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The new AJPM blog is a forum for professional discussion of the issues raised in the articles we publish and in selected perspective we solicit from leading authorities in prevention, public and population health.

We invite you to read the posts below and join the conversation.

From Evidence to Practice: Highlights from Active Living Research’s First Decade

January 7, 2014

alr-logo-clr_0_0It’s hard to believe that Active Living Research (ALR) has passed its 10-year anniversary. What an amazing journey we have had—one enriched with people so passionate about creating places where kids and adults are better able to walk, bike, and play so that they can live longer and healthier lives. These people include the 200+ researchers who have received ALR grants, the policymakers and practitioners who shape our streets, parks, schools, and neighborhoods, and the advocates who tirelessly fight for more physical activity across the nation.

Between 2001 and 2011, ALR experienced two major phases. In the first phase, ALR-1, the program built a multidisciplinary field of researchers from urban planning, education, public health, transportation, sociology, and leisure studies, among others, to study the effects of environmental factors and policies on physical activity among all Americans. In 2007, ALR’s mission shifted to focus on physical activity among children, to align with the Robert Wood Johnson Foundation’s (RWJF) then-new goal of reversing the childhood obesity epidemic by 2015. This new phase of ALR (ALR-2) focused on building a research field and evidence base to help reduce childhood obesity, and to accelerate the use of this evidence in informing policy and practice.

Below are highlights from two new papers in the AJPM by Barker et al. and Sallis et al., which report on progress across the 10 years:

  • ALR built a diverse and productive cadre of grantees representing 31 different disciplines.
  • ALR placed a lot of value on supporting the career development of younger, up-and-coming researchers and researchers from historically underrepresented backgrounds. As a result, more than a quarter of grantees were in the early stage of their careers, and 39% of these were people of color.
  • 30 studies focused specifically on African American, Latino, or lower-income groups, which are at highest risk of obesity.
  • Grantees have been quite prolific and reported a total of 309 publications as of 2011, and leveraged $127 million in additional research funds from other agencies.

The biggest change between ALR-1 and ALR-2 was an intentional strategy to expand and speed-up the use of research in informing policy. ALR published a total of 20 research briefs and syntheses on schools, parks and recreation, transportation, disparities, and the economic benefits of walkable communities. A revamped more user-friendly website, a bi-monthly e-newsletter, the Move! Blog, webinars, Facebook and Twitter pages, and research translation grants greatly increased the amount and frequency of evidence distributed.

Grantees have been very active in sharing their research with policymakers, advocates, and practitioners, with 41% of grantees reporting communication with an end-user during 2010. Across the 10 years, there were 62 cases of evidence informing policy or practice, with 50% of these resulting in an actual policy or practice change, mainly at the local level.

The program itself also made some significant policy impacts, such as helping shape the National Physical Activity Plan, and supporting initiatives in California and Virginia to mandate minimum minutes of physical activity in schools.

It’s almost 2015, RWJF’s target date for reversing childhood obesity. ALR is honored to have helped move the country toward this goal. But much work remains to be done, so we ask you to help us continue communicating the best state-of-the-science strategies for reducing childhood obesity as broadly as possible.

— Debbie Lou, PhD

Debbie Lou, PhD, ( is the Program Analyst with Active Living Research, where she translates and disseminates evidence on how policies and environments can promote physical activity. Debbie has a background in sociology with a focus on social justice issues.

The Final Frontier: Medicating the Corporation

December 31, 2013

23796316-happy-new-year-2014-greetingsSocial dilemmas are situations where collective interests are at odds with private ones. Neurobiology, culture, trust and social value orientation are among the factors that can influence how cooperatively people behave in social dilemma circumstances.

Social value orientation (SVO) is rooted in social psychology and is defined as a person’s preference about how to allocate resources between himself and others.  It corresponds to how much weight a person attaches to the welfare of others in relation to one’s own. The general concept underlying SVO is inherently interdisciplinary, and has been studied under different names in a variety of scientific fields.

According to Professor Paul van Lange, when people seek to maximize their gains, they are said to be proself. but when they are also concerned with other’s gains and losses, they are said to be prosocial. People with a prosocial orientation aim for joint outcomes and equality in outcomes, and tend to cooperate in social dilemmas. People classified as individualistic, however, primarily pursue their self-interest and try to maximize their own (absolute) outcome. People with a competitive tendency, like individualists, try to maximize their own outcomes, but they also seek to minimize the outcomes for others. They want to achieve relative advantage over others.

Social value orientation is associated with fundamental characteristics such as people’s political orientation, their attitude toward procedural justice, and how “socially mindful” they are in their behavior toward others. About 50%­–60% of people have a prosocial orientation, 20%–30% are individualists, and only 10%–15% are competitors. Competitors, however, receive vastly disproportionate prominence and attention, especially in countries such as the United States, where competitive metrics are the norm in business and entertainment.

Antisocial personality disorder, also called dissocial personality disorder, is a condition in which a person’s ways of thinking, perceiving situations and relating to others are dysfunctional. It results in a pervasive pattern of disregard for others and may include an impoverished moral sense or conscience.

The WHO International Statistical Classification of Diseases and Related Health Problems defines dissocial personality disorder to include the following characteristics:

  1. Callous unconcern for the feelings of others;
  2. Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
  3. Very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
  4. Incapacity to experience guilt or to profit from experience, particularly punishment;
  5. Marked readiness to blame others or to offer plausible rationalizations for the behavior that has brought the person into conflict with society.

A legal fiction is a fact assumed or created by courts, which is then used to apply a rule that was not necessarily designed to be used in that way. A common example is a corporation, which is regarded in many jurisdictions as a “person.” Corporate personhood is the legal concept that a corporation may be recognized as an individual in the eyes of the law.

The term “fiduciary” refers to a relationship in which one person has a responsibility of care for the assets or rights of another person. In a corporation, the board of directors, as a body, has a fiduciary responsibility for the decisions they make with regard to corporate assets and the rights of stockholders. The directors must always act in good faith, use their best judgment, and do their utmost to promote the corporation’s interests.

When we apply the legal fiction of corporate personhood, the exclusive focus on the interests of the corporation is obviously a proself orientation, and specifically a competitive orientation. With a capital C, that rhymes with T, and that spells Trouble.

In economics, an externality is a cost or benefit, which affects a party who did not choose to incur that cost or benefit. Air pollution is a readily understood example. When car owners use roads, they impose congestion costs on others, with negative externalities that include pollution, noise, carbon emissions, and traffic accidents. High healthcare costs and decreased productivity are just some of the negative externalities of the obesity epidemic. Excessive antibiotic use contributes to antibiotic resistance, thus reducing the future effectiveness of the drugs for everyone. And pharmaceutical company drug pricing policies and their focus on variations to existing drugs rather than new drugs for today’s health challenges result in externalities of disease burden and high mortality rates.

The commons dilemma is a specific class of social dilemma in which people’s short-term selfish interests are at odds with long-term group interests and the common good. How can it be mitigated?

Nobel prize winning economist Amartya Sen declares that market decisions will not account for externalities unless the decisions are forced on them by regulation, or unless they are influenced by taxes and subsidies and other added incentives of public finance. (Sen holds little hope for “huge changes in human mentality that make people think about the lives of others even when their own lives are not endangered.”) This implies that market decisions on public health will be continue to be based on completely wrong indications of the real costs and benefits.

A recent paper on school food in Mexico is illustrative.  In Mexico, schools have long been promoting the sale of unhealthy foods, and researchers studied stakeholders’ perspectives on proposed regulations that would address the situation. They got input from academics, parents, citizens, health professionals, and the food industry. For academics, citizens and health professionals, the primary issue is obesity, while for parents it is the health of children. The food industry did not contest the claim that the foods were unhealthy, but opposed regulation because it would cost income and jobs. They demanded policies aimed at families that included nutrition education and physical activity. The food industry also rejected the narratives and perspective of other stakeholders—improve the food environment and share responsibility—espousing instead the standard narrative of personal responsibility.

In this example, the collective “person” of the food industry exhibits textbook dissocial personality disorder. When corporate interests conflict with social or collective interests, the corporate entity often displays a “gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations.” It professes to have no choice under fiduciary responsibility, claiming to be structured to ignore other constituencies such as customers, the economy of the state, the region, and the nation, or to accommodate community and societal considerations.

Coordinated change among consumers and business is vital to make progress toward a healthy and sustainable life. Government must drive progress by taking a leadership role in setting out long-term policies that unite health, environment and economic goals. We deserve nothing less.

This is my final blog for AJPM. I have enjoyed sharing my thoughts with you over the past year, and I hope they stimulated your thinking and talking about health. Thank you for reading.  Stay well.

—Michael Lytton, AJPM Blog Editor

Taking Stock of Health in 2013

December 30, 2013

Another fascinating year in public and global health has passed. We are riding the whirlwind of multiple transitions that impact health, including:

  • FatherTimePrevAn aging population.
  • Widespread health illiteracy.
  • Increasing levels of dementia and mental illness, with ever-expanding public and private costs. Mental health must be integrated into healthcare delivery.
  • Changes in the burden of disease and an epidemiological shift from infectious diseases associated with underdevelopment to chronic diseases associated with longevity and urban lifestyles.
  • Malnutrition linked not only to famine and starvation, but also to high-calorie, low-nutrient diets in the developed world. As Margaret Chan, Director-General of the World Health Organization, commented recently, “It is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, and Big Alcohol.” The enormity of the problem is illustrated by the fact that the food industry is three times bigger than the tobacco industry. Fast food advertising in 2012 was $4.6 billion; energy drinks another $281 million.
  • New and re-emerging diseases evolving to become drug resistant.
  • Stubborn global inequalities in access to food, sanitation, vaccines and health care. For every eight people in the world today, one still goes to bed hungry, and despite advances in biomedical technology and capacity to enhance the quality of health care and prevention, the poor and disadvantaged suffer a vastly disproportionate burden of illness and disease.

Infectious diseases (especially HIV/AIDS) continue to pose a major threat to health, particularly in our interdependent and interconnected world. Moreover, the threat posed by infectious diseases will grow, as up to 2 billion people are projected to be living in dense urban slums by 2030.

Noncommunicable diseases such as diabetes, heart disease, stroke and cancer are now the leading case of death in the world. Described as the invisible epidemic, there is no single cure or cause for NCDs, but the common modifiable risk factors include poor diet, obesity, and inactivity. Poor education and low incomes are associated with rising NCDs in both developed and developing countries, and poor and disadvantaged populations have the highest rates of NCDs in high-income countries.

Exciting research continued apace in 2013. For example: we are rapidly expanding our understanding of the many roles that the microbiome plays in human health and disease; work is underway on a method to quickly identify antibiotics that can treat multidrug-resistant bacteria; a study suggests that sleep helps restore the brain by flushing out toxins that build up during waking hours; and a malaria vaccine was found safe and protective in an early-stage clinical trial.

Delivering basic vaccines remains one of the top priorities of the Bill and Melinda Gates Foundation. Bill is passionate about giving 22 million children who do not have access to lifesaving vaccines a healthy start to life. “We live in a world where we have the power to correct this injustice. We have the knowhow to produce effective vaccines, make them affordable, and deliver them to the children who need them.” He cites the invaluable part played by emerging country vaccine suppliers, who have become leaders in supplying the world with high-quality, low-cost vaccines, calling them “our most valuable partners in global health.”

The visionary and inclusive approach of the Gates Foundation is instructive. Many social factors play decisive roles in determining the health of individuals and communities, and solving social dilemmas and addressing the many social determinants of health requires multi-stakeholder perspectives.

In the United States, inequality has finally emerged as a focus of debate, where too many citizens live in economic fear. This reality is a product of such government actions as the recent failure to extend the Emergency Unemployment Compensation program, cutting off in the New Year 1.3 million people who had been receiving assistance. This shameful decision will affect jobless workers in every state, with an estimated 4.9 million workers missing jobless benefits by the end of 2014. Similar examples abound.

Public health will be among the casualties of such misgovernance, and will serve as a reminder that healthier lifestyles are a responsibility not just of individuals but also of societies as a whole. It should come as no surprise that trust in Congress among U.S. citizens dropped from 42% in 1973 to 10% in 2013. And in the face of frequent consensus in narratives and perspectives for many stakeholders, the issue is often not lack of awareness as much as lack of voice; too many conversations are closed to too many people.

The power of organizations that benefit from the status quo often outweighs desires for reform. Vested interests employ thousands of lobbyists in Washington to help members of Congress “understand the issues.” The pharmaceuticals and health products sector spent  $171 million on lobbying in 2013, the agribusiness sector bestowed  $111 million, and the food and beverage industry paid lobbyists $21 million. Meanwhile, the vegetables, fruits, and tree nut industry spent $3 million, and a pharmaceutical partnership contributed $112,500 to lobbyists to “fight chronic disease.”

Trust is an essential component of effective policymaking because it bestows legitimacy, and facilitates greater public willingness to abide by decisions and proposals made by politicians. A good example of broken trust is anxiety about the consequences and motivations of large-scale vaccination programs.

Disillusionment and skepticism underlie the increasing difficulty of governments to engage in conversations about values-based principles that transcend more populist, day-to-day political agendas, and strive to articulate a broader vision for society. Nevertheless, as Bill and Melinda Gates demonstrate, we cannot try to solve social dilemmas in isolation, as if politics, economics, technology, education, hunger, unemployment, science, depression, health system disparities, and power differentials are all disconnected from each other.

Happy New Year anyway, with a final word later in the week.

— Michael Lytton, AJPM Blog Editor

A Conversation with the Tooth Fairy

December 17, 2013

We were delightfully surprised to get a call from the office of the Tooth Fairy last week, and here are the highlights from that conversation.tooth fairy

TF:      Thanks for taking this impromptu call, but I needed to get a few things off my chest. You can imagine my schedule, what with all the dimes under the pillows and whatnot, and a lot of other responsibilities and issues that demand my attention.

AJPM: Such as?

TF:      Access to oral health, disease and injury prevention, and the link between oral health and general health are my top priorities right now. It’s really keeping my policy wonks busy. And don’t get me started about oral health literacy or those fruitcakes still arguing about fluoridation. You saw what happened in Portland, Oregon in May? That’s the fourth time they’ve rejected community water fluoridation since 1956, and each time they get the science wrong. It’s making me crazy.

AJPM:  Yes, Portland’s regular rejection of an evidence-based public health measure is a bit puzzling, but they are known for their eccentricities.

TF:      Eccentricities, my pouch of dimes! Of the 30 largest cities in the U.S., Portland is the only one that doesn’t fluoridate its drinking water to help prevent tooth decay!

By the way, did you see the latest study on fluoridation in the Journal of Dental Research? Good stuff. Don’t forget that the CDC calls fluoridation one of the 10 great public health achievements of the 20th century, and it’s endorsed by the biggies like the AMA and the WHO. What more do those fact-free thinkers in Portland need?

And speaking of the CDC, what’s with states not developing Oral Health Plans? 18 states have no plan! This also is making me crazy. Washington, DC is among those without a plan, which doesn’t surprise me, but what’s up with the rest? Pathetic. Get with the program! The CDC can help, so there’s really no excuse. And remember, more young children suffer from tooth decay than from any other chronic condition, including asthma.

AJPM: Good point. You mentioned access to oral health. What does this mean in practical terms?

TF:      It’s simple to say, harder to do; kids, teenagers, adults, and seniors can find and see a dentist when they need to, and everyone can afford it. That means enough dentists relative to the population, and a way for poor folks to pay for dental services.

Poverty is no fun, and to add to the misery financially strapped families, for a bunch of reasons, have higher rates of tooth decay. I don’t want to bore you with statistics, but close to one in four kids living in poverty have untreated decay, as do 42% adults aged 20–64, and the occurrence of untreated decay is nearly three times greater among adults aged 65 and over living in poverty. So far, too many publicly funded programs don’t cover oral health care for adults with low incomes.

It’s probably news to you that more than one-third of older adults aged 65–74 living below the federal poverty level are without teeth. Any idea what that means? Poor chewing efficiency can limit food choices and diminish the pleasures of eating. Being without teeth might also change your physical appearance and even affect speech. Folks report oral pain, food avoidance, and self-consciousness or embarrassment because of their mouth, teeth, or dentures. Social contact and intimacy can be restricted and your self-esteem can take a nosedive. In a nutshell, your quality of life suffers.

AJPM:  Yikes.

TF:      That’s not all. The medical, functional, emotional, and social consequences of oral health makes it an important contributor to overall health for individuals and the population. To take just one example, tooth loss among older people has been shown to be associated with both weight loss and obesity—often as a result of avoiding some foods and eating easier-to-chew junk food. Appropriate oral treatment would not only enhance quality of life but also encourage healthier eating patterns that could result in improved long-term health.

While on my soap box, I’ll argue that oral health must be better integrated into medical care. People reporting poor health are significantly more likely to have multiple chronic conditions (including oral health problems), but because these folks are more likely to visit a physician than a dentist, it’s important that clinicians recognize common oral conditions and risk factors, and refer the patient for subsequent treatment. Oral health care must be regarded as a specialty like cardiology, neurology, or internal medicine, rather than distal to general health.

Which reminds me, when are those health literacy people going to address jargon like “dental caries” and “edentulous” when they mean tooth decay and no teeth? It’s enough to bring back my bruxism. I must remember to send a stern memo to the IOM.

AJPM:  Thanks very much Tooth Fairy for sharing your thoughts, and keep up the good work.

— Michael Lytton, AJPM Blog Editor


Further Reading:

Dye BA, Li X, Beltrán-Aguilar ED. Selected Oral Health Indicators in the United States, 2005–2008. NCHS data brief 96. 2012.

Dye BA, Li X, Thornton-Evans G. Oral Health Disparities as Determined by Selected Healthy People 2020 Oral Health Objectives for the United States, 2009–2010NCHS data brief 104. 2012.

Lin M, Sappenfield W, Hernandez L, Clark C, Liu J, Collins J, Carle AC. Child- and State-Level Characteristics Associated with Preventive Dental Care Access Among U.S. Children 5–17 Years of Age.  Matern Child Health J 2012;16 (Suppl 2):320–9.

Griffin SO, Jones JA, Brunson D, Griffin PM, Bailey WD. Burden of Oral Disease Among Older Adults and Implications for Public Health Priorities. Am J Public Health 2012:102(3):411–418.

Malvitz DM, Barker LK, Phipps KR. Development and Status of the National Oral Health Surveillance System. Preventing Chronic Disease 2009;6(2).

Selwitz RH, Ismail AI, Pitts NB. Dental Caries. Lancet 2007;369(9555):51–9.

Bader JD, Rozier RF, Lohr KN, Frame PS. Physicians’ Roles in Preventing Dental Caries in Preschool Children: A Summary of the Evidence for the U.S. Preventive Services Task Force. Am J Prev Med 2004;26(4):315–25.

Truman BI, Gooch BC, Evans CA, Jr. The Guide to Community Preventive Services: Oral Health. Am J Prev Med 2002;23(1 Suppl 1):1–2.

Treadwell H, Ro M. Community-Based Oral Health Prevention: Issues and Opportunities. Am J Prev Med 2002;23(1 Suppl):8­­–12.

Stavisky J, Bailit H. The Robert Wood Johnson Foundation’s Response to Improving the Nation’s Oral Health. Am J Prev Med 2002;23(1 Suppl):13­­–15.

The Bigger Picture

December 9, 2013

Recently the IOM Roundtable on Health Literacy convened a workshop titled Implications of Health Literacy for Public Health, which included a presentation on a San Francisco program in which youth speak to youth about diabetes. The Bigger Picture Campaign is an anti-diabetes multimedia project; a collaboration between the UCSF Center for Vulnerable Populations and Youth Speaks, the leading nonprofit presenter of spoken-word performance, education, and youth development programs in the country.bigger-picture-logo

The campaign is designed to raise awareness about the social and environmental factors that have led to the explosive rise of type-2 diabetes in California. Its health literacy innovations include peer-to-peer communication, high-quality video public service announcements, eloquence and poetry, and frank messages about the social determinants of health. Check it out here, and if you have time to watch only one of the public service announcements, make it “Health Justice Manifesto,” a compelling wakeup call. The lack of healthy food choices and opportunities for physical activity in poor communities are key messages.

In addition to producing 11 public service announcements that are available on the Web, there have been 15 school assemblies, and the development of an educators’ toolkit, a free resource for educators and students to learn more about type 2 diabetes.

The plan is to take the program statewide in California, starting with such high priority areas (with large underserved communities) as Stockton, Richmond, and the Inland Empire, and eventually introduce it across the country. The presentations are potent, but to reach a wide audience, school administrators, nurses, wellness coordinators, and teachers must ensure that students have the opportunity to see and hear the campaign messages.

Last week the IOM conducted another workshop, this one for the Roundtable on Population Health Improvement and the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities. The daylong meeting examined the history and sociology of social change movements, with an aim to identify key elements of a theoretical and practical framework for movement building. This fundamentally political agenda is consistent with the San Francisco awareness program that also wants to change people’s thinking and priorities. And both workshops fit within the contextual bigger picture of social determinants of health.

Whether past social movements have relevant lessons to current population health crises or if information, no matter how it is packaged and delivered, is sufficient to mobilize effective action against broad social determinants of illness are issues for debate. Richard Carmona, the 17th Surgeon General of the U.S., describes the ‘trauma of politics’ in this country and issues a stern warning. “As Surgeon General I also realized that most of the disease and economic burden we incurred as a nation were preventable, but that the trauma of politics was a confounding variable that prevented us from addressing many of the issues in a timely, nonpartisan, evidence-based, scientifically driven manner.”

Can we acknowledge this part of the bigger picture, and if so do anything about it? Eventually. Maybe.

— Michael Lytton, AJPM Blog Editor

Further Reading in AJPM:

Carmona R. The Trauma of Politics: A Surgeon General’s Perspective. Am J Prev Med 2013;45(6):742–4.

Moulton AD, Albright AL, Gregg EW, Goodman RA. Law, Public Health, and the Diabetes Epidemic. Am J Prev Med 2013;45(4):486–93.

Ramirez AG, Ayala GX. Addressing Latino Childhood Obesity Through Research and Policy: Findings from the Salud America! Experience. Am J Prev Med 2013;44(3 Suppl):S173–296.

Kraak VI, Story , Wartella EA. Government and School Progress to Promote a Healthful Diet to American Children and Adolescents: A Comprehensive Review of the Available Evidence. AM J Prev Med 2012;42(3):250–262.

Kraak VI, Story M, Wartella EA, Ginter J. Industry Progress to Market a Healthful Diet to American Children and Adolescents. Am J Prev Med 2011;41(3):322–33.

Social Determinants of Health: Us and Them

November 27, 2013

The United Kingdom and the U.S. present strikingly different approaches to the social determinants of health (and illness). Health care is just one determinant of population health, along with factors that include social protection, access to employment, and supportive conditions for parenting, education, and family-building.

I previously mentioned the recent (October 30) WHO review of social determinants and disparities in the European region. The WHO takes a holistic view of social determinants of health, stating frankly that the lower health status of the poor, and the social gradient in health between and within countries, is caused by unequal distribution of power, income, goods, and services. The results are inequities in the immediate, visible circumstances of people’s lives—their access to health care, the quality of schools and access to higher education, their conditions of work, leisure, homes and neighborhoods, and the degree of protection from disadvantage or economic calamity as a result of ill health.

The WHO is blunt in describing the structural determinants and conditions of daily life that are responsible for a major part of health inequities. “This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.”

Poverty is especially salient, illustrated by the emerging research on the relationship between safety-net programs and toxic stress and its long-term consequences. Poverty, joblessness, and economic insecurity are a daily reality for many Americans. Long-term unemployment reached its highest levels on record in 2010, and today 36% of all unemployed workers (4.1 million) have been out of work for more than half a year. The minimum wage has been allowed to erode and is now 20% lower, after adjusting for inflation, than in the late 1960s. 17.6 million households experience food insecurity, and the Supplemental Nutrition Assistance Program (SNAP—formerly the Food Stamp Program) has 47 million participants. More than 90% of SNAP benefits go to families living below the poverty line and nearly two-thirds of the recipients are children, elderly, or disabled.

In this context, the U.S. House of Representatives has proposed cutting food stamp benefits by $40 billion over 10 years. These so-called hard-choice austerities would be in addition to the $5 billion in cuts that went into effect on November 1, when increases to SNAP that were included in the 2009 stimulus law were allowed to expire.

What can one say? Nicholas Kristof in an article for the New York Times describes Congressional slashing of food stamp benefits as “a mark of shortsighted cruelty.” Kristof also provides the assessment of Dr. Irwin Redlener, professor of pediatrics at Columbia University and president of the Children’s Health Fund: “The cutback in food stamps represents a clear threat to the nutritional status and health of America’s children. ”

Nobel Prize winning economist Joseph Stiglitz responded along similar lines:

There is no economic justification: The [farm] bill actually distorts our economy by promoting the kind of production we don’t need and shrinking the consumption of those with the smallest incomes. There is no moral justification either: It actually increases misery and precariousness of daily life for millions of Americans….[It] clearly harms both America’s children and the world’s in a variety of ways. For these proposals to become law would be a moral and economic failure for the country.

The federal actions in the U.S. are confounding, especially in comparison to responses beyond our borders. In 2005, in the spirit of social justice, the WHO established a Commission on Social Determinants of Health, publishing a final report in 2008. The Commission compiled evidence on what can be done to promote health equity, and identified three guiding principles of action: (1) acknowledge that there is a problem and ensure that health inequity is measured; (2) improve the conditions of daily life; and (3) tackle the inequitable distribution of power, money, and resources.

In Britain, the Secretary of State for Health commissioned an independent review of health inequalities, a project led by Professor Sir Michael Marmot, and in early 2010 a report Fair Society, Healthy Lives (the “Marmot Review”) was published. The recommendations of the Marmot Review focused on actions that could be taken outside the healthcare system to reduce health inequalities. Activities across the UK were undertaken on local implementation of the Review recommendations, and in 2011, the Institute of Health Equity was launched to support efforts to tackle inequalities in health.

The following year, Director-General Margaret Chan addressed the WHO Executive Board and emphasized the goal,

We want to see better health and well-being for all, as an equal human right. Good policies that promote equity have a better chance. We must tackle the root causes [of ill health and inequities] through a social-determinants approach that engages the whole of government and the whole of society.

Also in 2012, Dr. Cecil Wilson, the current president of the World Medical Association and former president of the AMA stated in his inaugural presidential address that a theme of his presidency was the social determinants of health.

In Britain, meanwhile, they rejected the common response of weary reluctance to the evidence on social determinants of health—it is simply all too difficult, or politically dangerous to face social and economic factors—the causes of the causes. Bravely moving forward, the Institute of Health Equity released a remarkable report in March 2013, its plain title hiding radical intent, Working for Health Equity: The Role of Health Professionals. This report focuses on actions and strategies that can be developed within the healthcare system, and particularly by the health workforce, where it is demonstrated there is abundant scope for effective action.

Royal Colleges and other organizations were asked to provide statements for action to give practical guides for health professionals to develop and use in their roles. The result was an enthusiastic response, with 19 statements for action provided by the following professional groups:

  • Nurses
  • Social workers and social care
  • Clinical Commissioning Groups
  • General practitioners
  • Pediatricians
  • Midwives
  • Obstetricians and gynecologists
  • Hospital doctors
  • Dentists and oral health teams
  • Psychiatrists
  • Medical students
  • Allied health professionals
  • Music therapists
  • Dieticians
  • Occupational therapists
  • Physiotherapists
  • Speech and language therapists
  • Paramedics
  • Radiographers

The report offers compelling evidence of how much the health system can do to influence wider social and economic conditions beyond ensuring equity of access and treatment. Britain is proving that those working within the health system have an important (but often underutilized) role in reducing health disparities through action on the social determinants of health.

Kudos. Definitely the Brits should keep calm and carry on. While we in the U.S. could at least try to do less harm.

—    Michael Lytton, AJPM Blog Editor

Further Reading in AJPM:

Marmot MG, Bell RG. Improving Health: Social Determinants and Personal Choice. Am J Prev Med 2011;40(1S1):S73–7.

Miller WD, Braveman PA, Williams DR, Kumanyika SK, (eds). Strong Medicine for a Healthier America. Am J Prev Med 2011;40(1S1).

The Early Years: A Path to Wellness or a Path to Illness

November 20, 2013

A catastrophe on the scale of the Philippines typhoon focuses critical attention on the susceptibility of poor and vulnerable populations to natural disasters. Yet, it is no less important to remember that poor and vulnerable populations, particularly children, are susceptible to shocks and health risks on a regular basis wherever they live.

Photo courtesy of Heinrock

Photo courtesy of Heinrock

In the late 1990s, Vincent Felitti and Robert Anda conducted a landmark study that examined the effects of adverse childhood experiences (ACEs)—including abuse, neglect, domestic violence, and family dysfunction—and found a persuasive connection between the level of adversity faced and the incidence of many health and social problems. The first article from the Adverse Childhood Experiences (ACE) Study was published in AJPM in 1998. It struck a deep chord and has been one of the most cited papers and requested full-text articles from the Journal in the past 15 years.

More recent articles by the authors include: Building a Framework for Global Surveillance of the Public Health Implications of Adverse Childhood Experiences (2010), and Adverse Childhood Experiences and the Risk of Premature Mortality (2009).

There is now a collective body of evidence suggesting that childhood traumatic stressors (“toxic stress” is the term used at the Center on the Developing Child at Harvard University) represent a common pathway to a variety of long-term behavioral, health, and social problems. There is growing acceptance that childhood abuse and other adverse childhood experiences are overlapping risk factors for long-term adult health problems and that the accumulation of these adverse experiences increases the risk of poor adult health.

Social determinants such as neighborhood economic distress and disadvantage, housing inadequacy, low social capital, poverty, low parental education, and lack of social support are all associated with child maltreatment. Community adversity alone exerts a persistent influence through a sequence of adverse social, behavioral, and psychological experiences (a chain of insults) that in turn contribute to adverse health outcomes.

Extensive biological and developmental research also shows that significant neglect—the ongoing disruption or significant absence of caregiver responsiveness—can cause more harm to a young child’s development than overt physical abuse. The consequences include subsequent cognitive delays, impairments in executive functioning, and disruptions of the body’s stress response.

And traumatic experiences in early life can not only leave emotional scars and developmental impairment, they appear to leave a genetic mark as well. Children who are physically abused and bullied tend to have shorter telomeres—structures at the tips of chromosomes whose shrinkage has been linked to aging and disease. Researchers have found associations between stress and accelerated telomere loss, and shortened telomeres correlate with several health problems, including diabetes, dementia, and fatigue. The findings are suggestive, but much more work needs to be done.

That children need to be protected is unarguable, but how to do so is open to debate. Britain and the United States are taking very different paths, a topic that I will explore in the next blog.

— Michael Lytton, AJPM Blog Editor


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