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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.

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

A Different Remembrance Day

November 15, 2013
Remembrance Day

Photo courtesy of Thurston Hanson

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,
And counting.
More than twice the number in the death-camps,
Eighteen times the count in Korea.
Seventeen Vietnams.
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.

Checking the Calendar

November 14, 2013

Diabetes infographicIn 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