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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.
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.
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
The CDC, WHO, and the UN Road Safety Collaboration encourage governments and nongovernmental organizations worldwide to commemorate November 17, 2013, as the World Day of Remembrance of Road Traffic Victims. The aim is to draw the public’s attention to motor vehicle crashes, their consequences and costs, and prevention measures. Automobiles, in their capacity to kill and injure, their resource depletion and emissions, their dominion over our landscapes, and their exclusion of healthier forms of transportation are surely among the most dangerous things ever produced by the human imagination.
Road crashes kill nearly 3,500 people each day and injure or disable 50 million each year around the world. Road traffic crashes are the leading cause of death among people aged 10–24 years worldwide and the leading cause of death among those in the first three decades of life in the U.S.
On November 14, just in time for the Day of Remembrance of Road Traffic Victims, the National Highway Traffic Safety Administration (NHTSA) released its Fatality Analysis Reporting System data. In 2012, 33,561 people died in motor vehicle crashes in the U.S., and another 2.36 million (estimated) were injured. These figures represent 3.3% more deaths than in 2011—the first increase in fatalities since 2005—and 6.5% more injuries, the first statistically significant increase since 1995.
For decades males have consistently comprised about 70% of motor vehicle fatalities. And in 2012 there were 10 times (1,858 versus 178) as many unhelmeted motorcyclist fatalities in states without universal helmet laws. No surprises in either case.
Of victims not in motor vehicles, fatalities among pedestrians increased for the third consecutive year, up 6.4% over 2011, while pedal cyclist fatalities increased by 6.5%. Between 2003 and 2012, the proportion of non-occupant fatalities has grown from 13% to 17%, with data showing that the large majority of pedestrian deaths occur in urban areas, at non-intersections, at night, and many involve alcohol.
Coincidentally, the NHTSA just released a report, 2012 National Survey of Bicyclist and Pedestrian Attitudes and Behavior. The survey is a status report on attitudes, knowledge, and behavior related to outdoor walking and bicycling. It updates national telephone survey data collected by NHTSA in 2002, and addressed safety and mobility issues, obtained trip information, and explored perceptions and use of public facilities such as sidewalks, bicycle lanes, and bicycle paths. It was administered to a probability-based sample of randomly selected people 16 and older.
When asked whether they felt threatened for their personal safety while riding a bicycle on their most recent travel day, 12% of respondents said that they felt threatened at some point on their ride. In terms of how their community was designed for bike riding safety, 27% of cyclists reported they were dissatisfied.
Similarly, when pedestrians were asked whether they felt threatened for their personal safety during the most recent day they had walked outside, 8% reported that they had. And 18% of respondents were somewhat or very dissatisfied with the design of their community for walking purposes.
In the face of such carnage and anxiety, information is made available. The NHTSA offers the 388-page report, Countermeasures That Work: A Highway Safety Countermeasures Guide for State Highway Safety Offices, 7th edition. The CDC has its Guide to Community Preventive Services, a free website resource to help you choose programs and policies to improve health and prevent disease in your community. Motor vehicle injury prevention is one of the 22 health topics on the site.
There is also the Day of Remembrance. It serves an important purpose because:
- it draws attention to the devastation caused and calls for government action
- it creates a link between road victims throughout the world
- lack of information about this catastrophe provokes social indifference
- the number of people killed and injured on the road represents the largest human-made disaster
- modern societies tolerate enormous numbers of victims of wholly preventable technical risks, and
- we remember lost lives and evoke the names of real people, who deserved to be alive today, to have fulfilled their dreams.
British poet Heathcote Williams gets the final word.
Seventeen million dead,
More than twice the number in the death-camps,
Eighteen times the count in Korea.
A hundred and thirty times the kill at Hiroshima,
Eight thousand five hundred Ulsters…
The Hundred Years war in a week.
The crusades in under thirty seconds.
A humdrum holocaust…the third world war nobody bothered to declare.
— Michael Lytton, AJPM Blog Editor
Further Reading in AJPM:
Vladutiu CJ, Marshall SW, Poole C, Casteel C, Menard MK, Weiss HB. Adverse Pregnancy Outcomes Following Motor Vehicle Crashes Am J Prev Med 2013;45(5):629–36.
Schlotthauer AE, Guse CE, Brixey S, Corden TE, Hargarten SW, Layde PM. Motor Vehicle Crashes Associated with Alcohol: Child Passenger Injury and Restraint Use, Am J Prev Med 2011;40(3):320–3.
Elder RW, Voas R, Beirness D, et al. Effectiveness of Ignition Interlocks for Preventing Alcohol-Impaired Driving and Alcohol-Related Crashes: A Community Guide Systematic Review, Am J Prev Med 2011;40(3):362–76.
Task Force on Community Preventive Services. Recommendations on the Effectiveness of Ignition Interlocks for Preventing Alcohol-Impaired Driving and Alcohol-Related Crashes, Am J Prev Med 2011;40(3): 377.
Krahl PL, Jankosky CL, Thomas RJ, Hooper TI, Systematic Review of Military Motor Vehicle Crash–Related Injuries, Am J Prev Med 2010;38(1 Suppl):S189-96.
Hall AJ, Bixler D, Helmkamp JC, Kraner JC, Kaplan JA. Fatal All-Terrain Vehicle Crashes: Injury Types and Alcohol Use, Am J Prev Med 2009;36(4):311–6.
Richter ED, Friedman LS, Berman T, Rivkind A. Death and Injury from Motor Vehicle Crashes: A Tale of Two Countries. Am J Prev Med 2005;29(5):440–9.
Elder RW, Shults RA, Sleet DA, et al. Effectiveness of Mass Media Campaigns for Reducing Drinking and Driving and Alcohol-Involved Crashes: A Systematic Review, Am J Prev Med 2004;27(1):57–65.
Rivara FP, MacKenzie EJ. Systematic Reviews of Strategies to Prevent Motor Vehicle Injuries. Am J Prev Med 1999;16(1 Suppl):S1–89.
Williams AF, Ctalano RF, Mayhew DR, Millstein SG, Shultz RA, Williams AF (editors). Teen Driving and Adolescent Health: New Strategies for Prevention. Am J Prev Med 2008;35(3 Suppl):S253–346.
Zaza S, Thompson RS (editors). Reducing Injuries to Motor Vehicle Occupants: Systematic Reviews of Evidence, Recommendations from the Task Force on Community Preventive Services, and Expert Commentary. Am J Prev Med 2001;21(4 Suppl):1–90.
In addition to a variety of other diabetes awareness efforts, the CDC Division of Diabetes Translation recognizes November 14 as World Diabetes Day.
Diabetes is the seventh leading cause of death in the U.S., and there are 371 million people living with diabetes worldwide. Another 280 million are at high risk of developing the disease. By 2030, half a billion people are expected to be living with diabetes.
The good news is that type 2 diabetes can be prevented or delayed. A number of studies have shown that people at increased risk of developing type 2 diabetes can significantly reduce their risk of developing the disease by making modest lifestyle changes including:
- Losing 5–7 percent of your body weight.
- Getting 150 minutes of physical activity per week.
- Eating a balanced diet, including fruits and vegetables.
— Michael Lytton, AJPM Blog Editor
The November issue of AJPM has an interesting paper on aspects of food security in the U.S. and its impact on health outcomes. An equally important article in the September issue discussed how agricultural subsidies are worsening obesity trends in America. My July blog discussed it.
October was an especially busy month in the world of food and public health. World Food Day was October 16, and during that week, Des Moines, Iowa, hosted the world’s premier conference on global food security. On the 17th, the World Food Prize was awarded for outstanding contributions in disciplines involved with the world food supply—food and agriculture science and technology, manufacturing, marketing, nutrition, economics, poverty alleviation, political leadership, and the social sciences. The conference also launched a yearlong centennial observance of the 100th anniversary of the birth of Dr. Norman Borlaug, the founder of the prize.
Howard G. Buffett (yes, that family) participated in the World Food Prize event and introduced his book, 40 Chances: Finding Hope in a Hungry World. Howard is the chairman and CEO of his private family foundation dedicated to improving the standard of living and quality of life for the world’s most impoverished and marginalized populations. Check out the 40 Chances principles here.
Food security is one of the three core areas of the Foundation’s work, and within it is a focus on agricultural resource development for smallholder farmers. This is the topic of a paper recently published on the SciDev.Net website, an excellent source of information about science and technology for global development. The paper argues for small-scale farming, tapping into local practical knowledge systems, and promoting diverse food networks that are more connected to communities and people’s nutritional needs. The authors make many good points, but the words “obesity” and “food waste” leapt out at me.
As a first step, researchers, funders, and policymakers need to identify and then re-evaluate assumptions about science, innovation, and food supply and access. Second, they need to ask the right questions about sustainable global food security, which is more than a short-term production issue. Instead of asking almost exclusively how to increase short-term yields, we should ask why even existing global production is denied to many needy people, while generating mass obesity and enormous amounts of food waste elsewhere.
I spoke with a co-author of the article, Georgina Catacora-Vargas, and discovered her to be a Bolivian recently engaged at a biotechnology research institute in Norway. (Norman Borlaug was of Norwegian ancestry. Coincidence?) Her fields of work are agro-ecology and biosafety, and in addition to Norway, she has experience in Bolivia, Lebanon, Brazil, and Costa Rica. She has worked for more than 10 years in multi-actor developmental projects centered on the promotion and establishment of local healthy food systems through agro-ecology, local organic markets, and participatory guarantee systems for organic produce.
Remarkably, Ms. Catacora-Vargas voluntarily led the Healthy Communities Project, an initiative held for 3 years in two rural areas of Cochabamba, Bolivia. The aim is to strengthen the knowledge of healthy food production and consumption by establishing organic family gardens and enriching food with ingredients from the local agro-biodiversity. Hands-on sessions on healthy food and organic gardening involved over 100 participants, including women, children and elders, three vulnerable groups in rural areas. The project included a baseline study, the results of which are currently being consolidated and analyzed for publication in the near future. The preliminary findings suggest that one project farming community with agricultural systems relying on modern inputs such as synthetic fertilizers and pesticides and geared to monetary markets, has higher levels of undernourishment (particularly among women) than the other project community practicing subsistence and diverse agriculture.
What strikes me is the relevance of such research for the U.S., as illustrated by the AJPM articles cited above. The USDA report Household Food Security in the United States in 2012 reveals that 17.6 million households are food insecure, which means having difficulty at some time during the year providing enough food for all household members. Almost 4 million of these households were unable to reliably provide adequate, nutritious food for their children. Very low food security, characterized by disrupted eating patterns and reduced food intake, was experienced by both children and adults in 463,000 households with children in 2012. To find those households in your region, go the Map the Meal Gap website. Find out what action you might take here.
Diet is central to better health in America, and food knowledge is basic to better eating habits. Americans, urban residents especially, are increasingly ignorant of where food comes from, have inadequate exposure to raw and unprocessed foods, are unfamiliar with local food sources and varieties, eat few raw and unpackaged foods, and are losing the skills of meal planning, cooking, and eating with friends and family. Denial of food insecurity or the health risks of poor diets is one thing, but to deny oneself the endless pleasures of cooking and eating is a real tragedy.
— Michael Lytton, AJPM Blog Editor
Health Literacy: Part 5 of 5
Bill Keller, the executive editor of the New York Times from 2003 to 2011, discusses health care in a recent Op-Ed column. He tells a wonderful story about innovations that are underway that promise to transform health care in America. Keller describes “accountable care organizations [that] have become the Silicon Valley of preventive care, laboratories of invention driven by the entrepreneurial energy of start-ups.” He cites “new medical SWAT teams—including not just doctors but health coaches, care coordinators, nurse practitioners—to intervene and encourage patients to live healthier lives. “
There is emerging brave talk about transforming health care from the market model of treating disease and selling medicine, to social policies of preventing illness and promoting well-being. Health literacy—the ability to make sound health decisions in the context of everyday life at home, in the community, at the workplace, in the marketplace, and the political arena—will be a key part of that transformation.
Health encompasses physical, mental, and social wellness, and is determined by individual behaviors, the environment, and by social, economic, political, and institutional factors or contexts, including the health system. Everyone exposed to 21st-century (especially urban) lifestyles is vulnerable to the behavioral and environmental risk factors that contribute to chronic disease, including unhealthy diet, physical inactivity, financial insecurity, poor housing, inadequate public transportation, workplace stress, limited green space, violence, pollution, and so forth. Obesity, high blood pressure, cardiovascular diseases, cancer, depression, diabetes and anxiety are just some of the examples of the metabolic, physiological, and psychological risk factors that form part of a holistic health literacy curriculum.
In this context, health literacy must equip all citizens with the means to adapt and cope in the face of environmental, economic, social, physical, and emotional challenges. This implies a shift in focus from the hospital to the home and from patient to population. It also asks if the focus on cognitive, rational choice behavior matches the reality of patients and consumers. (A recent study in the Netherlands reports that patient activation is a stronger predictor for seeking and using health information than functional health literacy). A possible approach to making such shifts is by conceptualizing health literacy as a catalyst of behavior change that produces positive health outcomes. This applies equally to those whose decisions and actions are making us ill, as to patients and consumers.
The transformative vision articulated by Bill Keller includes new health infrastructure such as gyms and community teaching kitchens, along with community-based healthy cooking classes, mental exercise programs and dance lessons. Citizens at home, in the community center or clinic, at school, in the workplace, and in the marketplace will be exposed to such health literacy fundamentals as the modifiable behavioral risk factors for noncommunicable diseases, and the ways to prevent and control them.
The argument that the medical perspective on factors influencing people’s health should be shifted toward a societal level is not new. In this journal in 2009 Freedman et al. called for public health literacy, stating that “[w]hereas health literacy has traditionally been operationalized as an individual-level construct, public health literacy takes into account the complex social, ecologic, and systemic forces affecting health and well-being.” This notion has been further developed and promoted in such documents as the 2006 European report, Navigating Health: The Role of Health Literacy, and the 2012 discussion paper, An Inter-Sectoral Approach for Improving Health Literacy for Canadians.
Linking these and other documents are the imperatives for a comprehensive approach and collective engagement. The language is explicit, calling for “a joint effort,” “multiple partners,” “all sectors,” and “all levels of society.” The broad reach of the emerging health literacy project encompasses governments, finance, agriculture, the health and education sectors, workplaces and businesses, community organizations, professionals, planners, policymakers, politicians, taxpayers, voters, families, and individuals.
And perhaps most significantly, such an inclusive mandate introduces the idea that those who are directly and indirectly, consciously and inadvertently, purposefully or accidentally responsible for the environmental, social, economic, political, and institutional factors that ultimately determine the state of our health, must eventually become health literate themselves, and thus the guardians of our well-being. It could happen.
— Michael Lytton, AJPM Blog Editor
Further Reading in AJPM:
Krist AH, Shenson D, Woolf SH, et al. Clinical and Community Delivery Systems for Preventive Care: An Integration Framework. Am J Prev Med 2013;45(4)508-16.
Fineberg HV. Public Health and Medicine: Where the Twain Shall Meet. Am J Prev Med 2011;41(4S3):S149-51.