Policy, systems, and environmental change: the current, faddish, cow-patty flavor of public health

One thing I have never shaken since my days as a rookie reporter is my penchant for calling out the obvious. This is one of the sacred duties of the press: to speak truth to power. This also means calling a spade a spade, and bullshit for what it is, and what it smells like.

Anyone who has ever worked in the business of reporting news and telling facts knows this is one of the press’s sacred trusts—and myths—and the clearer we are in doing that, the better our society is from having that unbiased information.

I captured these various images on Google when I typed in a few keywords, and clearly this concept has a lot of widespread acceptance by people who know a cow patty when they smell one.

I captured these various images on Google when I typed in a few keywords, and clearly this concept has a lot of widespread acceptance by people who know a cow patty when they smell one.

Today, I stumbled on Marcy Wheeler’s blog, the Empty Wheel, which tackles many hot-button policy issues. Last year she blogged about climate change in a piece called “The Cost of Bullshit: Climate Change, National Security, and Inaction.”  She pointed out that the cost for maintaining the status quo was too high, even when major government agencies from the Department of Defense and the Department of State concluded that the issue was a critical concern to U.S. national interests. Yet, no actions were being taken by the government, and all of the reports on the emerging crisis were “mere bullshit—more wasted government employees’ time and taxpayer money.”

Sure easy for a blogger not on the payroll to diss hard-working public workers and policy-makers, right? Or, is Ms. Wheeler simply calling out the obvious, like reporters have always done, or thought they were doing.

Will a public health fad meaningfully address the main killers of Americans?

The cost of bullshit has been on my mind late, particularly regarding public health jargon that inflates busy-looking arm-waving, but does not change reality.

For me, one of the most frustrating aspects of working in the public health is the field’s faddish way it labels its collective actions to address chronic disease issues, such as obesity, using fancy sounding concepts like “policy, systems, and environmental change.” Mon dieu, what big words, what big ideas.

This is an expression coming from the top, from the venerable U.S. Centers and Disease Control (CDC), to explain national efforts to tackle the monster that is chronic disease—the leading causes of death in our ever-fattening and ever growing income-unequal country.

These diseases kill seven in 10 Americans, and of the CDC’s meager budget of under $7 billion for our national public health effort is a mere drop in the bucket compared to other priorities of the $1.2 trillion national budget that is so-called “non-discretionary spending.”

The Congressional Budget Office released this info graphic on government spending and revenues for 2013. Go here for original: http://www.cbo.gov/publication/45278.

The Congressional Budget Office released this infographic on government spending and revenues for 2013. Go here for original: http://www.cbo.gov/publication/45278.

The CDC still estimates 18% of U.S. GDP spending is on healthcare, and a third of it at the place where the most outrageously overpriced and at the same time least effective primary care interventions can take place—hospitals.

So what do public health officials do, when faced with a handful of breadcrumbs thrown to them from Congress? They invent concepts that make it appear that public health is doing something, when there is little or no clear evidence population benefits are accruing based on investments at this level in the large ocean. Yes, I am talking about the catchy and jargon-laden ideas like “policy, systems, and environmental change.”

This is a hodge-podge of activities that encompass everything from starting farmers markets to promoting smoke-free buildings. Here are a couple of definitions I randomly found from some online sources:

  • State of Mississippi: “Our environment and the policies and systems in it shape the pattern of our everyday lives and have a profound influence on our health. The design and walkability of communities, the availability of low-cost fruits and vegetables, and the smoking policies in our workplaces have a direct impact on our physical activity, diet and health.”
  • State of Maryland: “Policy, systems, and environmental change (PSE change) refers to public health interventions that modify environments to provide healthy options and make healthy choices easy for everyone.”
  • Fairfax County Virginia: “Policy, systems and environmental change is a way of modifying the environment to make healthy choices practical and available to all community members. By changing laws and shaping physical landscapes, a big impact can be made with little time and resources. By changing policies, systems and/or environments, communities can help tackle health issues like obesity, diabetes, cancer and other chronic diseases.”

Budgets for this kind of intervention exist in most public health jurisdictions, and public health leaders are doing to the talk, because they have so few funds to do the walk. But public health experts end up playing in a small sandbox when these investments are measured against other spending, and then we spend a lot of time trying to convince ourselves through published papers, webinars, conferences, and the like that this is working. The illusion is powerful, like the illusory power of the Iron Throne in the Game of Thrones, except the shadow from a fad still does not make meaningful change when the numbers are crunched and the costs are calculated regarding chronic disease.

From the Game of Thrones, a lecture on power and illusion, for Westeros and beyond.

From the Game of Thrones, a lecture on power and illusion, for Westeros and beyond.

Public health departments who get funding through competitive grants from the CDC spearhead these efforts and then spend extensive amounts of time documenting their work trying to prove the bread crumbs made a difference to the overall health crisis facing Americans.

About $200 million was doled out from 2011 and 2012 through an effort called Communities Putting Prevention to Work (the amount initially announced in 2010 was about $380 million). In one case, Public Health-Seattle & King County published findings that show its CPPW-grant-funded efforts in schools cut youth obesity in specific schools by 17 points. Great job, except the funding was not permanent and it was not renewed when the grant ran out. The program is now in the past tense.

In 2014, public health professionals learned another funding source, the Community Transformation Grants, which also promote the policy, systems, and environmental work, is being cut too. Some can argue the money is being allocated to other programs that tackle chronic disease, focusing on heart disease and diabetes.

More musical chairs without really changing the big picture again?

I do not mean to belittle the work of public health people doing this work. They are my colleagues. I respect them. And the work being done, like promoting activities to reduce tobacco use and get more people eating healthy food, should be continued.

But as a field, I am convinced this type of work is self-delusional because it hides the nasty realities of how much larger issues shape the public’s health, such as how transportation budgets are allocated, how cheap petro-based energy is spurring obesity in measurable ways, how legislation is crafted by special interests at the state and federal level, and how the principle of health care is considered a privilege not a right in the United States. (In Denmark, by contrast, the public funds about 85% of all health care through taxes, and the system is rooted in both law and a social contract that is premised on system where all citizens are provided free and equal access to quality health care.)

Emilia Clark, mother of dragons in the smash HBO TV series Game of Thrones, is a good visual metaphor of what public health is not in the bruising world of budget appropriations at the state and federal levels of government.

Emilia Clark, mother of dragons in the smash HBO TV series Game of Thrones, is a good visual metaphor of what public health is not in the bruising world of budget appropriations at the state and federal levels of government.

The nasty realities we do not want to think about, using a contemporary TV metaphor, would be what happens when the violent kings of Westeros cut deals and cut heads, to maintain order in that mythical, lovable place with White Walkers, a giant ice wall, and fire-breathing critters. Mother of Dragons, public health is not, that is for sure!

I imagine a new fad will emerge in public health in the next three years, like it does in management. We might change the concept, but we likely may even have a smaller piece of the government pies.

No, public health jurisdictions cannot stop working until we see changes on these fronts. But the more we in public health delude ourselves that we are making a difference with scraps from the table, the more easily we are duped into accepting that the larger model is as it should be, and how it shall always be.

We will continue kvetching about farmers markets and soda machines, but not moving in a rigorous way upstream, where budget deals are made with transportation dollars, for starters. And I think we have to start being honest with ourselves about what we are accomplishing in the sandbox and whether this is the best use of our meager and diminishing resources.

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Cheap energy poses a threat to Americans’ health

One of the most talked-about initiatives taking place in public health, with funding supports from the Centers for Disease Prevention and Control (CDC), is policy, system, and environmental change to address the rise of chronic disease in the United States, the country’s leading cause of death. According to the CDC, chronic diseases are responsible for seven out of 10 deaths of all Americans annually, and one half of all Americans have at least one chronic illness. Worse, three-quarter of the $2.5 trillion (yes trillion) dollars spent annually on health care in the United States goes to battling chronic diseases. The CDC’s grant funding is being disbursed to health departments to undertake a range of interventions. But none of these interventions is going after what some say is one of major sources for the rise of obesity and chronic disease—the cheap price of energy in the United States.

According to Ian Roberts of the London School of Hygiene and Tropical Medicine, the overall obesity rate is highest in the United States among all other nations because the price of gasoline is very low. “So where gasoline is really cheap, we over-consume it, it’s bad for the environment and actually because we should be using food energy for human movement – if we use gasoline for human movement, then we store the food energy and you know where we store it.” And there are other costs associated with being a fat nation, says Roberts. “So there’s obviously an increased demand on food supplies, but also there is an increased demand on everything. You know, bigger people need more energy to move them. Airplanes take more energy to get off the ground. It takes more of the shares that, you know, of the Earth’s resources to actually support all that extra weight.”

In the United States, the U.S. Energy Information Agency estimates we use 317 million BTUs per person a year. In this country, nearly half of all of our energy comes from petroleum and natural gas, and the country ranks seventh globally in terms of per capita energy use, trailing Canada and some smaller nations like Luxembourg and Trinidad and Tobago. However, the United States is  No. 2 (19% of global demand) in terms of global consumption of energy after China (20.3% of global demand), which just took the No. 1 slot.

Feeder pipelines gather crude oil produced at Prudhoe Bay, which is eventually shipped to the lower 48 for consumption on the West Coast.

A significant negative outcome can be seen in the widening waistlines of Americans. Charles Courtemanche of the Department of Economics at the University of North Carolina at Greensboro published a study in 2009  (A Silver Lining? The Connection Between Gasoline Prices and Obesity) that found increases in gas prices were associated with an uptick in walking or bicycling and public transportation use (and more people walking to bus and subway stops) and a drop in the how often people eat at restaurants, all impacting weight. Courtemanche estimates that:

– A $1 rise in the price of gasoline would reduce overweight and obesity by 7% and 10% in the U.S. The reduction in obesity would save approximately 11,000 lives and $11 billion per year, savings that would offset 10% of the increased expenditures on gasoline.

– An 8% of the recent rise in obesity from 1979 to 2004 can be attributed to the decline in real gasoline prices during the period.

According to Dr. Brian Schwartz, professor at the Johns Hopkins Bloomberg School of Public Health’s Department of Environmental Health Sciences and co-director of the School’s Program on Global Sustainability and Health, cheap energy also is responsible for creating our built environment, which is exacerbating our poor health trends. Schwartz argues that since World War II, the United States and other developed countries “have invested in large tracts of low density, non-compact, single use developments, which are highly reliant on the automobile and often lack public transit options.  This type of housing and transportation system is totally reliant on cheap and plentiful oil.”

The built environment of U.S. suburbs has been shaped by the relatively cheap price of petroleum paid by U.S. consumers at the pump.

Schwartz argues the average foodstuff in the United States requires about 10 units of fossil fuel-based energy input for each unit of food energy derived from the food, and that ratio jumps to 100 to 1 for many meats. Less energy would lead to declines in food calories too, as many kinds of food would become too expensive to produce and too expensive for consumers. What’s more, Schwartz suggest that this unsustainable suburban lifestyle would change dramatically after peak oil, that future and historic moment when global production of both oil and natural gas reaches its historic peak and begins to decline, setting off chain reactions impacting every facet of our life to what we eat, how we work, how goods and people move about, and how nations respond on a massive scale. (Go here for a summary of peak oil and its health impacts, as explained by Schwartz.)

Schwartz also notes that our entire health care delivery system, on top of our suburban-sprawl development pattern, food production systems, and supply chains, also is tied to unsustainably cheap energy in the form of cheap fossil fuel. “Large energy-inefficient health care facilities are staffed by health care workers living in distant suburbs who require large quantities of paper, plastic, and electronics to do their work. Systems for provision of care will need to be completely redesigned to adapt to the new reality of more expensive energy.”

Portland, Ore., that oh-so progressive Northwest city that has become a beacon of contemporary planning that tries to vaguely resemble what they do in Netherlands or Denmark, for instance, already has assembled a Peak Oil Task Force, back in 2006. The group prepared a report and drafted a resolution, passed by the City Council in 2007. That resolution sets out an ambitious goal to “reduce oil and natural gas use in Portland by 50 percent in 25 years and take related actions to implement recommendations of the Peak Oil Task Force.” It may be no surprise Portland was recently ranked the No. 1 biking community in the United States.

What continues to baffle me is how unengaged or willfully silent the United States’ professional public health system is to the connection between cheap energy and health, notably obesity. I just did a keyword search today (Sept. 3, 2012) on the word “obesity” for the upcoming American Public Health Association (APHA) Annual Meeting and Exposition to be held in San Francisco in October 2012. There were 797 hits for the word–many for papers being presented on the topic. When I typed in the word “oil” I yielded 33 hits, some on the Deep Horizon oil spill and its impacts and others on shale gas development, such as a paper being presented by Dr. Roxana Witter of the University of Colorado called “Comprehending health implications of natural gas development through public health research.” But I saw no papers on any linkage between the so-called “obesygenic environment” and energy prices tagged under the word “oil” in the searchable database of presentations and papers. I did a search for the word “energy” and got 82 hits, but most related to topics like high-energy drinks, not on oil, gas, or energy policy issues impacting human health.

Seattle like other cities is entirely dependent on relatively cheap petroleum, and as a consequence suffers from some of the worst traffic congestion of any metro area in the country, as well as a sprawl development in the city and throughout surrounding King County.

I dream of the day when public health professionals will organize their advocacy less around what kids eat at school and talk more about what our state and national lawmakers are doing to create meaningful tax policy that prices energy–making it more expensive while using revenues to promote renewable energy sources–to create larger downstream impacts. To completely cede this issue to supporters of cheap energy and the status quo and to deny that there are serious public health implications by doing so is to turn one’s back on best available evidence and the duties those in the field have to promote healthy outcomes for the U.S. population.  I did try to raise this issue in one of my classes at the University of Washington School of Public Health, and was met with unusual silence. I hope one day perhaps UW faculty in the economics department, school of business, and schools of public health and public affairs get together one day to pursue research examing negative health impacts of national energy policy.

Health interventions, the positive face of geopolitical engagement

On June 14, Tom Paulson’s insightful blog, Humanosphere, put the spotlight on U.S. military initiatives underway in Africa as part of a grander strategic focus the U.S. Government is placing on Africa, through the U.S. Africa Command called Africom. He raised concerns about the dual efforts of the U.S. Government. On one hand, it was expanding its covert operations, purportedly to root out so-called terrorism networks and promote and training activities in Africa by building bases stretching from Djibouti to Ouagadougou, Burkina Faso, while at the same time trying to stomp out malaria, which kills about 600,000 Africans a year. According to a U.S. Department of Defense (U.S. DOD) press release, “Africom incorporates malaria prevention into much of its theater engagement, distributing mosquito nets and teaching new diagnostic techniques during training events throughout Africa.”

I think few could argue with the humanitarian goals of this type of health intervention, at least with some basic metrics. But in reality, health-related assistance usually has a broader function. Combining “hard” and “soft” power  is nothing new to geopolitics or the U.S. Government and its diplomatic, development, and military branches. The two often go hand in hand. Closer to home for most Americans, but still far away in the U.S. Arctic in communities along coastal Alaska, the U.S. Coast Guard has spent four years expanding its training activities and capacities in the Arctic to prepare for offshore oil drilling by Shell Oil Co. Production is scheduled to begin in the summer of 2012 in the U.S. portions of the Beaufort Sea, just north of one of America’s largest oilfield, Prudhoe Bay. Oil would then be shipped down the aging and half-empty Trans-Alaska Pipeline System (TAPS).

The Prudhoe Bay oildfield is one of United States richest oil producing areas, but its production is declining leading to offshore development.

The Coast Guard preceded its Arctic ramp-up with a much heralded health and logistics outreach, called Operation Arctic Crossroads, starting in 2009, to Alaska’s western coastal communities, such as Barrow and Kivalina. These were welcomed by the mostly Native residents and received high marks from nearly all quarters in Alaska. The Coast Guard is perhaps one of the most celebrated institutions in Alaska because of its humanitarian work saving countless lives and vessels, year after year, and because of the stellar reputation it has earned, demonstrated by its outstanding safety and rescue record. (I am a huge fan of the Coast Guard, if you cannot tell, having reported on their helicopter rescues numerous times as a reporter in Sitka, Ak., in 1993.) But the Coast Guard also has noted these outreach events in Alaska have been ultimately tied to the much larger issue of energy security and defense. The U.S. DOD reported “the Arctic has economic, energy and environmental implications for national security. Coast Guard missions there are increasing because Shell Oil Co. has permits to drill in Alaska’s Chukchi and Beaufort seas beginning this summer.” The U.S. DOD further notes, “Shell will move 33 ships and 500 people to Alaska’s North Slope, and will helicopter some 250 people a week to drilling platforms.”

Deadhorse is the main landing area for the North Slope oil and gas production facilities in Alaska.

The coast of the Beaufort Sea holds significant oil reserves that Shell Oil Co. will begin tapping in the summer of 2012.

All told, Shell spent some $2.2 billion for offshore leases alone, not to mention millions in legal wrangling, government relations, PR, advocacy in Alaska and in DC, and much more since the mid-2000s. The New York Times estimates Shell spent $4 billion in its quest for one of the biggest oil prizes in North America outside of the Athabascan oil sands of Alberta and shale oil finds in North Dakota. (Shell also is drilling for natural gas in the Chukchi Sea this summer also.) The issues framing a stronger U.S. commitment in the Arctic are natural gas and oil resources and a so-called “race for resources,” as it has been described by some, which concerns rights to those resources on the Arctic Ocean seabed floor.

The U.S. Energy Information Agency claims that nearly a quarter of untapped oil and natural gas resources are in the Arctic basin, which explains the significant interest by the major multinational oil exploration companies in the shallow Arctic waters off Alaska’s North Slope. Companies like Shell and ConocoPhillips and others have been staking out their claims for years by buying controversial offshore drilling leases that have been sharply contested in protracted legal fights with environmental groups and Native Alaskan residents of the North Slope Borough (the Inupiat). The Inupiat residents,  who, while mostly supporting onshore development, are concerned about the threat an oil spill or blowout in pristine Arctic waters, similar to BP’s spill in the Gulf of Mexico in 2010. Some Inupiat resident say that would harm their subsistence hunting of migratory bowhead whales, which have been hunted and eaten by these historic Arctic residents for thousands of years.

A whaling ship rests in the Arctic summer sun in Barrow, on the coast of the Beaufort Sea.

What is clear is that interventions premised on health care will likely be part of a larger strategic framework of  nations as powerful as the United States. Those actions, no matter how well-intentioned to improve health care from Kivalina to Kenya, must be understood in a much larger context of any nation’s political and economic interests. This is particularly true regarding access to and the development of natural resources, wherever those resources may be.