic of sickness among them. Although professional athletes are adults, and therefore should be free to make an informed choice for themselves, a competitive sports environment requires either all or none will use. Furthermore, we would not expect that children and youth are able to make an informed choice based on the evidence, and because the athletes are so high profile, their drug use would be a role model society is not ready to accept.

Given society’s reverence for sports “heroes,” this problem is not likely to go away. The attitudes among spectators and athletes are so basic to who we are that change is not going to be influenced by a prevention program. The cat and mouse game between hungry athletes, unscrupulous trainers and sports officials must therefore continue, trying to minimize cheating as much as possible.

Sunday, August 22, 2010

Texting to Good Health

Recently the Metro Health Department in Louisville has begun a texting program to assist teens in quitting smoking. Anyone can participate, but the principle target audience is youth, because of the growing dominance of texting as a means of communication in that age group. The texting program is provided by a third party vendor that has done some evaluation of the viability and effectiveness of this approach. Results are still limited but generally positive. Much more evaluation is needed before this can be called a proven cessation tool.

The procedure begins when students enroll in the Butt Out Louisville program. Enrollment is done by cell phone, and shortly after, the user begins to receive text messages several times per day. Messages provide guidance on the cessation process and encouragement not to relapse. An example of a text message is “Withdrawal symptoms are signs that your body is starting to heal. Remember to drink a lot of fluids, especially water.” There is some research and theory to support this program. Certainly the advice has been demonstrated to be helpful, and frequent messages (4-5 times per day) are reinforcing from a motivational perspective. Students don't have to seek out help; messages find them wherever and whenever.  There is enough theory and evidence to say this is an innovation worth testing further. Evaluation for a follow-up period is needed to give more assurance that this will really be effective.

A number of questions come up about the use of texting in this way. A government health department is expected to serve the entire population. However, there will be a disproportionate percentage of low income and minority youth who don’t have cell phones and texting service. This may extend a disparity that already exists: the prevalence of smoking is much greater among low income, poorly educated persons. Will the texting tool leave them even further behind? We will have to see.

Most schools don't permit students to use their phones at school during the school day.  Even though the cessation messages are timed to be evenly spread throughout the day, students will get them all at once when they get out of school.  This may distort the impact of keeping them focused on cessation throughout the day.  We will have to see.

Another question is whether it is realistic to believe that these texts will really break through with sufficient strength to impact motivation and behavior. For example, many teens will send and receive dozens of texts per day, sometimes more than 1,000 in a month. With that huge volume of text traffic, will the cessation texts just get lost in the noise? We will have to see.

Here is yet another question. The cessation texts will be delivered into a text ambiance which will influence the impact. For example, what are the topics of the body of texts students are receiving? Are they sending inappropriate pictures of themselves or others? Are they using texts for plagiarism and cheating? The point is, the texting environment has similarity to TV broadcasts. The TV producer sends out programming into households, with no control over the viewing environment to assure people are watching and thinking about content. Because of this basic characteristic of mass media, the unit effectiveness is likely to be low, offset by the promise to reach a large audience efficiently.  We will have to see.

In spite of the reservations, I'm excited about the potential of this technique.  If we find evidence that phones can be used this way to help students quit smoking, all the other issues are just academic details.  We can also look ahead to a time when the texting can be even further tailored to meet the exact needs of individual smokers.  This could be done with expert computer systems and entry of unique learning and motivational characteristics.  We will have to see.

TAFN  BBN BBT T:)T (If you can't read this, see the teenager nearest you.)

Friday, August 20, 2010

Is School Health an Impossible Dream?

This week school started up in these parts. The yellow buses are out before first light and continue well into early evening. We put high hopes on the schools to achieve a lot of society’s goals; we freely blame schools and teachers when those goals are not met. One wonders how the relentless growth of information is assimilated into a school year whose length has been fixed for decades. What becomes of knowledge deferred? Does it dry up like a raisin in the sun?

Among all the goals we want the schools to achieve this year is the quest for healthy children and adolescents. The rationale is that establishing good health early provides a basis for healthy adults. This becomes part of the framework of quality of life for individuals, progress and prosperity for society. Lofty vision this is, and one to which we’ve aspired for generations, starting early in the 20th century. There is also the belief, backed up by evidence, that some aspects of health are linked to learning. No Child Left Behind is put in jeopardy by many things, including poor health leading to diminished brain development, inability to concentrate and absenteeism.

And so in addition to the traditional PE and Basic Four Food Groups (now the Food Pyramid), we’ve had programs for drug free schools, alcohol free schools, tobacco free schools, violence free schools, and schools where only abstinence will be found. While none of these efforts have been a whopping success, we have built up a body of evidence; if best practice, as defined by evaluation research, was the guide in all these areas, we would be much further along toward Healthy People. However, this is America. There are no benevolent dictators to be seen. Consequently, the formation of school curriculum and policy is influenced by many voices and often conflicting values.

School health is compounded by the fact that kids don’t live in the school bubble, but encounter health influences in 3D, 24/7. Just like learning will be deficient in the absence of supportive families and community circumstances, it is hard for kids to form ideal health habits in many homes and neighborhoods. Every time kids pass billboards, convenience stores and fast food venues, it is a drive-by wilting of health valuing, subverting the positive influence of the school health program.

We can take some pride in knowing that things are getting better. We have learned some lessons, and though turning around the education enterprise is snail-pace slow, there are encouraging signs. For example, over the last 10 years, PE has been dwindling as schools have shifted instructional time to the critical accountability areas of standardized testing. More recently, we have recanted, partly in response to the obesity epidemic that has finally broken through to America’s radar screen. Not only are schools restoring PE and recess, but they are further demanding that PE time be exercise time, not standing around time, not locker room time. We are imposing rules for healthy school breakfasts and lunches, beginning to remove junk food vending, and putting limits on competitive foods, such as the band booster cake sale. These things are sound policy changes based on theory and research-based evidence. By themselves, still not enough.

We are still struggling to find ways to link schools with families with community institutions and leaders. There is every reason to expect that a united front, in which every segment of society is supportive of the same goals and strategies, putting equal value on the health of children, would bring about victory in school health promotion. However, that is truly an impossible dream. Society is too fractured with alternate value systems and opposing views. For most of the school health issues, constituents line up on various sides. It takes gifted leadership and some luck to bring enough support together on compromise positions to move the ball forward a few yards. I’m still waiting to see a Hail Mary touch down victory when it comes to child and adolescent health promotion, but we can take satisfaction in small victories, small progress none the less.

There is always next school year.

Thursday, August 19, 2010

Making Peace with Health Promotion

Last Christmas a family member gave me a membership to the National Rifle Association (NRA). It was a gag gift because he knows there are few people in the U.S. more opposed to what the NRA stands for. The NRA and I are in different time zones: I’m in Eastern time zone and it is in the Twilight Zone!  It is more than a disagreement. Let me clarify that I respect many gun owners and the right of responsible gun ownership. I just think the NRA is absolutely wrong about the propagation of a safe society and what would get us there.

This is relevant in a health promotion context because violence is a public health problem, sure-as-shootin. Violence has health implications because it is linked to death, injury, disability, and anxiety disorders. In addition, there is confidence in many quarters that violence can be prevented or at least reduced. Finally, a law enforcement approach will only take us so far. A more ecological perspective such as a comprehensive public health program shows much more promise. This would include school and public education, and media restrictions respectful of 1st Amendment rights but responsive to relentless portrayals of brutality and mayhem in movies, TV and video games. Other components would include finding ways to promote young people bonding with mainstream society values, family support, strategies to help youth identify with school values and complete more education, connecting kids with positive role models (e.g. Big Brothers Big Sisters), community focused policing, and of course paying attention to guns.

Gun control is not a magic bullet for community violence, but the evidence is clear that the explosion of guns into more and more places carried by more and more people does not promote the public’s health. Evidence shows that the presence of guns in communities and households is directly related to homicide and suicide rates. So what about gun control?

In general, gun restrictions have not been found to be effective in decreasing homicide and community violence. The Brady bill blocked a lot of gun sales but it was not possible to link this to decreased violence. With an estimated 200 million privately owned guns, restrictions are not enough to matter. However, the NRA encourages gun ownership by more and more people. Their view is summarized by “Guns don’t kill people, people do!” It makes a memorable slogan but otherwise is without merit. One could make a similar claim about autos: “Cars don’t kill people, drivers do!” This is equally false. Just like we have to address highway safety in a wholistic way , including regulation of the design and production of cars and who drives them, gun restrictions must be part of a comprehensive approach to violence prevention.

The NRA rejects out-of-hand a public health solution, approving no counter measures other than safe shooting courses. This is dishonest and disconnected from community conditions breeding and enabling violence.

It is worth noting that while it is easy to make the case for violence as a public health problem, there is a remarkable void of attention to violence by traditional public health agencies. At the federal level, the Centers for Disease Control has a unit devoted to violence; a few years back the NRA aggressively (but unsuccessfully) worked the political system to get CDC funding for violence prevention blocked. At state and local levels, violence prevention mostly reverts back to law enforcement; some school systems include anti-violence education in their curriculum, and some of those efforts have had modest results in students practicing more peaceful lifestyles.

Up to now, trends in violence and suicide have been mostly out-of-sync and unrelated to violence prevention efforts. The NRA is a barrier to a more promising public health approach, in the belief that violence would go away if all the “good “people were armed. In reality, much of our violence is not perpetrated by “bad” people, but by good people having a bad day.

In the classic words of Pogo, “We have met the enemy and he is us.”

Wednesday, August 18, 2010

Health Fair on Faith

This week will see the beginning of the Kentucky State Fair. This is paralleled by similar events in almost all U.S. states, designed to celebrate the importance of agriculture and to sell stuff. The Kentucky State Fair has a huge array of farm-related exhibits, including competitions for all types of animals and birds, equipment displays, rural food and craft exhibits and contests, and many other things totally unrelated to agriculture, but using the event as a marketing opportunity to reach the masses of people attending.

The Kentucky Department of Public Health is a principle sponsor of an area called Health Horizons. Other reputable organizations also participate, such as AARP, Anthem Blue Cross, and Walgreen's. In this exhibit, various screening services will be offered, including blood pressure, skin cancer, oral health and prostate screening, bone density testing, body fat analysis, lung capacity assessment, and several other modes of screening. I don’t know all of the organizational structure behind this effort, but I’m hoping they do more than just test.

In addition to the health screening, Health Horizons and another Exhibits area will have nonprofit and for profit vendors distributing all kinds of health information and selling many health-related products and services. Some of these exhibits will provide useful information. Others are well-meaning but misguided, and still others are knowingly perpetrating fraud. All that is required to be an exhibitor is to apply for booth space, pay the fee, and not be requesting an exhibit place to promote something illegal or severely violating community standards.

For perhaps the last 30 years, the health fair has become institutionalized as a common method of health promotion. The jury is mostly in on health fairs and the verdict is not encouraging. There seems to be a lot of confusion and muddled practice when communities and organizations want to mount these events.

If you are thinking about organizing a health fair, there are two basic questions you should answer. First, what do you want to achieve? Second, how will you know if you succeeded? Without good answers, you might get a news story in the back pages of the paper, but probably will have no impact on the public’s health.

If the health fair is going to feature health information, how are you engaging people in the information and is there a connection to other strategies to help people make changes? Information alone is almost never sufficient to change health-related lifestyles. Just because someone sits in a booth and gives away 1,000 brochures on nutrition does not mean that anyone’s diet and health actually improved.  There may have been more impact on the health of trees.

If the health fair includes screening, it is only effective if there is an infrastructure in place. What will happen with the results? Who will interpret the results to the persons screened? Do those persons have access to further assessment testing if screening results are positive? Is there someone who will work with a person to promote indicated lifestyle changes such as weight loss, dietary change, or smoking cessation? If these things are not part of the plan, such isolated screening may be health promotion malpractice.

Finally, if the health fair is open to any individuals and groups who want to pay for space to market health-related products and services, there should be evidence-based guidelines which determine acceptance, not just the ability to pay. Health promotion workers and sponsors of health fairs have an ethical obligation to the public, assuring that information distributed at the fair is true and that products and claims from vendors are based on legitimate medical evidence. Unfortunately, this is not the case at the KY State Fair, though in defense, decisions are not made by public health and health promotion professionals, but by those with more interest in business development and making the Fair profitable.

The U.S. is a pluralistic society in which freedom and diversity of speech and ideas are cherished. Still, at least in the health promotion spaces we control, the buyer should not have to beware.

Tuesday, August 17, 2010

Perfect Health Promotion

The other day my wife and I decided to freeze peaches.  We like them a lot, and unlike apples, grapes, bananas, and many other fruit, fresh peaches are only available in Kentucky in July and August.  As we were washing, peeling, cutting, mixing and bagging the fruit, I wondered about the conflicts in what we were doing.

We live in a suburban area where people have backyard gardens, but there is not much in the way of commercial farming other than feed corn, soybeans, and other field crops.  There are farmers' markets scattered around the city, open various days each week.  Farmers come 20-30 or more miles to sell their produce at these events.  Is seems like a social good to support these farmers and their rural communities, to share the wealth of urban areas and build cultural bridges between the best of both worlds.  Paradoxically, it may actually be greener to buy produce from Wal-Mart.  Even though their produce is shipped from several states away, the high level of efficiency in their supply chain might be gentler on the earth's resources than production and delivery by a more local farmer.  What should I weigh more, local values or faceless efficiency?

Back to my story.  We drove about 60 miles r/t to buy locally grown peaches.  In Kentucky, it is rare that one can go to a conventional retail store to buy fruits and vegetables grown in the state, even in the summer.  What is sold in corporate grocery chains almost always is grown somewhere else in the U.S. or other countries.  This is true even though many fruits and vegetables are now grown, and could be grown in larger quantities, by Kentucky farmers.  Part of the reason for the void of local produce in stores again has to do with supply chains and infrastructure.  It is also true that it is more efficient for a grocery wholesale distributor to deal with one large farm rather than 250 small farms.  For historical and geographic reasons, Kentucky farms tend to be small family operations rather than the massive corporate farms common in other parts of the country.  Here is the point.  I wanted to buy local because I thought the fruit might be better, or at least fresher.  However, the downside was I used several gallons of gas to buy what was available at Kroger's, about 1.5 miles away.  There was a small nutritional advantage but a modestly high environmental cost.

If I wanted to be really green, I would mostly eat things I could raise in the backyard, and use more energy efficient ways to preserve and store food I couldn't eat when it was fresh.  I'm going to pay to freeze a quart of peaches I won't need until next February.  Perhaps my frozen peaches are a little bit healthier (Who knows?) than a can of peaches I could buy in the winter, but is it worth the cost?  On the other hand, fresh peaches don't come with a nutrition label: a worthy health promotion goal is to cut down on foods that come with a label.  Then again, there would be benefits to health and to the earth if we all raised food in home and community green spaces.  Are there counter-balancing health promotion benefits to using time for things other than gardening?  I think there are.

Personal and public health promotion is not a simple matter.  General advice doesn't apply to every individual.  Sometimes we make compromises when there are conflicting values.  Raising animals for food on factory farms is environmentally destructive and wasteful of resources.  However, raising cows organically on a small ranch, where animals are treated more like pets, would make meat much more expensive.  The values of boutique beef production must be balanced against higher grocery bills.  Being able to spend less family dollars for food means more money for other things which might also promote health.

There is no perfection in health promotion guidelines.  Don't let the perfect be the enemy of the good.  Next winter I'm going to enjoy those peaches, added sugar and all.

Saturday, August 14, 2010

Health Progress Through a Baby's Face

Today a new addition to my family arrived as my niece gave birth to a healthy 7 lb girl.  This is a happy time for new parents and families, a time celebrated by poets and greeting card designers.  I won't try to add words to highlight the special joy of a new healthy life.  However, there is much to celebrate regarding the good health currently enjoyed by new mothers and babies.

In the public health world, issues related to pregnancy and the health of newborns and mothers is referred to as maternal and child health.  It has been a traditional emphasis area of public health because in the past there has been so much disease and death associated with pregnancy and childbirth.  The height of joy associated with having a healthy baby is mirrored by the lowest low when a mother dies in childbirth or a baby dies before birth or shortly after.

We have seen tremendous progress in this regard.  Though past statistics are somewhat uncertain, best estimates are that in 1900, 850 mothers would die for every 100,000 births.  These deaths would usually be from blood clots, hemorrhaging, infections, and extreme high blood pressure.  Given the state of the art of medical care at the time, there was not much to be done for women with these problems. Underlying factors were that nutritional practices were poor, and there was no reliable birth control to better space pregnancies and limit pregnancies at older ages when risks to the mother and child are greater.  Over the years since then, the rate has dropped to around 12.  This is an enormous accomplishment due to advances in medical care and public health primary and secondary prevention.

When babies die in the first year of life, the technical term is infant mortality.  In 1900, about 1 in 10 babies would not survive to the first birthday.  The rate in the U.S. is now about 7 deaths for every 1,000 births.  The following chart illustrates progress in infant mortality since 1940.  That sterile looking chart represents a triumph over suffering and misery of a special kind.  Though the rate of improvement is slowing, we have come a long way from the bad old days when the hope of childbirth was always tempered by a shadow of risk.

In spite of great progress, there is still some concern, because of disparity in two dimensions.  First, on an international perspective, the U.S. does not compare very well.  The graphic below shows infant mortality for a set of developed nations, and it indicates that U.S. babies die at twice the rate of Japanese and Swedish babies, and we are behind all of these and many more nations in this regard.

The other concern is the disparity between black and white babies.  The African-American infant mortality rate is double the rate for white infants.  These two disparities illustrate that though we have come a long way, there is still much progress to be made.  The following chart illustrates the racial divide with this measure.

The point I want to close on is the human face of suffering.  My niece and her family are ecstatic today because mom and baby are in excellent health and have every expectation to thrive in perfect health going forward to the first and many more birthdays.  Public health statistics sometimes are abstract and cold, illustrating something which didn't happen because it was prevented.  My great niece is the polar opposite of the mother and child suffering and misery which once was so everyday routine. For me, today, prevention and public health progress has a face.

Friday, August 13, 2010

Look Up to Health

The other day I did a tour of duty picking up my grandchildren after school. They are in the classes of 2021 and 2023, so are truly in formative years. The name of their school is Liberty Elementary. I wonder what values and attitudes might be formed by each day occupying a building with such a lofty theme? Some schools make students wear uniforms, with the belief that the cloths will tweak their psyches to believe “I am….SOMEBODY,” and behave in a more pro-social way. The state of New Hampshire has the official slogan “Live Free or Die.” It is a compelling precept stamped on the state’s license plates at the state prison machine shop. Yes it is. Nevertheless, words and transcendent ideas can transform how we live life.

It seems to me our society doesn’t inspire kids to flourish with all the things good health can empower. We don’t present excellence in health as something worthy of an aspiration. Many people, and maybe also youth, are inspired by the Olympics, but that only comes around for two weeks every two years, and in most years is tarnished by performance enhancing drugs. Professional sports could inspire kids, but the positive values that could be embodied by the pros are often overshadowed by million dollar contracts and “Get your chili dogs here!” There is really no personal inspiration coming from the medical care system. Somehow treatment of disease, even when it is a truly stunning feat of science and technique, doesn't translate into "How much better my life could have been if I had really taken advantage of great health promotion opportunities!"

For the last sixty plus years, behavioral scientists have painstakingly teased out factors (called “constructs”) that enhance the likelihood of someone making a change in their health habits. For example, people with social support for change are more likely to do so. When people think they gain more than they give up, they will more often make a pro-health change. People confidant that they can make a change are more likely to move in that direction. There are many more such constructs based on research evidence. In all the theory building that’s been done, inspiration has never been recognized as being important as a motivator or sustainer of health promoting change. However, there are connections. Things that inspire us resonate with our values, which have been seen for years as underlying factors molding our health lifestyles. Atmospheres that inspire healthy living are reinforcing in a vicarious way, and this is also soundly anchored in theory.

What if we were to name schools in ways that would provide inspiration and a higher health calling? For example, what about a school called “Lean Elementary School.” How about “Movement Elementary School?” Ok, that one needs work. Another idea might be "Green Elementary School." Neighborhoods troubled with violence could rename the school "Tranquility Elementary School." Obviously, inspiring names are not the final solution to changing America’s despicable health lifestyles, but they set a tone and lift kids' perspectives to something better.

It has been said that people perish without a vision. Perish can mean many things. However, names and words matter.

Thursday, August 12, 2010

Health Promoting Hands

In the history of public health there is the story of John Snow. Dr. Snow was a careful observer and analyst of a cholera epidemic in 1854 London. Before germ theory was understood, Snow was convinced that people were getting sick from a water cistern (the Broad Street pump), and removed the handle from that pump to block further contact with the contaminated water. From the perspective of London residents and even contemporary medical “experts,” the end of the epidemic was miraculous.

The dynamics of controlling a point source exposure are fairly simple, especially from the vantage of the 21st century. In contrast, many infectious disease threats are much more complex. To give a single instance, alarm has escalated in response to infectious diseases often acquired in health care facilities, and often resistant to anti-biotic treatment. An important example is methicillin-resistant staphylococcus aureas (MRSA). There are others, but MRSA is a good sentinel of this group of organisms. Each year there are about 90,000 hospital cases of MRSA with 15,000 deaths. With all infections acquired in hospitals there are about 1.7 million cases and 99,000 deaths. Tabulated together, these infections would be the 6th leading cause of death in the U.S.

Unlike Snow’s cholera outbreak, the MRSA epidemic is many times more complex. There are many things hospitals are doing to protect patients and personnel, but one of the most basic is hand hygiene. Very often these infections are transmitted by hands. Nurses and other workers are instructed to wash or sanitize their hands before and after any direct patient contact. However, hand hygiene in the hospital is like a wheel in a wheel in a wheel. First of all, in modern hospital care there is an astounding array of workers involved with each patient: often multiple physicians, numerous nurses and aids, dieticians and food service workers, allied health technicians and therapists, housekeepers, maintenance workers, volunteers, chaplains, and students in all of those fields. Often there will be many family members coming into a patient’s room as well. With the sheer number of hands and the range of understanding with respect to infectious disease transmission and risk, it is extremely difficult to get everyone to comply with what science has established as best-practice. Often staffing resources mean that nurses and aids are chronically pushed for time; frequent hand washing can add a significant time burden to their workday. Personnel don’t like to wash 100 times a day because it can take a toll on their skin. Human factors engineers are doing a better job pinpointing the placement and perfecting the design of sanitizers, sinks, soap and towel dispensers to create circumstances where hand hygiene is made easier and more convenient. Remember also that hand hygiene is a behavioral problem; no such problem is solved with information alone, but many other factors must be considered.

In light of all this complexity, it should be no surprise that the hospital workforce is not entirely compliant with hand hygiene best practice; this includes physicians. Unlike some health threats, like highway injuries which can be managed with peak risk time precautions, hospital acquired infection is a 24/7 risk. The overall threat of drug resistant infectious disease is truly a scary specter for the human family. Unless we can do a better job in managing anti-biotics, there is the real possibility that infectious diseases will be increasingly beyond our ability to control.

Now for some good news. From 2005 to 2008, hospital MRSA declined by 28%. That is great news for anyone who visits, works in, or is admitted to a hospital. It is a great victory for all the public health measures being instituted in every hospital. John Snow would be pumped.

Note: I want to thank my colleague, Dr. Ruth Carrico. Though not a source for this post, she has taught me about clinical infection control concepts.

Wednesday, August 11, 2010

Health Out of the Haze

When I was a child I was given a lot of homespun advice passing as serious health information. Have you ever heard these in the winter? “Wear a hat and scarf or you will catch your death of pneumonia! Don’t get your feet wet! And be sure to stay out of a draft.” Another one I used to hear was that if you read too much in low light you would go blind. There are hundreds of these, and most people have one to share. How do you know what is true? Whether you hear it from a family member or friend, see it in mass media or a book, or read it on a web site, it is necessary to do some filtering before you adopt a health promotion practice.

I would like to suggest some rules to judge the merits of health claims. The following ideas are suitable for those wanting to be independent and self-activated. Some people want to do their own research, so that they can be intelligent consumers and engage their health care providers in a meaningful question and answer session. The suggestions are not necessarily in order of importance.

First, if adopting the recommended practice requires the purchase of an item or service from the source of the recommendation, you should be cautious. This doesn’t mean go no further, but just ask a lot of questions. Legitimate health and medical sources usually do not conduct themselves like Billy Mayes. You should notice the type is louder here.

An important question is whether you can try the health practice in small increments or is it all or none. For example, if you were interested in the new shingles vaccination, your options are to get it or not. Once you get the shot, you can’t put it back in the bottle. On the other hand, if someone is recommending a one-day-a-week fast, you can try it without making an irrevocable decision. For those practices from which you can’t return, be more cautious upfront.

Never do anything on the basis of a message on a billboard, poster or bumper sticker alone. Many times these brief messages will be correct, but such venues cannot provide enough for an informed choice. If one of those short messages seems appealing and persuasive, you should follow up with additional research from other sources.

For any health claim, you should examine the evidence. This is hard for most people because it requires a lot of specialized knowledge and technical expertise. Even professional journalists have trouble with this. They will most often refer and resort to the two most well known medical journals, the New England Journal of Medicine and the Journal of the American Medical Association, not because they are always correct or the best journals, but they are recognized as generally reliable. Journalists use them so they don’t have to get into the weeds of medical research writing; they can just trust the findings.

Sometimes a reasonable shortcut from evaluating the evidence is to evaluate the source of the evidence. Are you getting it from a well known national organization or a respected institution in your community? Even better, if you can corroborate health advice from several sources (e.g. local health department, a hospital, and your physician) you can feel more secure in believing and acting. If you see or hear or read something from a source about which you have doubts, take that advice to a source you believe to be trustworthy, and see if their information agrees. Always know who is sponsoring or hosting a web site where you find health claims.

Remember that physicians, dentists, pharmacists and other health professionals can be very good sources of health information. There are some drawbacks, however. First, you have limited access; they may not be available when you need information. Even during an office visit, time is limited, and will usually prohibit an extended discussion or explanation of important health questions you have. Second, they usually know more about disease and treatment, less about health promotion. Your doctor can diagnose lung cancer but may not be able to help you quit smoking. That is not her or his training.

Because health information is sometimes difficult to negotiate, and because there is such an abundance of sources, it is easy to feel hazed and overwhelmed by it all. Many people just give up trying to understand. I don’t know that there is really a solution. The information superhighway has some inevitable casualties. I would like to suggest a one stop shop for user friendly and reliable health information. This is a web site called Wellness Information Zone, and the URL is http://www.wellzone.org/termsofuse.aspx The site was built by Humana. While they are a commercial business, their bias toward any particular health promotion information is going to be very minimal.

Finally, remember that health information and health promotion recommendations sometimes will change. What we think is true today, based on available evidence, may be found to be incorrect next year. That is just the nature of scientific discovery. For example, there was a time when obstetricians would suggest the option of drinking moderate amounts of wine for women to reduce the stress and anxiety sometimes a part of pregnancy. Now we know that alcohol in pregnancy should be avoided.

It may be true that more than half of all the health information disseminated to the public is not correct. Let the reader beware.

Monday, August 9, 2010

Health and Heat

Today in Kentucky promises to be another scorcher, embedded in an unusually hot summer. Like most people, I’m enjoying climate control in my car, home, and workspace. However, I’ve been wondering about the implications. Climate researchers seem convinced that average lows and highs are on a slow but steady incline which is continuing amidst daily peaks and troughs of temperature. In the winter when we have the occasional very cold day, that does not refute global warming, just as an unseasonably hot day is not further proof of global warming. Because of modern technology, our lifestyles and daily routines are the same whether it is 80 degrees or 90 degrees. The natural ecology is much more sensitive and is unprotected by the relatively simple devices and methods we use to protect us from extremes of high and low temperature. If temperature change induces changes in growing cycles or mating and spawning times, we don’t really have the capability to alter those types of effects. Climate change is likely to have more of a direct effect on the rest of the natural ecology, more of an indirect effect on us. Nevertheless, those indirect effects could prove to be significant, and possibly catastrophic.

At the same time, we are faced with energy problems. The tried and true carbon fuels, coal, petroleum and natural gas, are becoming harder and harder to acquire, both because they are non-renewable, and because many of the world’s sources are nations which seem to hate our success and our values. The economic impact of increasing oil prices is a threat to continued economic growth and prosperity, and potentially will challenge a world order of relative peace. Over a long time frame, other sources, such as solar and wind, nuclear energy, and fuel cell technology will be able to replace the carbon sources. In the meantime, Americans are in the uncomfortable position of having to drive less or more efficiently, be more sparing in their use of home electricity, turn up the AC temperature in summer months and turn down heating temperature in the winter. We are also being asked to replace inefficient appliances, incandescent bulbs, and install more insulation and replace older windows with designs more resistant to heat transfer in or out. The item in this list which will give the most visceral impact is getting used to hotter temperatures in the summer and cooler temperatures in the winter.

It is customary to say normal room temperature is 72 degrees. Of course for most of recorded history, room temperature may not have been much different from outside temperature, certainly in hot weather. Could we get used to living and working with summer room temperatures around 80 degrees? How would it effect us? Certainly a temperature of 80 degrees would not present a health risk, especially if people are adequately hydrated. It would seem very uncomfortable for most Americans, and would stimulate innovations such as ways to cut down on direct sunlight coming into houses, and perhaps new clothing designs to accommodate higher temps. Perhaps formal dress codes would fade away. Engineers would try to develop more efficient and sophisticated fans to promote air movement. There would be unintended consequences. For example, with an average room temperature increase of eight degrees, would there be more food poisoning, as microorganisms would have an even more favorable growing condition? Many people exercise indoors in the summer. How would exercise patterns change when thermostats are turned up to 80?

In the winter, the opposite would occur. Rooms would go from 72 to 65. There is no health hazard presented by such a change, and in fact, we might be even healthier. Again it would take a major adjustment, expecting to be comfortable at 65 when we’ve been used to 72-75. When Jimmy Carter was President he encouraged Americans to turn down their heat and put on sweaters. He was ridiculed for being a tree-hugger and pessimist. We like our Presidents to give us a good word, not necessarily the truth.

Those two things, hotter rooms in summer and cooler rooms in winter might help bridge the energy gap in the meantime, but we are all too self-indulgent to make the change, certainly without whining.

On the other hand, there are so many unknowns. I remember when Paul Ehrlich’s Population Bomb was an impending threat – world population was growing faster than the earth could accommodate, and we were facing a world wide collapse of societies and food chains. Yet here we are, forty years later, and the population explosion has been brought under control. Of course there are still limits to how many people can occupy Planet Earth, but the recognized threats are now different. Nevertheless, mankind has the capacity to innovate new technology and solve problems.

Do you think the future will be better or worse than current projections? Will we adapt and innovate enough to avoid planetary pitfalls, or does the path lead to entropy as the ecological order becomes more and more out of balance?

Sunday, August 8, 2010

Is Prayer a Health Promotion Strategy?

I believe health promotion is a cradle to grave proposition. That is, in all circumstances, there are things that can be done to enhance one’s well-being and health related quality of life. Obviously there are many missed opportunities for individuals and communities. Central to many peoples’ way of life is a turning to religion and prayer when they want their health to be better. Can this be considered health promotion?

Recently I read about an interview with Christopher Hitchens. He is a book author and journalist on many topics, but is most well known for being a very vocal atheist. It happens that Hitchens has pancreatic cancer with a prognostic window of only a few months. The central question of the interview was, as an atheist, how does he face death. There is the old saying “There are no atheists in a fox hole,” and by extension, there are no atheists with terminal cancer. Is this true? was the question.

I’m not going to answer that question. However, millions and perhaps billions of people (of many different faiths) with severe, and even more minor illness will turn to religious beliefs and practices, including prayer, hoping to get a reprieve or at least some relief. Is this a kind of health promotion?

With all proposed health promotion tools, the key question is “What is the evidence?” Does red wine really promote cardiovascular health? What is the evidence? Does fluoride really protect teeth without inflicting its own toxicity? What is the evidence? What is the evidence that hypnosis can help someone quit smoking? These are all fair questions if health promotion is guided by science and not by anecdote and folklore.

Of course applying standards of evidence to prayer and religiosity may not be appropriate. Religion is experiential, transcendent, right-brained, it is revealed truth, not discovered by the scientific method. At the same time, people of faith ask for and anticipate concrete healing. It is an objective question to ask whether they get it. Hitchens claims that his atheism has not wavered but many Christians are praying for his own miraculous healing. So we return to the question, can religious belief and practice protect from disease and promote health?

There is an institution called the Cochrane Library which produces systematic reviews of the medical and health literature. They will identify a specific question and search the world’s published literature to assess the consensus of all the research on that topic. They have very careful procedures to weed out opinion pieces and junk science, in an effort to base their conclusions on the best science available. As it happens, there is a Cochrane systematic review on what believers call intercessory prayer. They tried to answer the question, “Does someone who is prayed for, in addition to receiving routine medical care, have better results than someone only receiving medical care?”

The review found ten studies meeting high scientific standards; these studies captured about 7600 research subjects. The studies were set up with treatment groups who were receiving routine care plus standardized prayers from trained interceders; the control groups got medical care only. Because there might have been people outside of the study conditions who were praying for the research subjects, groups were randomized to minimize confounding of the experiments. Some studies were blinded: subjects didn’t know if they were being prayed for. On the other hand, if the intervention is about divine intervention, blinding techniques seem to be futile, certainly from the perspective of believers.

In the end, the result was that findings on this question are inconclusive. There were studies showing no effect but also some studies showing beneficial impact of prayer on health outcomes. The Cochrane researchers found no evidence to discourage praying for people’s health, but also not much evidence to recommend it. They admit that the whole enterprise of using the scientific method to test this question is problematic. It is difficult, and may be impossible to replicate real family and community circumstances, where prayer for a sick person is occurring, in an experimental design that controls as many variables as possible. In the end, neither proponents nor skeptics are likely to change their minds.

And the quest for evidence continues.

Friday, August 6, 2010

Moonshine Madness

When I was growing up, I used to read Al Capp’s classic comic strip, “Lil Abner.” The cartoon presented a cast of characters living in a fictional Dogpatch, Kentucky. They had all the unflattering stereotypes of Appalachian hillbillies: not too smart, lazy, quick to violence, and generally backward. Another one of the stereotypes was the presence in the shadows of the bootlegger distilling moonshine liquor, also known in Dogpatch as Kickapoo Joy Juice. These stereotypes are deeply resented by people living in Appalachian communities, and like all stereotypes, present as simple something that is complex and multi-layered.

Nevertheless, moonshine is a reality in many Appalachian communities, though it is also common in rural areas across the U.S. As a matter of fact, moonshine, by other names, is made in countries all over the world. It is estimated that about a million people in the U.S. make this illicit liquor, some for personal use and others to sell. There are some home producers who do this as a hobby or because of a mystique of doing something illegal. However, there are more basic structural reasons why moonshine exists.

Before the widespread regulation and subsidizing of farm products, farmers would resort to turning some of their grain crops into a mixture which could be boiled and distilled to make moonshine. It was economic insurance to hedge bets in an unstable agricultural marketplace. This is less of a motivator today because of government farm programs.

Another factor driving moonshine was the incentive of avoiding alcohol excise taxes. With distilled beverages sold legally, about half the purchase price is from the taxes included in the price. These “sin” taxes can be justified because of the social consequences driven by alcohol abuse: expenses in the criminal justice system, property damage, medical costs, welfare and family services, and so forth. Nevertheless, the tax is high enough to present a tempting option for entrepreneurs willing to take a chance. The moonshiners can significantly undercut the market and still make a tidy profit.

Remember that many counties in Kentucky, and about 15 other states have provisions for local option alcohol control. This means that a county can have a ballot referendum to decide whether alcohol will be sold. The so called “dry” counties usually will have slightly less per capita drinking, so health and social consequences of alcohol may be a little less. However, highway fatalities tend to be worse because people drive to the next county where they can purchase alcohol. Recent school drug surveys in Kentucky (the KIP Survey) show that among youth there is no difference in student drinking between wet and dry counties. Apparently dry county kids are more motivated to get alcohol, adults not so much.

So while the existence of dry county prohibition does not have much impact on alcohol consumption, the laws create a circumstance which supports moonshine production and bootleg sales. Government has some interest in this. For one thing, there are some extra risks associated with moonshine liquor. There is no quality assurance, since production methods and conditions are totally unregulated. Drinkers of this mountain dew may get a very high alcohol content and be exposed to toxins, including lead and methanol.

Moonshine is symbolic of many of our ill-conceived drug laws. It is legal to make beer and wine in your own home. However, if you build a still to make high concentration alcohol, you face a felony conviction and $15,000 fine. There is no obvious reason why government policy should try to dry up moonshine while giving the green light to home made beer and wine. This is similar to the penalty gap between powdered cocaine and crack.

National Prohibition was successful in decreasing (not eliminating) alcohol consumption by Americans. The policy was not a failure on that point, but many other factors made it not viable or constructive for the nation as a whole. Dry county policies have even less chance of being successful, especially at the present time. On the other hand, minimum purchase age laws do work, and have been proven to save lives. These laws only work where alcohol sales take place in the light of day; bootleggers don’t care how old you are as long as you have money.

A better approach is to focus on how to diminish the harmful effects of consumption, rather than directly going after consumption per se. It is really about evidence. What works, what doesn’t, what do we know, what don’t we know? Drug policy, as all public health policy should be based on substantial evidence, not Kickapoo Joy Juice.

Wednesday, August 4, 2010

Health in the Desert

What picture comes to mind with the word desert? I think of the solitary traveler who has been stranded and is hopelessly searching for water; his mind plays tricks as he sees mirages of water pools and fountains. I also think of indigenous nomads who manage to survive with a lifestyle out of the “stone age.” In my imagination they are thin and wiry with stunted growth, accompanied by a few emaciated goats. Their diet is usually not something featured on the Food Network. My only experience with desert landscapes is in Utah, Nevada, California, and Northwest Mexico. Death Valley is perhaps the jewel of those desert lands. It represents a void lacking all the necessities to support life. Not an image I want to associate with health promotion.

Recently health promotion advocates have been using the term “food desert” to describe urban neighborhoods in which few if any healthy food choices are available. These are quite common in medium and large cities. Food deserts are populated mostly with poor and minority residents, who are surrounded with fast food outlets, convenience store fare, and liquor sellers. It has been noted that when the grocery chains locate stores in food desert neighborhoods, the range of products is smaller and the quality and care invested in fresh fruits and vegetables is demonstrably poorer than is expected in more affluent neighborhoods. Typically, a large segment of residents have no cars, so in order to buy more healthy foods in a full service grocery, they have to take public transportation. Ask yourself when was the last time you rode the bus, including a transfer, to carry bags of groceries, with two kids and food stamps. Because most people don’t have such a challenge, they are unaware this is reality for millions of Americans.

In fairness it must be admitted that the lack of quality grocery offerings in many urban neighborhoods is not a simple example of racism and discrimination, except to the extent that markets are discriminatory. Hard rules of supply and demand do not consider social justice. Full service grocers don’t locate in some neighborhoods because area residents can’t buy the extra things whose sale makes a store’s business plan viable. In addition, many residents are not educated to make healthy choices; they understand that you can fill a stomach more cheaply with mass produced snacks than with fresh fruit.

Here is the paradox. In contrast to the geographic deserts where famine conditions are the norm, these deserts are filled with more obese people than in the affluent suburbs. Part of this is because of diabolically ingenious technology which has brought an oasis of high calorie low price junk food which is sold in the retail outlets on every corner. Another reason is that these neighborhoods are also exercise deserts. Usually there are no fitness centers, parks are unkempt and unsafe, sidewalks are broken and uninviting and there is a backdrop of fear because of gang violence and street crime. Residents again are typically not educated to value physical activity, and they more often than not will work for an employer who provides no facilities nor incentives for workers to stay fit.

People living in food deserts are inordinately exposed to the TV media world; it is another kind of desert. The media desert presents a diet consisting of soft drinks, alcoholic beverages, and fast food. Further, health is largely a function of taking medication. This is an idea desert in which really life-producing health information is nowhere to be found.

In Louisville the Health Department and the Mayor’s Office have started a project called “Health In a Hurry.” The idea is to work with corner store owners, providing financing and business support to create fruit and vegetable sections in their stores. There is also an effort to work with residents in the surrounding area to build a market for these healthy foods. Food desert neighborhoods are being targeted. There is one of these about two blocks from where I’m writing. It has a designated area for produce where none was to be found before. So far it is working; sales are picking up. On the other hand, the outside of the store is plastered with cigarette posters and banners.

Two steps forward, one step back. Patience is required. It takes a while to get out of a desert.

Tuesday, August 3, 2010

Big Food: Foe and Friend

One of the things distinguishing obesity control from tobacco control is that there is no clear enemy. For many years, health promotion advocates were faced with a formidable nemesis: a small group of powerful companies and a powerful farm lobby. The hey day of Big Tobacco is past, though tobacco control fights will not be over for quite some time.

In contrast, there really is no Big Food. Unlike tobacco, the food industry is not a monolith, but is dispersed among a huge array of companies, both producers and retailers, and even on the agriculture side, food is far more scattered among many crops and commodities. The basic approach to smoking is to discourage youth from starting and get smokers to quit. Obesity is far more complex, even if we just consider food and diet issues. We wanted to see Big Tobacco simply go out of business. That is not an option for the food industry. There was nothing of redeeming social value coming from Big Tobacco, other than jobs - not a trivial matter. That’s not the case with the food industry. There are often bad players, such as companies purveying foods high in fat, salt, and sugar with poor nutritional value. But the food companies could be good players and be a part of the solution. Rather than doing battle with a bad citizen (Big Tobacco), we will have to work with a lot of corporate players and many other segments of institutions and society-at-large.

Once upon a time, oranges were primarily seasonal foods, and almost considered delicacies outside of Florida and Southern California. A partnership between marketing and technology brought about not only increased orange consumption, but made orange juice a staple breakfast food in American culture. This is a perfect model of joining corporate interests with improving the public’s health.

What we need is for health promoters to collaborate with entrepreneurs to find ways to do for healthy eating what was done for oranges. Can we change society so that healthy eating is normal, just like OJ at breakfast is normal?

Extracting tobacco from our national life will not change much beyond people not smoking. Changing obesity patterns will fundamentally change life as we know it. This means that we have much more to learn in terms of prevention science, and it will be a long time before the population will look like a bell curve: small portions of very thin and very fat people at the far ends, with most people in the normal middle. In the meantime, health promotion must find more and more ways to partner with food companies, to promote the public’s good. Big Food doesn’t have to be Bad Food, at least not all the time.

Monday, August 2, 2010

One Step for a Giant Man

It was 1961 when President Kennedy inspired the nation with his call to land an astronaut on the moon, before the end of that decade. He did not live to see that accomplished, but it was a proud moment for those who did see it. The decade presented huge challenges to Presidential leadership, including Vietnam, Civil Rights battles, the Cold War, and national dismay with high profile assassinations. In spite of all the diversions which could have derailed the journey to the moon, NASA continued the research and planning to finally fulfill the President’s vision.

In 1971, President Nixon declared both the War on Drugs and the War on Cancer. This was perhaps emblematic of his temperament. The War on Drugs has been a failure, not because of its intention but because of the way it has been waged. Nevertheless, state and federal governments have continued to allocate billions of dollars per year to the task of diminishing the destructiveness of drug abuse in our society, and in that sense, Nixon’s leadership has had long term impact. The War on Cancer started with an allocation of $100 million to find a cure for cancer. In recent years the National Cancer Institute has been spending just shy of $5 billion on cancer research, 50 times Nixon’s allocation. While we have made much progress with some types of cancer, anything which can be called a cure is still nowhere in sight. The priority we have placed on space exploration, drug addiction, and the causes and treatments for cancer has greatly expanded our knowledge and capability. In that way, each of these “Wars” or priorities has reaped benefits.

Recently it was announced in the media that there is a gradual shifting of health dollars away from tobacco toward obesity. The nation’s anti-tobacco campaign started in the 1950s with population studies on smoking and cancer. Another early sentinel moment in the anti-tobacco campaign was the release in 1964 of the first Surgeon General’s report on smoking and health. Since those years, tobacco control efforts have been a priority of the public health community; strategies to reduce smoking have become more and more stringent and comprehensive. Our understanding of why people start and how to help them quit is not complete, but is infinitely more complete than in the early days.

As a result, we have gone from a time when over half of adult men smoked to now about 23% of men and 18% of women. Among all the ways we try to discourage smoking, one considered very effective is increasing price. Twenty years ago Big Tobacco Companies and Big Tobacco Farming and Big Tobacco Politicians were powerful enough that raising the price of tobacco taxes was very difficult to do. That genie is now out of the bottle, and all states are increasing their excise taxes, mostly to balance their budgets, but also to discourage smoking. This is going to continue for many reasons. Though some wish governments were more influenced by the health harm of tobacco, motives don’t really matter as long as policies and programs are in place. It is hard to imagine our society going back to smoking as it was done in the 1940s and 50s, regardless of public health funding.

Some in the public health community are raising alarm bells because shifting funding away from tobacco might signal that a loss of priority for what is still America’s number one most preventable cause of death. There is the concern that without continuing relentless pressure against tobacco marketers and those who benefit from tobacco use, our gains in the anti-tobacco campaign will be whittled away over time. To me that sounds alarmist, and for some, self-serving. There is a huge infrastructure in state and federal governments as well as community-based agencies supported by tobacco funding; these entities have a vested interest in seeing the funding continue. That is not to defame the good work that they have done, but simply to recognize that turning off the tobacco funding faucet threatens job and agency security.

What is the justification for shifting funding towards obesity? First, it is good stewardship to recognize that choices sometimes must be made. We can’t do it all. While all the trends with tobacco are going in the right direction, they are all going in the wrong direction with overweight and obesity. A fundamental social change has occurred with tobacco. Forty years ago you never heard the question “Do you mind if I smoke?” Now, smoking is considered socially unacceptable in many parts of our society. If you smoke it is not something you want people to know. This change was brought about by the priority placed on tobacco control by the public health enterprise in government and the public sector. Now we recognize a fundamental change in patterns of overweight. In the last 20 years the weight distribution has dramatically changed. Something has changed, and we are still trying to get our hands and heads around the causes and how best to respond.

I’m hoping that no leader will draft the “War on Obesity” label because it is overused and a dubious metaphor. Nevertheless, high profile funding changes by the Robert Wood Johnson Foundation and the U.S. Centers for Disease Control are symbolic of leadership determining to set a new priority for the very real threat of overweight and obesity in children and adults. Perhaps in ten years we will be inspired, not by one person walking on the moon, but by all of us walking in the moon’s light.