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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.

Tuberculosis in the limelight

May 22, 2014

While it is only two months past World TB Day 2014 celebrating when the late Dr. Robert Koch discovered Mycobacterium tuberculosis on March 24, 1882, I thought it would be important to transmit a couple of TB-related ‘events.’ First, I wanted to highlight David Scales et al. research letter to the May Edition of AJPM, pointing out the importance of having county-level TB data (http://www.ajpmonline.org/article/S0749-3797(14)00082-8/fulltext). Many of us may not know that such data, i.e. the CDC’s Online Tuberculosis Information System (OTIS), only provides state-level public surveillance data because of an agreement between the CDC and the states. However, county-level information would enable those in the field to identify sub-state TB clusters, which would assist public health efforts to halt the spread of TB across counties and states.

Yesterday, at the Detroit Medical Center, Dr. David Kissner, Medical Director of TB Clinical Services at the Institute of Population Health gave a wonderful talk and webinar on TB identification geared towards primary care physicians (PCPs). It was very informative and clinically profound, providing attendees with many case examples, with chest x-ray images to train the eyes of us working in primary care. Far too often, we physicians, as PCPs, miss these cases. Would it not be warranted that clinicians be alerted to TB clusters in their county or in relevant counties, rather than only non-specific state-wide alerts? Again, we realize the importance of county-level data.

We should know when and how to test for TB. Those at risk of exposure to or infection with TB initially need simply a TB skin test, but it is important to note that the induration of 5 or more millimeters is what is concerning, not an erythema of even 10 mm. The redness means nothing!

The radiological skill to detect TB, i.e. the mediastinal/hilar lymphadenopathy and the infiltrates with the classic lucent cavitations, are classic, easy to read, but easy to miss for the untrained and unprepared! I encourage all PMRs to attend Dr. Kissner’s webinar as well as to support efforts to make county-level data more accessible so that we can be prepared! You can register for Dr. Kissner’s webinar at http://miphtcdev.web.itd.umich.edu/trainings/tb-primary-care-find-it-recognize-it-and-know-what-do-webcast#.

The 14th Annual Michigan Communicable Disease Conference

May 19, 2014

Preventive medicine residents from the University of Michigan Program travelled north on Thursday to Bay City, Michigan to join the largest meeting of the state’s infectious disease epidemiologists and public health staff. While the trip up there was gloomy, cold, and rainy, when we absorbed the first presentation on the impact of medical history on public health and its upstream path, it seemed only symbolic of where we started. The progress we made in sanitation, sewerage and infection control, with the infamous Great Stink from the Thames that forced London MPs to meet outside of London, to the situation we are in now, was immense. However, as the meeting went on, we realized there were many challenges that we continue to face as a nation and in Michigan, specifically.

The presenters noted that:

  1. Carbapenem-Resistant Enterobacteriaceae (CRE) infections are increasing. That there is a potential threat from community spread and that the treatments available are extremely limited, with pan-resistant strains identified.
  • The importance of hand hygiene and contact precautions were highlighted. There was some good news with 51 cases in Michigan that were prevented.
  1. There is a Methicillin-Resistant Staphylococcus Aureaus (MRSA) and Clostridium Difficile Prevention Initiative, a collaborative between the Michigan Department of Community Health, Michigan Society for Infection Prevention & Control, and others to integrate evidence-based practice to reduce MRSA/CI in Michigan.
  • Monthly data collection from acute care centers and skilled nursing facilities and conference calls to communicate updates between collaborators has been ongoing since 2011.
  1. There has been a Hepatitis A outbreak in several counties in Michigan, of unknown source.
  2. Patterns of hospitalizations in Michigan for influenza has been found to be similar to national patterns.
  3. High rates of undervaccination in Michigan likely related to a high number of waivers. Michigan has the 4th highest number of waivers in the nation.
  4. There was a measles outbreak in Midland County in an unvaccinated family.
  5. Hepatitis C (HCV) diagnosis and treatments are underfunded from Medicaid, not matching increasing incidence and mortality rates and future expectations from HCV infection. The number of confirmed cases in Michigan have risen more than 50% since 2004. The number of young adults (18-25 years) is rising, so it is not just a cohort effect from those who were infected in the 1960s.
  • It is essential to incorporate measures of deduplication in HCV surveillance to ensure not counting cases more than once.

All in all, this was a great opportunity to learn of our state’s public health with regards to communicable disease. Though we were left concerned with several issues, for example the withdrawal of Medicaid funding for newer HCV treatments, our outlook and awareness improved markedly on our way back, as with the weather!

A lesson in cancer prevention from New York

May 8, 2014

In the March Supplement issue of the AJPM, Heather L.M. Dacus and colleagues at the New York State Department of Health (NYSDOH) in Albany, in collaboration with the CDC, describe a successful cancer prevention program conducted in two NYS counties.

Their program illustrates an important role of preventive medicine physicians in being the ambassadors of individual patient care to the population, here specifically in cancer prevention. Thus, known risk factors of cancer, such as tobacco use, poor nutrition, and sedentary lifestyle, as individual-level risk factors, are tackled at a population level for the most effective response. Isn’t this why we entered preventive medicine and public health in the first place?! We are in a unique position to implement tremendous positive change!

 

The study focused on the effects of a “common framework” with Division of Chronic Diseases at the NYSDOH, to enhance coordination and cooperation between different programs across the Division.

The NYSDOH carried out two community demonstration projects to “mobilize communities to be supportive of strategies that focus on policy, system, and environmental changes in order to reduce the risk of cancer among community residents.” Via existing (and strong) county community coalitions which consists of varied partners ranging from health care providers to local businesses, with support of the NYSDOH, each participant carried out respective roles in implementing evidence-based strategies to improve the population health of the community.

Beginning in January, 2013, these coalitions conducted three cancer prevention initiatives:

  1. Environmental change: increasing access to nutritious foods by improving food-procurement standards, with an aim to reduce obesity and, thus, contribute to cancer prevention.
  2. Systems change: eliminating formula feeding promotion in selected pediatric and obstetric offices so as to promote breast feeding. Breast feeding is linked with lower rates of childhood obesity and breast and ovarian cancer in breast-feeding mothers.
  3. Policy change: cooperating with municipalities (at least one) to improve leave policy of workers to remove obstacles to receiving timely routine cancer screening.

 

While evaluation of the program is essential in the long-term and we look forward to the authors publishing a follow-up, the first 6 months of the project have demonstrated successful implementation of key activities in the domains enumerated above, to a great extent.

NY has 106,000 cancer cases a year. While we, in Michigan, have only 53,000 (based on 2007 statistics: http://www.michigan.gov/documents/mdch/Ca_burden_MI_select_stats_1993-2011_371092_7.pdf), we also have about half the population of NY. For those of us currently doing or will be doing the rotation at the state-level (Michigan state) here, this article serves as an excellent model and resource as we evaluate our own cancer prevention/promotion approaches.

Welcome to the [updated 2014] official AJPM blog

April 30, 2014

As the current resident editor of the American Journal of Preventive Medicine (AJPM), it is with great pleasure that I am tasked with reigniting the official AJPM blog. The AJPM fellowship/resident editorship rotation for preventive medicine residents (PMRs) at the University of Michigan School of Public Health and the home of the AJPM editorial office has just been launched. Thus, I and the editorial team of the AJPM are beta testing this rotation! One of the experiences we will have (for the duration of the rotation, which varies) is to take a leading role in the AJPM blog, via writing weekly blog and post-blog articles.

ImageThe goals of the AJPM blog, which is currently PMR-led, are multiple:

  1. To provide a platform for PMRs all over the country to discuss their experiences in their respective residency programs. We plan to conduct additional activities to improve outreach to other PMR programs to hopefully increase resident, residency director, and resident alumni participation and contribution to the blog.
    Specifically, based on my own conversations with fellow PMRs, we welcome PMR-contributions discussing experiences with their rotations, particularly ones that are not necessarily program or city/state specific. Thus, national and international rotations are of great interest. Websites exist (e.g., http://www.globalmedicine.org/ GMN/residentsection.htm) that discuss potential organizations that could provide PMR rotations, but actual resident experiences in such rotations are, to my knowledge, lacking. I will certainly describe my own experience at the AJPM Fellowship rotation come the end of May.
  2. To identify and post job openings, career opportunities, new rotation sites, grant opportunities, etc…
  3. To provide a forum to network with fellow PMRs and/or preventive medicine investigators for potential research collaboration.
  4. Last but not least, to provide a platform for residents to talk about miscellaneous things related to their life as a resident in preventive medicine and/or after graduation from their program.

You may send blog ideas to: ajpm-blog@umich.edu. Thank you and I welcome your responses and ideas!

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, (dlou@ucsd.edu) 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

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